Every finding on record at Tomahawk Health Services

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent elopement or falls for 2 of 3 residents reviewed (R23, R5).R23 has a history of elopement attempts on and was assessed to be at risk for wandering and elopement. R23 wears a Wanderguard that alerts staff to her attempts to elope. On 02/24/26, R23 exited the facility without staff knowledge and without the Wanderguard alarm sounding. R23 was found by a citizen approximately 0.7 miles from the facility with approximately 1 inch of snow on top of her head. Police were called and were able to determine resident was from the facility.The facility's failure to provide adequate supervision created a finding of immediate jeopardy that began on 02/24/26. Director of Nursing (DON) B was notified of the immediate jeopardy on 03/19/26 at 3:10 PM. The immediate jeopardy was removed on 3/19/26 however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan and as evidenced by the following examples:Facility did not follow R5's care plan related to appropriate footwear to prevent falls and is at risk for wandering and eloping and no Wanderguard in place.Findings include: Example 1 The facility policy titled, Elopement/Unsafe Wandering last revised on 08/09/22, includes, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.Alarms are not a replacement for necessary supervision. R23 was admitted to the facility on [DATE] with diagnoses of early onset Alzheimer's disease, aphasia, generalized anxiety disorder, severe dementia with mood disturbance, major depressive disorder, and personal history of stroke without residual deficits. R23 was initially admitted to the secured Memory Care Unit (MCU) A Wanderguard trial was performed and successful on 06/27/24, and R23 was moved off of the secured unit and on to the East Wing. R23's care plan prior to the incident reads in part: Focus of potential for elopement related to dementia with interventions of allowing resident to vent feelings and/or frustration as needed, calmly redirect to an appropriate area, encourage socialization with others and provide recreational programming, and engage in activities/tasks to keep occupied (6/21/24). Focus of at risk for changes in mood related to anxiety and major depressive disorder with interventions of assess for physical/environmental changes that may precipitate change in mood (06/24/24). Focus of at risk for behavior symptoms (wandering, repeated movements, rejection of care) related to Alzheimer's Disease with interventions of redirect as able, offer meaningful activity, offer food or drink, use consistent approaches when giving care (08/28/24), redirection, reapproach as resident allows (09/23/24). Upon admission, R23 had a Brief Interview for Mental Status (BIMS) score of 3/15, which indicates severe cognitive impairment. R23's current BIMS dated 12/22/25, R23 had a BIMS score of 00, indicating severe cognitive impairment. Wandering risk assessments indicated R23 was a moderate risk for wandering for all assessments except 06/14/25 and the one completed on 02/24/26 (day of incident). On those two dates, R23's risk assessments indicated R23 was a high risk for wandering. R23's care plan prior to the elopement incident on 02/24/26 reads in part: Focus of potential for elopement related to dementia with interventions of allowing resident to vent feelings and/or frustration as needed, calmly redirect to an appropriate area, encourage socialization with others and provide recreational programming, and engage in activities/tasks to keep occupied (6/21/24). Focus of at risk for changes in mood related to anxiety and major depressive disorder with interventions of assess for physical/environmental changes that may precipitate change in mood (06/24/24). Focus of at risk for behavior symptoms (wandering, repeated movements, rejection of care) related to Alzheimer's Disease with interventions of redirect as able, offer meaningful activity, offer food or drink, use consistent approaches when giving care (08/28/24), redirection, reapproach as resident allows (09/23/24). The progress notes in R23's medical record stated R23 had two previous incidents of elopement from facility. On 10/9/24, R23 exited the building and was walking toward the park. Alarm did not sound upon R23 exiting the facility. On 10/10/24 following the elopement, behavior monitoring was revised for wandering and repeated movements of residents. R23's care plan interventions were added to redirect as able, offer meaningful activity, and offer food or drink. Surveyor did not find any documentation indicating if the Wanderguard or the door alarm was not functioning. On 02/15/25 at 1:00 PM, R23 exited the building and was seen by staff walking quickly down a nearby street. Surveyor did not find any documentation of changes/interventions after the elopement on 2/15/25 On 7/11/24 at 2:01 PM, progress note stated R23 gave the Wanderguard bracelet to a nurse. The Wanderguard looked as though it had been cut off. R23's care plan states: Date initiated 8/8/24. Revision 1/26/26. [R23] will accept care and medications as prescribed. Staff will check placement of code alert on resident's wrist q shift On 11/2/24 at 8:22 AM, R23's Wanderguard was inoperable. Progress note in R23's medical record states the charge nurse would be notified. No documentation noted until 3:41 PM, that the Wanderguard was functioning properly. Surveyor did find any documentation for follow-up to confirm what the facility did with R23's Wanderguard if anything. On 11/29/24 at 4:35 PM, progress note states the call light system was not working. At 5:23 PM, the progress note states the call light system/alarm system was not working. R23 was the only resident wearing a Wanderguard. The Wanderguard was in place and checked every shift. The alarms on all of the facility exit doors are checked daily by maintenance and this is logged when checked. The call light system and door alarm system are tied to the same sound board, which was not working at this time. On 06/20/25 at 10:14 PM, the progress note states R23's Wanderguard was inoperable. Surveyor could not find documentation following up on this statement of R23's Wanderguard not functioning nor what the facility did to correct this. On 1/19/26, night shift documented that R23's Wanderguard was not functioning. No documentation was found about whether Wanderguard was replaced or not. According to documentation received by the state agency, on 02/24/26 at approximately 1:04 PM, police were informed of an elderly female outside of a thrift store who was covered in snow and was wandering around and looked to be in distress. PO C observed R23 standing in the middle of the parking lot wearing a white coat and mittens with about an inch of snow on the top of R23's head. PO C pulled up next to R23 and asked if R23 was ok. PO C exited the and car saw R23 had R23's first name stitched on R23's coat. PO C asked again if R23 was ok and R23 showed PO C R23's mittens. R23 did not respond to PO C's questions. PO C guided R23 to the squad car and asked R23 to sit in the rear seat to warm up. PO C did not locate any identification on R23. PO C did locate a plastic band that appeared to be a sensor maybe from a nursing home to alert when R23 left the building and PO C asked dispatch to contact the nursing homes in the city and to call for an ambulance in case of this being a medical emergency. PO C then tracked R23's footprints in the snow and it appeared that R23 came from the south on the sidewalk on North 4th St. (North 4th St. is the main thoroughfare through Tomahawk with traffic consisting of passenger vehicles, buses, and semi traffic.) Dispatch then stated R23 had walked away from the facility, and staff did not notice that R23 had left the building. The ambulance and PO C then took R23 to the facility so they could obtain R23's paperwork for the hospital. PO C spoke to the nurse on duty. The nurse on duty stated R23 had dressed R23's self and walked out without them knowing. The facility stated R23 had done this in the past and they did not know why the alarm did not sound when R23 left. Hospital discharge summary indicated R23 was disoriented but physically unharmed. A progress note in R23's medical record stated R23 returned to facility on 2/24/26 at 2:24 PM. Wanderguard was discontinued, and R23's room was changed to the Memory Care Unit (MCU). MCU is a secure unit, and the residents in the MCU do not have Wanderguards. Later interviews will show that there are times when the MCU door does not close and does not signal staff that the door is ajar. R23's care plan post incident included in part: Intervention added to elopement care plan of at high risk for elopement updated on (02/24/26). Revision 2/25/26 states [R23] will accept care and medications as prescribed through next review date. Staff will check placement of code alert on resident's [R23] wrist every shift. Resident [R23] resides on MCU for long-term care updated on (3/19/26). On 2/24/26, R23 was wearing a Wanderguard bracelet, but the facility was unsure if it was functioning at this time. The door box alarm had been marked as functioning; however, it was discovered that the signal strength for the alarm to detect the bracelet was not set sensitive/strong enough. All of the facility exit doors are equipped with Wanderguard boxes. DON B provided Surveyor with a facility timeline of incident on 02/24/26 from their investigation. The document was titled, Elopement 2/24/26 Summary. The summary includes the following: 1:00 PM-1:07 PM, R23 left facility without Wanderguard system alarming. Of note - The police report shows that the call was received at 1:04 p.m. To travel .7 miles in 4 minutes, a person would have to go 10.5 miles per hour. 1:15 PM: Police Department notified facility of elopement. 1:20 PM: R23 transported to emergency room (ER) via Emergency Medical Services (EMS). 1:35 PM: Left voicemail for Power of Attorney (POA). 1:38 PM: Secondary POA updated. 1:45 PM: Notified [NAME] President of Success (VPS) for further instruction. 1:55 PM: Provider was notified. 2:05 PM: ER called facility with report for R23. 1410: R23's room was changed to the Memory Care Unit. 2:24 PM: R23 arrived back at facility. 2:25 PM: Skin, pain, psychosocial, and wandering assessments were completed. 3:00 PM: R23 was placed on additional 1:1 monitoring. On 2/24/26, an email was sent to the facility's Wanderguard system provider for assistance with the door alarm system. Of note-this has been an ongoing problem. The first elopement on 10/9/24 states the alarm did not sound upon R23's exit from the facility. The second elopement on 2/15/25, the alarm did not sound, and facility staff did not see resident until they noticed R23 walking down a nearby street. The facility investigation notes included in part: Upon this notification, staff were interviewed about the time R23 was last seen in the facility and R23's psychosocial status during the timeframes to which she R23 was seen. Per Therapy Director (TD) E, R23 was in the therapy department working with another resident at 12:50 PM. Staff report that they believe R23 became upset because a cup in R23's refrigerator was thrown away, but R23 did not make any suggestion of leaving the facility. Assistant Director of Nursing (ADON) J was interviewed as ADON J's office directly faces the front entry door, which R23 has exited in the past. ADON J stated that ADON J was in ADON J's office until 1300 with the office door open and did not see R23 exit the facility. No other staff witnessed R23 exiting the facility prior to the report of the elopement. From the interviews with the staff present, it can be determined that R23 left the facility between 1300-1307 and was located at 1315. Staff were interviewed if the Wanderguard door alarm system alerted at all in the last 2 hours prior to R23 leaving the facility and they deny hearing it sound. From the information gathered and maintenance checks of the system, the facility believes there was a fault in the system, which didn't alarm, allowing R23 to leave facility without alerting staff to R23's departure. The Wanderguards are tested by having a Wangerguard close to the door and opening the door to make sure that an alarm sounds. Surveyor found no documentation the facility interviewed any other staff or residents to determine which door R23 may have gone out if not the front door. Surveyor traveled several routes from facility to the thrift store and was able to determine the 0.7-mile distance indicated at minimum, a 12–14-minute walk. This facility is located about 280 feet from the Wisconsin River. The road where the facility is located is also one of the main routes to the elementary, middle school, high school, and a day care center. A technician arrived at the facility on 2/26/26 and Surveyor reviewed the information from that visit, and it stated: The technician inspected equipment, and everything appeared to be okay and functioning. Voltage was correct at 12.4 volts. The tech contacted tech support and explained the issue who stated it may be the specific tag used. Tech continued to do more testing and was able to duplicate what may have occurred simply by cupping the tag against the far side of his body away from the antenna, and it let him go through the door without setting off the alarm. This was tested several times with the same result. Tech then recontacted tech support and was walked through how to turn up the detection field to create a larger field for tag detection. Tech was able to expand the field, and it then started to detect the tag even while cupped in hand away from the antenna. Maintenance director asked for a quote to replace the Wanderguard system. Surveyor reviewed the log named, Daily check operation of door monitors and patient wandering system. The log indicates the alarm systems passed the check on 02/24/26 (the day of the incident). The alarm system sounds on the sound board near the nurse's station and Wanderguard alarms at the box on the door that it sets off. Surveyor requested a policy specific to the Wanderguard system. [NAME] President of Success (VPS) I stated the facility did not have one. Surveyor reviewed staff education completed after the incident. The education titled, Elopement/Unsafe Wandering, was initiated on 02/25/26 with some staff reviewing that day, continued with more staff between 02/25/26 and start of survey, and the rest of the staff being contacted by phone after surveyors entered the facility for survey. On 3/17/26 at 2:37 PM, Surveyor interviewed R23's Power of Attorney (POA) G and asked about R23's wandering/elopement. POA G stated that R23 removes the Wanderguard and places it under her armpit or in her shoe. POA G stated POA G has told this to the facility staff, but they do not listen. On 03/18/26 at 9:37 AM, Surveyor was at the nurse's station speaking with Certified Nursing Assistant (CNA) M. CNA M turned toward the Memory Care Unit (MCU) door and asked another staff member to close the door as CNA M could see a gap and a resident approaching the door. The other staff member closed the door. Surveyor asked why the door did not shut all the way. CNA M stated there is a latch at the top of the door that stops the door from closing if you open both doors at the same time. CNA M also said there is usually an alarm that sounds but it did not this time. CNA M stated that if it is bumped just right, it will not sound. On 03/18/26 at 9:40 AM, Surveyor observed R45 walking through the hall and entering the East wing. Housekeeper L approached R45 and redirected R45 toward the nurse's station where CNA M confirmed R45 lives on the MCU. R45 was then assisted back to the MCU by CNA M. On 03/18/26 at 11:54 AM, Surveyor interviewed RP D. RP D stated RP D arrived at the thrift store to meet RP D's spouse. RP D noticed R23 walking around in the parking lot, but other people were coming and going and didn't think much of it at first thinking maybe R23 was with them. RP D stated RP D went to the back of the building to assist someone with something, and RP D returned to see R23 was now walking around, and no one was with R23. RP D noticed an inch or more of snow on R23's head and called the police. RP D stated R23 was wearing a white windbreaker type coat and mittens. RP D stated R23 had tennis shoes and no hat. RP D stated 5 minutes or more passed from when RP D first observed R23 walking before calling the police. RP D checked the call log on RP D's cellphone and found RP D called PO C at 12:56 PM. On 03/19/26 at 7:09 AM, Surveyor interviewed Therapy Director (TD) E. TD E stated on the day of the incident, R23 was slightly agitated that morning. TD E tried to work with R23, and R23 was getting more agitated, so TD E stopped. TD E stated TD E last saw R23 at the nurse's desk but is not sure of the time. TD E stated it should be in the notes from that day. TD E stated R23 did not have R23's coat or mittens on at the time TD E last saw R23. On 03/19/26 at 7:19 AM, Surveyor interviewed CNA F. CNA F was working on the day of the incident. CNA F stated CNA F remembers last seeing R23 around lunch time between 12:30 PM-1:00 PM. CNA F remembers R23 was fixated on flowers and was observed taking them back and forth between R23's room and the dining room. CNA F stated R23 was then cleaning the hallway. CNA F stated the alarm did not sound. CNA F was first aware of R23 being gone when the phone call came in asking if they had any missing residents. CNA F stated all the staff went around and did a check, and R23 was the only one missing. On 03/19/26 at 8:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H. LPN H was working from the day of the incident. LPN H stated that day R23 was agitated and angry. LPN H last saw R23 walking with another resident down toward therapy but could not recall what time that was. LPN H stated R23 did not have R23's coat and mittens on at that time. LPN H did not hear an alarm and was first made aware R23 was missing when the police called to inform the facility. On 03/19/26 at 3:17 PM, Surveyor interviewed Director of Nursing (DON) B and Maintenance Director (MD) K entered the room. DON B asked MD K if all door alarms were working correctly. MD K stated the only one not working the way it should is the [NAME] Hall door. MD K stated MD K was waiting to find out what parts were compatible. Surveyor found no documentation as to how long the [NAME] Hall door has not been working. Currently the facility does not have any residents who wear Wanderguards. The facility's failure to provide adequate supervision for residents at risk for elopement/wandering and ensure door alarms were sounding properly created a reasonable likelihood for serious harm thus leading to the finding of immediate jeopardy. The facility removed the immediate jeopardy on 3/19/26, when it completed the following: Affected resident R23 did not experience any negative outcome from the on the elopement on 2/24/26. R23's care plan was reviewed and updated on 2/24/26 to include interventions to prevent further eolopements. There has been no further elopements since 2/24/26. Wandering risk assessment completed for residents currently residing in facility 3/19/26. There were 18 residents at moderate risk and 3 residents at high risk for elopement. Care plans for these residents were reviewed to ensure interventions are in place to prevent elopement risk. There are no current residents identifed with a Wanderguard signaling device. On 3/19/26, DON/designee initiated staff re-education on recognizing behavior changes and elopement/unsafe wandering policy. On 3/19/26, DON/designee initiated licensed nurse and maintenance director staff re-education on checking Wanderguards and checking for functionality. On 3/19/26, DON/designee initiated staff re-education on residents at risk for elopement plan of care which indicates interventions to de-escalate exit seeking behaviors and provide increase supervision. Employees will have education completed prior to their next scheduled shift. On 3/19/26, Medical Director, VPS, on DON reviewed policy on Elopement/Unsafe Wandering, with no changes made. ADHOC QAPI completed 3/19/26 to discuss root cause analysis and action plan. Attendees were DON, Medical Director, and VPS. ED/designee to complete audits on staff to determine if resident at risk for elopement are being monitored/supervised 4 x weekly for a period of 12 weeks. ED/designee to complete random audits of Wanderguard functionality and Wanderguard system check 2 x weekly for a period of 12 weeks. Results of these audits will be reviewed by QAPI for patterns, trends of concerns, further education, or process improvement needs. Frequency and continuation of audits will be adjusted at this time. The deficient practice continues at a scope/severity level of D as the facility continues to implement their action plan and as evidenced by the examples for R5. Example 2 R5 was admitted to the facility on [DATE] and has diagnoses that include post-traumatic stress disorder (PTSD), unspecified dementia with behavioral disturbance, wandering, repeated falls, and noncompliance with medical treatment and regimen due to unspecified reasons. R5 has a Brief Interview for Mental Status (BIMS) score of 4/15, which means severe cognition impairment. R5 has a legal representative for health care decision making. R5's Minimum Data Set (MDS) assessment, dated 04/24/2025, indicated no wandering behaviors. MDS (quarterly) dated 07/05/2025, indicated no wandering behaviors. MDS (quarterly) dated 10/27/2025, indicated wandering behaviors occurred 1-3 days during look back period. R5's care plan, last revised 12/09/2025, with target date of 04/21/2026, states: At risk for falls due to dementia, receiving anxiety meds, Dx (diagnosis) of wandering. Interventions include.ensure shoes have proper grip. R5's care plan, last revised 01/26/2026, with target date 04/21/2026, states: At risk for behavior symptoms (.repeated movements, wandering, abusive behaviors.) related to unspecified dementia, generalized anxiety disorder, post-traumatic stress disorder (PTSD), wandering. Interventions include under wandering: redirection, offer meaningful activity, offer 1:1 conversation as able and as resident allows. On 03/05/2026, R5 was evaluated by provider for routine psychiatric care. Provider documentation states in part: Patient also demonstrates yelling and screaming, wandering, abusive language. impulse control impaired.On 03/17/2026 at 12:04 PM, R5 was observed sitting in dining room wearing no shoes and socks that did not have grippers. R5 did not have Wanderguard bracelet (devices worn by residents to notify staff via alarm sound of residents attempting to elope from facility) in place. On 03/17/2026, at different intervals, Surveyor observed R5 ambulating in hallway between his room, and the dining room. R5 occasionally stopped at nurses' station to talk with staff. The nurse's station was located near front entrance of facility. R5 did not have a Wanderguard device in place. On 03/17/2026 at 2:00 PM, during interview with DON B, Surveyor asked if any residents in the facility were requiring use of the Wanderguard system. DON B stated there were no residents utilizing the Wanderguard system at that time. On 03/18/2026, R5 was observed lying on a couch in common area, which was located near front entrance of facility. Door to facility entrance/exit was approximately 20 feet distance from couch R5 was lying on. R5 did not have a Wanderguard in place. Resident was not in direct observation of facility staff. R5's medical record included the following incidents of R5 attempting to elope from the facility: 05/04/2025 at 3:40 PM, This RN saw resident [R5] outside front door talking to another resident. On 07/04/2025 at 11:10 AM, Resident [R5] attempted to walk away from facility due to not being given a lighter to smoke a cigarette. On 07/07/2025, Resident [R5] was seen walking down the driveway but did not get to the sidewalk. On 03/19/2026 at 9:39 AM, Surveyor asked certified nursing assistant (CNA) F if R5 wore a Wanderguard bracelet to alert staff to attempts at elopement. CNA F stated R5 did not wear a Wanderguard. Surveyor asked CNA F how staff monitor R5's whereabouts at all times and CNA F stated they do 30-minute checks on R5 and document on a check list kept at the nurses' station. CNA F stated R5 likes to go outside to check the mail because he is looking for a letter from his wife. The mailbox is located outside of the facility. CNA F stated front desk staff are usually there to keep an eye on R5. CNA F stated R5 has been found across the street at times. The street CNA F refers to is a public transportation street in front of facility with vehicles observed driving back and forth.On 03/19/2026 at 9:50 AM, Surveyor asked CNA M at nurses' station to provide the documentation sheets CNAs record on for monitoring every 30 minutes of R5's whereabouts. CNA M was unable to locate the sheet for current day. Surveyor asked vice president of services (VPS) I for documentation of every 30-minute checks by staff for R5's whereabouts. VPS I could not find any records for that date. VPS I stated a check sheet must not have been started on R5 that day. VPS I confirmed there was no documented proof of every 30-minute checks on R5 being done by staff. VPS I pulled the 30-minute check records for the past 30 days on R5. On 03/05/2025 between 2:00 PM and 10:00 PM, there was no documentation of every 30-minute checks on R5. On 03/06/2026 between 6:00 PM and 9:30 PM, there was no documentation for every 30-minute checks on R5. On 03/17/2026 between 12:01 AM and 6:00 AM, there was no documentation for every 30-minute checks on R5. On 03/18/2026 between 4:00 PM and 11:59 PM, there was no documentation of every 30-minute checks on R5. VPS I confirmed these dates lacked proof of staff observation of R5's whereabouts. VPS I stated all residents are assessed for risk of wandering behaviors and if a resident is determined to have such unsafe behaviors, a Wanderguard bracelet would be placed on that resident. VPS I stated all staff have been educated on wandering behaviors, how to use the Wanderguard system, what to do if an elopement occurs, and how to redirect residents who make attempts to elope.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for all 44 residents in the facility.The facility failed to protect residents from risk of transmission of communicable disease as follows: No airborne precaution signs posted on residents diagnosed with COVID Certified nursing assistant (CNA) staff not using proper N95 masks when entering rooms of positive COVID residents PPE carts stocked with one size N95 masks for all staff to use, despite FIT testing recommendations. Staff not using proper PPE during catheter care Proper hand hygiene not being used during wound care Commercial washer and dryer temperatures not monitored/logged to ensure proper decontamination of soiled linens. Dirty linens not covered in a shared shower room and a resident with dementia observed rummaging through them Commercial soaps, shampoos, deodorants, lotions observed open, undated, and partially used for more than one resident in a shared shower room. Used surgical masks lying on PPE carts outside of resident rooms Findings include: Example 1 The facility policy, titled Infection Prevention and Control Program last revised 07/23/2024, states in part: All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services.All staff shall use PPE according to established facility policy.single use devices must be discarded after use. Centers for Disease Control (CDC) guidelines for healthcare providers, dated 06/24/2024, indicate that COVID-19 is primarily airborne, spreading through inhalation of respiratory virus particles. The CDC recommends airborne precautions to be used in healthcare settings. On 03/17/2026 at 8:00 AM, upon entrance into facility, survey team was informed by Director of Nursing (DON) B that one resident tested positive for COVID-19 and airborne precautions were in place for that resident. At time of exit from facility on 03/19/2026, 11 residents and 4 staff tested positive for COVID-19. On 03/18/2026 at 10:36 AM, Surveyor observed certified nursing assistant (CNA) Q and CNA R exit room of a COVID positive resident wearing regular face masks. Airborne precaution sign was posted outside of resident's room. The sign indicated use of gown, gloves, fit-tested respirator (N95 mask) and additional PPE based on point-of-care risk assessment. Surveyor interviewed both CNA Q and CNA R what type of precautions are taken for a COVID positive resident. CNA Q and CNA R stated regular masking, gloving, washing hands and gowns. Surveyor asked both CNAs what resources are used upon entering a room with airborne precautions. CNA Q pointed to the sign posted outside of the resident's room. CNA Q stated she was not aware airborne precautions required an N-95 mask. On 03/19/2026 at 8:14 AM, Surveyor observed a resident in the memory care unit wander into room [ROOM NUMBER], another resident's room. No airborne precaution signs were posted outside of room. No PPE cart was outside of resident's room. CNA R informed Surveyor the resident who resided in room [ROOM NUMBER] tested positive for COVID the evening before. Surveyor asked CNA R when airborne precautions should be put in place for positive COVID cases and CNA R stated, Right away. CNA R stated it is difficult to keep wandering residents out of other residents' rooms and they cannot keep doors to rooms closed because most of the residents are at risk of falling. CNA R stated there are no other interventions they are aware of to keep wandering residents out of COVID positive rooms. Example 2 On 3/17/26 at 12:08 PM, Surveyor observed R39 was on airborne precautions. Shortly after this, Surveyor observed CNA W put on PPE and enter R39's room. CNA W did not put on a N95 as indicated. On 3/17/26 at 12:20 PM, Surveyor interviewed CNA W, who read sign outside R39's door and stated she should have worn an N95 mask and did not. On 3/18/26 at 2:29 PM, Surveyor interviewed DON B who stated when R39 was on airborne precautions, the expectation would be for staff to wear an N95 when entering the resident's room. Example 3 On 03/19/2026 at 11:00 AM, Surveyor observed PPE carts outside of rooms of positive COVID residents. One size (regular) of N95 masks was stocked in all the carts. Surveyor interviewed CNA F and CNA M if each staff person has their own fitted N95 mask to wear into airborne precaution rooms. CNA F stated, No, we just grab a mask out of the cart. At 11:10 AM, Surveyor interviewed DON B, who is also the infection preventionist, if all staff were FIT tested for N95 masks. DON B confirmed all patient care staff are annually FIT tested for proper N95 mask use. DON B stated regular size N95 masks are what is stocked in the PPE carts because that is the size most staff wear. DON B stated if a different size mask is needed, that staff person can go to a storage closet to obtain. Record review of FIT testing done on all staff indicated seven direct care staff who have worked from 03/17/2026 to 03/19/2026 during COVID outbreak at facility, were overdue on FIT testing. Last FIT test dates ranged from 08/06/2022 to 09/28/2024, which is past annual testing requirements. On 03/18/2026, Surveyor interviewed DON B on what staff expectations were for infection prevention with emphasis on current COVID outbreak at facility. DON B stated it had been over a year since some of the staff had COVID education. DON B stated all staff receive infection prevention training and are expected to follow infection prevention guidelines based on facility protocol. Example 4 R18 was admitted to the facility on [DATE] with diagnoses that include progressive multiple sclerosis and neuromuscular dysfunction of bladder. R18's orders include enhanced barrier precautions due to Foley catheter and wounds. On 3/17/26 at 9:27 AM, Surveyor observed R18's catheter hooked under bed. The end of catheter tube at the drain port was not in the holder but was lying directly on the floor. On 3/18/26 at 12:33 PM, Surveyor observed Certified Nurse Assistant (CNA) M empty R18's catheter bag. CNA M set urinal directly on floor, emptied catheter bag into urinal with drain port touching edge of the urinal. On 3/18/26 at 12:40 PM, Surveyor interviewed CNA M about using a barrier on the floor to keep urinal from contamination since it touches R18's open catheter tubing. CNA M stated she may have been told that at one time. On 3/18/26 at 2:30 PM, Surveyor interviewed DON B, who stated she would expect staff to put a barrier down on the floor before putting collection container on the floor. Example 5 On 3/18/26 at 12:15 PM, Surveyor observed Licensed Practical Nurse (LPN) H perform wound care on R18. LPN H applied inner dressing, removed her gloves and did not wash her hands or use hand sanitizer prior to putting on new gloves and completing the wound care. On 3/18/2026 at 12:30 PM, Surveyor interviewed LPN H, who stated she thought she washed her hands after each glove change. On 3/18/2026 at 2:30 PM, Surveyor interviewed DON B who stated the expectation is that staff should wash their hands or use hand sanitizer after removing gloves each time. Example 6 On 03/18/2026 at 7:00 AM, Surveyor observed and interviewed laundry aide (LA) T on the processing of dirty linen. Surveyor asked LA T to provide a log of water temperatures for the washing machine, as well as a temperature log for dryer. LA T stated the machines do not indicate water and air temperatures and there is no way for staff to monitor them. LA T stated maintenance can identify water and air temperatures, but laundry staff cannot. LA T stated no logs are kept of any temperatures. On 03/19/2026 at 8:26 AM, Surveyor interviewed Maintenance Director (MD) K on how washing machine water temperatures and dryer temperatures are monitored. MD K stated laundry staff monitor and keeps logs of those temperatures. Surveyor received clarification from both LA T and MD K on who monitors temperatures in laundry. MD K stated both the washing machine and dryer are older products, and there is no way to see a temperature display on the units. Both LA T and MD K confirmed there is no temperature logs being kept for either unit. MD K stated the water temperature that comes out of the hot water heater specifically for the washing machine is set at 145 degrees Fahrenheit. MD K and LA T stated they were not aware what recommended water temperatures were for sanitization of laundry during processing. Example 7 On 03/17/2026 at 9:16 AM, Surveyor observed a resident in shower room [ROOM NUMBER] rummaging through dirty linen hamper. Resident was pulling dirty linen towards body and digging deep into hamper looking for a shirt. Room to shower room [ROOM NUMBER] was open and no lid was on dirty linen hamper. Example 8 On 03/17/2026 at 9:16 AM, in shower room [ROOM NUMBER] Surveyor observed bottles of Head & Shoulders, Hairtage, Loreal and [NAME] Moisture brand shampoos located within the shower without caps and partially used. A bottle of Hempz lotion and one bottle of Eucerin lotion was observed on table next to shower, partially used. One container of Old Spice deodorant, with top off and signs of usage was observed on table next to shower. One partially used bar of Caress soap observed lying on table. None of these used products were labeled with a resident's name or dated when opened. Example 9 On 03/18/2026 at 7:05 AM, Surveyor observed a ripped clear garbage bag with soiled incontinent briefs lying on top of a soiled linen cart in the laundry collection area. Example 10 On 03/18/2026, Surveyor observed a used surgical mask lying on top of PPE cart outside of a resident's room who was positive for COVID. No staff were present near PPE cart.

Based on observation and interviews, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. This had the potential to affect all 48 residents that eat orally. Prepared food placed in the walk-in cooler had been covered but was not labeled or dated, food in dry storage was not covered or dated, and 2 opened containers of milk were in milk cooler without indication of when they were open or when they should be used by resulting in the potential for foodborne illnesses to spread.Findings include:The facility's guidelines titled, Labeling and Dating dated 2017, states in part, All foods should be dated upon receipt before being stored. Food labels must include: the food item name. the date of preparation/receipt/removal from freezer, the use by date as outlined in attached guidelines. Guidelines assume that food is properly stored, covered, and handled. Guidelines apply, regardless of storage location.On 3/17/26 at approximately 8:30 AM, during initial kitchen tour, Surveyor interviewed Kitchen Account Manager V, who replied, Yes, when Surveyor asked if the prepared individual pureed cake cups and the vegetables in the serving container, in the walk-in cooler, should be labeled and dated.Kitchen Account Manager V stated, these should have been dated, when two open containers of milk were found in the milk cooler.Surveyor observed an uncovered box of potatoes with no label or date. Kitchen Account Manager V stated, These had a cover on them with the date, but we had people helping us because of the storm yesterday, so I don't know what happened to it.

Based on observations, interviews, and record reviews, the facility did not ensure medication error rates are not 5 percent or greater for 4 of 5 residents reviewed during medication pass.The facility error rate was 22.22%. Example 1 The facility policy titled, Medication Orders, revised 01/23, states the elements of the medication orders include dose and dose form and any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. On 03/18/2026 at 7:25 AM, Surveyor observed LPN H administer Ferrous Sulfate to R21 without confirming the physician order contained a dosage for R21. R21's physician's orders dated 10/19/25 notes: Ferrous Sulfate one tablet by mouth every other day. Surveyor reviewed R21's notes and found that the dosage was not clarified with the physician. LPN H administered Ferrous Sulfate 325mg. There were no notes found in R21's record indicating the correct number of milligrams R21 was to receive. On 3/18/26 at 11:34 AM, Surveyor asked DON B what the expectation would be if a resident has an order for Ferrous Sulfate with no dosage. DON B stated the expectation would be for the staff to clarify the dose with the physician. Example 2 The facility policy dated 01/2026, titled, Medication Administration Subcutaneous Insulin, under the heading Insulin Pens, indicates, .8. Prime the insulin pen. a. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. b. Each click is 1 unit. c. Dial the pen up 2 units, unless otherwise specified by the manufacturer. d. Point pen needle towards the ceiling and gently tap the side. e. Press the button on the bottom all the way in, you should see a drop of insulin come out. If you do not see the drop, repeat the priming process. 9. Dial the dose to the prescribed insulin dose . On 03/18/25 at 7:25 AM, Surveyor observed LPN H administer Lantus insulin to R21. LPN H failed to prime the insulin pen before administering insulin dose. Example 3 On 03/18/26 at 11:14 AM, Surveyor observed LPN H administer Humalog 10units and Toujeo (330 units/ml)-40units of insulin to R39. Needle was not primed for either, resulting in incorrect dosing. Surveyor asked LPN H if they were aware of priming the pen needles. LPN H stated, We prime them when we first open one, but do not need to do them every time. Example 4 On 3/18/26 at 7:40 AM, Surveyor observed DON B administer Lantus insulin to R2. R2's physician orders state: Glargine (Lantus) insulin 43 units subcutaneous twice a day. DON B placed needle on the insulin pen and pulled up 45 units and administered the 45 units to the resident and said that is how the pen is primed. Because of the incorrect procedure, there is no way to determine whether R2 received the correct dose of insulin. Example 5 On 03/18/2026 7:53 AM, Surveyor observed DON B administer Lantus to R6. Order was to give Lantus 10 units subcutaneously every day. DON B drew up 12 units and administered the 12 units to the R6, which resulted in wrong dose of insulin. On 03/18/2026 at 11:34 AM, Surveyor interviewed DON B and asked about tracking and trending of medication errors. DON B said the facility tracks errors and addresses them at least quarterly in QAPI meetings.

Based on observations, interviews, and record review, the facility did not provide care adhering to accepted standards of practice for 4 of 5 residents reviewed. (R2, R6, R21, and R39)Faciity did not follow manufacturer guidelines for proper placement of continuous glucose monitoring device for R2, R6, R21, and R39.Nursing did not prime insulin pens before administering insulin to R2, R6, R39.Nursing administered a dose of Ferrous Sulfate to R21 without confirming with phsyician what the dose was. Order in R21's medical record did not state dosage. Example 1The facility policy with a revision date of 08/05/2022, titled, NSG - Blood Glucose Monitoring, states, The nurse will perform the blood glucose test utilizing the facility's glucometer as per manufacturer's instructions. On 03/17/26 at 9:28 AM. Surveyor noticed R2 was lying in bed with chest exposed and had a continuous glucometer sensor (Libre) applied to his/her upper left chest. Surveyor confirmed this with Licensed Practical Nurse (LPN) P who provided the manufacturer insert. According to the insert, it clearly stated the sensor is to be applied to the upper arms only. Surveyor asked LPN P if they were aware of the sites to use for the device. LPN P shared that they were having trouble with the Libres falling off, so she looked up alternative sites online and found they could be applied to the upper chest. Surveyor asked LPN P if they utilize alternative sites, do they obtain orders and approval from the physician. LPN P said she didn't even think about it. On 03/18/2026 at 7:25 AM, Surveyor asked R21 where the sensor device was located. R21 pulled down her shirt by the neck area exposing the sensor was placed on her left upper chest. On 03/18/2026 at 11:14 AM, Surveyor observed R39's glucometer sensor was placed on their upper left chest area. On 03/18/2026 at 7:53 AM, Surveyor asked and R6 showed their glucometer sensor was applied to their upper left chest. On 03/18/2026 at 7:53 AM, Surveyor interviewed Director of Nursing (DON) B and inquired about the placement of the glucose sensors. DON B stated they looked it up and found information online. Surveyor asked for their policy on the continuous glucose devices and DON B stated they did not have a policy for use of the devices and they did not obtain approval orders from the physician to use alternative sites. Surveyor reviewed R2, R6, R21, and R39's care plans and physician orders, and there was no mention that alternative sites may be used for the continuous glucose monitoring sensors. Example 2 The facility policy dated 01/2026, titled, Medication Administration Subcutaneous Insulin, under the heading Insulin Pens, indicates, .8. Prime the insulin pen. a. Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. b. Each click is 1 unit. c. Dial the pen up 2 units, unless otherwise specified by the manufacturer. d. Point pen needle towards the ceiling and gently tap the side. e. Press the button on the bottom all the way in, you should see a drop of insulin come out. If you do not see the drop, repeat the priming process. 9. Dial the dose to the prescribed insulin dose . On 03/18/2026 at 7:25 AM, Surveyor observed LPN H administer Lantus insulin to R21. LPN H attached the needle to the insulin, dialed up the dose, and administered the insulin to R21 without priming the needle. On 03/18/26 At 7:40 AM, Surveyor observed DON B administer Lantus insulin to R2. R2's orders was Glargine (Lantus) insulin 43 units twice a day. DON B placed needle on the insulin pen and pulled up 45 units and administered the 45 units to the resident and said that is how the pen is primed. On 03/18/2026 at 7:53 AM, Surveyor observed DON B administer Lantus insulin to R6. R6's order was to give Lantus insulin 10 units every day. DON B dialed up 12 units and administered the 12 units to the resident. On 03/18/2026 at 11:14 AM, Surveyor observed LPN H administer two insulins to R39. R39's insulins included Humalog and Toujeo. LPN H applied the new needles but did not prime the pens. Surveyor asked LPN H if they were aware of priming the pen needles. LPN H stated, We prime them when we first open one, but do not need to do them every time. Example 3 The facility policy titled, Medication Orders, revised 01/23, states the elements of the medication orders includes dose and dose form and any dose or order that appears inappropriate, considering the resident's age, condition, allergies or diagnosis, is verified by nursing with the prescriber. On 03/18/2026 at 7:25 AM, Surveyor observed LPN H administer Ferrous Sulfate 325mg to R21. When Surveyor was reconciling the medications, R21's physician order for Ferrous Sulfate, initiated on 10/19/25, stated to take one tablet by mouth every other day. There was no measurable dose on the order. There were no notes found in R21's record indicting the correct number of milligrams R21 was to receive. On 03/18/2026 at 11:34 AM, Surveyor interviewed DON B and asked what the expectation would be if a resident has an order for Ferrous Sulfate with no dosage. DON B stated the expectation would be for the staff to clarify the dose with the physician.

Based on interview and record review, the facility did not provide written information specifying bed-hold duration and payment policy to the resident or resident representative for 1 resident (R49) for 3 residents reviewed for bed-hold information in a sample of 13 residents. The facility failed to provide a written bed-hold agreement to R49's legal representative upon transfer to the emergency department (ED), or within 24 hours of transfer to the ED, or document in R49's medical record that bed-hold information was provided to a legal representative. This resulted in R49's legal representative to be uninformed of cost to resident to hold R49's bed, if desired, during R49's hospitalization. Findings include:The facility policy, titled Bed Hold Notice, last revised on [DATE], states in part: As part of the admission packet and at the time of a transfer to the hospital.the facility will provide the resident and/or resident representative written information that specifies.the duration of the State bed-hold policy.the reserve bed payment policy.in the event of an emergency transfer of a resident.the facility will document attempts.facility will keep a signed and dated copy of the bed-hold notice.in the resident's medical record.R49 was admitted to the facility on [DATE] and had diagnosis of recurrent falls, displaced left intertrochanteric hip fracture. On [DATE] at 9:00 PM, R49 was transferred to the ED after exhibiting increased lethargy, confusion, non-reactive pupil on the right and unstable vital signs. R49 was subsequently admitted to the hospital for further workup. On [DATE] at 12:31 PM, record review indicates the hospital case manager notified the facility R49 would not be returning to the facility upon discharge from the hospital. Record review of R49's medical record did not have a signed bed-hold policy included. R49's medical record had no documentation that R49 or R49's representative received notification, written or by phone, of facility's bed-hold policy.On [DATE] at 1:31 PM, Surveyor interviewed business office manager (BOM) U for evidence of a bed-hold notification provided to R49 or R49's representative following R49's transfer to the ED on [DATE]. BOM U stated a phone call was personally placed to R49's wife on same day of R49's transfer to the ED. BOM U stated R49's wife declined the bed to be held at the facility for R49, as it was planned for R49 to be moved to another facility upon discharge from hospital. BOM U stated the phone conversation with R49's wife was not documented in R49's medical record. BOM U stated it was not facility routine to document information provided to a resident or resident representative in a medical record if unable to do a written notification of bed-hold immediately upon transfer and BOM U was not aware this was a CMS (Center for Medicare and Medicaid Services) requirement. On [DATE] at 1:12 PM, Surveyor interviewed R49's representative if made aware of bed hold notification following R49's transfer to the ED. R49's representative could not recall a phone conversation regarding bed hold information and/or cost of a bed hold on [DATE]. R49's representative did, however, confirm it was decided R49 would not be returning to the facility, and informed someone at the facility not to hold a bed. R49's representative denied receiving a written notification of bed-hold policy. To be noted: R49 was discharged home from the hospital on hospice and expired a short time after, therefore is not available for interview.

Based on observations, interviews, and record reviews, the facility did not revise resident's care plan following the completion of a Minimum Data Set (MDS) assessment for 1 of 13 residents reviewed. R2's care plan notes that R2 receives opioids, foot care, daily feet inspections, blue boot to right foot, hand splints, and assist with urinal. R2 is a double amputee, is no longer receiving opioids, refuses hand splints, and has a Foley catheter in place.R2 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, contractures of both hands and knees due to palmar fascial fibromatosis, left below the knee amputation, cervical neck pain, bow back pain, neuropathy, enlarged prostate, and urinary retention. R2's Minimum Data Set (MDS) dated [DATE] indicates R2 uses an indwelling Foley catheter. R2's most recent Brief Interview of Mental Status (BIMS) score, dated 03/16/26, was 8 of 15 indicating moderately impaired cognition. On 03/17/2026 at 9:00 AM, Surveyor observed R2 lying in bed. R2 was noted to have had bilateral below the knee amputations and an indwelling Foley catheter. Surveyor asked R2 about his pain which R2 stated that he used to be on opioids that seemed to work the best, but it was all taken away to try other things. Surveyor asked about hand contractures and R2 stated that he used to have splints on at night but does not want them or like them. OPIOIDS: On 03/19/2026 at 9:02 AM, Surveyor interviewed Medication Assistant (MA) O who reported that R2 is no longer on opioids because he was more confused and it did not help. Surveyor reviewed R2's medication administration record (MAR) and found the last time R2 received an opioid was 12/1/25. Surveyor reviewed R2's care plan, last revised on 02/25/26, states, Opioid use r/t BKA to LLE, chronic pain. MDS assessment was completed on 12/17/25. The care plan was not revised to reflect R2's current situation. RANGE OF MOTION: Surveyor reviewed R2's care plan titled, ADL self-care deficit, with a revision date of 02/25/26. R2's care plan interventions include right hand splint - see orders. Surveyor reviewed the physician orders and found no orders for hand splints. On 03/19/2026 at 9:02 AM, Surveyor interviewed Medication Assistant (MA) O who reported R2 no long wears hand splints due to refusals, I can't even remember the last time I saw [R2] use them. MDS assessment was completed on 12/17/25. The care plan was not revised to reflect R2's preference. FOOT CARE: Surveyor reviewed R2's electronic health records (EHR) and found R2 had a right below the knee amputation upon re-entry to the facility on [DATE]. MDS assessment was completed on 12/17/25. R2's care plan titled, ADL self-care deficit, with a revision date of 02/25/26, states to use blue protective boot on the right foot when in bed. Care plan titled, Endocrine system, notes to provide diabetic foot care and inspect feet daily. MDS assessment was completed on 12/17/25. The care plan was not revised timely to reflect R2's current needs. URINARY CATHETER: Surveyor reviewed R2's EHR and found that R2 had an indwelling Foley catheter placed on 5/9/25. R2's care plan titled, ADL self-care deficit, with a revision date of 02/25/26, states, TOILETING: Assist of 2 ASSIST WITH MALE URINAL TO AVOID FRICTION ON PLASTIC. R2's MDS dated [DATE] indicated R2 utilizes an indwelling Foley catheter. R2's care plan was not revised to reflect his current status. On 03/19/2026 at 9:16 AM, Surveyor interviewed [NAME] President of Success (VPS) I and explained the concerns listed above. VPS I stated, Looks like we need to do a better job updating the care plans. They should have removed the old information.

Based on interview and record review, the facility failed to report events which had the potential to cause serious harm or injury for 1 of 3 residents reviewed (R23).R23 is cognitively impaired, eloped without facility knowledge, and the alarm system was not working properly.Findings include:R23 was admitted to the facility on [DATE].Most recent Minimum Data Set (MDS) assessment indicates a Brief Interview for Mental Status (BIMS) score of 00/15, indicating severe cognitive impairment.On 02/24/26 at approximately 12:50 PM, R23 was observed walking around the parking lot of a local thrift store by reporting party (RP) D. RP D called Police Officer (PO) C who responded shortly after. R23 was reported to have about an inch of snow on top of R23's head. PO C called Emergency Medical Services (EMS) who assisted in taking R23 to the hospital for evaluation. The facility was contacted and asked if they were aware R23 was not in the facility. The facility was not aware R23 had left. R23 had a Wanderguard bracelet on which did not set the alarm off upon exiting the facility. The facility reported the alarm system was faulty.The facility was not aware of R23 being missing until being contacted by law enforcement. The temperature the day of the incident was a high of 25 degrees, snowing, and had wind gusts at 15 miles per hour. R23's cognition is severely impaired. R23's jacket is described as a lined, lightweight satin [NAME] jacket. The facility is only about 280 feet from the river which increases the risk for harm. The thrift store where R23 was located is a 12-14-minute walk from the facility.Surveyor has determined due to the high-risk factors and potential for serious harm or injury; this incident was reportable to the State Agency. The facility failed to report the incident.

Based on interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident reviewed (R7).Facility staff did not obtain weights and vitals prior to or after dialysis appointments on several occasionsFindings include:Facility Policy titled, Hemodialysis, last revised 09/10/23, reads in part: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goas and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.The licensed nurse will communicate to the dialysis facility by utilizing the Pre-Dialysis Communication assessment, that will include.vital signs.documentation of weights.R7 was admitted to the facility on [DATE].R7's most recent Minimum Data Set (MDS) assessment reflects a Brief Interview for Mental Status (BIMS) score of 15/15, indicating no cognitive impairment.R7's pertinent diagnoses include acquired absence of kidney, chronic kidney disease stage 5, end stage renal disease, heart failure, history of malignant neoplasm of kidney, and dependence on renal dialysis.R7's pertinent physician orders include: Complete pre-dialysis assessment, print and send with resident to dialysis every Monday, Wednesday, and Friday. Vital signs weekly on day shift every Friday for shower day. Weekly weight (obtain reweight if change of 5 pounds since last weight) every Friday on day shift for shower day. Do not obtain blood pressure or blood draws on dialysis access site: left arm fistula.R7's care plan includes potential for weight fluctuations related to fluid status changes. Dependency on hemodialysis presence of fistula/graft/catheter related to chronic kidney disease end stage with intervention of record dry weights and report significant changes as ordered.Surveyor reviewed R7's Pre-dialysis assessments for February. Out of 12 days of dialysis, vital signs, minus blood pressure, were not completed prior to dialysis appointment. 7 of the 12 days there were no weights obtained. One pre-dialysis assessment was absent.Surveyor reviewed R7's Pre-dialysis assessments for March. Out of 7 days of dialysis, Vital signs, minus blood pressure, were not completed prior to dialysis. One day, no vitals signs, including blood pressure, were completed prior to dialysis appointment. 5 of the 7 dialysis days, no weight was obtained prior to appointment.Surveyor reviewed R7's post-dialysis assessments for February. Out of 12 days of dialysis, 3 assessments were absent. One day no weight was obtained after dialysis appointment.Surveyor reviewed R7's post-dialysis assessments for March. Out of 7 days of dialysis, no weight was obtained after dialysis appointment. On 03/04/26 there was an indication of an 11.4-pound weight loss. On 03/09/26, there was an indication of a 7.8-pound weight gain.Surveyor reviewed R7's Electronic Health Record (EHR). R7's orders indicate weekly weight and vital signs. Facility policy states both should be obtained before and after dialysis treatments which occur 3 times per week.On 03/19/26 at 12:56 PM, Surveyor interviewed Certified Nursing Assistant (CNA) M. CNA M stated R7 should have R7's weight obtained prior to dialysis appointments and on shower days. CNA M stated R7's vital signs should be obtained on dialysis days, and blood pressure every day.On 03/19/26 at 1:03 PM, Surveyor interviewed Registered Nurse (RN) S. RN S stated a full set of vital signs and weight should be completed on days of dialysis which are Monday, Wednesday, and Friday. RN S stated a pre-dialysis, and post-dialysis should be completed.On 03/19/26 at 1:07 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated it is the facility's expectation that nursing staff would obtain a full set of vital signs and weight before and after dialysis treatments. DON B stated there is a pre-dialysis assessment that gets completed and sent with R7 to R7's dialysis appointment. DON B stated there is a dialysis communication form that nursing staff completes, and monitoring in place for the fistula. It is DON B's expectation that all these tasks are completed.

Based on interview and record review, the facility did not notify the physician as indicated by parameters in physicians' orders for a significant weight increase for 1 out of 13 residents (R) R46. This is evidenced by:R46 was admitted to the facility 12/21/21 with a diagnosis that included atrial fibrillation. R46 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitively intact.R46's Quarterly Minimum Data Set (MDS) with an end date of 2/26/26, Section K: weight 128#.R46's care plan initiated 2/24/26, with a target date of 4/18/26, states, Actual dehydration or risk for alteration in hydration related to diuretic use. Goal: Will maintain adequate hydration as evidenced by good skin turgor, moist oral mucosa, and stable weights. R46 was hospitalized , diagnosed with congestive heart failure (CHF), and on 2/20/26 Furosemide, a diuretic, was prescribed 20 MG by mouth every morning.R46's physician orders dated 2/25/26 is as follows: daily weights, call Medical Doctor (MD) if weight change of 3 pounds in 1 day or greater than 7 pounds in one week, one time a day for CHF. Record review indicated no weights recorded or documentation of reason for not obtaining R46's weight on 3/8/26 and 3/10/26. On 3/12/26, R46's weight was 128.4 pounds. On 3/13/26, R46's weight was 131.8 pounds, indicating a weight gain of 3.4 pounds in one day.On 3/16/26, R46's weight was 124.4 pounds. On 3/17/26, R46's weight was 127.8 pounds, indicating a weight gain of 3.2 pounds in one day.Surveyor was unable to find documentation to support R46's provider was updated of weight changes. Surveyor requested and was not provided any evidence to indicate provider was notified.Surveyor requested facility policy for following physician's orders and/or change in condition and was provided with a document for practice guidelines for reporting changes in condition.On 3/19/2026 at 11:25 AM, Surveyor interviewed DON B, who stated the expectation would be that nursing staff report to provider as per orders indicated.

Based on observation, interview and record review, the facility did not implement the comprehensive care plan for accident prevention for 2 residents (R5, R43) of 3 residents reviewed for accidents in a sample of 13 residents. The facility did not implement care plan intervention of R5 always wearing grip socks or shoes when ambulating to prevent falls from occurring. This could result in R5 falling and sustaining serious physical injury.The facility did not implement care plan intervention providing gripper strips at R43's bedside to prevent falls when getting self out of bed. Findings include:The facility policy, titled Fall Prevention and Management Guidelines, last revised 07/18/2024, states in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury.Example 1R5 was admitted to the facility on [DATE] and has diagnoses that include post-traumatic stress disorder (PTSD), unspecified dementia with behavioral disturbance, wandering, repeated falls, and noncompliance with medical treatment and regimen due to unspecified reasons. R5 has a Brief Interview for Mental Status (BIMS) score of 4/15, which means severe cognition impairment. R5 has a legal representative for health care decision making. R5's care plan, last revised 12/09/2025, with target date of 04/21/2026, states: At risk for falls due to dementia, receiving anxiety meds, Dx (diagnosis) of wandering. Interventions include.ensure shoes have proper grip.Record review for R5 indicated R5 had 2 falls on 01/19/2026, 2 falls on 01/20/26 and one fall on 01/22/2026. Record review indicated documented wandering behaviors. On 03/17/2026 at 12:04 PM, Surveyor observed R5 sitting in dining room wearing no grip socks on feet and no shoes. Surveyor observed R5 ambulate in dining room and back to his room without proper grip socks or shoes on feet. Certified nursing assistant (CNA) staff were observed talking to R5 when up ambulating in hallway without shoes or grip socks. No CNA staff intervened or reminded R5 to place shoes/grip socks on for safety. On 03/19/2026 at 9:39 AM, Surveyor interviewed certified nursing assistant (CNA) F about fall prevention for R5. CNA F stated staff try to keep close eye on R5; however, R5 moves about independently and will take shoes off. Example 2R43 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction (brain stroke) affecting left side, vascular dementia with behavioral disturbances, wandering, generalized anxiety disorder. R43 has a BIMS score of 10/15, which means moderate cognitive impairment. R43 has a legal representative for healthcare decision making. R43's care plan, last revised 02/03/2026, with target date of 05/11/2026, states: At risk for falls due to weakness post CVA (cerebral vascular accident), dementia. Interventions include.gripper strips at bedside.Record review for R43 indicated on 02/27/2026 R43 was found sitting on floor in room [ROOM NUMBER] next to bed. R43 was attempting to get to bathroom. Record review indicated documented wandering behaviors. On 03/19/2026 at 8:10 AM, Surveyor observed R43 lying in bed resting. Surveyor did not observe signs of grip strips on floor next to R43's bed.

Based on observation, interview and record review, the facility did not follow the menu and did not notify residents of the menu change. This had the potential to affect all 43 residents in the facility. -The facility served a different meal than what was noted on the menu. The facility did notify residents of the menu change. -This resulted in residents complaining of the menu change. -This resulted in one resident (R28) requesting a bowl of cereal for lunch as he did not want what was posted on the menu. R28 was not notified of the menu change and was not given the option to receive the meal that was served. Findings: The facility's policy titled Menus, read in part, Menus will be planned in advance. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. On 01/13/25, Surveyor noted the lunch menu was Chinese Pork Chop Suey with egg rolls, fried rice, and diced pears. On 01/13/25 at 11:53 AM, Surveyor observed R41's meal tray and noted she received a hot dog, sauerkraut, parsley potatoes, a biscuit, and pudding with whipped topping. Surveyor read R41's meal ticket which read, Chinese Pork Chop Suey, egg roll, fried rice, and diced pears. R41 stated, Nothing on here is what was supposed to be served. R41 stated she often receives meals that are not consistent with what is posted on the menu. R41 reported she does not have a menu in her room and only knows what is being served if she looks at the menu posted by the dining room. On 01/13/25 at 11:55 AM, Surveyor observed R28 eating his lunch meal. Surveyor noted R28 was eating a bowl of Cheerios. R28 stated he did not want Chop Suey and had requested a bowl of cereal as an alternative. R28 reported he was not aware the menu changed, and Chop Suey was not being served for lunch. R28 reported he did not have a menu in his room but can ask staff what is being served. Surveyor noted all residents received the same food items as R41. Surveyor observed the menu posted near the dining room was covered with a piece of paper reading, Residents Meal of the Month, January 13-lunch, polish sausage, potatoes, sauerkraut, biscuit, and banana cream pie. On 01/13/25 at 12:09 PM, Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E bserved the menu posted near the dining room, indicating the Meal of the Month was being served. CNA E stated she was not sure when the menu changed. On 01/14/25 at 8:25 AM, Surveyor interviewed R20. R20 is the Resident Council president. R20 reported Resident Council has been choosing a Meal of the Month to be served each month. Members attending Resident Council choose a meal that is not usually served on the menu. R20 reported the dietary staff choose when the meal is served. R20 reported she was not aware the Meal of the Month was being served on 01/13/25. On 01/14/25 at 8:35 AM, Surveyor interviewed [NAME] F. [NAME] F confirmed dietary staff choose when the Meal of the Month is served. [NAME] F reported on the day Meal of the Month is served, the staff post it where the menus are posted. [NAME] F confirmed menus are not posted in resident rooms. [NAME] F stated Meal of the Month did not work for all residents, as there are only 3-4 residents that attend Resident Council, and these 3-4 residents were choosing a meal for all 40+ residents in the facility. [NAME] F reported sometimes the meal that is chosen is not consistent with all resident diets, and stated an example of a BLT sandwich, which is not adequate for residents receiving a pureed diet. [NAME] F stated she felt someone from the dietary department should attend Resident Council to ensure there was better communication about Meal of the Month. Cook F confirmed dietary staff need to change menu items throughout the four-week menu cycle as the approved menus are not always balanced meals. [NAME] F provided examples of two vegetables being served, with no starch, or two dessert items for one meal. [NAME] F stated she tries to make residents aware of changes, but she can't talk to all the residents. [NAME] F stated she has copies of the menus and has repeatedly asked staff to give copies to the residents. [NAME] F reported she was not sure who approved the menus. Surveyor noted menus were posted near each dining room. Surveyor observed the menus were posted high on the wall and may be difficult to see for residents utilizing wheelchairs. On 12/14/25 at 12:24 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A confirmed menus are created using a software system and are approved by a registered dietician (RD). A RD visits the facility monthly. On 12/14/25 at 2:48 PM, Surveyor interviewed Social Services Director (SSD) G. SSD G confirmed the facility's Resident Council has limited participation.

Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 sampled residents (R1). The facility did not follow hospital discharge orders to complete daily blood glucose testing to ensure safe blood sugar levels. Findings: R1 was admitted to the facility on [DATE] for rehabilitation after falling and fracturing the right knee. Diagnoses included right knee fracture, protein-calorie malnutrition, type 2 diabetes mellitus, and long-term use of oral hypoglycemic drugs. R1's Minimum Data Set (MDS) assessment, completed on 12/03/24, confirmed R1 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. On 11/22/24, R1's history and physical note indicates R1 developed hypotension and was sent to the emergency room . R1 was admitted to the hospital from 11/22/24-11/27/24. The hospital discharge summary revealed R1's diagnoses included sepsis, UTI, acute kidney injury, and type 2 diabetes. Surveyor found no blood sugars were being taken since readmission to the facility. R1's care plan, dated 11/08/24, states R1 has diabetes with interventions that include to obtain glucometer readings and report abnormalities as ordered. The hospital discharge summary, dated 11/27/24, notes recommendation to check daily blood glucose. Surveyor then requested all blood glucose levels checked since R1 was readmitted on [DATE]. On 01/14/25 at 12:43 PM, Surveyor interviewed Director of Nursing (DON) B who stated they have not been checking blood glucoses since R1 was readmitted . Surveyor showed DON B the order for daily testing in the discharge summary and DON B said, We totally missed that one.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 out of 8 residents on Enhanced Barrier Precautions (R23), staff did not change gloves or perform hand hygiene during observation of wound care. This is evidenced by: Facility policy titled, Enhanced Barrier Precautions, with most recent revised date of 08/08/24, stated in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .high-contact resident care activities include: .wound care: any chronic skin opening requiring a dressing. R23 was admitted to the facility on [DATE] with pertinent diagnoses of Multiple Sclerosis (MS) and secondary diagnoses including, pressure ulcer (PU) of the sacral region, stage 3, pressure ulcer of the right hip, stage 3, pressure ulcer of the left buttock, stage 3. R23's most recent Minimum Data Set (MDS) assessment, dated 12/16/24, indicated that R23 had pressure ulcerations, including three stage 3 PU that required treatments and dressings. On 01/14/25 at 9:46 AM, Surveyor observed Nurse Practitioner (NP) J and Registered Nurse (RN) I provide R23's wound assessment, including measurements of multiple PUs, wound cleansing, removal and applying of dressings. During this observation, Surveyor observed RN I remove gloves after assisting with removal of soiled dressings. RN I did not use hand hygiene before donning new gloves and went into hallway touching door frame and her gown. RN I then went outside R23's room to grab a box of dressings off med cart. Without changing gloves or hand hygiene, RN I entered back into room, set box of dressings on bedside table. RN I proceeded to straighten R23's sock on her foot and assisted with repositioning of R23. RN I held R23's upper leg and buttocks, touching skin near open wounds before removing her gloves, sanitizing hands, or donning new gloves. RN I assisted NP J with applying dressings. RN I took gloves off, did not sanitize her hands or reapply gloves, touched the outside of her gown sleeves, and then with her bare hands held R23's right thigh and buttock above wound areas. RN I stated, If I don't touch the wound, it should be okay, referring to her bare hands touching R23. RN I was reminded that R23 is on EBP. RN I then sanitized hands prior to donning gloves and completed wound cares. Immediately following observation, Surveyor asked RN I about care provided. Surveyor discussed with RN I appropriate hand hygiene for EBP and wound care. RN I stated, I should have had on gloves and verbalized understanding of lack of hand hygiene with removing of gloves and importance of appropriate use of personal protective equipment (gloves and gowns) with wound care/direct contact to protect R23 from infection and who is on EBP. On 01/15/25 at 10:21 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor discussed RN I's lack of appropriate infection control practices while observing wound care for R23. DON B voices agreement that she would expect for staff to practice appropriate hand hygiene. (i.e. change gloves after reentering R23's room, to wear gloves when touching R23's leg and buttock during positioning, and to sanitize hands before and after donning or doffing gloves).

Based on observation, interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice and preferences for 1 of 12 residents (R) reviewed. (R1). R1 was not given the right to choose to receive meal textures that R1 requested and prefers. This is significant to R1. This is evidenced by: According to Wisconsin State Statute GUIDANCE S483.60(d)(1)-(2) includes, in part, Providing palatable, attractive, and appetizing food and drink to residents can help to encourage residents to increase the amount they eat and drink. Improved nutrition and hydration status can help prevent, or aid in the recovery from, illness or injury. R1 was admitted to the facility on [DATE] for rehabilitation after falling and fracturing the right knee. Diagnosis included right knee fracture, protein-calorie malnutrition, type 2 diabetes mellitus, and adult failure to thrive. R1's Minimum Data Set (MDS) assessment, completed on 12/03/24, confirmed R1 scored 15/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. The updated facility matrix identified that R1 had an excessive unplanned weight loss; therefore, Surveyor was monitoring R1 during dining. R1's physician orders dated 11/08/24 includes a diet order for consistent carbohydrate cardiac diet with level 2 mechanically altered texture and regular thin liquids. On 01/14/25 at 7:45 AM, Surveyor observed R1 up in wheelchair in the dining room for breakfast. R1 received two 8oz cups of tomato juice, 8oz apple juice, 4oz strawberry health shake, pureed pancakes, ground sausage with gravy, and oatmeal. R1 was picking at the food and only ate a few bites. At 8:02 AM, Surveyor interviewed R1 and asked about the food that is provided. R1 stated, I have been eating this food since I came in. I mean look at it. It is like baby food. I had some teeth that were loose after I fell but it was only for a couple days and now the teeth are tight, and I have been asking for a regular diet for five weeks now and I keep getting told that the person that changes that is on vacation. On 01/14/25 at 8:07 AM, [NAME] F approached R1 and Surveyor in the dining room and stated, I keep asking the nurses to follow up on [R1's] meals because [R1] has been asking for weeks now for the regular meal and I cannot serve anything without the order changing. Review of R1's progress notes indicated that on 12/19/2024 at 10:42 AM, Registered Nurse (RN) H documented, Dietary came to writer after speaking with resident regarding concerns with diet. Resident does not like the mush she gets. Writer placed a speech eval as diet has been the same since admission. On 01/14/25 at 10:11 AM, Surveyor interviewed RN H who stated, I only know of the one time she complained and documented it and referred her to ST (Speech Therapy). I have not received any therapy updates yet. Surveyor asked for any follow up. RN H looked through R1's records and stated she did not see any follow up for R1's preference to not have the altered diet. On 01/14/25 at 10:15 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B who verified that in R1's case, a referral was sent to ST. Level 2 diet was ordered on admission. R1 is her own person, does not like to bother others, and they can see according to progress notes, there were no other complaints, but also no other follow up notes either. DON B provided ST notes. ST evaluation and plan of treatment notes for the period between 11/15/24-12/14/24 noted R1's oral exam was within normal function. There were no ST notes after 12/14/24. DON B informed Surveyor that she offered R1 to wait for the ST eval or sign risk vs benefit. R1 chose to sign the form so R1 could have a regular lunch today.

Based on interview and record review, the facility charged a resident for a service covered under Medicaid. This effected 1 of 5 sampled residents (R41). -The facility charged R41 for transportation services to a medical appointment, which is a covered service under Medicaid. -The facility charged R41 for transportation services which were not specifically requested by R41. -The facility did not inform R41, orally and in writing, of a charge for a service and what that charge would be. Findings: R41 was admitted to the facility on [DATE], with diagnoses including anemia, atrial fibrillation, and multiple myeloma. R41 scored 12/14 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R41's daughter assists R41 with her personal funds. R41's physician orders included an order for apixaban, a medication to prevent blood clots. On 01/13/25 at 12:47 PM, Surveyor interviewed R41. R41 stated, Last week I had an appointment, and their van driver was not available. They called my son-in-law, but he did not feel comfortable taking me. They called a van to take me, but the van driver wouldn't take me until I paid up front, so my son-in-law brought the money here and gave it to the nurse. When I got to my appointment, they told me that I didn't even have an appointment. They called the van driver to come back and get me to bring me back. When I got back here, the nurse told the van driver she had the money my son-in-law brought and paid the van driver. On 01/13/25, Surveyor reviewed the facility's admission packet, which read in part . Attachment A contains a description of the Basic Care and Additional Services, as well as the general coverage description based on payor source. The charges for items and services provided by the Center and included in the Basic Services daily rate, and those Additional Available Services not included, as well as the items and services and the charges for those items and services not covered by your third-party payor, Medicaid or Medicare are provided to you as part of the admission process. This Schedule of Charges may be amended by the Center from time to time, but Resident will be provided at least sixty (60) days advance written notice will be given for any changes made in these charges. Surveyor reviewed Attachment A and noted transportation services was not listed in the attachment. Surveyor requested the facility's policy for transportation services. The facility did not have a policy related to transportation services, but did provide Surveyor with a document titled, '2025 Schedule of Charges.' This document included transportation and indicated, Cost of Transport/See Business Office Manager. Surveyor reviewed R41's record and noted the following: -On 01/08/25, R41 was scheduled to have a blood transfusion related to low hemoglobin. Progress notes indicated the facility's van driver was not available on 01/08/25. R41's provider was updated, and the appointment was re-scheduled for 01/09/25. The facility arranged transportation with a transportation provider for 01/09/25. -On 01/09/25, R41 was transported to her medical appointment and back to the facility by an outside transportation service, by Transportation Driver (TD) C. The total miles roundtrip was 4.2 miles. -On 01/09/25, a progress note confirmed the facility received a telephone call from the medical provider indicating they did not receive the orders for R41's blood transfusion and it could not be completed. On 01/14/25 at 7:20 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated for residents receiving Medicaid services and needing transportation to medical appointments, the facility uses their personal van most of the time. If the van is not available, the facility uses outside transportation services. NHA A reported if outside transportation services are used the facility bills the charges for the service to Medicaid. On 01/14/25 at 11:43 AM, Surveyor interviewed TD C. TD C reported she does not bill Medicare/Medicaid for her services but charges the facility. TD C stated, I did contract with the facility, but I had to cut them off because they were behind on their bill. They called me to take [R41] to her appointment and I would have charged $50, but there was no return time, they were not sure when she would be done with her appointment, so I told them I would take her for $100, but I needed to be paid on that day. TD C confirmed she was paid $100 cash on 01/09/25. On 01/14/25 at 12:15 PM, Surveyor interviewed Business Office Manager (BOM) D. BOM D confirmed transportation is included in the daily rate for residents receiving Medicaid services. BOM D stated, The transportation service that took [R41] to her appointment won't do business with us due to outstanding bills and will only do private pay. Our driver was not available, and this transportation service was the only transportation provider able to take her. We talked with the resident about it, and she agreed to pay. The alternative would have been to reschedule her appointment through our driver. Surveyor asked BOM D if R41 signed anything agreeing to the charge, or if there was documentation to support R41 was aware of or agreed to the charge. BOM D reported there was no documentation of this. On 01/14/25 at 12:26 PM, Surveyor interviewed NHA A. NHA A stated, If we can't provide transportation we go through a transportation agency. This transportation agency will only provide transportation for private pay, and we wanted her to go to that appointment. [R41] paid privately for the transportation. We have to work on that on our end. She was offered the transportation service; she was ok with that. I feel like she should be reimbursed. On 01/15/25, Surveyor reviewed the receipt provided by TD C. The receipt confirmed on 01/09/25, R41 received transportation from the facility to a medical provider located 2.1 miles away and then a return trip back to the facility. The receipt confirmed on 01/09/25, $100 cash was paid in full for the transportation provided.

Based on observation, interview and record review, the facility did not store, prepare, distribute, and serve food by professional standards for food service safety. The facility distributed to residents eating in their rooms food that was uncovered and exposed to possible contamination. This has the potential to affect all 17 of 39 residents (R) (R36, R26, R3, R16, R25, R22, R31, R30, R24, R33, R18, R5, R28, R21, R10, R6, R19). Findings include: The facility policy, entitled Meal Distribution, dated September of 2017, states in part: 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. On 11/20/23 at 11:51 AM, Surveyor observed a lunch cart being delivered to the hallway labeled MCU that was on precautions due to COVID-19. All residents were served down this hallway and not in the main dining adjacent to the kitchen. Strawberry shortcake was served, and all desserts were uncovered. Residents residing down this hallway were: R36, R26, R3, R16, R25, R22, R31, R30, R24, R33, R18. On 11/20/23 at 12:10 PM, Surveyor observed lunch trays being delivered to resident rooms in the facility, not including the hallway labeled MCU. Room trays were brought to R5, R28, R21, R10, R6, and R19's rooms. All trays had uncovered strawberry shortcake. On 11/21/23 at 7:58 AM, Surveyor observed Certified Nursing Assistant (CNA) F walk approximately 45 feet past other residents' rooms to R5's room. The main meal was covered, but the cherries were not covered and were sitting out in the open in a small brown bowl. On 11/21/23 at 11:52 AM, Surveyor observed lunch trays being distributed and noticed that a room tray was delivered to R6 in their room; the tray was carried by CNA F approximately 40 feet past resident rooms, and an uncovered piece of cake was on the tray. Food was then brought to R19's room, approximately 20 feet from the food cart; the tray had uncovered cake and was taken past resident rooms. Surveyor then observed a tray for lunch being delivered to R10's room. Setup for lunch proceeded, and Surveyor noted that the cake was uncovered in this instance, too. On 11/22/23 at 12:46 PM, Surveyor interviewed Dietary Manager (DM) I and DM I's supervisor, Dietary District Manager (DDM) J, regarding food distribution to rooms. DM I and DDM J believed the food carts were being rolled to every room individually. DM I and DDM J would expect to have all food covered in the event that food needs to be moved or whenever food leaves the main kitchen area, as the policy suggests.

Based on observation, interview and record review, the facility staff did not perform hand hygiene when warranted, did not follow current standards of practice for Transmission-based Precautions (TBP), and did not offer hand hygiene to residents prior to eating. This facility practice has the potential to affect 9 residents (R24, R26, R36, R16, R30, R31, R18, R22, and R24) who reside in the Alzheimer Care Unit (ACU). This is evidenced by: Example 1 On 11/20/23 at 11:48 p.m., Surveyor observed Certified Nursing Assistant (CNA) P assist residents with lunch meal in ACU unit by delivering meal trays to residents in rooms and those eating in the common dining room (R24, R36, R16, R22, and R31). Surveyor observed CNA P open food cart, pull out residents' meal trays for service, deliver food trays to residents without completing hand hygiene before, during, or after meal service delivery. CNA P sat down with R24 to assist with feeding. CNA P did not complete hand hygiene prior to assisting R24 with meal. Surveyor observed CNA P leave R24 at dining table to assist other residents (R26 and R30) in their rooms. CNA P entered and exited both rooms without completing hand hygiene. Surveyor observed CNA P return to dining room to continue feeding assist with R24 without completing hand hygiene. On 11/20/23 at 2:12 p.m., following observation, Surveyor interviewed CNA P regarding standards of practice for hand hygiene. CNA P replied, I just forgot. On 11/21/23 at 11:13 a.m., Surveyor observed CNA Q open food service cart to assist with lunch meal service to residents in ACU. CNA Q did not complete hand hygiene prior to removing and handling resident meal trays from cart. On 11/21/23 at 11:38 a.m., following observation, Surveyor interviewed CNA Q regarding standards of practice for hand hygiene. CNA Q replied, I'm sorry. I'm still new. I should've washed my hands. On 11/21/23 at 11:50 a.m., Surveyor interviewed Infection Preventionist (IP) and Licensed Professional Nurse (LPN) G regarding standards of practice for hand hygiene. LPN G stated that all staff are required to complete the minimum of hand hygiene of sanitizer with all residents before and after care. On 11/21/23 at 12:06 p.m., Surveyor interviewed Director of Nursing (DON) B regarding standards for practice for hand hygiene. DON B stated all staff are required to, at a minimum, complete hand hygiene to include washing with soap and water or hand sanitizer before handling food, providing cares to resident, or when visibly soiled. Surveyor requested hand hygiene policy. Surveyor received policy titled, Hand Hygiene with most recent revision 11/02/22, in part states: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Example 2 Record review of R24 showed a positive covid test on 11/14/23 with contact precautions put into place on that date. Surveyor also received policy titled, Covid-19 Prevention, Response and Reporting with most recent revision 5/18/23, based on standards of practice recommended by Centers of Disease Control and Prevention in part states: Empiric Transmission-based Precautions (should be used when resident is unable to wear source control as recommended following exposure. AND HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to transmission-based precautions and use a NIHOS-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. On 11/20/23 at 10:42 a.m., Surveyor entered ACU and observed R24, R31, and R30 ambulating in hallway independently without any PPE. Surveyor observed one staff member working in the unit at the end of the hallway wearing a surgical face mask and personal glasses. At various times, Surveyor observed R24 and R30 enter other resident's rooms, touch items inside, and walk out. This occurred multiple times while observing the unit. The ACU has two residents covid positive and were unable to comply with TBP and PPE. On 11/20/23 at 12:12 p.m., Surveyor observed R24 sit at a dining table with another resident, R36, leaving approximately 2 feet of distance between the two residents. Two other tables were occupied in the dining room by R30 and R22 at the same table, and R16 sitting alone. The expectation expressed by DON B was that when residents were unable to comply with TBP and PPE requirements related to covid, staff would still assist with residents participating in social distancing of at least 6 feet (when possible) when in dining room for meals. Surveyor observed CNA P enter dining room and sit at the table with R24 to assist him with eating. Surveyor observed CNA P and Medication Aide (MA) R enter R24's room at 1:52 p.m. with posted contact precautions signage and Personal Protective Equipment (PPE) cart outside of door without donning the required PPE. CNA P donned a gown, surgical face mask, and gloves. MA R donned a gown, N95, gloves, and goggles over glasses, entered R24's room, and closed door. Surveyor observed MA R open R24's door and remove gown, gloves, and N95 while in resident's room, and disposed of in designated receptacle. MA R then walked to sink in dining room to wash hands with soap and water. MA R did not don a surgical face mask after removing N95. When staff are working in a unit with covid positive residents that are unable to comply with TBP and PPE, staff are expected to wear face mask and eye protection at all times while in the unit. Surveyor also observed CNA P exit at the same time while also doffing gown and gloves in trash receptacle in resident's room. CNA P did not complete hand hygiene after doffing gloves and being in TBP room. On 11/20/23 at 2:12 p.m., following observation, Surveyor interviewed CNA P regarding standards of practice with TBP. CNA P stated that for covid positive residents, staff need to wear eye protection, mask, gloves, and gown. Surveyor observed that CNA P was wearing personal glasses and asked CNA P if those would be considered compliant for this resident's TBP and CNA P replied that it was. Surveyor asked CNA P what kind of mask would be required to wear for this TBP resident and CNA P replied, Whatever mask you get fit for. Surveyor asked CNA P for more clarification. CNA P responded, You know. Those N95s or whatever. Surveyor asked if the surgical mask CNA P was wearing met that requirement. CNA P replied that it did not and that she didn't have hers on the unit. Surveyor was unable to interview MA R as he left unit immediately after. On 11/21/23 at 11:50 a.m., Surveyor interviewed LPN G regarding TBP and covid positive residents. LPN G stated that all staff should be following posted signage of PPE expectations based on TBP and that PPE carts are to be outside of every room requiring extra PPE. Regarding covid precautions, LPN G states that policy is for all staff working in a unit where residents are unable to wear a mask or follow TBP, staff are required to always wear a surgical mask and eye shields with side coverage. If direct care is provided for a resident with covid, then they follow CDC guidelines of gloves, gown, N95 mask, and goggles with side coverage and to complete hand hygiene when donning/doffing PPE. Surveyor interviewed DON B regarding standards of practice for TBP and covid. DON B stated that all staff are required to, at a minimum, complete hand hygiene regardless of TBP and when residents are unable to follow TBP, staff are required to offer hand hygiene and to keep social distancing as much as possible when residents are covid positive. She further states that if residents wish to eat in dining room and are covid positive, then staff will ensure that resident is not sitting at the same table with another resident to meet social distancing standards. Surveyor requested TBP and covid policy. Example 3 On 11/20/23 at 11:24 a.m., Surveyor observed CNA P assisting residents with lunch meal in ACU. Five residents (R24, R36, R16, R22, and R31) sat in dining room to eat their meal. Surveyor sat in dining room and observed CNA P deliver meal trays without offering hand hygiene to any resident. Surveyor asked CNA P where the hand sanitizer was located. CNA P responded by pointing to the corner of the dining room and stated it was the only one closest to the dining room, otherwise the sink in the dining room could be used with soap and water. Surveyor did not observe any residents use hand sanitizer or wash with soap and water. Following observation, Surveyor interviewed CNA P regarding offering hand hygiene to residents. CNA P stated, Well, we can offer it, but they never do it. On 11/21/23 at 11:12 a.m., Surveyor observed CNA Q in ACU assist with lunch meal service by delivery meal trays, setup, and assist as needed. No hand hygiene was offered or completed for the four residents (R22, R31, R36, and R16) who were sitting in dining room for lunch. Following observation, Surveyor completed interview with CNA Q regarding standards for practice for hand hygiene with residents. CNA Q responded, I'm still new and just trying to remember everything. On 11/21/23 at 11:50 a.m., Surveyor interviewed LPN G regarding standard of practice for hand hygiene with residents and meals. LPN G stated that universal standard precautions, at a minimum, is hand washing. On 11/21/23 at 12:06 p.m., Surveyor interviewed DON B regarding standards of practice for hand hygiene with residents. DON B stated staff are required to offer hand hygiene to residents and to keep social distancing as much as possible. Surveyor requested hand hygiene and covid precaution policy. Surveyor received policy titled, Covid-19 Prevention, Response and Reporting with most recent revision 5/18/23, based on standards of practice recommended by Centers of Disease Control and Prevention in part states: Empiric Transmission-based Precautions should be used when resident is unable to wear source control as recommended following exposure. Surveyor also received policy titled, Hand Hygiene with most recent revision 11/02/22, in part states: Basic hand hygiene with soap and water or sanitizer to be used before and after eating.

Based on observations, interviews and record reviews, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 1 of 1 residents reviewed for restraints (R21). R21 had a pommel cushion without a physician order for use, the medical symptom the cushion is being used to treat or an assessment to determine appropriateness of its use. Furthermore, the device was not indicated in R21's care plan. The facility did not consider this device as being a potential restraint. This is evidenced by: The facility's policy titled Restraint Free Environment dated 9/22/22 was reviewed. The policy states, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Physical Restraint refers to any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to .using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts that the resident cannot remove and prevents the resident from rising . Under Compliance Guidelines, the policy includes the following information: - Behavioral interventions should be used and exhausted prior to the application of a physical restraint; - The facility is responsible for the appropriateness of the determination to use a restraint; - Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints; - Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. R21 has medical diagnoses that include, but are not limited to, severe dementia with behavioral disturbance, repeated falls, anxiety disorder and hypersexuality. The most recent Minimum Data Set Assessment (MDSA) was a Significant Change in Status assessment dated [DATE]. According to this assessment, R21 was scored a 4/15 on the Basic Interview of Mental Status (BIMS), indicating severe cognitive deficit. R21 also requires extensive staff assistance to meet her most basic daily tasks of bed mobility, transfers, dressing, personal hygiene, toileting and bathing. R21 was also listed as being non-ambulatory with no range of motion limitations and is frequently incontinent of bladder and bowel function. According to this MDSA, R21 had experienced 2 or more falls with no apparent injuries and one fall with minor injuries during the assessment period. The assessment period was from the last assessment date of 9/21/23. Restraints were not coded on this assessment. Surveyor reviewed the Comprehensive Care Plan (CCP) for R21 and noted the following problem areas: 1. Resident is incontinent of urine related to disease process of dementia. The start date for this problem area was 11/23/22. - Toileting: Resident to be prompted every 2-3 hours (11/23/22) 2. At risk for behavior symptoms such as hallucinations, yelling/screaming, frequent crying related to Alzheimer's disease/dementia (Initiated 9/21/23) Target behaviors: Behavior yelling/screaming, frequent crying 3. Inappropriate (physical) sexual behavior (hypersexuality) related to cognitive impairment Goals: a. Will carry out sexual behavior with self only in privacy of own room b. Will not initiate contact of a sexual nature with residents or staff c. Will not make sexual comments to residents or staff d. Will remain clothed in public areas 4. Resident is at risk for falls related to deconditioning/weakness and history of falls (Initiated 11/4/2020 and last revised 11/20/23) Interventions: - Anticipate and meet the Resident's needs. Encourage the Resident to always call for assistance. - Education the Resident on fall prevention measures. Assure Resident that calling for help is not a bother. The pommel cushion was not addressed in the CCP. Surveyor then requested the Certified Nursing Assistant (CNA) Care Card. In reviewing the CNA responsibilities on this care card, the pommel cushion was not listed. OBSERVATION: - On 11/21/23 at 7:32 AM, R21 was noted to be in her room seated in the wheelchair with the pommel cushion underneath her and the pommel between her thighs. - At 7:48 AM, R21 was served the morning meal in her room. - At 8:06 AM, the meal tray was removed by Certified Nursing Assistant (CNA) F. - From 8:06 AM- 8:58 AM, R21 was noted to be sitting in her room with television on, in wheelchair with the pommel device between her thighs. R21 was frequently calling out in a low voice and drawn out moan maaaamaaaa. - From 9:00 AM - 9:08 AM was noted to be talking to herself. - At 9:08 AM, R21 rolled down the top blanket on her bed then sat beside the bed with right elbow against the arm rest of the chair and chin in right hand. R21 continued to call out for Mama and talk to herself. Surveyor continued to observe R21 and noted that at 9:40 AM she fell asleep in the wheelchair. - At 10:05 AM, Licensed Practical Nurse (LPN) G entered R21's room and gave her a strawberry shake. LPN G then left the room. Note: There was no encouragement or attempts to reposition or toilet R21 at that time to have release from the pommel device. - At 10:21 AM, Life Enrichment Coordinator (LEC) H removed R21 from the room and took R21 to the lobby area to participate in an activity. Surveyor followed and continued to observe the activity and engagement of the residents participating. - The activity started at 10:30 AM and ended at 10:50 AM. R21 remained in the lobby area following the activity, until 11:10 AM, at which time LEC H propelled R21 back to R21's room in preparation for the noon meal. At 11:24 AM, Surveyor approached CNA F and asked what R21's needs were in relation to repositioning and toileting. CNA F stated that R21 will activate the call light when she needs to go to the bathroom. CNA F stated R21 is both continent and incontinent and that staff are to check R21 every two hours. Surveyor then asked CNA F what R21's behaviors consisted of. CNA F stated that R21 gets upset with herself if she is incontinent, calls out for her mama or son or refuses to eat. When asked the reason for the pommel cushion, CNA F stated that R21 has a behavior of touching herself, or masturbating, and then would slide out of the chair. The pommel cushion is used to prevent her from doing that and falling. Note: There were several entries noted in R21's Medical Record of masturbation resulting in slips from the wheelchair. At 11:34 AM, Surveyor approached Director of Nursing B (DON) and asked the reason for the pommel cushion for R21. DON B stated the device was used for fall prevention as she would slide out of the wheelchair. Surveyor then requested the assessment for the device. DON B stated that she wasn't aware the device could be considered a restraint. DON B stated the device was a recommendation from therapy and therapy completed the assessment. DON B and Surveyor entered R21's room to review the device. R21 was unable to remove the device, as it was fully attached to the cushion she was sitting on and not removable. R21 stated that she hated the cushion and that it hurt her, and pointed to her vaginal area. Surveyor asked DON B what the expectation of staff was in regards to giving R21 periods to be free of the device. DON B stated staff were to stand R21 up and offer toileting and repositioning every 2-3 hours. DON B stated staff are to at least check her to see if she needs to go to the bathroom. Surveyor explained the observation of over 4 hours in which this was not done. DON B stated, OK, yes they should have asked her in between 7:30 and now. At 12:49 PM, CNA F assisted R21 out of the wheelchair and to the bathroom. R21 was incontinent of urine. Note: This was an observation of 5 hours 7 minutes in which R21 was not assisted out of the device for a period of relief from the pommel cushion. On 11/22/23 at 11:38 AM, Surveyor interviewed Physical Therapy Assistant (PTA) L regarding the pommel device for R21. PTA L stated that R21 was on the therapy case load back in September, and on 9/29/23, he made the recommendation to use the pommel device. PTA L stated . we just wanted to keep her from sliding forward out of the wheelchair. I did not realize I needed to evaluate it for a potential restraining device. I just wanted her to have better posture and positioning in the chair. I did not assess it. PTA L presented Surveyor with the Therapy Communication Form for Nursing, dated 9/29/23 that states, PT (patient) was issued pommel cushion to help aid with proper positioning due to episodes of sliding out of wheelchair with standard cushion. At 11:51 AM, Surveyor interviewed DON B and asked what the expectation is of any device before initiating. DON B stated, I would expect more than just writing it on a piece of paper. I would expect a full assessment of the device. Then I would expect monitoring the device and giving the resident periods on each shift to be free of the device, stand them up and take them to the toilet.

Based on interviews and record reviews, the facility did not complete and submit a Significant Change in Status (SCS) Minimum Data Set Assessment (MDSA) within 14 days after determining a SCS has occurred for 1 of 13 residents (R27) reviewed for assessments. This is evidenced by: R27 has medical diagnoses that include, but are not limited to, chronic obstructive pulmonary disease, protein-calorie malnutrition, diabetes mellitus-type II with neuropathy and peripheral vascular disease. In reviewing the Medical Record of R27, Surveyor noted the most recent MDSA completed was a quarterly assessment with the Assessment Reference Date of 8/27/23. R27 was admitted to hospice services 9/27/23 in which a SCS MDSA had not yet been completed. On 11/21/23 at 1:55 PM, Surveyor telephoned Staff C, who is the Corporate Director of Clinical Reimbursement. Staff C stated that Staff C oversees the MDS schedules, insurance updates and has direct discussions with the facilities regarding changes in residents that would constitute a significant change assessment. Staff C stated that she is the main contact for the MDSAs. Staff C also stated that the Company recently hired float staff to complete MDSAs which she then reviews to ensure accuracy and is also responsible to submit them. Staff C and Surveyor discussed R27, and Surveyor informed her that R27 was admitted to hospice services and asked what would trigger a significant change assessment in a resident. Staff C replied that any two changes of improvement or decline that are significant, as well as enrollment or disenrollment in hospice services would entail assessment for a significant change, in which the resident would be discussed to determine if the changes are self-limiting with the potential for the resident to recover or if the changes are expected to be long-term. Staff C stated that she is currently working on a quarterly assessment of R27 and did not know of R27's enrollment in hospice. Surveyor asked Staff C if a SCS MDSA should have been completed. Staff C stated, Absolutely a significant change should have been done. It was missed on our end.

Based on observation, record review, and interview, the facility did not provide preventative care for pressure injuries for 3 of 3 residents (R) reviewed for actual and potential pressure injuries (R196, R17, and R23.) R196 was admitted with pressure injuries. Interventions of the air mattress and wheelchair cushion were not put in place to promote healing and prevent pressure injuries from developing. R196 developed 2 new open areas within 13 days of admission to the facility. The open areas have defined borders and slough that meet the definition of a stage III pressure injury. R17 is at risk for the development of pressure injuries. Surveyor observed R17 up in her wheelchair from 6:30 am until 10:45 am when she was laid down for incontinence care. R17's care plan directs staff to reposition and provide incontinence care every 2 hours to prevent skin breakdown. R23 is at risk for the development of pressure injuries. Surveyor observed R23 with lack of repositioning from 6:30 am until she was laid down at 10:55 AM. R23's care plan directs staff to reposition and provide incontinence care every 2 hours to prevent skin breakdown. This is evidenced by the following: Resident (R) 196 was a [AGE] year old admitted to the facility from an acute care hospital on 10/20/2022. R196 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R196's admission Minimum Data Set (MDS) dated [DATE] noted under Mental Status resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated that R196 has some moderate cognitive impairment. Under the section of the MDS that speaks to functional abilities, it indicated that R196 required extensive assistance with all Activities of Daily Living but that R196 was independent with eating. The MDS showed that R196 was frequently incontinent of bowel and occasionally incontinent of urine. Under the section that refers to skin, it is noted that there was 1 Stage II ulcer and 1 Stage III ulcer present at admission. There was also moisture associated damage. The MDS documents R196 has a pressure reducing mattress and chair. Throughout the survey from 11/1/2022 through 11/4/2022, Surveyor observed R196 in bed lying on his back or right side. At these times there was not a pressure reducing mattress on the bed, nor a wheelchair with a pressure reducing cushion in the room. R196 was not observed up and out of bed. On 11/2/2022, Surveyor asked to observe the dressing changes to the wounds. Per the nursing staff, the wound nurse had changed the dressings on 11/1/2022 and the daily dressing change was done at hour of sleep. This was unable to be observed. The following wound nurse notes were done at each assessment by the wound nurse: 10/25/22 Wound nurse rounds on the Pressure Injury weekly tracker are the following; Wound 1 : Left buttock 1.6 cm x 1.0 wide unable to measure depth Stage III, notes specialty mattress and cushion. This is not present on the bed at observation 11/2/22 at 9:50AM. Wound 2: Right buttock 2.0cm long 0.6cm wide no depth Stage III Wound 3. Bilateral lower buttock 6.0cm x 10cm no depth stage II On the Non-pressure injury weekly tracker is wound number 4. Wound 4: Lower back spine 1.6cm x 1.0cm unable to measure depth not staged. The above forms indicate that there is a specialty mattress and specialty cushion in place. Skin review-weekly dated 10/30/2022 notes that there are no new skin impairments present. It notes a wound number 6 that was developed in house to R196's right lower buttock and that there are two areas present. It describes the wound as 0.2cm long, 0.1cm wide with no depth. It states the tissue is bright red and/or blanches to touch and that the wound edges are distinct, outline clearly visible, attached and even at the wound base. It identifies that this is the first observation of these areas. 11/01/22 Wound nurse rounds Wound 1: On admission left buttock 1.5cm long 0.8cm wide stage III cant measure depth. 11/1/22 improving Wound 2; Right buttock on admission 1.8cm long x 0.5cm wide stage III cant measure depth. 11/1/22 improving Wound 3. Bilateral lower buttocks 6.0cm long x 9.0cm wide no depth Stage II 11/1/22-improving Wound 4: Lower back/spine 0.7cm long 0.6cm wide depth unable not staged. Improving 11/1/22-improving. On the Non-pressure weekly tracker is wound 5 and 6. 5. Acquired in house on 10/25/22 on the right buttock. Measures 0.2cm long, 0.2cm wide with 100% slough. 6. Acquired in house on 10/25/22 on the right buttock. Measures 0.2cm long, 0.2cm wide with 100% slough. The above forms indicate that there is a speciality mattress and specialty cushion in place. Surveyor did not observe these interventions in place during the survey. The open areas are located on the buttocks that have direct pressure when R196 is in a seated position. The update to the physician on 10/25/22 documents, Resident admitted to facility 10/20/22 with multiple skin alternations and two areas (#5 and #6) open areas from incontinence after admission. McKnights Long Term Care News, May 2020 issue: If a pressure injury is forming within the MASD (Moisture Associated Skin Damage) .Denuded skin from MASD stays superficial, with a red/pink wound bed. If a pressure injury is starting to form within the denuded area, it will have granulation, slough, and/or eschar tissue. National Pressure Injury Advisory Panel stage 3 definition: Stage 3 Pressure Injury: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. Review of resident's baseline care plan, notes that there are actual pressure areas but no interventions are on the baseline care plan . Initiated 10/24/22. Review of Comprehensive Care Plan initiated 11/01/2022: Resident is frequently incontinent. Interventions are evaluate bowel and bladder pattern, Check R196 prior to meals and in the PM for incontinent episodes. Communicate changes in urine color to the nurse. Place call light within reach. Provide incontinence care perineal care after each incontinence episode. Use barrier cream each time. To encourage adaptive equipment. Resident has actual skin integrity break and or pressure sores. To apply chair cushion to wheelchair, geri chair, or Broda chair. Ensure proper placement and and clean daily. Assess and measure all skin integrity areas per policy. Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications. Initiate skin monitoring forms per facility policy. Initiate treatment per Physician order. Monitor and report any new open areas, drainage, increased drainage or pain to the nurse immediately. Pressure redistribution mattress for offloading. Provide treatment to wounds per current treatment order. Assess wounds for signs and symptoms of infection with each dressing change/treatment. Report findings of redness warmth, swelling or increased drainage or pain to the Physician immediately. Review of R196's Physician orders: Wound care: After cleansing with wound cleanser, TAO, [MEDICATION(S)], secured with hypaflix tape to open area lower back at spine. This is dated with start date of 10/26/2022 Wound Care: Chamosyn to open areas on both buttocks and to the red area with peri care/incontinence care every shift for wound care. Dated 10/23/2022. Pressure redistribution cushion to chair-dated 10/20/2022. Pressure redistribution mattress-dated 10/20/2022. Diet order of 10/20/2022 was 2 Gram Sodium Diet regular texture, regular thin consistency. Air mattress/pressure redistribution mattress - dated 11/2/2022. On 11/2/2022, Surveyor interviewed Director of Nursing (DON) B regarding R196. DON B stated that R196 initially was admitted for therapy, and the resident had not been getting out of bed. There had been talk of Hospice care and getting an air mattress within the next couple of days. DON B stated there is a cushion on the wheelchair. DON B stated R196 got up on Sunday 10/30/22 for a shower and that seemed to help him. DON also stated they had acquired a new order for an alternating pressure reducing air mattress today. Surveyor pointed out there had already been an order in place on 10/20/2022. DON B stated they were not aware of that. Surveyor pointed out the chartings indicated many times that R196 had these in place but did not. DON B agreed that R196 did not currently have a pressure reducing mattress in place to his bed. Surveyor requested air mattress specifications for the Panacea Original Foam mattress that R196 had since admission. The owners manual states in part, Warning: This mattress is not intended for stage III or IV pressure ulcers . On 11/3/22, DON B notified Surveyor they had found a pressure reducing mattress and were inflating it to see if there were any leaks. If there were no leaks they would be placing it on the bed today. On 11/2/22, Surveyor spoke with Certified Nursing Assistant (CNA) G who has been working at the facility for a year. Surveyor asked about what she does for R196. CNA G stated that R196 has bed sores. He doesn't like to get up so I reposition every 1-2 hours when he lets me. Today he let me put him on his left side. R196 is also able to reposition himself. CNA G is aware it's worse for him to stay in bed then to get up. They got him up once but he was leaning so forward he was going to fall out of chair so they put him back to bed. He does not have an air mattress and thinks he had a thin blue cushion on his wheelchair at the time. The facility did not put interventions in place to prevent further skin breakdown on a resident whom they knew had pressure areas prior to admission. This caused actual harm to R196 as he developed 2 new open areas that have slough while being a resident at the facility for the last 13 days, meeting the National Pressure Injury Advisory Panel definition for a stage III pressure injury, . Example 2: On 11/02/22 at 6:30 AM, Surveyor observed R17 up in wheelchair in the lounge in front lobby. R17 remained in the lounge until 7:45 AM when Surveyor observed R17 in the dining room up in her wheelchair. R17 remained in dining room until she was transported back to front lobby and placed in front of television. R17 remained in the front lounge in front of television until 10:45 AM when she was transported to her room. On 11/02/22 at 10:55 AM, Surveyor observed R17 in bed. R17 had been transferred to bed by CNA K and Licensed Practical Nurse (LPN) C with use of a hoyer lift. CNA K reported R17 had been incontinent of bowel movement and was slightly wet of urine. CNA K and LPN C changed R17's brief while she was in bed. Surveyor spoke with CNA K and LPN C about R17. LPN C reported R17 is dependent on staff for repositioning and incontinence care. R17 should be provided incontinent care and repositioning every 2 hours, before and after meals due to risks related to incontinence and her inability to reposition self. On 11/02/22 at 10:55 AM, Surveyor spoke with Registered Nurse (RN) L who is the unit manager for R17's living unit. RN L expressed R17 is dependent on staff for repositioning and incontinence care. R17 should be repositioned and provided incontinence care every 2 hours per her plan of care. On 11/02/22 at 11:33 AM, Surveyor spoke with DON B regarding R17 and her plan of care. DON B indicated R17 is at risk for the development of pressure injury due to incontinence and inability to reposition self. R17 should be checked, changed and repositioned every 2 hours due to her advanced dementia, incontinence of bowel and bladder and inability to communicate. R17 has a history of pressure injury but has been healed for a long time. R17 has not had a urinary tract infection. R17 is at risk for skin breakdown and infection and should be repositioned every 2 hours and be provided incontinence care due to dependence on staff to meet incontinence care and repositioning needs. Surveyor reviewed R17's record and noted her most recent quarterly Minimum Data Set (MDS) dated [DATE] notes: R17 rarely understands and is rarely understood and is severely cognitively impaired. R17 requires extensive assist of 2 staff for for bed mobility. R17 is dependent on 2 staff for toilet use, personal hygiene and transfer. R17 Is always incontinent of bladder and bowel R17 Has no urinary tract infection. R17 has no pressure injury and is at risk for pressure ulcer development Surveyor reviewed R17's care plan and noted: Focus: Resident has actual skin integrity problem eschar covered heal related to lack of consistent mobility. Date Initiated: 7/05/2019 Goal: Resident will have intact skin, free of redness, blisters or discoloration by/through review date. Date Initiated: 7/17/2019, Revised on: 12/15/2020, Target date: 1/05/2023 Interventions/Tasks: ~Incontinent care Q2hrs (every 2 hours) ~Reposition Q2H (every 2 hours) to prevent skin breakdown. Example 3 On 11/02/22 at 6:30 AM, Surveyor observed R23 up in wheelchair in the lounge in front lobby. R23 was seated next to R17 in the lounge. R23 remained in the lounge until 7:45 AM when Surveyor observed R23 in the dining room up in her wheelchair. R23 remained in dining room until she was transported back to front lobby and placed in front of television. R23 remained in the front lounge in front of television until 10:45 AM when she was transported to her room. At 10:55 AM, Surveyor observed R23 in bed. R23 had been transferred to bed by CNA G and CNA F. CNA G reported R23 urinated in her brief after she was transferred to bed and her brief was likely wet before she urinated. CNA G and CNA F changed R23's brief while she was in bed. Surveyor spoke with CNA G and CNA F about R23. CNA G reported R23 is dependent on staff for repositioning and incontinence care. R23 should be provided incontinent care and repositioning every 2 hours due to skin skin breakdown risks related to incontinence and her inability to reposition self. CNA F indicated she and another staff from night shift had gotten R23 up from bed at approximately 6:15 AM and R23 had not been laid down until Surveyor observed R23 in bed at 10:55. CNA F indicated this is R23's usual schedule. Surveyor asked CNA G and CNA F why R23 is not repositioned or changed every 2 hours. CNA G responded due to lack of staffing, CNAs are unable to reposition and change residents as they should be. On 11/02/22 at 11:00 AM, Surveyor spoke with Registered Nurse (RN) L who is the unit manager for R23's living unit. RN L expressed R23 is dependent on staff for repositioning and incontinence care. R23 should be repositioned and provided incontinence care every 2 hours per her plan of care. On 11/02/22 at 11:33 AM, Surveyor spoke with DON B regarding R23 and her plan of care. DON B indicated R23 is at risk for the development of pressure injury due to incontinence and inability to reposition self. R23 should be checked, changed and repositioned every 2 hours due to her incontinence and inability to communicate her needs to staff. R23 at risk for skin breakdown and infection and should be repositioned every 2 hours. R23 should be provided incontinence care due to dependence on staff to meet incontinence care and repositioning needs. Surveyor asked DON B about staffing to meet resident needs. DON B expressed it is usual for the facility to staff day shift with 3 CNAs and 2-3 nurses in addition to herself. PM shift is scheduled with 3 CNAs and 2 nurses. Night shift is scheduled with 2 CNAs and 2 nurses. CNA staff need to call on the nurses for assistance to reposition and provide incontinence care if other CNAs are busy with other residents. The facility has sufficient staffing to meet resident needs. Surveyor reviewed R23's record and noted her most recent quarterly Minimum Data Set (MDS) dated [DATE] notes: R23 Rarely understands and is rarely understood and is severely cognitively impaired. R23 Requires extensive assist of 2 staff for for bed mobility, transfer, toilet use and personal hygiene. R23 Is always incontinent of bladder and bowel R23 Has no urinary tract infection. R23 has no pressure injury and is at risk for pressure ulcer development Surveyor reviewed R23's care plan and noted: Focus: Urinary Incontinence related to disease process of dementia Date Initiated: 7/07/2020 Goal: Resident will be free from skin breakdown Date Initiated: 7/17/2019, Target date: 1/01/2023 Interventions/Tasks: ~Provide Incontinent care Q2hrs (every 2 hours) ~Resident to be repositioned Q2H (every 2 hours) to prevent skin breakdown.

Based on observation, record review, and interview the facility did not provide adequate supervision to prevent falls for 1 out of 5 residents reviewed for accidents and incidents from a total sample of 14 residents. R2 had 6 falls from 06/19/19 through 07/01/19. R2 sustained a head injury that required staples, a head injury that required laceration glue, a head injury that required first aid and a broken left arm as a result of these falls. The facility determined the root cause of R2's falls was related to unmet toilet needs. The interventions implemented did not address R2's toilet schedule. The facility implemented episodic supervision for R2 and noted this intervention was successful in preventing falls; however R2 was not provided supervision continuously while she was experiencing an acute change in condition following a [MEDICAL CONDITION]. Surveyor observed fall care plan interventions not implemented on the morning of 07/08/19. The facility's failure to develop and implement interventions based on the root cause and to provide supervision to R2 created a finding on immediate jeopardy that began on 6/19/19. Surveyor notified the Nursing Home Administrator of the immediate jeopardy on 7/16/19 at 11:27 a.m. The immediate jeopardy was removed on 7/16/19. However, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan. This is evidenced by: R2 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The MDS assessment dated [DATE] indicated R2 was able to make self-understood and understands others; had moderate cognitive impairments; had no mood indicators; had no behaviors or signs of [MEDICAL CONDITION]; required limited staff assist for dressing, toilet use, and hygiene and only supervision for ambulation in corridor; was continent of bladder and bowel; no pain; and stable weight. R2's care plan included an approach, dated 12/10/18 of Resident is at risk for/Hx (history) of falls r/t (related to) gait balance problems. Interventions dated 12/10/18 included assuring resident to call for assistance, use proper footwear, placement of the call light, and education on fall prevention. On 6/18/19, R2's care plan was updated with approaches of use of a bed alarm when resident is agitated, confused, and attempting to crawl out of bed; and, use of a bedside commode. Review of the falls investigation report dated 6/19/19 noted R2 had made several attempts to self-transfer prior to the first of her three falls on 6/19/19. The nurses notes indicated the first fall was at 1:30 a.m., the second fall was at 3:00 a.m., and the third fall was at 6:30 a.m. It was the third fall where R2 sustained a [MEDICAL CONDITION] that required the emergency room evaluation and staples to R2's back of scalp on the left side. All three falls were related to R2's need to urinate. Review of the NP (Nurse Practitioner) progress notes dated 06/19/19 read R2 had an acute change in mental status, was evaluated at the emergency room and diagnosed with [REDACTED]. The NP ordered as-needed [MEDICATION NAME] to treat the [MEDICAL CONDITION] and anxiety. R2 had been independent with toilet use and transfers prior to the [MEDICAL CONDITION] and infection. R2 reported the need to use the bathroom, self-transferred in her room, and fell . Two symptoms of a urinary tract infection are urinary frequency and urgency. There is no evidence of closer supervision or any changes to the care plan that occurred after the first and second falls. There were no changes to R2's toilet schedule. The falls investigation report noted R2 had a fall on 06/24/19 at 6:30 a.m. Staff responded to an alarm sounding in R2's room and found R2 sitting on the floor between the bed and the commode. R2 had suffered a laceration above her left eye that required first aide, steri-strips, and ice. R2 had hit her head on the bed. R2 again was attempting to toilet self. R2 had been moved into a different room closer to nurses' station prior to this fall. The root cause as determined by the facility again was self-transfer attempts to respond to toilet needs. R2's care plan was updated to include a landing mat next to the bed. This intervention did not address R2's toileting needs identified as the root cause by the facility. Review of the nurses notes between 06/19/19 and 06/24/19 identified R2 would request to toilet every 20-30 minutes and make multiple self-transfer attempts throughout the day. R2 would at times use the call light, but not consistently. R2 continued to have symptoms of [MEDICAL CONDITION] and anxiety and was treated with as-needed [MEDICATION NAME] 2-4 times per day. A fall investigation report noted R2 had another fall on 06/25/19 at 7:00 p.m. R2 had slipped off of the bed while attempting to self-transfer to the commode. The bed alarm was sounding. The root cause of the fall as determined by the facility was R2's attempt to use commode which was across the room. A CNA did witness R2 fall as she responded to the alarm sounding, but she did not arrive in time to help R2. The intervention was to move the commode closer to the bed. A fall investigation report noted R2 had a fall on 06/26/19 at 1:45 p.m. Staff responded to the alarm sounding to find R2 lying face down on the floor. R2 complained of left arm and leg pain. R2 was sent to the emergency room for evaluation. R2 received a laceration above the left eye and fractured her left humerus (upper arm bone). The root cause of the fall was R2's self-transfer attempts to toilet self. Review of the nurses' notes indicated R2 would often turn off alarms and continued to self-transfer to the toilet 10-22 times per eight hour shift. Upon return from the emergency roiagnom on [DATE], R2 required 1:1 supervision at the nurses' station. On 6/27/19, the facility updated R2's care plan to include: ~Moving R2 to a room closer to the nurse's station for safety (Although staff may be able to respond to the alarm quicker, the intervention does not address R2's need or desire to toilet.) ~Use of hip protectors (were not received in the facility until 7/8/19) ~Place commode in room to shorten transfer distance for toileting purposes (The use of a bedside commode had been an approach since 6/18/19) ~Review information on past falls and attempt to determine cause of falls for prevention and to minimize injuries. (The facility had consistently identified the root cause of R2's falls to be related to her attempting to use the bathroom.) Review of the fall investigation report noted R2 had another fall on 06/27/19 at 3:30 a.m. R2 was assisted into bed approximately 1 hour before she fell and was no longer under 1:1 supervision. R2 was found on the floor on her way to the bathroom. R2 did have a Foley catheter, yet R2 was responding to a desire to use the bathroom. The root cause as determined by the facility was R2 had slipped off of the bed while self-transferring. The intervention was to place a scoop mattress, which was added to the care plan on 6/27/19. Contrary to the fall investigation, the nurses' notes on 6/27/19 indicated R2 ambulated from the bed to the bathroom using quad cane and fell into the bathroom door. The nurses' notes did not indicate R2 slipped off of the bed. The root cause does not correspond to the fall investigation, and the care plan interventions did not address R2's toilet urges. Review of the nurses' notes indicated R2 received 1:1 supervision on 06/28/19 during the night hours. R2 had no falls during that time period. On 06/29/19 R2 was sent to the emergency room due to uncontrolled arm pain. R2 returned with new orders for [MEDICATION NAME]/[MEDICATION NAME] 1-2 tablets every 6 hours as needed for pain. Also on 06/29/19, R2 was started on [MEDICATION NAME] to treat ongoing [MEDICAL CONDITION] as a result of the [MEDICAL CONDITION]. A fall investigation report noted R2 had another fall on 07/01/19 at 7:00 p.m. R2 was found sitting on the floor next to the bed. R2 received a head injury and was sent to the emergency room for evaluation. The root cause of the fall as determined by the facility was R2 had attempted self-transfers and was having pain. The intervention was to add a motion alarm to alert staff prior to R2 exiting the bed. According to the DON, the motion alarm was ordered but not yet available as of 07/03/19. R2 returned from the emergency room with orders to treat pain with [MEDICATION NAME] 1-2 tablets every 6 hours as needed. Review of the nurses notes dated 07/02/19 indicated 1:1 supervision was effective for R2's fall prevention. On 07/02/19, 07/03/19, and 07/08/19 Surveyor interviewed AS (anonymous staff)-I, CNA H, CNA-C, CNA-B, and CNA-R. All indicated R2 would not have fallen if there were more staff to provide additional supervision. Cross-reference F725. Additionally, CNA-B, who was interviewed on 07/03/19 at 11:15 a.m., indicated R2 now needs 1 staff to assist her with eating since her multiple falls and injuries. On 07/03/19 at 9:15 a.m., Surveyor interviewed the ADON (Assistant Director of Nurses) regarding R2's care needs. The ADON stated R2 was provided 1:1 staff supervision and did not fall when the staff person was a CNA or licensed nurse but did fall when the 1:1 was provided by a hospitality aide. A hospitality aide is not a Certified Nursing Assistant and is unable to provide hands-on care or assistance to a resident. On 07/08/19 at 3:03 p.m., Surveyor interviewed RN-E (Registered Nurse) regarding R2's care needs. RN-E stated the fall prevention interventions that were successful most of the time included toileting R2 every 30 minutes, watch close, 1:1 supervision, adequate pain control, and anticipate R2's needs. RN-E stated R2 was often with direct supervision from the licensed nurse and R2's safety was maintained during those times. On 07/08/19 beginning at 8:41 a.m., Surveyor observed R2 seated in the wheelchair. LPN-D (Licensed Practical Nurse) and CNA-B assisted R2 to the commode then assisted R2 into bed. R2 was not wearing the hip protectors, contary to the care plann. R2 was resting in bed, but the bed was not in the lowest position, contrary to the care plan. In addition, the motion alarm was on the floor and not on, contrary to the care plan. Surveyor observed R2 in bed in this manner until 11:03 a.m. when Surveyor alerted the DON to the non-implemented care plan interventions. At 11:03 a.m. the DON lowered R2's bed several inches and confirmed the bed had not been in the lowest position. The motion alarm was still on the floor and not turned on. At 11:36 a.m., Surveyor noted R2's motion alarm was attached to the bed and functioning. Cross reference F725. The failure to provide supervision and to develop interventions based on the root cause analysis created a finding of immediate jeopardy. The facility removed the jeopardy on 7/16/19 when it had completed: 1. Reviewed and updated R2's fall risk care plan and CNA care plan; 2. Completed fall risk assessments for in house residents and reviewed and revised care plans as appropriate; 3. Licensed nurses were educated, prior to the start of their next scheduled shift, on incident prevention procedures, investigations, notifications, assessments, documentation, interventions, and fall management; 4. DON and ADON were educated on reviewing resident incident reports and completing root cause analysis. Reviews to be completed prior to the daily Interdisciplinary Team meeting for review by the team; 5. Developed and implemented audit plan for documentation, root cause analysis, and care plan updates.

Based on observation, record review, and interview the facility did not have sufficient staffing to meet the care needs of residents resulting in serious harm and the potential for serious harm, impairnment, or death to 1 of 5 residents (R2) reviewed for falls. R2 sustained six falls in 13 days, all related to the need to toilet herself. These falls resulted in a head injury that required staples, a head injury that required laceration glue, a head injury that required first aid and a broken left arm Staff interviews indicated the falls could have been prevented had there been more staff to closely supervise the resident. Failure to provide staffing to meet the needs of R2 created a finding of immediate jeopardy, beginning 6/19/19. Surveyor notified the Nursing Home Administrator of the immediate jeopardy on 7/16/19 at 11:27 a.m. The immediate jeopardy was removed on 7/16/19. However, the deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread). Staff interviews indicate that CNAs (certified nursing assistants) are unable to complete all daily care needs for residents (showering, toileting, oral care, ambulation, shaving) and are forced to complete two-person transfers by themselves because there are not enough staff. This could impact all 47 residents. This is evidenced by: Citations were issued under Resident Rights, Quality of Care, and Nursing Services that are a direct result of inadequate staffing patterns. The survey was conducted following 2 complaints regarding short staffing, odors, and residents not receiving hygiene and dressing assistance. The facility has 4 hallways where residents reside; West, East, New and the ACU (Alzheimer's Care Unit). The ACU has an alarmed closed door with a current census of 11. The ACU was usually staffed with 1 CNA (Certified Nursing Assistant) and a HA (Hospitality Aide) for days and evenings shifts. The licensed nurse would spend 1-2 hours on the ACU during the day and evening shifts. The West hall had 16 residents. The East hall had 14 residents. The New wing had 6 residents. The 36 residents on the West, East, and New wing were cared for by 2 CNAs. The total resident care load was 18 for the East aide and 19 for the West aide. The New wing was divided between the East and West aide. The East aide would take the residents on the left side of the hall and the West aide would take the residents on the right side of the hall. According to the facility Census and Condition Report completed 07/03/19, 45 residents needed staff assistance with bathing, 7 residents needed staff assistance with eating, 44 residents needed staff assistance with toilet use, 39 residents needed staff assistance with transfers, and 45 needed staff assistance with dressing. On 07/02/19 at 7:50 a.m., Surveyors entered the facility and noted the staff posting on the top of the nurses station. The staff posting indicated a census of 47 and 3 CNA staff scheduled to care for 47 residents. The DON (Director of Nurses) or NHA (Nursing Home Administrator) had not arrived at the start of survey. Example 1: R2 has had 6 falls in 13 days, from 06/19/19 to 07/01/19. The facility identified root cause was R2's response to toileting needs. During those falls, R2 has suffered a [MEDICAL CONDITION] which required staples to close, lacerations over the left eye (2 occassions), a fractured humerous, and a head injury. Interviews with staff found R2 would consistently attempt to self-transfer to respond to a toileting need. Staff interviews also revealed that when R2 received supervision by a CNA or a licensed nurse, R2 did not have any falls. On 07/02/19 at 2:01 p.m., Surveyor interviewed AS-I (anonymous staff) who stated R2 would not have fallen if there were more CNAs to watch her. AS-I stated R2 requested to use the toilet every 15 minutes and would attempt to toilet self when staff could not help her. On 07/03/19 at 9:15 a.m., Surveyor interviewed the ADON (Assistant Director of Nurses) regarding R2's care needs. The ADON stated R2 was provided 1:1 staff supervision and did not fall when the staff person was a CNA or licensed nurse but did fall when the 1:1 was provided by a hospitality aide. A hospitality aide is not a Certified Nursing Assistant and is unable to provide hands-on care or assistance to a resident. On 07/03/19 at 9:30 a.m., Surveyor interviewed CNA-H regarding R2's care needs. CNA-H stated R2 requested to use the toilet every 5-50 minutes. CNA-H stated with another staff person on the wing, falls could be prevented for R2. On 07/03/19 at 10:50 a.m., Surveyor interviewed CNA-C regarding R2's care needs. CNA-C stated when R2 was provided 1:1 care there were no falls those times. CNA-C stated if R2 would have been provided 1:1 supervision, she would not have fallen. On 07/03/19 at 11:15 a.m., Surveyor interviewed CNA-B regarding R2's care needs. CNA-B stated R2's falls could be prevented if staff could provide 1:1 and watch her close. CNA-B stated R2 now needs 1 staff to assist her with eating since her multiple falls and injuries. On 07/08/19 at 9:30 a.m., Surveyor interviewed CNA-R regarding R2's care needs. CNA-R stated more 1:1s would have prevented R2's falls. On 07/08/19 at 2:35 p.m., Surveyor interviewed CNA-G regarding R2's care needs. CNA-G stated R2 would definitely not have fallen if we could have provided her with 1:1 supervision. CNA-G stated we just did not have enough staff to watch her close. (Refer to F689.) Example 2: On 07/02/19 at 8:30 a.m., Surveyor observed 6 residents seated at a long table in the dining room for breakfast. Record review later revealed 5 of those residents are dependent on staff for eating and the sixth required verbal cues during the meal. CNA-J and CNA-Q were assisting those residents. CNA-J and CNA-Q were observed to stand over the residents and move from person to person to assist all residents with their meals. (Refer to F550.) CNA-J stated she was assigned to the West wing and the right side of New wing for a total of 19 residents. CNA-Q stated she was assigned to East wing and the left side of New wing for a total of 18 residents. In addition to 2 CNAs attempting to assist 5 residents with eating, the Surveyors also noted between 7:50 and 8:40 a.m., R1, R2, and R3 in their rooms with the breakfast tray on the bedside table and the residents still in bed without eating any breakfast. At 8:45 a.m., Surveyor met with the DON (Director of Nurses) and NHA (Nursing Home Administrator) and confirmed facility census at 47 and staffing with 3 CNAs and 1 of those CNAs had to leave mid shift in order to attend an appointment. The DON stated desired staffing was 4 CNAs on days and evening shifts and 2 CNAs on the night shift. The DON acknowledged the staffing problems with recruiting and retaining CNAs but stated a resident load of 18 or 19 was a reasonable resident load for 1 CNA to complete in an eight hour shift. On 07/03/19 at 8:10 a.m., Surveyors again noted the same 6 residents seated in the main dining room with 2 staff helping with eating. CNA-B stated her resident load today was 18 and CNA-H stated her resident load today was 19. Example 3: On 07/02/19 at 7:50 a.m., Surveyors identified a bowel and urine odor coming from R1's room. The odor was present until 10:30 a.m. The urine odor remained through the afternoon. At 2:01 p.m., Surveyor interviewed a staff member who requested to remain anonymous. The staff stated urine and bowel odors are noted because R1 does not always get the help he needs. Staff stated R1 was often incontinent of urine and bowel. On 07/03/19 at 8:34 a.m., Surveyor noted R1 lying in bed still dressed in the same clothes worn the day before. There was a urine odor present. (Refer to F584.) Example 4: The MDS (Minimum Data Set Assessments) for R1 and R4 were found to be submitted late. On 07/03/19 at 8:45 a.m., Surveyor interviewed the MDS-RN. The MDS-RN confirmed R4's admission MDS was completed late. The MDS-RN stated she is often pulled to work as a floor nurse and cannot get her MDS work completed on time. (Refer to F636.) Example 5: The facility employs hospitality aides to assist in the facility. As a hospitality aide, those staff are not to provide any hands on care to residents. Interviews with hospitality aides, CNAs, and family find hospitality aides have been provding hands on care to residents including feeding, transfers, toileting, and bathing. (Refer to F728.) On 07/02/19 at 2:01 p.m., Surveyor interviewed AS-I (anonymous staff) who reported she has been a caregiver for a number of years and she often feels overwhelmed with the resident load she has been assigned. AS-I stated on the weekends there is no leadership staff to help with meals. AS-I stated the facility has been staffing with only 3 CNAs on days and expecting the CNAs to stay over into the next shift without advanced notice. AS-I stated she was unable to complete a shower today, rarely gets her residents shaved, does not have time to help with oral hygiene, ambulation, or toilet assistance every 2-3 hours according to the care plan. AS-I stated she has residents on her case load that require 2 staff for transfers and she has transferred them by herself because there was no staff to help. AS-I stated the managers do not get into the building until after 8:00 a.m. and much of the work has been done. AS-I stated she has asked the managers including the DON, ADON (Assistant Director of Nurses), NHA, and MDSC (Minimum Data Set Coordinator) for more help but rarely gets any help. AS-I also stated the managers do not attempt to call staff in to replace a staff member who could not report to work. AS-I staff stated she will get a message from a co-worker requesting her to come to work, but will not get a call from a manger. On 07/03/19 at 9:05 a.m., Surveyor interviewed the ADON regarding staffing. The ADON confirmed staffing patterns of 3 CNAs for 47 residents on days and evening shift have been prevalent. The ADON stated she does not assist CNA staff with showers or morning hygiene cares, but does assist with toileting and feeding residents. On 07/03/19 at 9:30 a.m., Surveyor interviewed CNA-H regarding staffing. CNA-H stated the resident work load she usually takes was very heavy and she often could not get all of her work done during her shift. On 07/03/19 at 10:50 a.m., Surveyor interviewed CNA-C regarding staffing concerns. CNA-C stated the CNAs are often mandated to work a 12 or 16 hour shift and the DON does not ask them but rather just changes the schedule without the CNAs' knowledge. The DON stated to CNA-C that if she does not work the mandated shift, the aide will be disciplined for abandoning the residents. CNA-C stated 2 staff are expected to assist 5-6 residents with eating and care for 36 residents. CNA-C stated her resident load was too much and she often does not get her showers done, was unable to toilet residents every 2-3 hours, unable to ambulate residents, and unable to provide oral care. CNA-C stated some residents need 2 persons for transfers which was often nearly impossible to find another caregiver. CNA-C stated some nurses are good about helping with transfers and others will not help. CNA-C stated the managers do not help on the floor unless Surveyors are in the building. On 07/03/19 at 11:15 a.m., Surveyor interviewed CNA-B regarding staffing patterns. CNA-B stated she has worked at the facility for [AGE] years and recently the staffing has been very difficult. CNA-B stated she usually works West wing and was responsible for 18 residents. CNA-B stated she does the best she can, but often showers do not get done, nail care, and oral care also does not get done. CNA-B stated 2 person transfers also occur with only 1 staff because there just was no other choice. CNA-B stated residents don't get toileted as often as they should and that creates odors and skin problems. On 07/08/19 at 9:10 a.m., Surveyor interviewed CNA-K regarding staffing and qualified staff. CNA-K stated she worked on the ACU to help with programing for dementia care. CNA-K stated the ACU should always have at least 2 staff present due to elopements and unpredictable behaviors. CNA-K stated the HA (Hospitality Aide) is not allowed to do any hands on cares but would count as a second staff person. CNA-K stated other CNAs report to her frequently that they are unable to get their work done due to the heavy resident load. CNA-K stated 18-19 residents for 1 CNA was an impossible care load and could not be done. CNA-K stated she is aware HA were helping with direct resident care. On 07/08/19 at 9:30 a.m., Surveyor interviewed CNA-R regarding staffing. CNA-R stated the usual staffing pattern was 3 CNAs on days and evenings and 2 CNAs on night shift. CNA-R stated she worked all shifts. CNA-R stated with 1 additional CNA the work load is much improved. CNA-R stated it was very challenging to get all of the work done like showers, shaving, toileting, and oral care. CNA-R stated she does the best she can. On 07/08/19 at 2:45 p.m., Surveyor interviewed CNA-G. CNA-G stated she started with the facility as a HA and was not allowed to do any hands on resident care. CNA-G stated with only 3 CNAs on days and evenings, it was often not possible to get all of your work done. CNA-G stated as a HA, I would help the CNAs with some hands on care. CNA-G stated there was little help with direct resident care from the managers. On 07/08/19 at 3:03 p.m., Surveyor interviewed RN-E (Registered Nurse) regarding staffing. RN-E stated the staffing patterns are usually 2 licensed nurses and 3 CNAs on days and evenings. RN-E stated the HA were not allowed to do any direct resident cares, but likely are doing some. RN-E stated it has been very challenging for the CNAs and HAs to get the work done and RN-E suspected some cares were not done due to the high resident care loads. Example 6 On 7/8/19 at 8:20 AM, Surveyor entered the ACU (Alzheimer's Care Unit) and noted 2 staff on the unit, CNA-C and HA-[NAME] There were 11 residents living in the ACU, all of which have advancing Dementia, and some of which have behavioral tendencies, including elopement attempts or exit-seeking. Surveyor asked CNA-C what the normal staffing was for the ACU. CNA-C stated. Normally it's one CNA and one H[NAME] When asked what the responsibilities of the HA were, CNA-C stated, They are supposed to only pass linens, answer call lights, cut up residents food, stock supplies, that kind of thing, but they have been working as actual aides because we are so short staffed. When I work, I don't let them do any resident care. Hospitality Aides are staff that have not yet completed certification as CNA's and are currently enrolled, or plan to be enrolled in a CNA program. These staff are not yet qualified to perform the responsibilities of a CNA (resident bathing, transfers, toileting and feeding). CNA-C was asked what tasks she is unable to complete as a result of being the only CNA on the floor. CNA-C stated When it's just me, showers often do not get completed because I cannot spend 20-30 minutes in the shower and leave the floor with nobody to watch the other residents. (R9) is constantly trying to go out the exits, even has now tried to kick out windows to leave. I can't leave them unwatched while I am doing showers. CNA-C further stated that she has incorporated Family-O's assistance in watching residents while she went after R9, who left the building. At 8:30 AM, Surveyor approached HA-A and asked her what tasks she performs when on duty. HA-A stated, I am supposed to just be a spare hand. I help feed, walk residents to their rooms and do a lot of activities with the residents. I am not supposed to do resident bathing, toileting, transfers or lifts. HA-A further stated that she has been helping with the tasks of transfers and bathing because there is only one other CNA on the floor. HA-A stated that the facility employs other HA staff that also complete regular CNA duties because of the short staffing. She stated that she is currently enrolled in the CNA certification program and begins her clinical training next week. HA-A stated that she has not had any previous training to complete these tasks. At 9:26 AM, HA-A stated that she was approached last week by the Director of Nursing (DON) when the survey team first entered the building, and was told Don't do any hands on cares today because the State is in the building. At 9:58 AM, Surveyor interviewed LPN-D (Licensed Practical Nurse) who is responsible for residents living on the ACU on this date. LPN-D was asked to approximate the amount of time she spends on the ACU for treatments, medications or just general observation and monitoring. LPN-D stated she is also responsible for the West wing, outside of the ACU so generally only spends about 1 1/2 hours total on the ACU. During this time, she stated she is passing out medications or completing any treatments that need to be completed. She stated she does not spend time on the unit to assist CNA staff or monitoring of the residents unless she is called to the unit by the CNA staff to help them out. She stated there is no nurse on the ACU unless they are doing the medications or treatments. At 10:00 AM, the Surveyor interviewed the Activity Director (AD) in regards to her responsibilities with the conduction of activities on the ACU. The AD stated she is generally responsibile to conduct activities throughout the building including the ACU. She is the only activity staff in the facility. She stated that she tries to go back into the ACU twice daily, but that she is very busy and not always able to. The AD stated that CNA staff are responsible to conduct activities on the ACU. Surveyor asked how this is completed as CNA staff are very busy with the provision of cares and the management of behaviors. The AD shrugged her shoulders and stated, I try to get back there. I'm busy though and can't always get there. I try the best I can. She further stated that the HA's do some activities with the ACU residents and at times, she will bring some of the residents off the ACU for mainside activities, such as music programs. At 11:32 AM, Surveyor spoke with Family-O and asked him how he feels cares are in the facility. Family-O is the spouse to R14, who lives on the ACU. Family-O stated that he comes every day and feeds R14 her noon meal. He stated, There are a few good CNAs but everyone else is really unqualified. They (facility) use hospitality aides to work back here and they don't know what they are doing. They do all the work that a CNA does but aren't supposed to. If I wouldn't come every day to feed R14, she wouldn't get fed. There just aren't enough CNAs to take care of these people. Most of the people that live back here (ACU) are really confused and need much more attention than the girls can give them. At 2:15 PM, Surveyor interviewed CNA-M and asked her about staffing on the ACU. CNA-M has worked in the facility for one month and informed the Surveyor that she received her CNA Certification one month ago. Prior to receiving this, she worked in the facility as a hospitality aide. CNA-M stated that she works the evening shift on the ACU, and generally is the only CNA on the floor, sometimes there is a HA that also works. She stated that when she worked as a HA, she was supposed to only pass snacks and linens or answer call lights. However, CNA-M stated that most times I was thrown on the floor to work as a CN[NAME] I was scheduled as a CNA even though I wasn't supposed to, I was doing resident transfers, toileting, bathing and feeding. When asked if she had prior training for the ACU, CNA-M stated that she followed a lead CNA for 3 days on mainside, not the ACU and, on the ACU, I was kind of thrown into it, thrown into the fire. Surveyor then asked CNA-M on days that she is on the floor by herself, what tasks she is unable to complete. CNA-M stated, I can't do showers if I am alone because I can't leave the other residents unwatched. At 2:26 AM, Surveyor spoke with CNA-N, who was the CNA on the ACU on this evening shift. CNA-N stated she had been working in the facility since (MONTH) (YEAR). She stated that the normal staffing for the ACU is 1 CNA and occasionally a HA is on the floor with her. She stated the HA's .have been doing regular CNA work even though their not supposed to. Surveyor asked CNA-N what tasks she is unable to complete when she is on the floor alone. CNA-N stated, I have to take short-cuts. I can't do showers because I need to be out here (hallway) watching other residents, so showers don't get done and I need to do cares quickly so that I can be out in the hall, so a lot of times, I don't do oral cares. At 3:35 PM, Surveyor interviewed the ADON (Assistant Director of Nursing) regarding the expectations of the HA's. The ADON stated that HA's are not to do any hands-on cares. They are to answer call lights and can walk with residents if the resident is independent with ambulation. The HA's can also assist with meal set up but are not allowed to feed. She stated, No hands on until they are checked off with that particular task in their CNA class. On 7/8/19, Surveyor spoke with the NHA (Nursing Home Administrator). The NHA acknowledged challenges with staffing. The NHA stated the facility tried a staffing agency but so far, the agency has not sent any staff. The failure to provide sufficient staff created a finding of immediate jeopardy. The facility removed the jeopardy on 7/16/19 when it had completed the following: 1. Staffing patterns reviewed daily for open shifts with adjustments before the morning stand up meeting; 2. Staffing projections reviewed daily for upcoming week; 3. Staff educated on appropriate duties for hospitality aides; 4. Admission referrals to be screened by Interdisciplinary Team prior to admission to ensure sufficient staff to meet resident needs; 5. Implementation of Resident Centered Staffing Committee; and, 6. Secured contracts with agencies to provide additional nursings staff.

Based on observation, interview, and record review the facility did not ensure 1 of 6 residents reviewed for pain (R8) had a pain management program designed to promote comfort and improve quality of life. R8 had [DIAGNOSES REDACTED]. R8 had also had several falls and a decline in mobility. According to staff, R8 had daily indicators of distressed behaviors including calling out, repeated nonsensical unidentifiable verbiage varying in levels of volume, crying, restlessness, and facial grimacing. Nursing staff assessed R8 as having pain several days each month. Despite this, no as needed pain medication was administered. This is evidenced by: R8 has current [DIAGNOSES REDACTED]. R8's most current MDS (Minimum Data Set) was dated 8/23/18. The MDS indicated R8 ~ Had a BIMS (Brief Interview for Mental Status) score of 0 indicating R8 had a severe cognitive impairment; ~ Mood indicators including little pleasure in doing things, appearing down, depressed, or hopeless, trouble concentrating; ~ Had verbal behavioral symptoms directed toward staff including screaming and cursing which occurred 1 to 3 days during the look back period; ~ Had other behavioral symptoms not directed towards others including pacing, screaming, or disruptive sounds on 1 to 3 days during the look back period; ~ Wandered on 1 to 3 days during the look back period; ~ Required the assistance of 1 staff person for all aspects of care; ~ Had indicators of possible pain on 1 to 2 days; and ~ Had 2 or more falls. R8's pain care plan was dated 5/18/17. The care plan indicated R8 had the potential for pain due to [MEDICAL CONDITION] arthritis and pain. The care plan had the following approaches. ~ 5/18/17, .Administer [MEDICATION NAME] per MD (Medical Doctor) orders. Give prior to treatments, therapy or cares .Anticipate Resident's need for pain relief and respond as soon as possible to any complaint of pain .Ask Resident about which positions are comfortable, encourage frequent repositioning .Document pain on 1-10 PAINAD (Pain Assessment in Advanced Dementia) scale or using pain faces. Monitor response to [MEDICATION NAME] and pain alleviation measures .Explore non pharmacological pain alleviating interventions such as heat, ice, massage, elevation, relaxation, repositioning and food .Monitor/document for side effects of pain medication .Observe Resident during cares for signs of pain i.e. facial grimacing, hesitancy with movement, furrowed brows, saying 'Ouch', refusing to move or transfer . ask Resident about their pain with each encounter .Update Physician on effectiveness of [MEDICATION NAME] and pain treatments as necessary . A PAINAD pain scale is utilized to assess indicators of pain in persons with dementia. The assessor evaluates 5 different indicators of pain including breathing, negative vocalizations, facial expressions, body language, and consolability. Each indicator is scored from 0 to 2 depending on the persons behavior. The score is tallied and ranges from 0 to 10. A pain level of 1-3 indicates mild pain, 4-6 moderate pain, and 7-10 severe pain. Surveyor completed a review of a pain assessment completed on 8/20/18. The pain assessment indicated R8 had indicators of pain on 3 to 4 days rated at an 8. This indicated R8 had severe pain. Surveyor completed a review of R8's physician orders [REDACTED]. ~ On 5/17/17 [MEDICATION NAME] 200 mg (milligrams) was ordered twice a day. [MEDICATION NAME] is an [MEDICAL CONDITION] used in persons with [DIAGNOSES REDACTED] diseases such as [MEDICAL CONDITION] arthritis. It is not classified as an [MEDICATION NAME] or pain reliever. ~ On 7/27/17 Tylenol 650 mg was ordered every 4 to 6 hours as needed. ~ On 1/30/18 Tylenol 1000 mg was ordered twice a day. Surveyor completed a review of R8's MAR's (Medication Administration Records) over the past 5 months and noted the following. July ~ From 7/1/18 through 7/31/18 R8 received both the [MEDICATION NAME] and Tylenol as ordered. R8 received no as needed Tylenol. The facility by practice monitors pain every shift. Surveyor reviewed R8's pain level from 7/1/18 to 7/31/18 and noted R8's had pain recorded 17 days ranging anywhere from 1 to 7 on a PAINAD scale of 0-10. R8 received no additional pain medications. There were no new approaches implemented in attempt to control R8's indicators of pain. Surveyor completed a review of R8's nursing notes and noted the following. ~ 7/5/18, .Crying episodes X 3 (three times) .What was the resident doing prior to or at the time of behavior/mood: Sitting in chair in her room. Sitting in the dining room . August ~ From 8/1/18 through 8/31/18, R8 received both the [MEDICATION NAME] and Tylenol as ordered. R8 received one additional dose of Tylenol on 8/16/18. Surveyor reviewed R8 assessed pain level from 8/1/18 through 8/31/18. R8 had pain recorded on 15 days ranging from 2-7 on a PAINAD scale of 0-10. R8 received only one additional dose of Tylenol. There was no indication the facility recognized and assessed R8's continued indicators of pain. There were no changes to R8's plan of care in attempt to manage R8's indicators of pain. ~ 8/15/18, .Behavior/Mood: Crying off and on most of shift. No tears .What was the resident doing prior to or at the time of behavior/mood: Sitting in dining room. Laying in bed. Interventions attempted: 1:1 (one to one). Reassure. Redirect. Distract .Effectiveness of the interventions: Effective only a little while than new episode . ~ 8/16/18, .Crying episodes X 4 .Interventions attempted: 1:1. Reassure, toilet, redirect, distract .Effectiveness of the interventions:: Effective for a while . ~ 8/24/18, .Crying episodes X 6 .Interventions attempted: 1:1 Redirect. Reassure Effectiveness of the interventions: Effective for a while . ~ 8/25/18, .Crying Episodes X 6 .Interventions attempted: 1:1, Redirect, reassure, offer snacks, offer fluids .Effectiveness of the interventions: Effective for a little while . ~ 8/27/18, .crying out .Interventions attempted: staff attempted to give her activities, walked with her, toileting, 1:1 .Effectiveness of the interventions: no change . ~ 8/29/18, .Crying episodes ongoing most of shift .What was the resident doing prior to or at the time of behavior/mood: Laying in bed, sitting in recliner, sitting in dining room, walking in hallway .Interventions attempted: 1:1. Reassure. Redirect. Distract. Ambulate. Toilet. Snacks. Fluids. Stuffed animals. Dolls .Effectiveness of the interventions: Ineffective. No change with [MEDICATION NAME] on board On 8/29/18 the facility identified the current medication regimen was ineffective in managing R8's pain indicators. There were no changes made to R8's plan of care. ~ 8/30/18, .Crying episodes 5 X this shift . What was the resident doing prior to or at the time of behavior/mood: Laying in bed, sitting in dining room, walking in hallway, and sitting in recliner . Interventions attempted: 1:1. Toilet. Ambulate. Music. Reassure. Stuffed animals and baby dolls. Put into bed Effectiveness of the interventions: Effective for a while . September ~ From 9/1/18 through 9/30/18, R8 received both the [MEDICATION NAME] and Tylenol as ordered. R8 received no additional Tylenol. Surveyor reviewed R8's assessed pain level from 9/1/18 through 9/30/18. R8 had pain recorded on 26 days ranging from 2 to 9 on a PAINAD scale of 0-10. No additional Tylenol was given. R8 had continued indicators of pain. R8's pain at times was severe. There was no indication the facility recognized and assessed R8's continued indicators of pain. There were no changes to R8's plan of care in attempt to manage R8's indicators of pain. ~ 9/5/18, .Crying episodes X 5 .What was the resident doing prior to or at the time of behavior/mood: Laying in bed, sitting in dining room, sitting in recliner .Interventions attempted: 1:1. Reassure, redirect, toilet. Snacks .Effectiveness: Effective for a while . ~ 9/14/18, .Crying episodes > 8 X (greater than 8 times) .What was the resident doing prior to or at the time of behavior/mood: Laying in bed. Sitting in recliner. Walking in hall. Sitting at dining room table .Interventions attempted: 1:1. Reassure. Toilet. Take for a walk. Give fluids. Give snacks. Effectiveness of the interventions: Effective only for a while . ~ 9/18/18, .Crying episodes >5 X .What was the resident doing prior to or at the time of behavior/mood: Sitting in dining room. Laying in bed. Sitting in recliner .Interventions attempted: 1:1 . Reassure; Reposition; Toilet; Activities offered, fluid and snacks given Effectiveness of the interventions: Effective for a while . ~ 9/21/18, .Crying episodes > 5 X .What was the resident doing prior to or at the time of behavior/mood: Sitting in dining room. Sitting in recliner. Laying in bed .Interventions attempted: 1:1. Sit with. Toileted. Walked with. Snacks and fluids given .Effectiveness of the interventions: Effective for a while . ~ 9/27/18, .Crying episodes X 4 .What was the resident doing prior to or at the time of behavior/mood: Laying in bed. Sitting in recliner. Sitting in dining room .Interventions attempted: 1:1. Toileted. Redirected. Repositioned. Reassured .Effectiveness of the interventions: Effective after a while . October ~ From 10/1/18 through 10/31/18, R8 received both the [MEDICATION NAME] and Tylenol as ordered. R8 received no additional Tylenol. Surveyor reviewed R8's assessed pain level from 10/1/18 to 10/31/18. R8 had pain recorded on 17 days ranging from 1 to 8 on a PAINAD scale of 0-10. R8 received no additional Tylenol. There were no changes made to R8's plan of care in attempt to manage R8's pain. ~ 10/3/18, .Crying episodes 5 times .What was the resident doing prior to or at the time of behavior/mood: Laying in bed. Sitting in recliner. Sitting in dining room .Interventions attempted: 1:1. Toileted. Walked with her. Offered snacks or fluid .Effectiveness of the interventions: Effective for a while . ~ 10/6/18, .Crying >5 X, pacing, and calling out .What was the resident doing prior to or at the time of behavior/mood: Sitting in dining room, recliner, and walking the hall .Interventions attempted: 1:1. Redirect. Distract. Reassure. Toilet. Walk with her .Effectiveness of the interventions:: Effective for a while . ~ 10/13/18, .chanting and crying with her eye closed most of the day .What was the resident doing prior to or at the time of behavior/mood: happened most of the day .Interventions attempted: 1:1, reposition, food, fluids, toileting .Effectiveness of the interventions: no chznge (sic) . ~ 10/17/18, .Crying episodes this afternoon > 5 X .What was the resident doing prior to or at the time of behavior/mood: Sitting in dining room Interventions attempted: 1:1 Toileted. Reassured. Snacks offered. Walked with .Effectiveness of the interventions: Ineffective . ~ 10/22/18, .crying and calling out throughout the day .What was the resident doing prior to or at the time of behavior/mood: resident seems to do this most of the time she is awake only stopping when she is asleep or when she is eating .Interventions attempted: 1:1, redirect .Effectiveness of the interventions: no change . ~ 10/29/18, .Resident has been crying and calling out most of the day .Started upon waking this am and with the exception of when she rested she has been crying and calling out .Interventions attempted: 1:1, redirection, food, fluids, toileting .Effectiveness of the interventions: no change . ~ 10/31/18, .calling out/ crying .Off and on throughout the day .Interventions attempted: food, fluids, toileting, assisting resident to lay down .Effectiveness of the interventions: Resident calls out most of the time when she is awake . ~ 10/31/18, .Resident was in her room when she started sobbing uncontrollably in her chair .Staff assisted her out of her chair. Telling her that dinner was on the way soon. But she seemed to be in pain . Effectiveness of the interventions: After she received her scheduled Tylenol there was a bit of improvement. She may need something stronger than Tylenol if this continues . R8's distressing behaviors indicative of pain had escalated since 7/5/18. It was not until 10/31/18 the facility identified the possibility R8's distressing behaviors being related to pain. Despite that, to date, there have been no changes made to R8's plan of care to improve R8's pain and quality of life. November ~ From 11/1/18 to 11/27/18, R8 received both the [MEDICATION NAME] and Tylenol as ordered. R8 received no additional Tylenol. Surveyor reviewed R8's assessed pain level from 11/1/18 to 11/27/18. R8 had pain recorded on 12 days ranging from 2-7 on a PAINAD scale of 0-10. There was no additional Tylenol give. There were no changes made to R8's plan of care in attempt to manage R8's pain. On 11/26/18 at 11:38 AM Surveyor observed R8 being escorted to the dining room by CNA-I (Certified Nursing Assistant). Surveyor noted R8 had distressed facial expression with a sorrowful furrowed brow. Once R8 was seated in a chair, R8 rocked herself back and forth. R8 was also noted to talk in a distressed sounding nonsensical unidentifiable verbiage. On 11/26/18 at 2:44 PM Surveyor observed R8 walking down the hall with CNA-I. R8 had a distressed look on her face, was grimacing, and talking again in varying levels of volume and speed nonsensical unidentifiable verbiage CNA-I identified as gibberish. On 11/27/18 at 2:42 PM Surveyor noted R8 in bed. R8 was noted to have eyes close, talking in a distressed nonsensical verbiage audible in the hall. The volume of R8's voice varied from soft to loud. Surveyor noted R8 continuously bent knees up and down shifting her buttocks from side to side. On 11/27/18 at 3:40 PM Surveyor noted R8 in the dining room. R8 again had distressed sounding non-scensical verbiage, was crying, and calling out daddy. CNA-H indicated R8 had been taken for a walk had been given something to eat. CNA-H stated those interventions were not effective. CNA-H stated, This is what she does. On 11/28/18 at 10:48 AM Surveyor noted R8 sitting in recliner in her room with the foot rest elevated and R8's eyes closed. R8's had distressed sounding continuous non-scensical verbiage in varying levels of volume and speed, intermittent crying, intermittent grimacing, and a sorrowful distressed look on her face. Surveyor noted R8 would intermittently raise and lower her left leg on and off the foot of the recliner chair. On 11/27/18 at 2:45 PM Surveyor spoke with CNA-H about R8. CNA-H indicated R8 cries a lot, babbles, yells, and sometimes calls out daddy, daddy, daddy. CNA-H indicated she felt R8 had a decline in her walking abilities, and didn't walk as good as she used to. CNA-H indicated R8 was also leaning back when she walked. CNA-H stated sometimes R8 wouldn't walk or couldn't walk. CNA-H pointed to a wheel chair in R8's room indicating that's why we have a wheel chair. All of R8's behaviors as noted above were indicators of pain. Utilizing the facility's PAINAD scale Surveyor identified R8's pain level ranged from 5 indicating moderate pain to 9 indicating severe pain during the observations as noted above. On 11/28/18 at 10:34 AM Surveyor spoke with LPN-G (Licensed Practical Nurse). LPN-G indicated she was the nurse typically assigned to the dementia care unit. Surveyor asked LPN-G what R8's behaviors were. LPN-G indicated R8 cries, is restless, fidgets, mumbles, and does not open eyes. Surveyor asked LPN-G if she felt R8 had pain. LPN-G indicated she did not think R8 had pain however LPN-G stated R8's hands were sore and she did not like having them touched. On 11/27/18 at 5:27 PM Surveyor spoke with the ADON (Assistant Director of Nursing). The ADON indicated she was also the director of the dementia care unit where R8 resides. Surveyor asked the ADON about resident behaviors. The ADON indicated residents with dementia who were acting out typically had something that is bothering them or an unmet need. The ADON indicated it could be noise, being over tired or over stimulated, or the resident could be experiencing pain. Surveyor asked the ADON about R8. The ADON indicated R8's behaviors had been challenging. The ADON identified R8 as having distressing behaviors. The ADON indicated she was not sure what the causative factors or triggers to R8's behavior were. Surveyor asked the ADON if R8 had pain. The ADON indicated R8 was on scheduled Tylenol and as needed Tylenol and was on [MEDICATION NAME]. Surveyor asked what the facility had done to rule out pain as the cause of R8's distressing behaviors. The ADON indicated she was not sure. On 11/28/18 at 11:06 AM Surveyor spoke again with the ADON. The ADON indicated R8 was just discussed at their behavior meeting on 11/14/18. The ADON indicated they identified R8 as having continued daily episodes of weepiness or crying typically during the day shift. The ADON indicated the team recommended they watch and wait and review R8's behaviors again in 3 months. Surveyor reviewed R8's behaviors, medications, PAINAD assessments and Surveyor observations with the ADON. The ADON indicated she felt R8 did have pain at times. The ADON indicated they should have addressed R8's pain and sought out additional modalities to improve R8's pain. On 11/28/18 at 12:52 PM Surveyor spoke with NP-J (Nurse Practitioner). NP-J indicated she followed R8 in the facility. NP-J indicated R8 had been challenging and it was difficult to determine if R8's pain was physical or psychological. NP-J indicated it would be prudent to look at all possibilities to determine causative factors for behaviors. NP-J indicated the only way to determine if R8's behaviors were caused by physical pain was to offer additional pain medication and assess the results.

Based on observations, interviews, and record reviews, the facility did not provide individualized interventions to dementia care resulting in distress and a continuation and/or escalation of behavior patterns. Additionally, the facility relied on medications to control resident behaviors, creating a risk for side effects associated with these medications. This resulted in actual and potential physical declines, agitation, and distress for 7 of 9 residents reviewed for dementia. For 7 of 9 residents reviewed for dementia care: ~There was no comprehensive evaluation of each person's daily routines, medical conditions, description of behaviors, and how they communicate needs; ~There was no evidence staff identified causal/contributing factors to behaviors such as medical conditions, adverse reactions to medications, or other factors such as boredom, anxiety, personal needs not being met, fatigue, etc; and/or ~Staff did not develop care plans that addressed specific behavioral expressions, goals, and individualized approaches for responding to or preventing target behaviors and/or expressions of distress. 1. The facility did not comprehensively assess Resident #1's behaviors, identify remediable causes, did not identify some of the behaviors as potential side effects to a medication, and did not develop and implement an individualized plan of care to assist Resident #1 in avoiding the development of behaviors and to assist with de-escalating behaviors that are already occurring. Instead, the facility implemented several medications, with multiple dosage changes in a short period of time. [MEDICATION NAME] was the first medication that was ordered on [DATE], which has side effects of restlessness, distress, dizziness, somnolence, hypertension, headache, hallucinations, or increased confusion. Resident #1 began to demonstrate several of these symptoms. The facility did not assess these as potential side effects; rather, they were identified as behaviors, and treated with other [MEDICAL CONDITION] medications of [MEDICATION NAME], and [MEDICATION NAME]. Even though the dose of [MEDICATION NAME] and [MEDICATION NAME] was increased, the facility did not complete a root cause analysis of the behaviors to determine the causative factors and/or individualized approaches for Resident #1. Resident #1 did not have a complete social history to determine individualized customary routine. The facility did identify that Resident #1 enjoyed pets, news, church and being outdoors. However, none of these interventions were used as approaches to prevent behaviors. The family had shared with the facility a number of approaches to use when Resident #1 appeared to be having difficulties. Although behaviors began in shortly after admission in February 2014, the facility did not actively involve the family and document the approaches until late May 2014. These approaches were never included in the care plan or on the CNA Care Cards. Resident #1 also has a history of chronic pain. Again, the family made the facility aware of this, but pain was not addressed for Resident #1 until May 2014 and was not assessed as being a potential cause for his behaviors. Subsequently, Resident #1's behaviors were not adequately addressed and staff called the police when they were no longer able to control Resident #1. Resident #1 was handcuffed and family took the resident home for the evening. 2. Resident #2 had a [DIAGNOSES REDACTED].#2 had behaviors of anger, fighting, aggression towards others, pacing, combativeness, yelling, shouting, crying, weeping, agitation, restlessness, delusions, hallucinations, and attempting to elope. According to staff, Resident #2's behaviors started after admission to the facility. While the facility identified the behaviors, there was no indication the facility completed a comprehensive assessment of Resident #2's medical, physical, mental nor psychosocial status to determine underlying causes of Resident #2's distressing behaviors. There was no care plan implemented based on Resident #2's specific individual needs directing staff on how to manage Resident #2's behaviors to minimize and/or eliminate the behaviors in order to improve Resident #2's quality of life and well-being. Resident #2 was also placed on multiple psychoactive medications including antipsychotic medications. There was no consideration on the part of the facility the psychoactive medications could be causing and/or making Resident #2's distressing behaviors worse. Lack of completing a comprehensive assessment to determine the root cause of Resident #2's distressing behaviors and implementing an individualized care plan based on Resident #2's specific needs led to a significant decline in Resident #2's overall functioning including physical functioning, psychosocial well-being, anorexia and weight loss, and falls. 3. Resident #3 has behaviors of "continuous pacing" and "agitation" for which Resident #3 receives [MEDICATION NAME] as needed. There was no definition of what "agitation" is for Resident #3 and when administering the [MEDICATION NAME] would be appropriate. There was no assessment of Resident #3's behaviors to determine the root cause for the distress. There was also no evidence that individualized, nonpharmacological interventions were tried prior to administering [MEDICAL CONDITION] medications. 4. Resident #5 had a [DIAGNOSES REDACTED].#5 had behaviors of restlessness, agitation, [MEDICAL CONDITION] and falls. While the facility identified these behaviors, there was no indication the facility completed a comprehensive assessment of Resident #5's medical, physical, mental or psychosocial status to determine underlying causes of Resident #5's behaviors. There was no care plan implemented based on Resident #5's specific individual needs directing staff on how to manage Resident #5's behaviors to minimize and/or eliminate the behaviors to improve Resident #5's quality of life and well-being. Consequently, Resident #5 was observed on all days of the survey to either be sleeping in the Broda chair or in constant motion by either propelling the Broda chair forward or backward with his feet, propelling his chair forward by utilizing the hand rails, leaning over attempting to pick up items off the floor, putting on/taking off socks, or manipulating the variety of positioning devices on the Broda chair. Staff also indicated Resident #5 would "fight" with them during cares. 5. Resident #7 had periods of calling out. While the facility defined the calling out as a behavior, there was no comprehensive assessment completed to determine underlying causes of Resident #7 calling out. There was no individualized care plan directing staff on how to mange Resident #7's calling out. 6. Resident #6 had facility defined behaviors of calling out, shouting, and cursing. While the facility identified the behaviors, there was no comprehensive assessment completed to determine underlying causes of Resident #6's behaviors. There were no individualized approaches developed based on the comprehensive assessment to minimize and/or eliminate Resident #6's behaviors to improve Resident #6's quality of life and well-being. 7. Resident #4 has [DIAGNOSES REDACTED]. Resident #4 had an altercation with another male resident. There was no evidence that the situation was comprehensively assessed to identify potentially remediable causes. There were no nonpharmacological interventions attempted. Immediately following the incident, the dose of Resident #4's antianxiety medication was increased. The failure to provide person-centered care for residents with dementia aimed at understanding, preventing, relieving, and/or accommodating residents' signs of distress created a finding of immediate jeopardy. The immediate jeopardy began on 6/3/14. The NHA (Nursing Home Administrator) and RN Consultant were notified of the immediate jeopardy on 6/23/14 at 3:45 p.m. The immediate jeopardy was not removed by the exit date of the survey. In addition to the residents in immediate jeopardy, the facility failed to provide appropriate pain management for 2 of 11 residents reviewed for pain, and 1 of 2 residents was not provided with an assessment by a Registered Nurse when a change in condition was reported. For 2 of 11 residents reviewed for pain: ~Resident #1 has a [DIAGNOSES REDACTED]. Resident #1 was displaying behaviors which were treated with antipsychotic medications. Staff did not assess to determine if the behaviors could have been non-verbal indicators of pain. In addition, the facility does not have a systematic process for a comprehensive pain assessment and/or for documentation when administering a prn (as needed) [MEDICAL CONDITION] medication. The licensed nurse will tag the physician order, which goes into the progress note and will document if effective or ineffective. There is no assessment of the pain or behavior, no descriptors of type of pain, any nonpharmacological approaches used prior to administering any prn medication, any documentation of possible triggers such as pain, constipation, loneliness, boredom, etc., for the behaviors and if the medication was effective or not, as evidenced by. ~Resident #11 has [DIAGNOSES REDACTED]. Documentation when the as-needed pain medication is administered does not include a comprehensive assessment of Resident #11's pain prior to administration or after administration to determine effectiveness. For 1 of 2 residents who had a change in condition: ~Resident #12 had a change in condition. There was no evidence of an RN (Registered Nurse) assessment after the event and no ongoing monitoring of her condition. This is evidenced by: Example #1 (also cross reference F329): Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was admitted from home after his wife fell and broke her hip. She was also admitted to the facility for rehab and shared a room with Resident #1. The admission note, documented by the DON (Director of Nursing) states, "...reports resident has been occ (occasionally incontinent of urine...Usual bowel pattern daily..Reports appetite good with no restrictions, has had difficulty marinating weight...Does have chronic back pain, used [MEDICATION NAME] PRN (as needed) at home for same...Likes to watch TV before going to bed...Tends to nap several hours a day. Likes sweets at HS (Hour of Sleep) as well..." The Initial MDS (Minimum Data Set) assessment dated [DATE] revealed: *Signs and symptoms of [MEDICAL CONDITION] such as inattention which comes and goes. *Resident says he has less energy and feeling tired. Having problems concentrating on things and being so fidgety or restless that he has to be moving around a lot more than usual. *Wandering occurred 4 to 6 days, but less than daily, which puts him at significant risk of getting to a potentially dangerous place and significantly intrudes on the privacy of others. *Activities that are very important is to be around pets, keep up with the news, go outside to get fresh air and participate in religious services. *Sometimes is understood and understands. *Ambulates independently and requires assistance of 1 staff for dressing, hygiene, and toilet use. Review of the Behavior symptom CAA (Care Area Assessment) indicated the following was addressed: *Triggered condition is wandering. Is this problem/need: Actual. Seriousness: Resident is immediate threat to self. *Nature of the behavior disturbance was left blank, nothing was checked/addressed. *Medication side effects that can cause behavioral symptoms was left blank, nothing was checked. *Hospital records indicate he was a smoker and was on a nicotine patch which could have affected his behavior. *Illness or conditions that can cause behavior problems. Constipation was checked. (This problem was not addressed until 5/29/14 when [MEDICATION NAME] (laxative) was ordered.) *Factors that can cause or exacerbate the behavior (from observation, interview, record). Sensory impairment, such as hearing or vision problems was the only box checked. *Cognitive status problems. Dementia was checked. *Other considerations such as the actions and responses of family members and caregivers can aggravate or even cause behavioral outbursts was left blank, nothing was checked. *Care Plan Considerations. Avoid complications and Minimize risk boxes were checked. *Describe impact of this problem/need on the resident and your rationale for care plan decision. "Will proceed to plan of care as resident has wandered throughout the facility and attempts to go outside." *Referral to other Disciplines. Nothing was documented. The CAA was completed by the SW (Social Worker) on 2/13/14. There was no comprehensive assessment to determine the underlying cause of Resident #1's behaviors identified in the MDS. Care Plan initiated on 2/11/14 includes, "I sometimes have behaviors which include walking out the front door and trying to catch a ride. I walk around the hallways with no real sense of where or what I want to be doing. Goals-My behavior will stop with staff intervention." There are no measurable objectives/goals. Interventions include, "Attempt interventions before my behaviors begin. Give me my medications as my doctor has ordered. Help me to avoid situations or people that are upsetting to me. Let my physician know if my behaviors are interfering with my daily living. Offer me something I like as a diversion. Please tell me what you are going to do before you begin." The care plan did not include specific interventions to use to prevent behaviors from occurring, no description of situations to avoid, and no specific things Resident #1 likes for diversions. On 2/7/14, Physician order [REDACTED]. Review of Resident #1's progress notes and care plans revealed no care plan was developed for the [MEDICATION NAME]. Therefore, there was no goal for the treatment. Review of Resident #1's Side Effects Monthly Flow Sheets and Progress Notes found that side effects of [MEDICATION NAME] were not being monitored. According to Nursing 2013 Drug Handbook side effects of [MEDICATION NAME] include, but are not limited to: *aggressiveness, agitation, anxiety, ataxia (lack of voluntary coordination of muscles), confusion, depression, dizziness, fatigue, hallucinations, headache, [MEDICAL CONDITION], pain, somnolence, [MEDICAL CONDITION] [MEDICAL CONDITION]. *anorexia, constipation, diarrhea, nausea, vomiting. *incontinence, urinary frequency, UTI. *Arthralgia (severe pain in the joint), back pain. *[MEDICAL CONDITION], coughing, shortness of breath, flu-like symptoms, pneumonia, upper respiratory tract infection. *rash. *abnormal gait, falls, injury. Resident #1 was also receiving [MEDICATION NAME] (an antidepressant) 20 mg every day. According to Nursing 2013 Drug Handbook, side effects of [MEDICATION NAME] include: *nervousness, anxiety, [MEDICAL CONDITION], dizziness, suicidal behavior, fatigue; *nausea, anorexia, impaired digestion, constipation, abdominal pain; *respiratory tract infection, cough, respiratory distress. Review of Resident #1's medical record including Progress Notes, physician progress notes [REDACTED]. ~2/26/14, Resident #1 fell in his room after sitting on a wheeled walker. ~3/2/14, Resident #1 was asking about wife's whereabouts frequently. "Relaxes when he sees her." ~3/3/14, Resident #1 was transferred to the ACU (Alzheimer's Care Unit) and an order for [REDACTED]. According to the Nursing 2013 Drug Handbook, [MEDICATION NAME] has side effects that include [MEDICAL CONDITION], agitation, dizziness, depression, visual disturbances, and abdominal discomfort. There was no care plan developed identifying the definition of what agitation was for Resident #1, and no development of nonpharmacological interventions to attempt prior to administering the [MEDICATION NAME]. There was also no care plan developed that addressed adjustment to life in the ACU and also living without his wife, who had been his primary caregiver. ~3/5/14, Resident #1 grabbed the shirt of another resident. [MEDICATION NAME] given at 12:32 p.m. for "restless, agitated, becoming aggressive" and 8:02 p.m. for "increased agitation" without evidence of nonpharmacological interventions attempted or attempts at trying to identify what might have triggered Resident #1's behaviors. ~3/6/14, Complained of stomach pain, offered toileting with no results. ~3/7/14, [MEDICATION NAME] given for "increased agitation" that was ineffective. 5 hours after receiving the medication, Resident #1 received a second dose after becoming agitated with signs of increased anxiety. No evidence of nonpharmacological interventions attempted and no evidence of an assessment of the agitation and aggression to determine root cause and to rule out remediable causes. ~3/7/14, physician progress notes [REDACTED]. He seems to be tolerating the [MEDICATION NAME] 5 mg p.o. b.i.d." ~3/8/14, Resident #1's wife was discharged to home. ~3/9/14, Resident #1's family visited and Resident #1 was calm. That same day at 1:44 p.m. and 7:36 p.m., Resident #1 received [MEDICATION NAME] for "agitation" and "restlessness and increased agitation" respectively. According to the Behavior Monitoring Flow Sheet, staff tried "one on one, activities, and redirect" that were "Effective," therefore the reason for administration of the [MEDICATION NAME] is not evident. There is no documented assessment to identify what might be triggering the resident's behaviors. There is no indication that staff considered the possibility that his behaviors might be related to anxiety or distress from being without his wife, who had been discharged home the previous day. ~3/10/14, "Resident became agitated, appears to be sudden change in mood. He was pacing back and forth at the kitchen area. CNA was in the kitchen with other residents playing trivia game. Resident #1 came up to the table where the CNA and residents were sitting. He was angry and yelled at the CNA making motion to hit her. Nurse did one on one with resident. He walked away and seemed fine. He had no other episodes like this throughout the shift...he does become frustrated when he is unable to find words and speak words properly..." [MEDICATION NAME] was given at this time despite the one-on-one supervision being successful. There was no assessment to identify what may have triggered Resident #1's anger. ~3/11/14, Resident #1 received [MEDICATION NAME] for "increased agitation." ~3/12/14, Resident #1 received [MEDICATION NAME] for "anxiety, weepiness." ~3/13/14, Resident #1 received [MEDICATION NAME] for "restless, continuous pacing." Resident #1 is up ad lib and can ambulate independently. There is no assessment demonstrating that Resident #1's actions were more than walking through the unit. ~3/14/14, Resident received [MEDICATION NAME] at 12:26 a.m. for "restless, continuous pacing." ~3/14/14, Resident #1 received [MEDICATION NAME] at 11:44 p.m. for "anxiety and restlessness. Was noted to be attempting to enter other resident's rooms." There was no evidence of nonpharmacological interventions being attempted prior to administration of the [MEDICATION NAME] and no documented assessment to identify what might be triggering the resident's behaviors. Of note, [MEDICAL CONDITION] is a side effect of [MEDICATION NAME]. ~3/16/14, Resident #1 received [MEDICATION NAME] at 12:44 p.m. for "increased agitation." ~3/16/14 at 4:30 p.m., Resident #1 was yelling at another resident and pounding on the dining room table. At 6:07 p.m., effectiveness is documented as "Unknown. Resident continous (sic) to pace, move furniture and is anxious, continue one on one, redirect." ~3/16/14 at 11:43 p.m. states, "Resident is pacing all shift. At one point he was attempting to pick imaginary things of (sic) the floor. He began to crawl on the floor saying this needs to get fixed. He kneeled on the floor and became slightly unbalanced and tipped to one side...he continued to attempt to kneel on the floor but staff was able to redirect him..." According to an interview with Resident #1's daughter, Resident #1 worked as a contractor; was always fixing things; staying busy. Even though the note indicates Resident #1 wanted to fix something on the floor, there was no evidence of an activity being offered to allow Resident #1 to continue a life long pattern. ~3/17/14, Resident #1 given [MEDICATION NAME] for "weepy with increased agitation." No evidence of nonpharmacological interventions. ~3/19/14, Resident #1 was seen by the NP who documented, "...While on the unit he has been somewhat agitated. He is weeping at times...I am concerned about this agitated behavior as well as the weeping that he is exhibiting. I am going to treat him with an antidepressant. I am going to start [MEDICATION NAME] 2.5 once daily for 2 weeks, then increase to 5 mg daily..." Monthly Behavior Flow Sheets did not reflect Resident #1 having difficulties with weeping. Progress Notes indicate weeping two times. Tearfulness or Weeping was not added as a target behavior to the Monthly Behavior Flow Sheets. In addition, Resident #1 was already receiving the antidepressant [MEDICATION NAME] ([MEDICATION NAME]). This would be considered duplicative therapy. (Refer to F329.) Review of Resident #2's care plan does not indicate the use of [MEDICATION NAME] on the care plan, therefore there is no goal to evaluate if the medication is effective or not and what nonpharmacological interventions should be tried. According to Nursing 2013 Drug Handbook, side effects of [MEDICATION NAME] include: *[MEDICAL CONDITION], dizziness, anxiety, confusion, delusions, impaired sleep quality, fatigue, [MEDICAL CONDITION]; *urinary frequency; *constipation, anorexia, abdominal pain. Under Nursing Considerations, it states, "Many patients experience a period of increased restlessness, including agitation, [MEDICAL CONDITION], and anxiety especially at start of therapy." The Side Effects monitoring form was not updated to include [MEDICATION NAME]. ~3/21/14, Resident #1 received [MEDICATION NAME] for "increased agitation." No evidence of nonpharmacological interventions. ~3/22/14, Resident #1 was found at 1:30 a.m. sitting on the floor in a puddle of urine. The Fall Assessment form did not address the possibility of side effects of [MEDICATION NAME] and [MEDICATION NAME]. There was no documentation indicating Resident #1 received any [MEDICATION NAME] on 3/22/14, 3/23/14. ~3/24/14, Resident #1 was seen by the NP who ordered scheduled [MEDICATION NAME] 0.5 mg twice a day in addition to the as-needed [MEDICATION NAME] 0.5 mg. ~3/25/14, Resident #1 entered another resident's room and was "bumped into the wall." ~3/26/14, Resident #1 was sent to the hospital with increased temperature and decreased oxygen saturation levels. Resident #1 was admitted to the hospital, and returned on 3/28/14. ~3/28/14, a Behavior Summary note states, "Pacing-restlessness, being agitated and fearful are all being monitored by staff...Not seeing anything consistent in report to warrant a trigger for behavior yet resident is still adjusting to being transferred to this wing. Flow sheet indicates that giving food or fluids or removing resident from environment are interventions that have been successful." Surveyor # reviewed the March Behavior Flow Sheets and noted the following: -27 instances of pacing/restlessness. Food and fluids were offered 1 time with improvement. -9 instances of agitation. Food and fluids were offered 2 times with improvement. There was no evidence that the Progress Notes were reviewed in order to provide a comprehensive review of Resident #10's medication use, lack of nonpharmacological interventions, possible side effects of the medications, or to determine a root cause/trigger of the behaviors. ~4/3/14, "NP updated re (regarding) resident's increased irritability, restlessness and requesting cigarette yesterday PM (afternoon). Staff reports that he is probably smoking when he goes out with spouse. Direction to continue to monitor and NP will review on...rounds." According to the Behavior Flow Sheets, Resident #1 has only had 1 episode of agitation from 3/22/14 through 4/3/14. On 4/3/14, day shift documented 1 episode of agitation, as-needed [MEDICATION NAME] was administered. ~4/3/14, per NP order on 3/19/14, Resident #1's [MEDICATION NAME] increased to 5 mg one time a day. Despite the addition and increase in the [MEDICATION NAME], along with [MEDICATION NAME], and [MEDICATION NAME], staff were only monitoring for a side effect of drowsy/dizzy/falls. ~4/4/14, Resident #1 was yelling at other residents in the dining room and was not easily directed with food, fluids, and toileting. ~4/5/14 at 8:00 a.m., Resident #1 sat on the edge of the bed yelling at someone only visible to him. He was redirected and laid back down. There was no evidence of an assessment being completed in order to determine if this was a side effect of Resident #1's medications. ~4/6/14, Resident #1 went out with spouse. From 4/6/14 through 4/9/14, Resident #1 had 1 documented episode of agitation with redirection providing improvement. ~4/9/14, Resident #1 was seen by the NP. The NP Progress Note states, "...He becomes quite agitated in the afternoon and especially agitated after he has been on an outing with his family. Staff do have a hard time calming him down and redirecting him after he has been out, but usually the afternoon is when he becomes the agitated...He wants to move around the unit. He does appear mildly agitated, some anxiety as well...I am going to increase the Lorazapam ([MEDICATION NAME]) to 0.5 mg tid (three times a day)..." With the NP order, Resident #1 will be receiving 1.5 mg per day. The standard of practice for [MEDICATION NAME] maximum dose for the elderly is 2 mg per day. There was no evidence that the facility assessed Resident #1's agitation/anxiety and/or restlessness to determine possible triggers, identify remediable causes, and review/revise the care plan to include individualized nonpharmacological interventions before increasing the [MEDICATION NAME] dose. ~4/12/14, "Resident observed having hallucinations this shift. Seen sitting on the edge of his bed talking to and petting his dog. Asked writer 'Isn't she a pretty dog? Also asked for some water and a hot dog for the dog. Staff observed him 'walking' his dog with his arm extended, mimicking a person holding onto a leash. Talking to the dog: 'slow down' and 'that's a good girl.'..." Of note, Resident #1 had been out with family prior to this entry. He would have seen his dog during his outing with family. ~4/14/14, Resident #1 was seen by the NP for abdominal pain. The NP ordered labs, but did not review medications to determine if the abdominal pain was related to the [MEDICATION NAME], or the increased usage of [MEDICATION NAME]. All of these medications have a side effect of stomach upset/abdominal pain. ~4/17/14, as-needed [MEDICATION NAME] 0.5 mg was given at 6:19 p.m., and was effective. With this administration, Resident #1 was at the top of the daily dosage for older adults. ~4/18/14, Resident #1 was seen by the physician. The physician progress notes [REDACTED]. The pharmacist questioned the need for both of them...He does use the [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg tid (three times a day) prn (as needed)...We will plan on discontinuing the [MEDICATION NAME]. Continue with the [MEDICATION NAME]" The documentation by the physician is inaccurate. The NP order for [MEDICATION NAME] is for 0.5 mg three times a day, and as-needed [MEDICATION NAME] 0.5 mg every 6 hours as needed. ~4/18/14, as-needed [MEDICATION NAME] was given for "pacing, getting too close to other residents, and pulling on wheelchairs and chairs." Behavior Flow Sheets do not document any behaviors and no nonpharmacological interventions attempted prior to administration of the [MEDICATION NAME]. ~4/22/14, indicate that [MEDICATION NAME] 0.5 mg was given at 12:47 a.m. for pacing and attempting to go into other resident rooms. There were no behaviors documented on the behavior monitoring log and no evidence of nonpharmacological interventions attempted prior to administration of the [MEDICATION NAME]. ~4/23/14, as-needed [MEDICATION NAME] was given at 3:37 p.m. for "anxious, pacing, pounding on window in kitchen. There is no progress note on that day. No behaviors documented on the behavior monitoring log and no evidence of nonpharmacological interventions attempted prior to administration of the [MEDICATION NAME]. ~4/27/14, "Resident was irritable and easily agitated...threatening towards peers, staff and visitors...redirected to a quiet area and brief one on one was provided and was effective...He has been pleasant, watching TV and walking about the unit..." ~4/30/14, as-needed [MEDICATION NAME] 0.5 mg was given at 12:44 a.m. for restlessness, inability to settle for sleep, and "wandering about unit." The behavior monitoring log indicates having episodes of restlessness, pacing and agitation. Interventions are 1:1, redirect and return to room which were either the same or ineffective. ~4/30/14, as-needed [MEDICATION NAME] was given at 3:55 p.m. for agitation. With this administration, Resident #1 received 2.5 mg, which is above the maximum dose for older adults. ~5/1/14 as-needed [MEDICATION NAME] was given at 12:08 a.m. and 5:44 p.m. Progress note dated 5/1/14 states, "Resident very agitated, swing fists at staff. Resident cursing at staff and other residents. PRN [MEDICATION NAME] was not effective." Behavior monitoring sheets indicate having behaviors of pacing, restlessness, tearful and agitation. Intervention was the [MEDICATION NAME]. This is a total of 2.5 mg in 24 hrs. which is over the maximum dose for the elderly. On 5/1/14 at 10:45 p.m., Resident had a fall with no injury. The Fall Investigation states Resident #1 reached down and was patting the floor before "seating himself on floor." Since Resident #1's admission on 2/4/14, there has been no assessment of Resident #1's behaviors to determine triggers, causative factors (physical, emotional, environmental, personal needs, mismatch in cognitive skills and activities/routines); develop individualized interventions including nonpharmacological interventions including a program of activities that meet his cognitive abilities and personal preferences/desires. There has also been no monitoring of the specific medications to determine if behaviors are more appropriately identified as side effects. ~5/4/14, as-needed [MEDICATION NAME] given for increased agitation at 8:33 a.m. The Behavior Monitoring Flow Sheet does not indicate any nonpharmacological interventions were attempted. It is documented as "9" which means "refer to nurse's notes." ~Progress Notes on 5/4/14 indicate Resident #1 was in a "foul mood." At 7:15 a.m., Resident #1 was holding a CNA by the arms and would not let go. "Able to redirect to come to dining room for morning coffee and let go of CNA." Resident #1 then started pacing the hall and dining room yelling. Staff stepped in between Resident #1 and other residents. The DON was notified. Resident #1 threw a bowl of cereal on the floor. Staff were able to direct Resident #1 into an empty room and calls were made to family and to police. During this time, Resident #1 continued to grab at the staff. The police arrived and Resident #1 struck out at the police officer and was handcuffed. At the same time, Resident #1's family arrived with his dog. Resident #1 began to calm and sat quietly petting the dog. Family took Resident #1 home for the day. He returned that afternoon and was quiet. Following the incident, there was, again, no assessment of Resident #1's behaviors, no identification of triggers, no identification of remediable causes including pain, and no individualized interventions. Review of Resident #1's care plan found no updates despite the escalation in Resident #1's behaviors. ~5/4/14 at 8:55 p.m., Resident #1 was found "tangled up" with another resident. Resident #1 was documented as calm. Despite that, police were called again. Family was also called and t

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who had not received antipsychotic medications were not given the medications and those residents who did receive them received gradual dose reduction, and behavioral interventions. This resulted in physical, mental and psychosocial declines to 2 of 13 residents (Residents #2 and #1) and created a finding of immediate jeopardy. 1. Resident #2 had a [DIAGNOSES REDACTED].#2 entered the facility after living independently at home. Resident #2 came into the facility walking without any type of assistive device, continent of bowel and bladder, and requiring limited assistance with ADLs (Activities of Daily Living). Prior to entering the facility, Resident #2 had never been on any type of psychoactive medication. After admission to the facility, Resident #2 developed distressing behaviors defined by the facility as anger, fighting, aggression toward others, pacing, combativeness, yelling, shouting, crying, weeping, agitation, restlessness, delusions, hallucinations, and attempting to elope. While the facility identified the behaviors, there was no indication the facility completed a comprehensive assessment of Resident #2's medical, physical, mental nor psychosocial status to determine underlying causes of Resident #2's distressing behaviors. There was no care plan implemented based on Resident #2's specific individual needs directing staff on how to manage Resident #2's behaviors to minimize and/or eliminate the behaviors in order to improve Resident #2's quality of life and well-being. Instead, over a period of less than 2 months, Resident #2 was also placed on multiple psychoactive medications including [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]. During the time the medications were being ordered and given, there was no indication the facility attemptednonpharmacological interventions based on Resident #2's individual needs prior to administering the medication, there were never any changes made to Resident #2's plan of care, and behaviors were not specifically identified nor quantified. Additionally, behavior monitoring sheets indicated Resident #2 had behaviors only for a period of for approximately the first 2 weeks after admission. During the time frame in which these multiple medications were being utilized, Resident #2 had a significant decline in overall functioning. There was no consideration on the part of the facility if the psychoactive medications were causing the decline in Resident #2's condition and/or making Resident #2's distressing behaviors worse. Lack of completing a comprehensive assessment to determine the root cause of Resident #2's distressing behaviors, including a comprehensive medication review and implementing an individualized care plan based on Resident #2's specific needs, led to a significant decline in Resident #2's overall functioning including physical functioning, psychosocial well-being, anorexia and weight loss, and falls. On 6/10/14, Resident #2 had a significant change in condition and clergy was called to administer last rites. 2. Resident #1 was receiving [MEDICATION NAME] twice a day. [MEDICATION NAME] is an Anti-Alzheimer medication used for moderate to severe Alzheimer's dementia which has numerous side effects including, but not limited to, aggressiveness, agitation, anxiety, confusion, depression, dizziness, fatigue, hallucinations, pain constipation, incontinence, dyspnea, pneumonia, upper respiratory tract infection and falls. The facility did not develop a care plan with measurable goals and/or interventions to monitor for side effects. There was no evidence that [MEDICATION NAME] was considered for the increased behaviors since this was the first new drug ordered. Resident #1 was receiving [MEDICATION NAME] (antipsychotic) medication for a [DIAGNOSES REDACTED]." Targeted behaviors being monitored did not include delusions. Resident #1 did have an altercation with another resident and staff that involved the police during 2 different episodes which initiated the [MEDICATION NAME]. The facility did not create or implement a care plan and nonpharmacological interventions in an attempt to manage the behavior sought to be treated by the [MEDICATION NAME]. The care plan had no measurable goals to evaluate the ongoing need for the medication. On 5/18/14, the order was increased without adequate indications to do so. There was no evidence that nonpharmacological interventions were put into place prior to increasing the dose. In addition, there was no evidence that the facility assessed for any physical underlying cause of the behavior. Resident #1 also had an order for [REDACTED]. The facility did not monitor to determine the frequency of episodes of anxiety, despite the frequent use of [MEDICATION NAME] prn. On 4/10/14, the order was increased without adequate indication. There was no evidence that nonpharmacological interventions were put into place prior to increasing the dose. In addition, there was no evidence that the facility assessed for any physical underlying cause of the behavior. Resident #1 received 2.5 mg (milligrams) on 4 separate days, which is an excessive dose for the elderly. Resident #1 also has an order for [REDACTED]. The plan of care does not address the use of antidepressant medication use and does not include nonpharmacological interventions in an attempt to manage behavior sought to be treated by the antidepressant. The care plan had no measurable goals to evaluate the ongoing need for the medication. The failure to provide person-centered care for residents with dementia instead of antipsychotic medication created a finding of immediate jeopardy. The immediate jeopardy began on 6/3/14. The NHA (Nursing Home Administrator) and RN Consultant were notified of the immediate jeopardy on 6/23/14 at 3:45 p.m. The immediate jeopardy was not removed by the exit date of the survey. In addition to residents in immediate jeopardy, the facility failed to ensure: ~2 of 13 residents receiving antipsychotic medications received gradual dose reductions, adequate indications for use, adequate monitoring, and did not receive excessive doses (Residents #3, and #4). ~1 of 13 sampled residents was free from unnecessary medications (antibiotics), when there was no indication for use. 3. Resident #3 was receiving [MEDICAL CONDITION] medication with no clear indication of its use, no justification, no behavior monitoring, no nonpharmacological individualized interventions in place prior to administration of the medication, and no underlying medical cause was assessed prior to administering a [MEDICAL CONDITION] medication such as pain. 4. For Resident #4: ~A request for a GDR (gradual dose reduction) of Resident #4's [MEDICATION NAME] was declined by the physician without evidence that the GDR would be clinically contraindicated; ~The dosage of [MEDICATION NAME] was increased without adequate indications; ~After a GDR of [MEDICATION NAME] was attempted, Resident #4 had an altercation with a peer. The dose was immediately increased back to the original dose without any nonpharmacological interventions attempted; ~Resident #4 continues to receive [MEDICATION NAME] at an excessive dose for elderly residents without adequate indications. 5. Resident #11 received 3 courses of antibiotics without adequate indications for use. This is evidenced by: Example #1 (also cross reference F309): According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an antipsychotic medication and used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Adverse reactions include, sleepiness, dizziness, [DIAGNOSES REDACTED], abnormal gait, personality disorder, tardive dyskinesia, fever, orthostatic [MEDICAL CONDITION] (low blood pressure when standing), urinary incontinence, rigidity, sweating. Overdose signs and symptoms included, agitation, aggressiveness, reduced level of consciousness, [MEDICAL CONDITION], [DIAGNOSES REDACTED], hypertension (high blood pressure) or [MEDICAL CONDITION] (low blood pressure). The "Nursing 2013 Drug Handbook" indicated, "...Black Box Warning Drug may increase risk of cardiovascular or infection-related death in elderly patients with dementia...isn't approved to treat patients with dementia-related [MEDICAL CONDITION]" According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an anxiolytic and used to treat anxiety. Adverse reactions include drowsiness, sedation, agitation, dizziness, weakness, unsteadiness, [MEDICAL CONDITION], nausea, change in appetite. Overdose signs and symptoms include drowsiness, confusion, lethargy, ataxia (balance problems), [MEDICAL CONDITION], coma, death. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an anxiolytic and used to treat anxiety and panic disorders. Adverse reactions include [MEDICAL CONDITION], irritability, dizziness, anxiety, confusion, drowsiness, sleepiness, impaired coordination, ataxia, lethargy, restlessness, agitation, nightmare, [MEDICAL CONDITIONS], nausea, increased or decreased appetite, anorexia, increased sweating, and feeling warm. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an antidepressant and used to treat depression. Adverse reactions include, sleepiness, orthostatic [MEDICAL CONDITION], anorexia, anxiety, agitation, dizziness, confusion, and fever. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an antidepressant. Adverse reactions include sleepiness, dizziness, abnormal thinking, and confusion. According to the "Nursing 2013 Drug Handbook," [MEDICATION NAME] is an anticonvulsant medication and used to treat [MEDICAL CONDITION] and panic disorders. Adverse reactions include drowsiness, agitation, ataxia, behavioral disturbances, confusion, anorexia, and changes in appetite. All of the above drugs, with the exception of [MEDICATION NAME], can cause anorexia, [MEDICAL CONDITION], and agitation. Resident #2's admitting [DIAGNOSES REDACTED]. Resident #2's admission MDS (Minimum Data Set) dated 12/23/13 indicated Resident #2: ~ Was able to make self understood and usually understood verbal content; ~ Had a BIMS (Brief Interview for Mental Status) score of 1, indicating a severe cognitive impairment; ~ Had [MEDICAL CONDITION] including inattention, and disorganized thinking which did not fluctuate; ~ Had no mood indicators; ~ Had verbal behavior symptoms 1 to 3 days; ~ Walked independently with supervision; ~ Required limited staff assistance with bathing, dressing, grooming, and using the toilet; ~ Frequently incontinent (of notation Resident #2's admission 3-day bladder log dated 12/16/13 through 12/18/13 indicated Resident #2 had 1 incontinent episode over the 3-day period); ~ Had no pain or falls; and ~ Weighed 144 pounds. Resident #2's most current MDS was dated 3/25/14 and showed a significant decline in his condition. Specifically, the MDS indicated Resident #2: ~ Was usually understood and sometimes understands; ~ Had a BIMS score of 0, indicating a severe cognitive impairment; ~ Had symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking which did fluctuate; ~ Had 3 mood indicators; ~ Rejected care, wandered, ~ Walked with supervision; ~ Required limited to extensive for bathing, dressing, grooming, eating, and using the bathroom; ~ Was frequently incontinent; ~ Had 3 falls; and ~ Weighed 120 pounds. Observations made by Surveyor # and # during the course of the survey indicated Resident #2 had a further decline in overall functioning from March to June 2014. Resident #2 now requires extensive assistance of 1 to 2 staff persons for all aspects of care, including walking, has had numerous falls, and has had continued weight loss. (Refer to F274.) Resident #2's most current CAA (Care Area Assessment) for behavior was dated 12/17/13. Several components of the CAA are incomplete including "Nature of the behavior...Medication side effects...Illness or conditions that can cause behavior...Factors that can cause or exacerbate the behavior..." The CAA indicated, "... resident has verbal symptoms directed at others... Resident is a new admission...displayed verbal aggression towards others with recent placement...new orders for additional anti-anxiety medications, family...comes to facility when aggressive behavior displayed...Staff has discovered watching church videos are calming...bathing appears to calm resident...Will proceed to care plan to minimize risk and continue with interventions to calm resident at times of increased anxiety..." The CAA did not clinically assess nor critically analyze Resident #2's behaviors. Resident #2's behavior care plan was dated 12/16/13. The care plan indicated Resident #2 had behaviors of yelling, shouting, crying, agitation, combativeness, aggression, restlessness, and anger. The care plan had the following approaches: ~ 12/16/13, "...Assist me to watch church video...Attempt interventions before my behaviors begin...Do not seat me around others who disturb me...Give me medications my doctor has ordered...Help me maintain my favorite place to sit...Help me avoid situations or people that are upsetting to me...may call family to assist in redirection...Let my physician know...if my behaviors are interfering with my daily living...Make sure I am not in pain...Offer me something I like as a diversion...tell me what you are going to do before you begin...Reduce external stimuli as possible, speak in gentle, calm, soft but firm voice..." ~ 12/18/13, "...may bath to assist with calming..." ~ 1/2/14, "...Administer medications as ordered..." ~ 1/31/13, "...Monitor for s/sx (signs and symptoms) of anxiety towards others and attempt redirection..." None of the above interventions, with the exception of 2, are individualized based on Resident #2's specific needs. Surveyor # completed a review of a facility form titled "Social History". Resident #2's "Social History" was not dated. It indicated Resident #2 worked on a farm and worked as a painter, liked watching TV, bingo, gardening, and being out in the sun. The "Social History" did not include Resident #2's prior life patterns and preferences, and customary responses to things such as stress, anxiety, pain, hunger, and fatigue. The "Social History" did not include information obtained by Resident #2's family regarding how they managed Resident #2's responses to stressors while at home. The "Social History" also did not include Resident #2's life's pleasures. Surveyor # completed a review of a hospital record dated 12/16/13 and titled "Discharge Summary." The "Discharge Summary" indicated Resident #2 lived at home. The "Discharge Summary" indicated Resident #2 was taken to the hospital after found wandering outside in the early morning hours. The "Discharge Summary" indicated, "...had several episodes, during this admission, where he seemed to be remembering events from the Korean War. At times, he would get somewhat emotional...On several occasions he did become a little agitated and he did make an attempt to leave the hospital...They found that if they walked him around and kept him busy, that he did better. Additionally, if he would sit with staff members, he did much better...he did [MEDICATION NAME] (antianxiety medication)[MEDICATION NAME] (antipsychotic medication) order which he did not require..." The "Nursing Section" of the hospital discharge records indicated, "...enjoys sitting where there are people around. Needs supervision at all times. Continent bowel/bladder...No behaviors or agitation while hospitalized the last few days. Likes to be kept busy..." The facility did not capture the information regarding Resident #2 being a war veteran including flash backs from the war. There was no care planned direction to staff on how to manage Resident #2's flash backs. Surveyor # completed a review of Resident #2's medication regimen. Dates the medications were started and/or changed are as follows. All drugs are noted in milligrams (mg). [MEDICATION NAME] 12/16/13 2.5 mg every day as needed. 12/28/13 2.5 mg every day. 12/30/13 2.5 mg twice a day. 1/12/14 5.0 mg twice a day. 2/7/14 10 mg every day. 5/28/14 7.5 mg every day. 6/2/14 10 mg every day. 6/4/14 7.5 mg every day for one week. 6/12/14 5 mg every day. (Of note, surveyors entered the facility on 6/3/14 to begin the investigation.) [MEDICATION NAME] 12/16/13 0.5 mg twice a day as needed. 12/19/13 0.5 mg every 4 hours as needed. 12/23/13 0.5 mg three times a day. On 12/30/13 the [MEDICATION NAME] was discontinued. [MEDICATION NAME] 1/3/14 0.5 mg three times a day as needed. 1/10/14 0.5 mg every day at bed time. Both doses of [MEDICATION NAME] were discontinued on 2/12/14. [MEDICATION NAME] 2/3/14 2.5 mg every day. 2/24/14 5.0 mg every day. This was the dose at the time of the survey. [MEDICATION NAME] 2/26/14 7.5 mg every day at bedtime. 3/19/14 15 mg every day at bedtime. 6/4/14 7.5 mg every day at bedtime. This was the dose at the time of the survey, which started 6/3/14. [MEDICATION NAME] 2/12/14 0.5 mg twice a day. This was discontinued on 3/10/14. 2/12/14 0.5 mg every day as needed. This was discontinued on 3/10/14. 3/10/14 0.5mg three times a day as needed. This was the dose at the time of the survey, which started 6/3/14. From 12/16/13 through 2/12/14, all of the above medications were started with the exception of [MEDICATION NAME]. This was a period of less than 2 months. According to facility records, [MEDICATION NAME] was started in an attempt to improve Resident #2's appetite. The facility utilized a form titled "Behavior Monthly Flow Sheet." Surveyor # completed a review of Resident #2's "Behavior Monthly Flowsheets" and noted the following: ~ December 2013. From the date of admission through 12/24/13, there were no behaviors documented. From 12/25/13 through 12/30/13, there were daily behaviors documented. Targeted behaviors were noted as "agitation," "pacing," and "striking out." The behaviors were not quantified. Documentation for the night shift was blank on all days. ~ January 2014. From 1/1/14 through 1/7/14, the form is blank. From 1/8/14 through 1/13/14, Resident #2 had 7 episodes of behavior documented. Documentation on the night shift was blank for the entire month. Targeted behaviors were noted as "angry," "danger to others," and "fighting." The behaviors were not quantified. ~ February 2014. From 2/1/14 through 2/28/14, Resident #2 had 23 episodes of behavior documented. Documentation on the day and evening shifts was not consistently completed. There was no night documentation for the entire month. Targeted behaviors were noted as "angry," "danger to others," and "fighting." The behaviors were not quantified. ~ March 2014. From 3/1/14 through 3/31/14, Resident #2 had 3 episodes of behavior documented. Targeted behaviors were noted as "angry," "fighting," and "danger to others." Documentation on the day and evening shifts was not consistently completed. There was no night documentation for the entire month. The behaviors were not quantified. ~ April 2014. From 4/1/14 through 4/30/14, there were no episodes of behavior documented. Targeted behaviors were noted as "angry," "fighting," and "danger to others." Documentation again on the day and evening shift was not consistently completed and there was no night documentation the entire month. ~ May 2014. From 5/1/14 through 5/31/14, there were no episodes of behavior documented. Targeted behaviors were noted as "angry," "fighting," danger to others." Documentation again on the day and evening shift was not consistently completed and there was no night documentation the entire month. Surveyor # completed a review of a facility form titled "Side Effects Monthly Flow Sheet." The form directed the user to code a multitude of side effects including [MEDICAL CONDITION], drowsiness, increased falls, anxiety, agitation, sweating, weakness, weight change, confusion, [MEDICAL CONDITION]. Surveyor # completed a review of Resident #2's "Side Effects Monthly Flow Sheet" from 12/16/13 through 6/5/14 except January 2014 flow sheet. January 2014 flow sheet was not received by Surveyor # . The "Side Effects Monthly Flow Sheet" indicated for all months reviewed, Resident #2 had indicators of potential side effects on only 2 occasions, both noted as drowsiness. None of the months reviewed were consistently completed on the day and evening shift. There was no night shift documentation during any month reviewed. Surveyor # completed a review of Resident #2's nursing notes and MARs (Medication Administration Records) and noted the following: On 12/16/13 a nursing note indicated Resident #2 had been admitted to the facility. The nursing note indicated, ."..Smiling & (and) pleasant...family reports appetite very good...ambulates independently & has had no recent falls per family...Requires set-up & cues by staff for all ADLs (Activities of Daily Living)..." According to the MAR, on 12/16/13, Resident #2 received [MEDICATION NAME] 0.5 mg once. There was no indication for why, and no indication if nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. On 12/17/13, a nursing note indicated, "...doing well with his new environment...had one episode of crying during lunch was given a PRN (as needed)..." According to the MAR, on 12/17/13, Resident #2 received [MEDICATION NAME] 0.5 mg once. According to the nursing notes, [MEDICATION NAME] was given for a one-time episode of crying. There was no indication that nonpharmacological interventions were attempted prior to administering the [MEDICATION NAME]. On 12/18/13, there were no nursing notes. According to the MAR, Resident #2 was given 2 doses of [MEDICATION NAME]. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. On 12/19/13, a nursing note indicated, "...very restless, agitated, angry. Attempting to strike another resident. Yelling out at resident...pacing, shaking fists...Stated that he was going to 'pop him in his jaw'...Redirection...No intervention effective...call placed to Dr (doctor)...about increasing prn (as needed) [MEDICATION NAME] agitated raising voice, entering into other resident's personal space...express concern about (sic) furnace not working (sic)..." There was no indication the facility attempted to determine why Resident #2 became so upset with another resident or why Resident #2 felt the furnace needed to be fixed. There were no new interventions added to Resident #2's plan of care to remove the stressors causing Resident #2's agitation. Instead, the facility obtained an order to increase Resident #2's [MEDICATION NAME]. Resident #2 had a significant change in his demeanor since admission. There was no indication the facility completed a comprehensive clinical assessment to determine what the causative factors were, including reviewing the new medication, [MEDICATION NAME], which Resident #2 had been placed on. According to the MAR, on 12/19/13, Resident #2 received 2 doses of [MEDICATION NAME]. Nursing notes continue: ~ 12/20/13, "...doing well so far this shift, daughter was here...during breakfast...received PRN [MEDICATION NAME] this am...shown behaviors such as raising voice to staff and trying to leave the unit...has been agitated most of the second half of the shift...PRN [MEDICATION NAME] given...Interventions were mostly not effective..." On 12/20/13, Resident #2 received 3 doses of [MEDICATION NAME]. Resident #2 was receiving increasing doses of [MEDICATION NAME]. There was no indication the facility completed a comprehensive clinical assessment to determine the underlying causes of Resident #2's continued behaviors, and implemented specific individualized approaches to direct staff on how to manage Resident #2's behaviors. Nursing notes continue: ~ 12/21/13, "...Had very minimal outbursts...weepy in the TV room..." According to Resident #2's MAR, on 12/21/13, Resident #2 received 3 doses of [MEDICATION NAME]. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. Nursing notes continue: ~ 12/22/13, "...was given PRN at 0530 (5:30 a.m.) for increased agitation...removed cable cord from his TV and placed TV in the bathroom...pacing...agitated...trying to go home...given PRN..." According to Resident #2's MAR, on 12/22/13, Resident #2 received 3 doses of [MEDICATION NAME]. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. There was no indication the facility attempted to determine the causes of Resident #2's behaviors. Nursing notes continue: ~ 12/23/13, "...Has been given prn [MEDICATION NAME] while awake...has not had any prolonged episodes of agitation. Singing this am during breakfast, became weepy at times...Dr...informed that resident has used PRN [MEDICATION NAME] frequently since admission. New order received to schedule [MEDICATION NAME] 0.5 mg po (orally) TID (three times a day), continue PRN order..." Resident #2 had been in the facility for 1 week. In 1 week's time, Resident #2's medication was increased twice without first analyzing the triggers to determine the cause of Resident #2's behaviors. There were no new interventions added to Resident #2's care plan. According to Resident #2's MAR, on 12/23/13, Resident #2 received 3 doses of [MEDICATION NAME]. Nursing notes continue: ~ 12/24/13, "...wandering...refused to eat supper..." According to Resident #2's MAR, Resident #2 received 5 doses of [MEDICATION NAME] to equal 2.5 mg. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. Nursing notes continue: ~ 12/25/13, "...somewhat anxious and restless...Did medicate with prn [MEDICATION NAME]. [MEDICATION NAME] was ineffective during the noc (night)..." According to Resident #2's MAR, on 12/25/13, Resident #2 received 6 doses of [MEDICATION NAME] to equal 3.0 mg. This exceeds the recommended per-day dosage for the elderly. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. Nursing notes continue: ~ 12/26/13, "...Has been pleasant of mood...stated that he plan to leave for 'home' later today causing disruption among a few residents...anxious and restless on and off most of the shift. Two episodes of weeping. Wandering and unsettled...No aggressive behaviors to note..." According to Resident #2's MAR, on 12/26/13, Resident #2 received 4 doses of [MEDICATION NAME] to equal 2.0 mg. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. Nursing notes continue: ~ 12/27/13, "...restless...pacing...stating that he has to do something, he has to leave...Prn [MEDICATION NAME] given...Resident talking to people not there. Unable to redirect conversation..." According to Resident #2's MAR, on 12/27/13, Resident #2 received 5 doses of [MEDICATION NAME] to equal 2.5 mg. There was no indication why and no indication that nonpharmacological interventions were attempted prior to administering [MEDICATION NAME]. In addition to Resident #2's significant change in behavior, Resident #2 was hallucinating. There was no indication the facility completed a comprehensive assessment to determine the potential cause of Resident #2's hallucinations. According to the Long-Term Care Facility Resident Assessment Instrument Manual Version 3.0, potential indicators of [MEDICAL CONDITION] include hallucinations and/or delusions. Hallucinations and/or delusions could be due to [MEDICAL CONDITION] typically caused by an acute treatable illness, infection, or reaction to medications. Nursing notes continue: ~ 12/28/13, "Fax sent to Dr...concerning increase in agitation and medication changes made since hospitalization ...received...orders for [MEDICATION NAME] 2.5 mg daily and DC (Discontinue) scheduled dose of [MEDICATION NAME] making noise in room...discovered that he had thrown things in his room all over the room...stated when asked if he knew how the room came to be disrupted, that 'someone had come in and messed it up'...This is the second time this Resident has been disruptive on the unit since his admit...talking to people not there. Thought his chair in room was a little girl and yelled at it because it did not respond to him...yelling at another resident in the dining room...appeared to be angry...pacing...attempts made to redirect...Interventions attempted were not effective. Family was called to come in..." Resident #2 continued with symptoms of [MEDICAL CONDITION]. Additionally behaviors were escalating and the facility called the family. Despite this, there was no comprehensive assessment completed to determine underlying causes of the [MEDICAL CONDITION] and increasing behaviors. The facility's response was to obtain order for another medication, [MEDICATION NAME]. According to Resident #2's MAR, on 12/28/13, Resident #2 received 3 doses of [MEDICATION NAME]. Nursing notes continue: ~ 12/29/13, "...Refused lunch...starting to pace the hallway, walking up to doors and testing out the door knobs. Able to redirect for approx (approximately) 45 min (minutes)...then starting to get slightly resistive with redirection. Talking about the 'lady who fell and does she need help.' Unable to redirect with this subject. Family called...Son...will be in shortly...started becoming tearful and then inconsolable...Daughter came to facility..." According to Resident #2's MAR, on 12/29/13, Resident #2 received no [MEDICATION NAME] and 1 dose of [MEDICATION NAME] 2.5 mg. Nursing notes continue: ~ 12/30/13, "...restless...trying to leave unit via the fire exit door and banging the windows of the lunch room. When he was redirected by staff he became increasingly restless and disruptive to other residents. Family was called...agitated...calling out, pacing, moving furniture. Very difficult to redirect...Daughter...contacted and came in...New orders received to increase [MEDICATION NAME] to 2.5 mg BID (twice a day) and d/c (discontinue) [MEDICATION NAME] ([MEDICATION NAME])...seen by NP (Nurse Practitioner)...New order received for [MEDICATION NAME] 2.56 (sic) PRN once in 24 hours for agitation/aggressive behaviors...resident continues with pacing, talking to people not there, wanting to go to work, wanting to go home..." According to Resident #2's MAR, on 12/30/13, Resident #2 received 2 doses of [MEDICATION NAME], (prior to the [MEDICATION NAME] being discontinued) and 2 doses of [MEDICATION NAME]. Resident #2's behaviors continued to escalate. Resident #2 also continued to show symptoms of [MEDICAL CONDITION]. Despite this, there was no comprehensive clinical assessment of Resident #2's condition to determine underling causes, there was no determination of what triggered Resident #2's behaviors, and there were no changes made to Resident #2's plan of care to direct staff on how to manage Resident #2's behaviors. The facility's response was again to obtain orders for more medication. Resident #2 had been in the facility for 16 days. During that period of time, Resident #2's [MEDICATION NAME] was changed 4 times, including the order to discontinue it. Within a 48 hour time frame, Resident #2's [MEDICATION NAME] was ordered and increased twice. Nursing notes continue:

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who had not received antipsychotic medications were not given the medications and those residents who did receive them received gradual dose reduction, and behavioral interventions. This resulted in physical, mental and psychosocial declines to 2 of 13 residents (Residents #2 and #1) and created a finding of immediate jeopardy. The failure to provide person-centered care for residents with dementia instead of antipsychotic medication created a finding of immediate jeopardy. The immediate jeopardy began on 6/3/14. The NHA (Nursing Home Administrator) and RN Consultant were notified of the immediate jeopardy on 6/23/14 at 3:45 p.m. The immediate jeopardy was removed on 7/3/14, but noncompliance remains at the lower scope and severity level of E (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility needs to fully implement their plan throughout the facility. This is evidenced by: On 7/9/14, surveyor # verified that the facility had removed the jeopardy at F329 on 7/3/14. The immediate jeopardy was removed when the facility: 1. Completed in-depth psychosocial assessments including residents likes and dislikes, decription of behaivors, identify triggers for the behaviors, and develop individualized person-centered care plans on residents in the ACU (Alzheimer's Care Unit); 2. Completed comprehensive clinical assessments on residents in the ACU to identify medical symptoms that may be triggering behaviors; 3. Updated ACU residents' behavior monitoring flow sheets with specific targeted behaviors; 4. Updated ACU care plans updated with resident specfic behaviors, interventions, and medications; 5. Educated all nursing staff on effective use of the behavior monitoring sheets; and, 6. Educated all staff on principles of care of persons with dementia; The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/pattern) as the facility needs to fully implement its action plan. Additionally, surveyor # discovered during record review that facility staff had given PRN doses of [MEDICATION NAME] to Resident #12 on 7/2/14, 7/4/14, 7/5/14, 7/6/14, and 7/7/14 without first attempting nonpharmacological approaches to help relieve her anxiety and distress.

Based on observation, interview, and record review, the facility did not ensure that 3 of 7 sampled residents reviewed for catheters and bladder incontinence, received proper assessment, appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. Resident #3 had an indwelling catheter inserted at the emergency roiagnom on [DATE] and was sent back to the facility with orders to remove the catheter in 2 weeks (5/25/14), push fluids and monitor urine output. The indwelling catheter was removed on 5/29/14, 4 days late. Following removal, there was no bladder assessment or clinical monitoring. On 6/3/14, the catheter was reinserted after a family member identified abdominal distention to the facility. There was no intakes recorded or consistent urine output documented per physician orders. Resident #3 now has a urinary tract infection and is being treated with an antibiotic. Resident #4 has a [DIAGNOSES REDACTED]. The facility initiated a voiding pattern data collection tool and bladder assessment at the time of Resident #4's admission to the facility. The data collection is incomplete and indicates Resident #4 did not ask to use the bathroom and there was no evidence that he was assisted to use the bathroom. Resident #4 has had a number of falls related to his bladder incontinence. Resident #7 was to be assisted with incontinence care every 2 to 3 hours. Resident #7 also had a history of [REDACTED]. On 6/3/14, Resident #7 was not assisted with incontinence care for at least 6 hours and 30 minutes, at which point Resident #7's adult brief was noted to be saturated with both urine and stool. This is evidence by: Example #1: Resident #3 has [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 3/22/14, indicated Resident #3 is severely cognitively impaired, frequently incontinent and requires extensive assistance of one staff for toilet use. Resident #3's physician orders [REDACTED]. This medication is for pain. According to 2013 Nursing Drug Handbook a side effect of [MEDICATION NAME] is [MEDICAL CONDITION]. A nursing note, dated 5/9/14, indicated Resident #3's wife reported yesterday that resident is not himself. Staff were to attempt to obtain a temperature and urine specimen. There was no follow-up documentation to the 5/9/14 entry. A progress note, dated 5/11/14, indicated resident was discovered kneeling on the floor in the hallway. Resident had a urinalysis done and facility is waiting for the results. Resident has frequency and urgency. Under assessment, the nurse documented that he has been very dizzy with very recent poor balance. The evening shift nurse documented on 5/11/14, that Resident #3's wife was visiting most of the day and thinks he should go to the emergency room because Resident #3 had not voided today and his abdomen is distended. The nurse documented abdomen slightly distended but soft and he has been more confused the last 2-3 days with unsteady gait. The physician was consulted with new orders to obtain a urine specimen for urinalysis with culture and sensitivity, may catheterize or obtain clean catch. RN-FF (Registered Nurse) straight cath (catheterized) Resident #3 with no return of urine. According to Fundamentals of Nursing, "...Insert the catheter steadily about 20 cm (8 in) or until urine begins to flow." (Rational, if no urine return, the catheter is not in far enough.) It should be noted that Resident #3 is not circumcised, therefore the staff would have to pull down the foreskin to clean the meatus and straight cath for urine, then pull the foreskin back into place. On 5/11/14, RN-FF documented that at 7:30 p.m., she was notified by the staff that Resident #3 foreskin is not covering head of penis and the head of the penis is swollen. Staff and writer unable to bring foreskin back into proper position covering head of penis. Resident is having discomfort. RN-FF updated the physician on the foreskin position and that resident has not voided the last 16 hours per wife and staff's failure to obtain urine via catheter. Received new orders to send resident to ER. RN-FF documented that she was updated by the physician at 9:00 p.m. that the emergency room obtained 500 cc of urine when he was catheterized. He will return with a Foley catheter in place and to keep in for 2 weeks until the swelling resolved. Instructions were given not to pull foreskin back until swelling is resolved. *Review of the Emergency Department note indicated the facility reported foreskin was trapped around the base of the glans of the penis, unable to reduce. The facility performed a straight catheterization and no urine came out. By the time the staff at the nursing home tried to reduce the foreskin back over the glans of the penis, they were unable to get it over the glans of the penis as the glans of the penis had become quite [MEDICAL CONDITION] (swollen) and [DIAGNOSES REDACTED]tous (inflamed). He subsequently presents here for attempted reduction of the foreskin. A bladder scan was performed in the emergency room with revealed almost 800 cc of urine. Impression: [MEDICAL CONDITION] with swollen glans of the penis. Plan: Foley catheter will be kept in place for 2 weeks. This was reviewed with the staff at Golden Living Center's Golden Age. Push fluids and monitor urine output. An entry on 5/12/14, indicated the NP reviewed the urinalysis results and Resident #3 was negative for urinary tract infection. Surveyor # requested all of Resident #3's Intakes and Outputs during the two weeks (5/11/14 through 5/25/14). Surveyor # received no fluid intakes. Outputs were hand documented on a pink sheet of paper with no indication where the outputs came from. Surveyor # asked the DON (Director of Nurses) where did the outputs come from. The DON stated the nurses obtained the information from the nursing notes. Review of the pink sheet of paper indicated: ~No outputs on the day shift on 5/12/14, 5/15/14, 5/16/14, 5/20/14, 5/26/14; ~No outputs on the evening shift on 5/12/14, 5/15/14, 5/16/14, 5/18/14, 5/20/14, 5/21/14, 5/22/14, 5/26/14; ~No outputs on the night shift 5/12/14, 5/15/14, 5/16/14, 5/17/14, 5/20/14, 5/21/14, 5/22/14, 5/24/14, 5/25/14, 5/27/14. Review of the medication/treatment/nurse's notes indicated the indwelling catheter was to be removed on 5/25/14. The NP (Nurse Practitioner) wrote an order for [REDACTED]. On 6/5/14 at 2:45 p.m., Surveyor # asked the DON why the catheter wasn't discontinued in 14 days per the physician order. The DON stated, "I think it was on the holiday weekend and we decided it could wait." When asked who she was referring to as "we," the DON stated, "I meant me." The DON stated she talked with the NP about discontinuing the catheter on 5/29/14. Surveyor # informed the DON that Surveyor # saw this order written on 5/28/14. Review of Resident #3's nursing notes from 5/29/14 (catheter was removed) to 6/3/14 (catheter was reinserted), do not indicate any type of bladder assessment and/or monitoring of urinary status, only a "Care Tracker" indicating how many times a person is incontinent/continent. There was no documentation of any intakes or outputs during this time. This information would be critical in monitoring for [MEDICAL CONDITION]. On 6/4/14 at 12:45 p.m., Surveyor # requested Resident #3's bladder assessment when the indwelling catheter was removed. The DON provided an incomplete bowel/bladder assessment dated [DATE]. There was no bladder assessment completed after the indwelling catheter was removed. The DON stated, "I guess we should have done one." On 6/3/14 at 8:45 p.m., Surveyor # observed family reporting to the nurse that Resident #3 had urinary distention. With the assistance of the family member, RN-EE inserted an indwelling Foley catheter in Resident #3. Review of the documentation by RN-EE stated Resident #3 had abdominal distention. RN-EE received an order to reinsert the catheter. RN-EE did not document what the output was or if she had any difficulty with the insertion. The physician also ordered that a urinalysis be done. Surveyor # spoke with Resident #3's daughter-in-law who stated she was present and assisted with the catheter insertion and the nurse obtained 1100 cc urine. Resident #3's daughter-in-law stated that Resident #3 had [MEDICAL CONDITION] a couple of weeks ago and did not think the facility was monitoring any intake and outputs to determine if there was any further concerns with urinary output. On 6/4/14, physician ordered to administer Bactrim DS (double strength) 800/160 mg (milligram) one tablet twice a day for UTI (urinary tract infection) for 7 days. Example #2: Resident #4 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is the enlargement of the prostate gland which compresses the urethra and impedes urine flow from the bladder (urine retention). This leads to a person needing to urinate frequently and with urgency. Resident #4's MDS assessments, dated 11/28/13 and 2/28/14, both indicate Resident #4 is frequently incontinent of bladder and is not on a toileting program. Resident #4's care plan, dated 3/14/14, includes a problem of "Alteration in elimination of bowel and bladder..frequent functional and urge bladder incontinence r/t (related to) cognition with dx (diagnosis) of Alzheimer's dementia, [MEDICAL CONDITION]" initiated 11/21/13. Approaches all dated 11/21/13 include: "...Evaluate frequency/timing of incontinence episodes, noted to be frequently incontinent of bladder, does not always use toilet for elimination...Prompt and assist to toilet q (every) 1 1/2 to 2 hrs (hours) while awake as resident is not aware of appropriate time or place for elimination...Provide assistance of one with toileting needs, usually responds to prompting and assistance without difficulty...Use of pull ups for incontinence protection..." This plan was developed before the voiding pattern data collection period was completed. On 11/22/13, the facility began the "Incontinence Tracking: Day #1" form. The instructions say, "Hourly Check (6 am - 9 pm). Offer toileting every two hours if unable to communicate needs." The form indicated Resident #4 was "Dry" 7 of the 9 hours documented, and "Incontinent" the other 2 hours. Staff are to document if Resident #4 was toileted by circling either Y for yes or N for no. These were left blank. On 11/23/13, "Incontinence Tracking Day #2" form was started. The instructions for Day 2 state, "Prompt to void every hour (6 am - 9 pm). Greet resident. Wait 5 seconds for the resident to self-initiate request to toilet. Offer toileting every hour." The form indicated Resident #4 was "Dry" 12 times, "Incontinent" 2 times. 2 hours were not documented. Resident #4 voided 2 times, however there was no indication that he was prompted every hour to use the bathroom. Staff are to indicate if Resident #4 accepted the prompt to void or if he refused. These were left blank. On 11/24/13, "Incontinence Tracking Day #3" form was started. The instructions for Day 3 state, "Prompt void every 2 hours for 24 hours. Greet resident. Wait 5 seconds for the resident to self-initiate request to toilet." The form indicated Resident #4 was "Dry" 14 times and "Incontinent" 9 times. 1 hour was not documented. Again, staff did not document if Resident #4 was prompted to void every 2 hours, however there was documentation that he voided 3 times in the 24-hour period. By not consistently offering and/or documenting toileting activities, the evaluator cannot accurately determine an individualized program to assist Resident #4 in restoring as much normal bladder function as possible. On 6/5/14, Surveyor # spoke with the DON about the bladder assessments. The DON indicated it is her expectation that staff assist residents to the bathroom. Surveyor # asked if staff should wait for residents cognitive impairments to request to use the bathroom. The DON stated staff should not wait, they should be prompting the resident to use the bathroom. The DON indicated staff should be documenting this in "Care Tracker." Surveyor # requested a copy of Resident #4's bladder activity from Care Tracker. On 6/5/14, Surveyor # received the information. According to the report Resident #4: ~Was incontinent 2 times and continent 2 times on 11/22/13; ~Was incontinent 2 times on 11/23/13; and, ~Was incontinent 2 times on 11/24/13. The additional information did not demonstrate that resident was toileted every 2 hours and/or every hour depending on the day of the Incontinence Tracking. Review of Resident #4's Progress Notes and Post Fall Investigations found that Resident #4 has had 4 falls in the last 3 months directly related to his incontinence. (Refer to F323.) Despite this, staff did not re-evaluate Resident #4's voiding patterns and bladder incontinence to develop and implement an individualized toileting program. Example #3: Surveyor # completed a review of Resident #7's clinical record and noted the following. Resident #7 had current [DIAGNOSES REDACTED]. Resident #7's most current MDS (Minimum Data Set) was dated 5/15/14 and indicated Resident #7 had a severe cognitive impairment and required the assistance of 1 to 2 staff persons for all aspects of care. The MDS also indicated Resident #7 had a UTI in the last 30 days. Resident #7's elimination care plan, dated 5/6/12, directed staff to assist Resident #7 with "...check and change..." Resident #7 every 2 to 3 hours. Surveyor # completed a review of Resident #7's urine cultures. Surveyor # noted Resident #7 had a positive urine culture indicating a UTI on 5/9/14. Resident #7 was treated with an antibiotic. On 6/3/14 at 9:00 p.m., Surveyor # observed CNA-GG (Certified Nursing Assistant) assist Resident #7 with incontinent care. Surveyor # noted Resident #7's adult brief was saturated with both urine and stool. CNA-GG completed frontal peri care. Surveyor # noted during frontal peri care that CNA-GG needed to complete multiple swipes in order to remove all stool which had collected around Resident #7's meatus (entrance to urethra) and vaginal area. Surveyor # spoke with CNA-GG following the observation. CNA-GG indicated she started work at 2:30 p.m. Surveyor # asked CNA-GG when she last assisted Resident #7 with incontinence care. CNA-GG stated she hadn't been able to get to Resident #7 until she put her to bed at 9:00 p.m. Resident #7 was not assisted with incontinence cares for at least 6 hours and 30 minutes. On 6/11/14 at 8:15 a.m., Surveyor # spoke with LPN-AA (Licensed Practical Nurse). LPN-AA indicated she expected the CNAs to follow resident care plans. LPN-AA stated if the CNAs were unable to complete a task including toileting, they were to let the nurse know.