Every finding on record at Twin Ports Health Services

Based on observation, interview and record review, the facility did not establish 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 10 of 79 residents (R) observed for infection control practices.Certified Nursing Assistant (CNA) I did not perform proper glove changes and hand hygiene during cares.Staff did not use appropriate infection control practices. No hand hygiene between residents while passing meal trays and the meal trays were placed on dirty Personal Protective Equipment (PPE) container. CNA D served R78 a meal tray and placed it on a contaminated surface. Example 1 Facility policy titled, Hand Hygiene revised 11/02/2022 stated in part: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand hygiene table .Between resident contacts .Before and after handling clean or soiled dressings, linens, etc . Before performing resident care procedures .Before and after providing care to residents in isolation .When in doubt. On 1/21/2026 at 8:08 AM, Surveyor observed CNA E take a tray into room [ROOM NUMBER] marked with an Enhanced Barrier Precautions (EBP) sign at the door. R71 resides in room [ROOM NUMBER] and has a Foley catheter. CNA E did not perform any hand hygiene when entering or exiting room [ROOM NUMBER]. CNA E then went to the meal tray cart and grabbed a new tray and took it to room [ROOM NUMBER]. room [ROOM NUMBER] is marked with an EBP sign at the door. R69 resides in room [ROOM NUMBER] and has a feeding tube. CNA E did not perform any hand hygiene when entering or exiting room [ROOM NUMBER]. CNA E then took the plate cover back to meal cart, then went back into room [ROOM NUMBER], then back to meal cart without performing hand hygiene. CNA E picked up a new tray from the cart, delivered it to staff person entering room [ROOM NUMBER] with a resident who is on droplet precautions, then went into room [ROOM NUMBER] which had two residents without precautions and after leaving room [ROOM NUMBER] performed hand hygiene. CNA E then took meal tray to room [ROOM NUMBER] marked with an EBP sign. R22 resides in room [ROOM NUMBER] and has Extended-Spectrum Beta-Lactamase (ESBL) (a urinary tract infection (UTI) caused by bacteria (usually E. coli or Klebsiella) that are resistant to common antibiotics like penicillin and cephalosporins) in the urine. CNA E did not perform hand hygiene when entering or exiting room [ROOM NUMBER]. CNA E then went to meal tray cart and picked up a tray for a resident in room [ROOM NUMBER]. R8 resides in room [ROOM NUMBER] and is on EBP for Methicillin-Resistant Staphylococcus Aureus (MRSA) (a wound typically appears as a painful, red, swollen bump or abscess that may resemble a spider bite or pimple, often accompanied by pus, warmth, and fever). While in room [ROOM NUMBER] CNA E was seen picking up and moving R8's reacher, touching R8's blankets, moving R8's tray table, then removed tray from room [ROOM NUMBER] as R8 was not hungry. No hand hygiene was noted. CNA E went to meal cart to put R8's tray down then answered call light in room [ROOM NUMBER] with an EBP sign on the door. R72 resides in room [ROOM NUMBER] and has a history of MRSA in a wound. CNA E did not perform hand hygiene when entering or leaving room [ROOM NUMBER]. On 01/21/2026 at 8:22 AM, Surveyor interrupted CNA E's meal tray pass as Surveyor felt the observations made were sufficient and resident's safety was now a concern. Surveyor interviewed CNA E regarding no hand hygiene observed with meal tray pass to multiple resident rooms. CNA E replied, Let me check. I don't think that we have to gown up before going into a room when just passing trays. Surveyor responded, It is not the gowning that is my concern, but instead the lack of hand hygiene when entering and exiting rooms with EBPs especially when I saw you touching things in the room like the reacher, blankets and bedside table. CNA E replied, Yes, I will definitely work on the hand hygiene thing. On 01/22/2026 at 7:43 AM, Surveyor interviewed Director of Nursing (DON) B about the observations made of CNA E entering multiple resident' rooms on EBP without performing hand hygiene. DON B replied, Regardless of EBP, staff should utilize standard precautions and should perform hand hygiene when entering and when leaving all resident rooms. Example 2 On 01/21/26 at 9:31 AM, Surveyor observed CNA I provide peri care to R32 while R32 was in bed. CNA I donned gloves and began washing R32 in the genital area. Surveyor observed CNA I clean bowel movement (BM) off R32's bottom. CNA I then rolled R32 from side to side and then placed new brief on R32 with contaminated gloves. CNA D entered into R32's room and assisted CNA I with boosting R32 into bed. Surveyor did not observe CNA I doff contaminated gloves before readjusting R32 into bed, placing blanket over R32, and adjusting R32's pillow with contaminated gloves. On 01/21/26 at 10:01 AM, Surveyor interviewed CNA I and asked what CNA I's process is for providing peri care and hand hygiene. CNA I reported that CNA I should have doffed contaminated gloves before placing any clean items on R32 and touching R32's surfaces that did not pertain to providing peri care. On 01/22/26 at 10:28 AM, Surveyor interviewed DON B and asked DON B's expectation for hand hygiene during peri cares for R32. DON B reported that CNA I should have taken contaminated gloves off after providing peri care, before adjusting blankets and repositioning R32, and then touching all surfaces. DON B reported the expectation is that CNA I complete hand hygiene with washing hands or hand sanitizer after completing peri cares. Example 3 Facility policy, titled Transmission Based (Isolation) Precautions, dated 9/24/2024, states: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's modes of transmission. 1. Facility staff will apply Transmission -Based Precautions, in addition to standard precautions to residents who are known or suspected of being infected or colonized with certain infectious agent requiring addition control to prevent transmission. R78 was admitted to the facility on [DATE], and has diagnoses of Alzheimer's disease, non-Alzheimer's dementia, renal insufficiency, high blood pressure and anemia. R78's Minimum Data Seta (MDS) assessment, dated 11/25/25, indicated R78 is severely cognitively impaired, and is dependent or requires substantial assistance for movement and activities of daily living; bathing, dressing, hygiene and transferring to toilet. R78's care plan, updated 1/20/26, states infection of respiratory tract for acute respiratory infection. Interventions include hand hygiene prior to entering room and upon removing PPE, implementation of infection control policy and procedures for specific infection/illness. On 1/22/26 at 8:04 AM, Surveyor observed CNA D take a tray out of the food cart located down the hall by room [ROOM NUMBER], which is R29's room. CNA D turned around and put food tray down on top of the isolation precaution contaminated garbage can outside of R29's room. CNA D put on gown, gloves and a mask, picked food tray off the contaminated surface, and took it down to R78. CNA D entered R78's room with contaminated food tray and came out of room with gown, gloves and mask off and contaminated food tray was left in R78's room. R78 is on droplet precautions. R29 is on contact precautions for a different illness than what R78 has. On 1/21/26 at 1:41 PM, Surveyor interviewed CNA D about infection control processes when passing food trays. CNA D stated when passing trays, you need to complete hand hygiene before and after you bring a tray into a room and put on full personal protective equipment (PPE) when going into an isolation room. Surveyor asked CNA D if the PPE cart and trash can outside of a room in the hallway is considered clean or dirty. CNA D initially stated clean. Surveyor clarified is the white can for garbage and soiled PPE. CNA D stated yes. Surveyor asked if CNA D still considers that clean. CNA D stated, Well where should we put it then. Surveyor stated to CNA D that CNA D has to consider if the area is clean or dirty first before setting down something. CNA D stated it holds garbage and agreed it would be dirty. Surveyor asked about observation of putting a food tray on top of a white garbage when putting on her PPE before entering a room. CNA D stated, oh yeah, I did that. I shouldn't have. It is dirty. Normally someone is out here helping us pass trays, holding them while we put on our PPE. CNA D stated CNA D should have put PPE on first. On 1/22/26 at 1:41 AM, Surveyor interviewed Infection Assistant Director of Nursing (ADON) C who is the primary Infection Preventionist (IP) for the facility. ADON C stated the expectation when passing food trays is to sanitize hands (perform hand hygiene) before touching a tray, check what is on the tray, making sure it is correct, provide a hand wipe to residents, deliver tray, and before the next one sanitize hands again and start over. Surveyor asked if anything changes when a room is in isolation or has precautions. ADON C stated that when residents are in isolation or have precautions, staff should put on PPE prior to going into their room, then take it off and sanitize before they leave. They then need to put PPE on again if needed and go retrieve a second tray. Surveyor asked if the white bins outside room doors by PPE carts are considered a clean or dirty space. ADON C stated CNA D told ADON C about that. ADON C stated CNA D shouldn't have taken the tray until CNA D put on her PPE first. We have been trying to bring trays to everyone, so they can put on their PPE first.

Based on observations, interviews and record reviews, the facility did not provide wound management or diabetic management by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 3 residents (R32) reviewed.-Staff did not provide wound care dressing as ordered by physician for R32. -R32's air mattress settings were not appropriate per R32's weight based on offloading measures to minimize skin breakdown. -Staff did not administer short acting insulin to R32 when Blood Glucose (BG) was high.Findings include:Facility policy titled Change in Condition of the Resident, last revised 09/20/22, stated in part, .When a resident presents with a possible change of condition or noted changes in mental or physical functioning: 1. Assess the residents need for immediate care medical attention. #2. Assess/evaluate the resident. This assessment/evaluation could include, but is not limited to, the following: a. Vital signs, oxygen saturation, blood glucose level. 3. Notify resident physician. A. Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden in onset.Surveyor reviewed manufacturing instructions titled, Med Aire Plus 10 Alternating Pressure and Low Air loss Bariatric mattress, states in part, . Page 12, General: This product is designed to provide redistribution while maximizing comfort to patients. Please be sure to operate this equipment as instructed to optimize its value. Page 7, Control unit Figure 1 states, this digital control unit includes intuitive controls for adjusting the air pressure based on the patient's weight and comfort level. Seat inflate increases air pressure for additional sacral support during head of bed elevation. Max firm is available for patient transfers or other patient care procedures. Page 14, Recommended Linen: Deep pocketed fitted or flat sheets are recommended. Multiple layering of linens or under pads beneath the patient should be avoided, when possible, for the prevention and treatment of pressure injuries.R32 was admitted to the facility on [DATE] with readmission on [DATE], with diagnoses in part, metabolic encephalopathy, muscle wasting and atrophy, severe sepsis acute infection, diabetes mellitus type 2, hypertension, congestive heart failure, cerebral infarction, hypothyroidism, and absence of right leg below the knee.R32's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/05/26, indicates R32's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. R32 has impairment on both upper and lower extremities requiring total dependence on staff assist for personal hygiene, toileting, transferring, and rolling left to right.Surveyor reviewed R32's physician orders:-On 11/05/24 Nursing to check air mattress every shift to assure proper setting of current weight and function. Update maintenance with concerns every shift. -On 09/03/25 Barrier cream to coccyx Q shift and after each incontinent episode. Update provider as needed with concerns every shift to protect skin. -On 12/31/25 Wound care to IAD to thighs. Remove old dressing, cleanse with soap and water, pat dry, apply 6x6 comfort bordered foam dressing.-On 12/31/25 Monitor dressing to thighs for placement. Update provider with concerns every shift.Surveyor reviewed R32's skin integrity care plan which states in part, altered skin integrity non pressure related to history of area to left/right buttocks, redness to groin and coccyx.-Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings-Provide pressure reduction/relieving mattress-Provide thorough skin care after incontinent episodes and apply barrier cream-Treatments as ordered.Surveyor reviewed R32's activities of daily living (ADL) self-care deficit care plan which states in part,-Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse.-Toileting: Assist of 2 with check and change every 2-3 hours and as needed.-Transfer: A-2 with Hoyer lift.-Ambulation: non-ambulatory.-Bed mobility: Assist of 1 with repositioning, Assist of 2 with boosting.-Dressing: Assist of 2.Surveyor reviewed R32's potential pressure ulcer development which states in part,-Bolster air mattress provided.-Provide thorough skin care after incontinent episodes and apply barrier cream.-Treatments as ordered.Example 1On 01/20/26 at 2:18 PM, Surveyor observed Certified Nursing Assistant (CNA) J enter R32's room and provide incontinent care. Surveyor observed no dressings on R32's coccyx gluteal fold thigh area as ordered for dressing to be applied daily. Surveyor observed open areas bilaterally on lower gluteal folds exposed with feces and urine on open wounds.On 01/20/26 at 2:45 PM, Surveyor interviewed CNA J and asked CNA J when CNA J transferred R32 up into the wheelchair for the day, did CNA J observe R32 to have a dressing in place bilaterally on R32's coccyx gluteal folds area. CNA J reported that CNA J is just now getting R32 up for the day. CNA J reported to Surveyor that when CNA J was in R32's room this morning repositioning and changing R32's brief, there were no dressings in place on R32.On 01/21/26 at 6:51 AM, Surveyor entered R32's room and observed Registered Nurse (RN) G pushing medications and fluids through R32's PEG tube. Surveyor observed R32's bed highly inflated and the air mattress at its highest setting. Surveyor observed that the air mattress settings did not match R32's weight of 218 pounds for the air mattress to function appropriately and provide correct off-loading.On 01/21/26 at 7:03 AM, Surveyor observed CNA I use a bath blanket folded 3 times under R32 to reposition R32 in bed. Surveyor observed bath blanket to be wrinkled under R32 on air mattress. Surveyor asked CNA I if it is normal to use a bath blanket under R32 on air mattress versus a chuck. CNA I stated, Sometimes we don't have enough chuck pads to use. On 01/21/26 at 7:41 AM, Surveyor entered R32's room with CNA D and Unit Manager (UM) H to reposition R32. Surveyor observed CNA D and UM H reposition R32. Surveyor observed that the air mattress settings did not match R32's weight of 218 pounds for the air mattress to function appropriately and provide correct off-loading. On 01/21/26 at 8:01 AM, Surveyor interviewed UM H and asked if R32's air mattress was in correct settings to provide off-loading to prevent potential skin breakdown. UM H reported to Surveyor that UM H was unaware R32's settings were not based on R32's weight as physician ordered. UM H reported to Surveyor that UM H would investigate this as it's maintenance that sets the air mattresses upon admission or when implemented.On 01/21/26 at 8:16 AM, Surveyor interviewed RN F and asked if RN F knew the air mattress was inflated beyond R32's weight limit. RN F reported that maintenance usually sets up the air mattress. Surveyor asked RN F about the settings on the air mattress and if staff need to verify the air mattress settings. RN F reported that nurses are to be checking the air mattress on every shift to ensure it is correctly inflated per resident's weight. Surveyor asked RN F about R32's coccyx wounds on lower gluteal folds. RN F reported that RN F is calling them moisture associated due to incontinence and family taking R32 outside the facility and not bringing her back every 2 hours for repositioning. On 01/21/26 at 8:25 AM, Surveyor pulled RN F into R32's room to observe the air mattress inflation settings. RN F reported the settings were between [PHONE NUMBER]lb weight. RN F reported that R32's air mattress settings shouldn't be that high as R32 is only around 218 lbs. Surveyor asked RN F if the air mattress settings were not properly set could it affect R32's pressure off-loading capabilities. RN F reported that it very well could be affecting off-loading. Surveyor asked RN F who is responsible for setting the air mattress settings. RN F reported that maintenance and Unit Manager H usually set the air mattresses up upon admission.On 01/21/26 at 8:29 AM, Surveyor, RN F, and UM H entered R32's room to observe air mattress settings and UM H reported to Surveyor that UM H will fix R32's bed to correct air mattress settings and reach out to maintenance to make sure R32's bed is not broken.On 01/22/2026 at 8:37 AM, Surveyor interviewed Director of Nursing (DON) B and reported to DON B that Surveyor observed R32 to not have wound dressings on bilaterally to coccyx/gluteal folds area as ordered by physician. Surveyor asked DON B's expectation for dressings not on R32's coccyx/gluteal folds area. DON B reported to Surveyor that DON B had interviewed CNA J about the dressings not being on and if CNA J knew they should be on. DON B reported to Surveyor that CNA J stated CNA J did not know they were supposed to even be on or to report to nurse on duty. Surveyor asked DON B's expectation for linens under R32 while in bed on air mattress. DON B reported that staff usually utilize chucks or a draw sheet under R32 when boosting and changing R32 in bed. Surveyor reported to DON B that Surveyor observed CNA I use a bath blanket folded 3 times under R32 to reposition and use as a chuck pad but that the bath blanket was wrinkled under R32 on air mattress. Surveyor asked staff why that was being used instead of a chuck and CNA I stated, Sometimes we don't have enough chuck pads to use. Surveyor asked DON B if using a bath blanket was acceptable practice. DON B reported that staff shouldn't use it if it is wrinkling as Surveyor reported. On 01/22/26 at 8:58 AM, Surveyor interviewed DON B and asked DON B what the expectation is of air mattress settings for R32. DON B reported that R32's order refers to adjusting air mattress settings to R32's weight and every nurse should be checking the settings every shift to make sure R32's air mattress settings are appropriate. Example 2Facility policy titled Continuous Glucose Monitors (CGM), last revised 11/14/23, stated in part, .1. Continuous glucose monitor results are only for the resident and/or residents' representative to monitor glucose levels. 6. CGM use requires a physician order. The order should indicate instructions for use such as a. When periodic finger stick glucose readings may be required (and at what intervals) in addition to the use of the CGM, and b. The frequency in which the nurse is to record the glucose readings in the electronic medical record. #7. Treatment decisions may not be solely based on CGM values. Considerations of how the resident is feeling along with a finger stick to confirm blood glucose value will be used for treatment decisions of hypo/hyperglycemic episodes. #10. Nurse will review the resident's CGM value when doing a finger stick to verify the CGM value id within the acceptable range. If the CGM value is outside of acceptable range, the nurse will instruct the resident to calibrate the device.Surveyor reviewed manufacturing instructions for Freestyle Libre 3 plus sensor which states in part, .C. Glucose readings determine background color at top of phone screen, orange indicates High glucose (above 250 mg/dL). D. Trend arrows show where your glucose levels are headed. Arrow pointing straight up is Glucose is rising quickly more than 2mg/dL per minute. CGM and Blood Glucose Monitoring (BGM) readings differ as BGM is measuring the glucose directly from the blood and then CGM measures glucose in the interstitial fluid. Glucose enters the blood stream first then diffuse into the interstitial fluid. As a result, changes in the blood glucose levels whether they are increasing or decreasing will be reflected in the BGM readings before they appear in the CGM readings. This is known as a lag.Surveyor reviewed R32's physician orders:-On 07/21/25, Monitor Libre every shift and use reader to retrieve Blood Glucose [BG] checks every shift.-On 10/10/25, Insulin regular Human injection solution, inject 6 units subcutaneously three times a day for diabetes. Hold if BG is less than 120. Update provider if BG is less than 70 or greater than 400.-On 10/10/25, Insulin regular Human injection solution, inject as per sliding scale: if 150-199= 3 units; 200-249= 6 units; 250-299= 9 units; 300-349= 12 units; 350= 15 units. Update provider if blood sugar is greater than 400, subcutaneously three times a day for diabetes.-On 12/19/25, Apply Libre 3. Change every 15 days. Needs calibration upon application every shift.-On 01/01/26, Lantus Solo Star subcutaneous solution pen injector 100Unit/ML, inject 40 units subcutaneous one time a day related to type 2 Diabetes Mellitus, take with breakfast.-On 01/21/26, Insulin Regular Human Injection Solution 100 UNIT/ML (Insulin Regular (Human)) Inject 5 unit subcutaneously one time only for diabetes mellitus for 1 Day.Surveyor reviewed R32's Alteration in BGs with hyperglycemic and hypoglycemic episodes states in part,-Administer medications as ordered.-Report abnormal results per physician parameters and guidelines.Surveyor reviewed R32's BGs from dates ranging 01/01/26-01/22/26.-On 01/21/26 at 11:11 AM, 353 mg/dl.-On 01/21/26 at 11:12 AM, 393 mg/dl.-On 01/21/26 at 1:00 PM, 276 mg/dl.-On 01/21/26 at 4:02 PM, 500 mg/dl.-On 01/21/26 at 4:03 PM, 500 mg/dl.-On 01/22/26 at 7:58 AM, 399 mg/dl.Surveyor reviewed R32's progress notes that indicated,-On 01/21/26 at 12:10 PM, Writer left message for a call back from physician regarding R32 not receiving insulin this morning due to R32 was sleeping and not eating. R32 was 361, 353, 399, and then 281. Waiting on call back.-On 01/21/26 at 3:01 PM, Writer spoke with RN from community care team regarding R32 not receiving insulin this morning due to resident [R32] sleeping and not eating. Provider gave the ok to hold breakfast insulin and lunch if resident is not awake. Writer updated RN that resident [R32] woke after lunch and ate muffin with mountain dew so short acting insulin was given. Will continue plan of care.-On 1/21/2026 at 3:58 PM, Resident BG 500 at 3:30 PM. Contacted provider and provider ordered 5 units regular insulin 1 time dose give now.On 01/21/26 at 7:41 AM, Surveyor entered R32's room with CNA D and UM H to reposition R32. Surveyor observed R32's Libre BG machine alarming on R32's cell phone. Surveyor asked UM H what the alarm was. Unit Manager H reported to Surveyor that the alarm was R32's BG check from Libre machine and it notifies staff on cell phone. Surveyor observed R32's BG to be 399 with arrow pointing upwards. Surveyor asked UM H what the arrow meant on the Libre machine. UM H reported that the arrow meant that R32's BG was still climbing. UM H reported to Surveyor that UM H would ask RN G if RN G has given insulin yet to R32. Surveyor observed UM H walk out of R32's room and approached RN G to let her know R32's BG result of 399. RN G reported to UM H that RN G would be going into R32's room shortly.On 01/21/26 at 11:59 AM, Surveyor interviewed RN G and asked if RN G had received R32's short acting insulin for breakfast. RN G reported that since R32 did not get up for breakfast, RN G held short acting insulin. Surveyor asked RN G how RN G knows to hold R32's insulin since R32 did not get up for breakfast. RN G stated, I just decided to use my judgement and not give her, her short acting insulin. Surveyor asked if RN G notified the provider on call. RN G reported that RN G has not had a chance yet to call the provider. Surveyor asked RN G if it is normal practice to hold a short acting insulin for over 4 hours before notifying the provider on call. RN G reported that RN G should have called earlier right after deciding to hold the short acting insulin for further orders from the provider in case provider wanted R32 to still have the insulin.On 01/22/26 at 8:37 AM, Surveyor interviewed DON B and reported to DON B that Surveyor observed R32's Libre glucose monitor beeping 399 with arrow up relaying that R32's Blood Glucose (BG) was high while in R32's room with Unit Manager H on 01/21/26. Surveyor asked DON B what expectation would be of managing the Libre and R32's BG. DON B reported that if R32's Libre was alarming with an arrow up it meant that R32's BGs was still actively going up. DON B stated to Surveyor, I expect staff to assess [R32] for any symptoms, perform a manual BG check, and notify physician right away. Surveyor asked DON B was DON B aware that R32 did not receive short acting insulin on 01/21/26 in the AM but then had to have additional 5 units given as R32's BG went up to 500 at 3:30 PM on 01/21/26. DON B reported that DON B was unaware of the additional short acting insulin needing to be given hours later but was aware of the hold of short acting insulin. Surveyor asked if DON B wrote this as a significant medication error. DON B reported to Surveyor that RN G should have notified the provider on call within an hour on holding R32's short acting insulin from earlier in the morning on 01/21/26. On 01/22/2026 at 12:43 PM, Surveyor interviewed DON B about the physician order not specifying periodic finger sticks glucose readings and intervals of completion along with the Libre BG machine. Surveyor also notified DON B that Surveyor could not find that the blood sugar result from 01/21/26 at 3:30 PM was taken again with a manual verification BG check and then the machine calibrated. DON B reported that DON B is sure that the staff member from second shift did complete this task but that it was not charted so unsure at this time. DON B reported that once there is a high BG check from 400 and above that all BGs should be rechecked manually.

Based on interview and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 resident (R) reviewed. (R44)R44 was admitted to the facility with stage 3 PIs to left trochanter (hip) and left buttock and stage 2 PIs to the right hip and right buttocks. Facility staff did not complete a comprehensive PI assessment to include measurements and description of R44's PIs on admission. Facility staff on the following assessment documented all the PIs only at a stage 2. This is evidenced by:Facility's policy titled Pressure Injuries and Non pressure Injuries with the revised date of 07/20/22 documented in part, The staging of pressure injury is consistent with the recommendations of National Pressure Injury Advisory Panel (NPIAP) and the RAI Manual, Section M.1. Upon admission: a. A head-to-toe body evaluation will be completed on every resident upon admission/readmission and will be documented on the Admission/readmission Evaluation UDA. i. If pressure Injury: Initiate the Pressure Injury Weekly Tracker UDA - one per wound. NPIAP documented in part, Pressure Ulcer Assessment1. Assess the pressure ulcer initially and re-assess it at least weekly. 1.1. Document the results of all wound assessments.3. Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor.CMS's RAI Version 3.0 Manual October 2025 documented in part, Section M, For each pressure ulcer, determine the deepest anatomical stage. At admission, code based on findings from the first skin assessment that is conducted on or after and as close to the admission as possible. Do not reverse or back stage. Consider current and historical levels of tissue involvement.R44 was admitted to the facility on [DATE]. R4's current diagnoses of severe protein-calorie malnutrition, weakness, adult failure to thrive, pressure ulcer of back, buttock and hip stage 2, PI left hip unstageable, personal history of physical injury and trauma, mild cognitive impairment, pressure ulcer of left buttock stage 3, personal history of traumatic brain injury, and depression.R44's Minimum Data Set (MDS) dated [DATE] admission 5 day assessment documented BIMS score of 14, meaning intact cognition. Moderate assistance needed from staff for toilet hygiene and personal hygiene and independent with bed mobility. R44 is at risk for PI with two stage 2 PIs on admission, one stage 3 present on admission, and one unstageable present on admission.R44's admission evaluation completed on 12/24/25 documented a skin impairment present to the right trochanter (hip) PI stage 2, left trochanter (hip) PI stage 3, right buttock PI stage 2, and left buttock PI stage 3. This assessment did not include measurements and descriptions of the PIs.On 12/31/25, a pressure injury weekly tracker was completed with the left trochanter (hip) as stage 2 and left gluteal fold (buttock) as a stage 2. Note, this stage was back staged from the admission assessment of a stage 3.On 01/21/26 at 2:20 PM, Surveyor interviewed Director of Nursing (DON) B asking for R44's PI assessment on admission. DON B stated R44 had an admission assessment completed with the wounds listed. Surveyor reviewed with DON B the assessment did not include measurements of the wound and only stages. The stages for two of the wounds were at a stage 3 and when the PI were assessed on 12/31/25 the PIs were staged at a 2. DON B stated she will need to review further. Surveyor asked what the expectation of assessment on admission. DON B stated would expect a full assessment with measurements on the day of admission. On 01/21/26 at 2:30 PM, Surveyor interviewed Registered Nurse (RN) F asking if the staging of a PI at a stage 3 would continue at the same stage and not back stage to a stage 2. RN F stated when RN F assessed R44 on 12/31/25 the PIs were at a stage 2. RN F did not assess R44 on the day of admission. On 01/21/26 at 2:38 PM, DON B stated RN G completed the admission assessment and RN G took the stage levels from the hospital notes. RN G could not recall the observation of the wound. DON B stated would expect a documented full assessment of the PI be completed on the day of admission.

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R)(R1) reviewed.The facility does not have a policy or procedure in place to assess risk for residents storing and using a personal vehicle on facility premises.R1 eloped from facility using personal vehicle parked on facility premises.This is evidenced by:State Operations Manual, Appendix PP, states in part: The facility must ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision.to each resident to prevent avoidable accidents. This includes: identifying hazard(s) and risk(s), evaluating and analyzing hazard(s) and risk(s), implementing interventions to reduce hazard(s) and risk(s), and monitoring for effectiveness and modifying interventions when necessary.'Risk' refers to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influences the likelihood of an accident.R1 was admitted to the facility on [DATE] with pertinent diagnoses of cognitive communication deficit, other symptoms and signs involving cognitive function following cerebral infarction, and alcohol abuse.R1's admission Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.R1's care plan, dated 04/09/25, with a target date of 07/08/25, states: .history of alcohol abuse with interventions to educate on risks of leaving the facility to seek out substances and/or early, unplanned discharge, increase monitoring and supervision of resident and their visitors, and report changes in mood.Of note: no wandering behaviors were noted prior to incident.R1's care plan, dated 05/27/25, with a target date of 07/08/25, states: Potential for elopement due to history of resident leaving facility unescorted with interventions of accompany to meals and scheduled activities, allow to vent feelings and/or frustration PRN, observe for and report decline in ADL ability or behaviors, check alert bracelet functioning per manufacturer recommendations, remove items that may trigger attempt to leave facility (i.e. boots, coat).Surveyor reviewed R1's wandering risk assessment, dated 04/02/25, and noted a score of 3 - low risk.On 07/18/25, Surveyor reviewed facility reported incident submitted on 05/23/23 that states: [R1] notified facility staff that he would like the keys to his van, that are stored within the Business Office for safe keeping, that is parked in the facility parking lot to retrieve some papers. Facility staff walked with [R1] to vehicle and [R1] stated that he was going to grab some paperwork. [R1] stated that he wanted to start the car since it has been sitting for a while. [R1] stated he wasn't going to leave and preceded to drive forward and continued to leave the facility parking lot and leaving the facility ground. POA contacted. Police department contacted. Medical Director notified. Investigation ongoing.Of note: no documentation of R1 having a personal vehicle at facility on or after admission was noted. No risk assessment was documented for R1 having vehicle on facility premises or safety to drive a vehicle was noted.On 07/18/24 at 12:54 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A for the facility's policy/procedure for residents having a personal vehicle onsite. NHA A stated there wasn't one. Surveyor asked what risk assessment was completed for R1 to safely operate and store a personal vehicle on facility premises. NHA A stated no risk assessment was completed. Surveyor asked NHA A how R1 would access his personal vehicle. NHA A stated the facility stored the keys in the business. No other safety measures were implemented. Surveyor asked if any residents currently residing in facility had a personal vehicle onsite. NHA A stated no.On 07/18/25 at 2:00 PM, Surveyor interviewed NHA A about any additional policy or procedure changes implemented after incident. NHA A stated no additional policies were implemented for residents having a personal vehicle and no risk assessments were implemented to assess for safety if a resident were to have access to a personal vehicle on facility premises. Surveyor asked NHA A if she could see the potential risk associated with not having a procedure in place for this. NHA A acknowledged this.

Based on observation, interview and record review, 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 78 of 78 residents that eat orally. Food (milk and lettuce) placed in the walk-in cooler had been opened but was not labeled with an opened date, resulting in the potential for foodborne illnesses to spread. Findings include: The facility's policy entitled Food Storage dated 8/16/2022, states in part, .Refrigerated food storage: . f. All foods should be covered. Labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. On 9/23/2024 at 9:50 AM during initial kitchen tour with Dietary Manager (DM) G, Surveyor observed a gallon of opened milk and lettuce in a covered container placed on shelves in the walk-in cooler. Neither had been labeled with an opened on or use by date. Milk had a received date of 9/17/24. Lettuce was not labeled with any dates. On 09/23/24 at 10:14 AM, Surveyor interviewed DM G regarding expectations for milk and opened food in refrigerator. DM G said they would expect that milk have an open date in marker and DM G did explain that the date on the milk was a received-on date. DM G would expect the milk to be used up in at minimum three days and usually it does not make it more than one day. DM G also expects that lettuce that is placed back in the fridge would be labeled with the open date.

Based on interview and record review, the facility failed to ensure that written bed hold notice and reason for transfer required for facility-initiated transfers was provided to the residents or resident representatives at time of hospital transfer or within 24 hours of transfer for 2 of 2 residents (R7 and R66) reviewed for hospitalization . This is evidenced by: The facility policy, entitled (I) Transfer and Discharge last reviewed and revised on 07/15/22, states under Section 7 (i), Provide a notice of the resident's bed hold policy to the resident and representative at the time of the transfer, as possible, but no later than 24 hours of the transfer. Example 1 R7 was admitted to the facility on [DATE] and has diagnoses that include congested heart failure, diabetes mellitus, chronic kidney disease, and post-traumatic stress disorder. R7's Minimum Data Set (MDS) assessment, dated 05/03/24, indicated that R7 was transferred to an acute care hospital with return anticipated. On 05/03/24, R7 was emergency transferred to hospital due to uncontrolled nosebleeds following prior nasal surgery. R7 returned to the facility on [DATE]. Example 2 R66 was admitted to the facility on [DATE] and has diagnoses that include anemia, diabetes mellitus, history of liver transplant and hypertension. R66's MDS assessment, dated 06/1/24, indicated that R66 was transferred to a critical access hospital with return anticipated. On 06/18/24, R66 was emergency transferred to hospital due to critical lab values. R66 returned to facility on 06/19/24. On 09/24/24 at 1:36 PM, Surveyor requested bed hold notice documentation for R7 and R66 provided to the resident and/or representative at the time of the transfer or within 24 hours of the transfer. On 09/24/24 at 1:57 PM, Social Services Director C stated inability to locate bed hold notification provided to the resident and/or representative at the time of the transfer or within 24 hours of the transfer.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 18 sampled residents (R) R6, to meet a resident's medical, nursing, and psychosocial needs that are identified. R6 did not have a comprehensive person-centered care plan for trauma informed care identifying triggers related to post traumatic stress disorder (PTSD). Findings: The facility policy titled, Trauma Informed Care, dated 10/18/22, states: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs to trauma survivors by minimizing triggers and/or re-traumatization. Example 1 R6 was admitted to the facility on [DATE] with diagnoses that included renal failure, heart failure, depression, and PTSD. R6's admission Minimum Data Set, dated dated [DATE], indicates R6 has a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) and indicated R6 has PTSD. On 09/23/24 at 1:06 PM, Surveyor interviewed R6 regarding PTSD and triggers. R6 shared facility is aware of the diagnoses and has had no issues since admission. On 09/09/24, facility completed a trauma-informed care observation assessment regarding findings of physical abuse from husband in past and 9 years ago attacked with intent to kill by adult child. The assessment identified triggers that remind R6 of the events and were identified as loud voices, screaming and someone walking up from behind quietly. On 09/24/24 at 2:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding R6 having PTSD and triggers. CNA D stated was unaware of R6 having any specific triggers for PTSD. CNA D stated unawareness of any triggers causing re-traumatization since admission. On 09/24/24 at 2:25 PM, Surveyor interviewed Registered Nurse (RN) E and RN F regarding R6 having PTSD and triggers. Both RN E and F stated were unaware of R6 having PTSD or what may trigger re-traumatization. Both RN E and RN F stated unawareness of any triggers causing re-traumatization since admission. On 09/25/24 at 11:10 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding trauma informed care process. NHA A stated that an assessment is completed by the Social Services Director. If the assessment identifies areas of focus and triggers are identified it was to automatically pull to the care plan. NHA A stated a contact to the information technology department has been made to make facility changes to ensure process is completed appropriately for future residents. NHA A shared a copy of a care plan developed on 09/24/24 to address PTSD.

Based on interview and record review, the facility did not send a copy of the discharge notice to the Office of the State Long Term Care Ombudsman for 3 of 7 residents reviewed who were discharged with return anticipated. (R7, R25 and R66). This is evidenced by: The facility policy, entitled Transfer and Discharge last reviewed and revised on 07/15/22, states under Section 7(k). Emergency Transfers/Discharges, Social Services Director (SSD), or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list. Example 1 R7 was admitted to the facility on [DATE] and has diagnoses that include congested heart failure, diabetes mellitus, chronic kidney disease, and post-traumatic stress disorder. R7's Minimum Data Set (MDS) assessment, dated 05/03/24, indicated that R7 was transferred to an acute care hospital. On 05/03/24, R7's medical record indicated R7 was emergency transferred to hospital due to uncontrolled nosebleeds following prior nasal surgery. R7 returned to the facility on [DATE]. Example 2 R66 was admitted to the facility on [DATE] and has diagnoses that include anemia, diabetes mellitus, history of liver transplant and hypertension (high blood pressure). R66's MDS assessment, dated 06/18/24, indicated that R66 was transferred to a critical access hospital. On 06/18/24, R66's medical record indicated this was an emergency transfer to the hospital due to critical lab values. R66 returned to facility on 06/19/24. On 09/24/24 at 1:36 PM, Surveyor requested documentation of notice of hospital transfers for R7 and R66 to State Long-Term Care Ombudsman from Social Services Director (SSD) C. On 09/24/24 at 1:57 PM, SSD C stated inability to locate documentation to support notification of hospital transfer to Ombudsman. 40590 Example 3 R25 was admitted to the facility on [DATE] and has diagnoses that include type 1 diabetes mellitus with diabetic polyneuropathy and hyperglycemia. R25's Minimum Data Set (MDS) assessments indicate that R25 was discharged to the hospital on 08/16/24 and returned to the facility on [DATE]. Nurses note dated 08/16/24 states that R25 was sent to the Emergency Department (ED) for shortness of breath and low oxygen saturation. Nurses note dated 08/17/24 states that R25 was admitted to the hospital for rhinovirus and hyperkalemia. On 09/24/24 at 3:48 PM, Surveyor received the list for August 2024 discharge notifications to the State Ombudsman. R25 was not on this list. Surveyor requested ombudsman notice for R25 from SSD D. SSD C stated inability to locate documentation to support notification of hospital transfer to Ombudsman. The State Ombudsman was not notified for R25's 8/16/24 hospitalization .

Based on observation, interview and record review, the facility did not ensure a resident with a urinary catheter received appropriate treatment to prevent urinary tract infections for 1 of 2 residents (R) with urinary catheters. (R33) Certified Nursing Assistant (CNA) did not follow proper procedure for urinary catheter care to prevent risk of infection. Findings include: R33 was admitted to the facility on [DATE] following acute hospitalization for severe urosepsis. R33 had a long-term indwelling Foley catheter due to diagnoses including, multiple sclerosis with neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia [enlargement of the prostate] with urinary retention. R33 had a history of recurrent urinary tract infections (UTIs). Review of R33's medical record identified R33 had 4 UTIs since admission to the facility. Facility policy entitled, Catheter Care last reviewed/revised on 03/15/23, stated in part: .1. Catheter care will be performed with a.m. and h.s. cares and as needed .Male: 15. Gently grasp penis, draw foreskin back if applicable. 16. Using a circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). 17. With a new moistened cloth, starting at the meatus moving down, cleanse the shaft of the penis. 18. With a new moistened cloth, starting at the urinary meatus moving outward, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter. 19. Dry area with towel. 20. Perform hand hygiene . On 09/12/23 at 7:29 AM, Surveyor observed CNA E provide morning catheter care for R33. CNA E performed hand hygiene with alcohol based hand rub (ABHR) before entering R33's room. CNA E asked R33 if it was okay for Surveyor to observe the catheter cares. R33 gave approval. CNA E applied clean gloves and gathered a wash basin with warm water, soap, washcloths and towels at the bedside table. CNA E uncovered R33 and unfastened the incontinent brief and pulled down. CNA E took a wet washcloth from basin and applied liquid soap. CNA E washed R33's lower abdomen, groin area, between legs, under penis, and around scrotum, then with the same washcloth washed around the urinary meatus around the catheter and down the catheter tubing. CNA E placed the washcloth in a plastic bag and took a new washcloth from the basin and rinsed R33's skin in the same order as washing. CNA E placed the rinse washcloth in the plastic bag and took a clean towel and dried R33's skin in the same order as washing. CNA E and CNA F continued to provide morning cares and assist R33 to groom and dress. Immediately following the observation, Surveyor interviewed CNA E and asked what the proper procedure was for urinary catheter cares. CNA E stated they were taught they were supposed to wash starting at the urinary meatus out in a circle and then down the catheter tubing and penis. CNA E stated they did the catheter cares for R33 in the opposite direction today. On 09/12/23 at 2:56 PM, Surveyor interviewed Director of Nursing (DON) B and reported the above observation of catheter cares for R33. DON B stated CNA E should have performed catheter cares by cleansing around the urinary meatus first and then down the catheter before washing the rest of the perineal area. DON B confirmed R33 has had 4 UTIs since admission to the facility and is on a prophylactic antibiotic due to a history of severe urosepsis.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when staff did not perform hand hygiene after removing soiled gloves during care observations. This affected 2 of 4 residents (R) observed for cares. (R33 and R328) Certified Nursing Assistant (CNA) did not perform hand hygiene when changing gloves during catheter cares. CNA did not perform hand hygiene when changing gloves after emptying urinary drainage bag. Registered Nurse (RN) did not perform hand hygiene after removing gloves following wound care. Findings include: Example 1 Facility policy entitled Hand Hygiene, last reviewed/revised on 11/02/22, stated in part: .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 . On 09/11/23 at 2:47 PM, R33 stated they had a long-term indwelling Foley catheter with frequent infections. Record review identified R33 had 4 urinary tract infections since admission to the facility on [DATE]. On 09/12/23 at 7:29 AM, Surveyor observed CNA E provide morning catheter care for R33. CNA E performed hand hygiene with alcohol based hand rub (ABHR) before entering R33's room. CNA E applied clean gloves and provided urinary catheter cares, washed R33's perineal and rectal areas, and applied a barrier cream to R33's bottom. CNA E removed the gloves and applied clean gloves without washing hands or using ABHR. CNA E continued to provide morning cares and assist R33 to groom and dress. Immediately following the observation, Surveyor interviewed CNA E and asked what the proper procedure was when changing gloves. CNA E stated they were taught to wash hands or use hand sanitizer between glove changes, but they forgot to do that when providing cares for R33 this morning. On 09/12/23 at 7:29 AM, Surveyor observed CNA F empty R33's urinary drainage bag. CNA F performed hand hygiene with ABHR before entering the room and then applied clean gloves. CNA F placed a paper towel on the floor beside the bed and placed a graduate on the paper towel. CNA F proceeded to empty the urinary drainage bag using the proper procedure. Following the procedure CNA F removed the soiled gloves and applied clean gloves without washing hands or using ABHR. CNA F then continued to assist CNA E with morning cares for R33 Immediately following the observation, Surveyor asked CNA F what the proper procedure was for changing gloves during cares. CNA F stated they were taught they were supposed to wash hands or use hand sanitizer when changing gloves. CNA F stated they did not do that when changing gloves during cares for R33. On 09/12/23 at 2:56 PM, Surveyor interviewed Director of Nursing (DON) B and reported the above observation of catheter cares for R33. DON B stated both CNA E and CNA F should have performed hand hygiene after removing dirty gloves and prior to donning clean gloves. 46694 Example 2 R328 was admitted to facility on 08/02/23 with a Brief Interview for Mental Status (BIMS) of 15 indicating that R328 was cognitively intact. Diagnoses include displace fracture of right hip and right pubis fracture. R328's doctors' orders include lamb's wool to toes every morning. Paint scabs with betadine daily and leave open to the air. On 09/11/12 at 11:14 AM, Surveyor observed Registered Nurse (RN) D perform wound care for R328. When RN D finished wound care, RN D threw the garbage in the garbage can, removed the gloves and left the room without performing any hand hygiene. Surveyor followed RN D to the medication cart, where RN D began typing on the computer without performing hand hygiene. On 09/13/23 at 8:00 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C. Surveyor asked what the expectation is for a nurse that has just completed a task like wound care regarding hand hygiene. ADON C replied, You should always perform hand hygiene following any cares of a resident.

Based on observations, interviews and record reviews, the facility did not ensure accuracy of MDS (Minimum Data Set) Assessments for 6 out of 21 residents reviewed. R29 had errors in Sections A, H, I, M, and P. R57 had errors in Sections I, M, N, and Z. R69 had errors in Sections I, M, N, and Z. R16 had errors in Sections A, J, N, I, and P. R74 had errors in Section N. R75 had errors in Section A. This is evidenced by: Example 1: R29 was admitted to the facility on [DATE] following an [MEDICAL CONDITION] (broken blood vessel) and stroke that resulted in [MEDICAL CONDITION] (paralysis). Additional [DIAGNOSES REDACTED]. The facility completed a quarterly MDS assessment for R29 on 04/19/19 with the following data inaccurately coded: ~Section A admitted was 03/07/13. ~Section H current toilet program. ~Section I coded for depression. ~Section M coded for not at risk for pressure injuries. ~Section P coded for daily use of a physical restraint in bed and in chair. The facility completed an annual MDS assessment for R29 on 01/25/19 with the same MDS data coded in Sections A, H, I, M, and P. Section A: R29 was originally admitted on [DATE]. This data was confirmed with R29's spouse. Section H: According to the RAI (Resident Assessment Instrument) manual a toilet program must be individualized and specific to the resident's toilet history. The RAI manual noted a check and change program does not qualify as a toilet program. The facility's CNA (Certified Nursing Assistant) care card noted R29 was on a every 2 hour check and change program. On 06/11/19 at 10:30 a.m., Surveyor interviewed CNA-A who stated R29 was on a check and change program and was unaware of her toilet needs or when she was wet or soiled. The facility developed a care plan titled Alteration in elimination . on 03/20/13 for R29 which directed staff to check and change every 2 hours. Section I: The RAI manual notes active [DIAGNOSES REDACTED]. R29 was not taking any anti-depressant medications. R29 scored a zero on the depression screen indicative of no depression symptoms. Section M: R29 was at risk for pressure injury development due to immobility, diabetes, [MEDICAL CONDITION], incontinence, obesity, and recent history of a resolved stage 4 pressure injury on her coccyx. The facility completed a Braden Skin at Risk assessments on 12/20/18 and R29 scored a 12 which was high risk for pressure ulcer development. The facility completed a Braden Skin at Risk on 01/20/19, 02/20/19,3/20/19, and 04/20/19 and R29 scored a 13 which was high risk for pressure ulcer development. The facility developed a care plan titled At risk for alteration in skin integrity . on 05/31/17 and noted R29 to be at risk for pressure injuries due to immobility, incontinence, and history of resolved pressure ulcer. On 06/12/19 at 5:30 p.m., Surveyor interviewed the DON (Director of Nurses) who stated any resident who was immobile, incontinent, had diabetes, and had a history of [REDACTED]. Section P: The facility completed restraint assessments on 05/28/19, 04/26/19, 03/26/19, 02/21/19, 01/29/19, and 12/26/18 and noted R29 used a tray table as a communication device and used an abdominal binder to prevent dislodging of the gastric tube. The assessments noted both devices were not considered restraints and did not meet the definition of restricting R29's movement. The facility developed a care plan titled Use of communication board while in the w/c. Device is not used for restraint purposes .Use of abdominal binder to prevent dislodging of PEG tube. This care plan was initiated on 11/27/17. On 06/12/19 at 5:30 p.m., Surveyor interviewed the DON regarding R29's restraint use. The DON stated she did not agree with coding R29 as having a restraint. The DON stated R29 was quadriplegic and unable to move voluntarily thus the tray table did not impede movement. The DON stated the tray table was used as a communication device when resident was seated in the Broda chair. On 06/10/19 at 1:38 p.m., Surveyor observed R29 seated in the Broda chair participating in activities using the tray table as a communication device. Surveyor made additional observations of R29 seated in the Broda chair with the tray table in place to aide her in eating breakfast and lunch independently. On 06/10/19 at 2:00 p.m., Surveyor interviewed R29's spouse. R29's spouse stated R29 needed the tray table to help her feed herself and to communicate basic needs by pointing to the yes/no signs on the tray. R29's spouse stated he was pleased with the use of the tray table and did not feel it restrained any movement. Example 2: R57 was admitted to the facility on [DATE] and readmitted on [DATE], 03/15/19, and 04/01/19 with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a quarterly MDS assessment for R57 on 5/24/19 with the following data inaccurately coded: ~Section I was not coded for a MDRO (multi-drug resistant organism) or TBI. ~Section M was not coded for at risk for pressure injuries. ~Section N was not coded for 7 days of antipsychotic use. The facility completed an annual MDS assessment for R57 on 01/21/19 with the following data inaccurately coded: ~Section I was not coded for TBI. ~Section M was not coded for at risk for pressure injuries. ~Section N was not coded for 7 days of antipsychotic use. ~Section Z was not coded with 14 days of the assessment reference date. Section I: Review of R57's hospital discharge summary dated 04/01/19 noted R57 was treated with antibiotics [MEDICAL CONDITIONS] and ESBL (extended spectrum beta-lactamase). Both of these bacteria are considered multi-drug resistant organisms. Review of a physician progress notes [REDACTED]. Review of R57's comprehensive care plan did not include the TBI [DIAGNOSES REDACTED]. Section M: The facility developed a care plan titled Resident is at risk for skin integrity . on 05/07/19 for R57. The care plan noted R57's risk factors to be immobility, incontinence, and scratching/picking behavior. In addition, the Braden skin at risk score indicated R57 was at risk for pressure injuries. Section N: Review of the MAR (medication administration record) noted R57 was taking [MEDICATION NAME] which is classified as an antipsychotic medication. R57 received 7 days of [MEDICATION NAME] during the (MONTH) and (MONTH) MDS assessments. The facility developed a care plan titled Resident has order for [MEDICAL CONDITION] medication .Anti-psychotic on 03/12/18 for R57. According to the care plan, the facility was tracking behaviors and effectiveness of the antipsychotic medication via the MAR. Section Z: The annual MDS had an assessment reference date of 01/03/19 and a completion date of 01/21/19. According to the RAI manual, the MDS assessment must be completed within 14 days of the assessment reference date. R57's annual MDS should have been completed on 01/17/19, not 4 days later. On 06/11/19 at 2:30 p.m., Surveyor interviewed MDS-RN who stated she was unaware of R57's TBI diagnosis. MDS-RN stated she added the [DIAGNOSES REDACTED]. On 06/13/19 at 10:30 a.m., Surveyor was approached by the DCR (Director of Clinical Reimbursement) regarding R57's MDS assessments. The DCR agreed the MDS assessment was coded incorrectly and stated she would make modifications and resubmit the MDS assessments for R57. Example 3: R69 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a quarterly MDS assessment for R69 on 06/09/19 with the following data inaccurately coded: ~Section I a UTI (urinary tract infection) was not coded. ~Section M was coded for not at risk for pressure injuries. ~Section N was not coded for anticoagulant and antibiotic medications. ~Section Z was not coded within 14 days of the assessment reference date. The facility completed a significant change in status MDS assessment for R69 on 03/29/19 with the following data inaccurately coded: ~Section M was coded as not at risk for pressure injuries. ~Section N was not coded for anticoagulant medication use. Section I: R69 was treated for [REDACTED]. According to the RAI manual, facilities must code UTI if there is a diagnosis, treatment, and evidenced based criteria to support the diagnosis. The facility completed an infection surveillance form and determined R69 had a UTI. The facility determined R69 met the McGeer's criteria for a UTI. On 05/17/19, R69 [MEDICATION NAME] milligrams twice daily for 7 days to treat the UTI. Section M: The facility developed a care plan titled Resident is at risk for skin integrity . for R69 on 10/10/18. The facility identified immobility, incontinence, and obesity as risk factors for R69's skin risks. Section N: Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. Section Z: According to the RAI manual, all MDS assessments must be completed within 14 days of the assessment reference date. The quarterly MDS completed on 06/09/19 for R69 had an assessment reference date of 05/22/19 and was due for completion on or before 06/05/19. The quarterly MDS assessment was 4 days late. On 06/13/19 at 10:30 a.m., Surveyor was approached by the DCR regarding R69's MDS assessments. The DCR agreed the MDS assessment was coded incorrectly and stated she would make modifications and resubmit the MDS assessments for R69. Example 4: R16 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an annual MDS assessment for R16 on 03/29/19 with the following data inaccurately coded: ~Section A admitted was incorrectly coded as 05/26/16. ~Section J pain frequency was not completed. ~Section N was incorrectly coded as antibiotics received for 7 days. ~Section P restraints used in bed and chair daily was incorrectly coded. ~Section P alarms used in bed and chair daily was incorrectly coded. The facility completed a quarterly MDS assessment for R16 on 12/27/18 with the same data inaccurately coded in Sections A, J, N, and P. Section A: The original admitted for R16 was 01/11/08. The facility coded an admitted [DATE] and this was incorrect. This was confirmed by electronic record review or R16's census report. The DCR stated if the facility staff do not refresh an MDS when originated, some of the data would not carry over. The DCR confirmed R16's admitted to be 01/11/08. Section J: According to the RAI manual, when the resident can not answer the pain interview questions, staff are to be interviewed regarding pain symptoms and frequency. R16's annual and quarterly MDS assessment were not completed for pain frequency. The DCR stated the MDS-RN should have interviewed staff to complete Section J pain frequency. The DCR stated she provided education to the MDS-RN to conduct staff interviews to complete pain questions. Section N: R16 was coded as taking 7 days of antibiotics during the look back period for both MDS assessments reviewed. Review of the MAR indicated [REDACTED]. Section P: The facility developed a care plan titled I have physical functioning deficits . for R16 on 11/06/14. The care plan directed staff to assist R16 into the wheelchair and apply the seat belt, then wheel R16 out into the main dining room to participate in activities. The care plan also noted R16 used an abdominal binder at all times to secure the gastric tube. The care plan included the use of a bed alarm when R16 was in bed. It did not include the use of any chair alarm. The facility developed a care plan titled Use of abdominal binder to prevent dislodging .Use of seat belt .Devices are not used for restraint purposes . for R16 on 02/26/18. The facility also completed physical restraint assessments for R16 on 05/28/19, 04/26/19, 03/26/19, 02/21/19, 01/29/19, and 12/26/18. The physical restraint assessments supported the care plan and state the use of the seat belt was not considered a restraint for R16, thus should not have been coded. On 06/12/19 at 5:30 p.m., the Surveyor interviewed the DON regarding R16's seat belt. The DON stated R16's seat belt was not a restraint but was a device used for her [MEDICAL CONDITION]'s due to her involuntary spasms. The DON stated R16 was unable to make any voluntary movements due to her [MEDICAL CONDITION], thus the seat belt did not impede her mobility. The DON stated the abdominal binder was used to prevent dislodging of the gastric tube R16 used for all nutrition, hydration, and medications. On 06/13/19 at 10:30 a.m., Surveyor was approached by the DCR regarding R16's MDS assessments. The DCR agreed the MDS assessment was coded incorrectly and stated she would make modifications and resubmit the MDS assessments for R16. On 06/11/19 at 10:30 a.m., Surveyor interviewed CNA-A regarding R16's care needs. CNA-A stated R16 only used a bed alarm and never used a chair alarm. CNA-A stated R16 wore an abdominal binder at all times and gloves on both hands at all times. CNA-A stated the seat belt was used for short periods when R16 was up in her specialized wheelchair and never in bed. CNA-A stated R16 was constantly jerking without any control and spends most of her time in bed. On 06/11/19 and 06/12/19 at 2:30 p.m., Surveyor observed R16 seated in the specialized wheelchair with the seat belt secured in place. R16 was participating in activities. R16 was observed to have involuntary movements of her entire body every few seconds. R16 made no voluntary movements during the observations. The facility provided Surveyors with a PIP (Performance Improvement Plan) dated 06/04/19 which identified MDS errors related to immunizations, Section G Activities of Daily Living, and Section H catheters. On 06/13/19 at 8:40 a.m., Surveyor discussed MDS accuracies and PIP findings with the NHA (Nursing Home Administrator) The NHA stated the facility was alerted to the MDS coding errors when the Five Star Nursing Home compare report showed a drop from five stars to two stars due to coding data. The NHA stated the facility investigated this decline in ratings and determined errors in MDS coding and developed a PIP. Surveyor discussed multiple MDS coding errors in other sections of the MDS that had not been identified by the facility and not included in the PIP as the reason the citation was issued. In addition, the MDS coding errors impacted the survey resident selection as well. Example 5: R74's [DIAGNOSES REDACTED]. While R74 was residing in the facility, he was closely monitored by the Cardiac Clinic and was receiving [MEDICATION NAME], an anticoagulant (AC) as part of his medication regimen, with changes in dosages being made according to his laboratory work. In reviewing the Minimum Data Set Assessments (MDSA's) the facility completed for R74, the Surveyor noted that Section N of the OBRA (Omnibus Budget Reconciliation Act) assessment did not accurately reflect R74's medications: [REDACTED] - Admission MDS dated [DATE]: The anticoagulant ([MEDICATION NAME]), Diuretic ([MEDICATION NAME]) and opioid ([MEDICATION NAME]) R74 was taking, was not coded on this assessment. On 6/12/19 at 10:47 AM, the Surveyor interviewed the MDS Coordinator regarding R74's medications. The MDS Coordinator stated she would look into the assessment. At 12:18 PM, she returned to the Surveyor and stated that she had indeed coded the wrong discharge on R74's assessment, I should have coded him as going home, as he was discharged to home with his mom and Dove services. Example 6: R75 was admitted [DATE] for therapy services and strengthening. The facility completed a discharge Minimum Data Set assessment dated [DATE]. According to the assessment, the facility coded R75 as being discharged to the hospital when he was actually discharged home on[DATE] with home services. On 6/12/19 at 10:47 AM, the Surveyor interviewed the MDS Coordinator regarding R75's discharge. She stated she would verify the discharge status of R75. At 12:18 PM, The MDS Coordinator and the Director of Clinical Reimbursement approached the surveyor. The MDS Coordinator stated, I modified the MDS .I miscoded his discharge. The Director of Clinical Reimbursement stated that she has been doing some education and needed to modify several MDS's. She noted inaccuracies on MDS Assessments. She stated that it was first evident when she was reviewing the influenza vaccines being inaccurately coded and .when I started digging, I found other inaccuracies as well. She further stated that the facility recently implemented a Performance Improvement Plan (PIP) however, is now noticing additional coding errors in other sections of MDS assessments. She stated the goal is to eventually have a part-time MDS Coordinator it is a big load with one person doing assessments on 70 residents. She stated that she is aware of the issues with inaccuracies and is working on getting them fixed.

Based on interview and record review, the facility did not ensure 5 of 20 residents (R36, R12, R47, R57 and R69) reviewed for MDS (Minimum Data Set) Assessments, accurately reflected the residents status. The facility did not complete the entire Section C, Cognitive Patterns, for R36 on both MDS assessments completed. The facility did not code accurately or completely on MDS's for R12, R47 and R57 to include falls and/or medications. R69 was admitted on [DATE] with Quetiapine [MEDICATION NAME] an antipsychotic medication. This medication was not coded R69's Minimum Data Set assessment dated [DATE]. Example 1: R 36 has medical [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessments (MDSA) completed for R 36 revealed the facility did not complete Section C 100 -1000: Cognitive Patterns, in both of the OBRA (Omnibus Budget Reconciliation Act) assessments completed for R36. This entailed the admission assessment dated [DATE] and the Quarterly assessment dated [DATE]. Both MDSA's were coded as Not Assessed. This section assesses an individual's mental status, memory recall, daily decision-making skills and [MEDICAL CONDITION]. The facility did complete their own assessment titled Brief Interview For Mental Status dated 11/19/17. However, a score was not indicated for R36. Instead, it states To Be Determined and the entire assessment was left blank. The facility completed another Brief Interview For Mental Status assessment dated [DATE] and assessed R36 as being Cognitively Intact. However, this information was not transferred on to the OBRA assessment. On 4/5/18 at 10:06 AM Surveyor interviewed the MDS Coordinator (MDSC) on how she completes the MDS Assessments. MDSC stated the Social Worker (SW) is responsible for completion of Section C. The Surveyor asked her to bring up R36's two OBRA MDSA's and together, reviewed Section C. She also noted that the section was coded as being not assessed. When asked why it would be coded as not assessed, MDSC stated that she could not speak for the SW but .it probably means that she couldn't get to the assessment by the end of the assessment period . At 10:30 AM, the Surveyor interviewed the SW regarding the sections she is responsible for completing on the MDSA's. The SW stated that she completes sections D, E and Q and recently, within the last few months, started completing Section C. Prior to a few months ago, SW stated the MDSC was responsible for completing Section C. The SW referred the Surveyor to the sections of the MDS that identifies the initials of the person completing that particular area. When reviewing both MDSA's, the MDSC's initials were listed as completing Section C. At 10:37 AM. the Surveyor re-interviewed the MDSC regarding the statements made by the SW. MDSC stated the reason her initials are identified as completing Section C was because the SW did not complete her assessment timely. MDSC had to go in and code not assessed for this reason. Example 2 R12 was readmitted to the facility in (MONTH) of (YEAR). His [DIAGNOSES REDACTED]. Observations by Surveyor found that he is dependent of the assistance of staff to transfer in and out of his wheel chair. R12's MDSs for Section J, the section indicating falls both recent and in the past was not assessed and coded. According to the nursing notes and Risk Management notes R12 has fallen on 12/16/17, 10/29/17 and 0/31/17. The MDSs dated 3/26/18, 1/5/18, and 11/10/17 were blank. Example 3 R47 was admitted to the facility in (MONTH) of (YEAR). Included in his [DIAGNOSES REDACTED]. Since his admission he has received the antipsychotic drug [MEDICATION NAME] for a mood disorder. This drug has never been coded on his MDSs. Example 4 R57 has was admitted to the facility in (MONTH) of 2013. Included in her [DIAGNOSES REDACTED]. The MDS dated [DATE] is coded that R57 had one fall. The nursing notes and risk management reports indicate she had 3 falls in the reportable time frame, 2/15/18, 1/9/18, and 1/3/18. On 4/18 at approximately 10:30 a.m. Surveyor asked the MDS coordinator to review these errors in coding and report back if the information was wrong or if a correction should be submitted. No information was received. Example 5: Surveyor review of R69's physician's orders [REDACTED]. QUEtiapine [MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth two times a day related to Dementia in other Diseases Classified elsewhere without Behavioral Disturbance. started 01/15/18. This is a antipsychotic medication. Surveyor review R69 's admission 5 day Minimum Data Set Assessment ((MDS) dated [DATE], indicates a score of 2 for mood, no behavioral symptoms and no antipsychotic. The antipsychotic was not coded on this MDS. On 04/05/18 08:34 AM Surveyor interviewed the MDS nurse. Surveyor and MDS nurse reviewed R69's Admission MDS dated [DATE]. The MDS nurse indicated don't know what happened with not coding the antipsychotic. On 04/05/18 11:44 AM per(NAME)MDS nurse: verified that she missed R69's Quetiapine [MEDICATION NAME] on the MDS.

Based on interview and record review the facility did not ensure 1 of 20 sampled residents (R53) had a significant change MDS (Minimum Data Set) when a decline in overall status occurred that was not self-limiting. R53 had a significant decline in function due to the loss of both lower extremities. The decline was not captured by the facility. This is evidenced by: According the the RAI (Resident Assessment Instrument), a significant change in status MDS is required when a condition occurs when a resident experiences a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline. Surveyor completed a review of R53's MDS's and noted the following. R53's admission MDS was dated 12/8/16. The MDS indicated R53; ~ Was cognitively intact; ~ Had no mood indicators; ~ Required no assistance with bed mobility and supervision for transfers; ~ Walked with limited assistance of one staff person; ~ Required limited assistance for hygiene; ~ Was continent of bowel and occasionally incontinent of bladder; ~ Had no pain; and ~ Had no weight loss. R53's MDS dated [DATE] to the next required assessment dated [DATE] indicated a decline in multiple care areas. R53's next required assessment was noted as a quarterly assessment. The assessment was dated 3/8/18. The MDS indicated R53; ~ Had a mood indicator score of 3; ~ Required extensive to total assistance of 1 to 2 staff persons for all aspects of care including bed mobility, transfers, using the bathroom, dressing and hygiene needs; ~ Did not walk; ~ Was frequently incontinent of bowels; ~ Had pain; and ~ Had weight loss. The MDS dated [DATE] should have been completed as a significant change MDS. This would have triggered the facility to complete a comprehensive assessment of R53's status. This in turn would have trigger the facility to review of R53's plan of care in order to ensure R53 was receiving the care required. On 4/5/18 at 10:05 a.m., Surveyor spoke with the MDSC (Minimum Data Set Coordinator), the CCN (Corporate Clinical Nurse) and DON (Director of Nursing). Surveyor reviewed the changes as noted in the above MDS assessments with the MDSC. The MDSC indicated she had not thought R53's changes should have triggered a significant change MDS. The MDSC indicated she did use the RAI manual to assist her in completing MDS assessments. On 4/5/18 at 11:40 a.m., the MDSC approached Surveyor and indicated she had spoken with their regional clinical reimbursement specialist and they were looking over R53 to determine whether or not there had been a significant change in R53's status. The MDSC also stated they were in the window of when a significant change MDS needed to be done. According to the RAI manual, once a significant change in condition has been noted the MDS must be completed within 14 days. R53's significant change was noted at least by 3/8/18 when the quarterly MDS was completed. The facility was not in the window of time in which a significant MDS must be completed.

Based on observation, interview, and record review, the facility did not ensure 1 of 10 sampled residents with falls had an environment as free from accident hazards as possible. R28 had multiple falls, including injury falls. The facility did not complete a thorough investigation following every fall in order to determine the root cause of the fall, place interventions based on the root cause of the fall, nor ensure fall precautions were in place. R28 subsequently continued to fall. This is evidenced by: R28 has current [DIAGNOSES REDACTED]. R28 is also legally blind. R28's most current MDS (Minimum Data Set) was dated 1/18/18. The MDS indicated R28; ~ Had both short and long-term memory problems; ~ Required extensive to total assistance of 1 to 2 staff persons for all aspects of care; ~ Did not walk; ~ Could not maintain balance without staff support; and ~ Was always incontinent of both bowel and bladder. R28 fall care plan was dated 10/2/13. The care plan had the following approaches. ~ 10/2/13, .Call light or personal items available and in easy reach .Footwear to prevent slipping .Gait belt with transfers .Grab Bars on bed for bed mobility . Keep environment well lit and free of clutter .Orientation to roommate, staff, and surroundings as needed d/t (Due to) vision deficits .Pressure alarm in W/C & (Wheel Chair and) bed Toilet plan per CP (Care Plan) . ~ 11/3/15, .Safety strips at bedside .Gripper socks on at HS .Body pillows for support and repositioning .When resident chooses to sleep in the morning, staff will do 30 minute safety checks . ~ 7/28/16, .Staff to ensure resident not twisted in bedding .When resident listening to music, place sensory item in lap . ~ 1/5/17, .Staff to ensure small lap-throw blankets are not placed on residents bed. To be used when up in w/c only . ~ 5/22/17, .Place Dysem under cushion and alarm on w/c to prevent cushion from sliding forward when resident is scooting in chair . ~ 6/15/17, .When resident showing signs of restlessness in bed, staff to get her up in w/c and bring her out of room for staff to monitor . ~ 6/20/17, .Q2 hr (Every two hour) checks with toileting to ensure resident is wearing both gripper socks . ~ 7/12/17, .Music to be played softly in room at night to calm resident prn (as needed) . ~ 10/19/17, .When up in wheelchair, resident not to be left unattended in lobby. Staff to keep her in sight . ~ 11/11/17, .to be assisted to quiet location .to reduce stimuli and provide music of choice . ~ 11/27/17, .Resident to be assisted to bed following dinner meal . ~ 3/28/18, .Bed in low position . ~ 3/30/18, .Room Change with a bariatric bed to allow for resident to move more freely in bed . Surveyor completed a review of R28's falls. Information regarding falls was noted in multiple different formats within the facility's electronic charting system including nursing notes, a form titled Post Fall Assessment and a form titled Risk Management. According to the CCN (Corporate Clinical Nurse) the Risk Management form was the facility's investigation. Surveyor completed a review of all 3 forms and noted the following. On 5/22/17 R28 had a non-injury fall. A nursing note indicated at 6:30 p.m., .CNA (Certified Nursing Assistant) heard resident's alarm and turned to find her slaying (sic) on the floor in front of her W/C (wheelchair) under her spot at the dining room table .was wearing well-fitting shoes, the floor was free of clutter, and the room was well lit .Resident could MAE (Move All Extremities), and sat up on her own .Recommendations: Place Dysem under chair cushion on W/C to prevent the cushion from sliding forward when resident is scooting in chair . Surveyor did not receive a Post Fall Assessment following R28's fall on 5/22/17. The facility's investigation reiterated the information found in the nursing note dated 5/22/17. The form indicated the root cause of R28's fall was R28's cushion slid when R28 was scooting forward in a wheel chair. On 6/14/17 R28 had a non-injury fall. A nursing note indicated, .Resident found sitting on her bedroom floor next to her bed at 2100 (9:00 p.m.) .was resting comfortably in bed before fall .shows no s/s (signs or symptoms) of pain or discomfort .Intervention: staff to get her up in the wheel chair and bring out to a common area when restless . The Post Fall assessment dated [DATE] indicated R28 did not have gripper socks on, and was attempting to get out of bed. The intervention put into place was to apply gripper socks. According to R28's care plan, R28 should have had gripper socks on. The facility's investigation reiterated the information found in the nursing note dated 6/14/17. The form indicated the root cause of R28's fall was restlessness. The nursing note however indicated R28 was resting in bed. The facility added a new approach which included to assist R28 in the wheel chair and bring R28 to a common area when restless. On 6/15/17 R28 had a non-injury fall. A nursing note indicated, .Resident found sitting on floor at the end of her bed at 1400 (2:00 p.m.) .With one gripper sock removed. Floor was dry, free of clutter . no apparent injury .Intervention: every 2 hours checks with toileting to ensure resident si (sic) wearing both gripper socks . The Post Fall Assessment reiterated the information found in the nursing notes dated 6/15/17. The immediate intervention put into place was .Staff education . The facility's investigation indicated the root cause of the fall was R28 had removed one gripper sock. The facility placed a new intervention to check to ensure R28 had gripper socks on every 2 hours when assisting R28 with using the bathroom. R28's care plan indicated from a fall the day prior to assist R28 into a wheel chair when attempting to get out of bed. On 7/10/17 R28 had a non-injury fall. A nursing note indicated, .2355 (11:35 p.m.) resident had an unwitnessed fall in room next to bed. Bed alarm was sounding prior to fall. CNA responded and found resident sitting next to bed. Resident alert and talking per baseline. VS(Vital Signs) .stable. No pain at this time . Resident is known to talk to self and attempt to transfer self without assistance . Bed and wheelchair alarm in place per careplan .Recommendations: Assist resident's need q (every)hour .Play low music during night .staff to get her up in the wheel chair and bring out to a common area when restless . The Post Fall Assessment reiterated the information found in the nursing note dated 7/10/17. The form also indicated R28 had been incontinent and that staff were again re-educated. The facility's investigation reiterated the information found in the nursing note dated 7/10/17. The form also indicated R28 was .likely awake/active . R28's care plan already had an approach to assist R28 into a wheel chair and bring to a common area when restless. Information also indicated R28 had been incontinent. There was no indication the facility assessed R28's bladder function in order to determine if R28's toileting plan was appropriate. R28 had several falls from her bed. There was no indication the facility thoroughly investigated the circumstances regarding R28's falls from bed. Each facility form and nursing notes all had different information, none of which was comprehensively assessed. There was no indication if R28's body pillows were in use as care planned. On 7/27/2017 R28 had a non-injury fall. A nursing note indicated, .Resident found sitting on the floor and leaning on her wheelchair in the family room at 1900 (7:00 p.m.) .Full head to toe assessment conducted .No areas of concern during skin check. Resident showed no s/s of pain . The Post Fall Assessment reiterated the information found in the nursing note dated 7/27/17. The form under the title Care Plan .List New Immediate Interventions . was blank. The facility's investigation reiterated the information in the nursing note. The investigation indicated, .Root cause: Resident fell asleep in wheelchair. Intervention: Provide HS (hour of sleep) cares and assist to bed . On 10/7/17 R28 had a non-injury fall. A nursing note indicated, .at 2320 (11:20 p.m.) resident's alarm was heard. CNA and writer went to room and found resident on the floor, in a seated position facing bed. No signs/symptoms of injury . There was no Post Fall Assessment completed. There was no investigation following the fall of 10/7/17. There were no new interventions put into place to prevent further falls. On 10/19/17 R28 had a fall with injury. A nursing note indicated, . At 1950 (7:50 p.m.), staff were all coming out of rooms on wing when we heard pressure alarm go off in lobby. We hurried to lobby and found resident laying on floor in front of wheelchair. We carefully turned resident onto her back. Quick assessment performed at that time. ROM per resident's norm. Found 1 to 1-1/2 in bruise to left forehead with slight abrasion. Immediately applied cool pack to head. Resident was then lifted from floor with mechanical lift and transported to room and then bed. No other injuries found .History of falls, dementia and poor to no vision .Found 1 to 1-1/2 in (inch) bruise to left forehead with slight abrasion. Immediately applied cool pack to head. Resident showed no signs of pain except when cool pack applied to forehead .Recommendations to continue pressure alarms in both bed and wheelchair . The Post Fall Assessment reiterated the information found in the nursing note dated 10/19/17. The Post Fall Assessment also indicated R28 was not to be left unattended in the lobby. The facility's investigation indicated, .Root cause: Resident restless in wheel chair. Intervention: When restless in wheelchair, resident not to be left unattended in lobby, keep in sight, assist to bed if appropriate . On 11/11/17 R28 had a non-injury fall. A nursing note indicated, . 07:45 (7:45 a.m.) .Aide called nurse into room, nurse walked in and resident was laying on the floor at the foot of her bed. Bed alarm was going off when aide went into room. Bed was in lowest position .Resident not able to get up on her own and is blind .no signs or symptoms of pain . Recommendations: Add more siderails to bed or push bed against wall to help. The Post Fall assessment dated [DATE] reiterated the information found in the nursing note dated 11/11/17. The facility's investigation indicated, .Root cause: Resident requiring stimuli/activity upon waking. Intervention: Resident to be assisted to stereo .to provide activity/music of choice .during down time . R28 was already supposed to have music playing and be assisted into a wheel chair when attempting to get out of bed. There were no new interventions put into place. On 11/24/17 R28 had a non-injury fall. A nursing note indicated, .Aide heard pressure alarm going off at 1920 (7:20 p.m.) and went to resident who had been sitting in wheelchair in hallway. Just as aide arrived, she saw resident on knees in front of wheelchair and then she laid down on floor. Resident was asleep. Writer came immediately after and saw resident sleeping on floor. Resident was assessed .No injuries noted . The Post Fall assessment dated [DATE] reiterated the information found in the nursing note dated 11/24/17. The facility's investigation indicated, .Root cause: Resident was in w/c became tired and laid on floor. Intervention: Assist Resident to bed following dinner meal if tired . This was R28's third fall from the wheel chair. There was no indication through the facility's investigation they assessed R28 wheel chair positioning. R28 already had an approach to assist R28 to bed when tired. There were no new approaches added to R28's plan of care to prevent further falls. On 3/1/18 R28 had a non-injury fall from the wheel chair. A nursing note indicated, .14:23 (2:23 p.m.) CNA .states resident pushed herself forward in the chair, landed straight on her bottom and rolled backwards. Resident did not hit head .Resident is . blind and has limited awareness of surroundings. Resident did not seem anxious before fall .did not appear to be in pain, with or without movement. Resident did not have any redness to back, or bottom, or any where else. Resident appeared tired . The Post Fall assessment dated [DATE] reiterated the information found in the nursing note dated 3/1/18. The facility's investigation indicated, .Root Cause: w/c cushion soiled. removed from w/c for cleaning. Intervention: appropriate surface provided while w/c cushion being washed . The facility's investigation indicated R28 had been incontinent. There was no indication the facility re-assessed R28's bladder status in order to determine if R28's current toileting schedule was still appropriate. On 3/15/18, R28 had an injury fall from the wheel chair. A nursing note indicated, . 15:31 (3:31 p.m.) .A family member yelled to a cna that a resident needed help in the common area. The CNA ran to the resident just as she was falling out of her chair. The resident fell to her knees then face first onto the floor. ROM (Range of Motion) and vitals WNL(Within Normal Limits) .has bruises no (sic) both knees and a large black and blue goose egg to the middle of her forehead .When writer approached resident she was on the floor on her stomach crying ouch. She then rolled onto her side and held her forehead with her hands .Large black and blue goose egg to the middle of her forehead. Both knees black and blue. During assessment resident was found to have large amounts of stool in her rectal pouch . The Post Fall Assessment reiterated the information found in the nursing notes dated 3/15/18. The facility's investigation indicated, .Root cause: Resident needing to have a bowel movement. Interventions: Assist to the bathroom .obtain order for suppository . This was the third time the facility identified R28's fall was associated with an unmet toileting need. There was no indication the facility comprehensively assessed R28's bowel and bladder status in order to determine the most effective toileting schedule. Additionally, this the the fifth time R28 had a forward fall from the wheel chair and second time R28 sustained head trauma. There was no indication the facility assessed R28's wheel chair positioning to ensure R28 was seated in a fashion to maintain safety. On 3/28/18 R28 had a non-injury fall from the bed. A nursing note dated 3/28/18 indicated, .Writer standing outside of room [ROOM NUMBER] at 0700 (7:00 a.m.) this morning, heard a noise as if the bedside table was pushed and then a voice repeating the word 'ow!' .Resident was last seen sleeping on bed .responded immediately to find resident in the fetal position on the floor in between her bed and her roommates bed, laying on her right side and her head pointing to the foot end of the beds. Recommendations: Resident assisted into w/c after morning cares . The Post Fall Assessment indicated R28 was not wearing gripper socks, was getting out of bed, the bed alarm was not sounding and R28 had been incontinent. The form indicated staff were re-educated. R28's care plan had not been followed. R28 was supposed to be wearing gripper socks, and a bed alarm. Neither were in place. Additionally R28 was noted to have been incontinent. There was no indication the facility assessed R28 bladder status in order to determine if R28's toileting schedule was appropriate. The facility's investigation indicated the root cause of the fall was R28's inability to know where the edges of the bed were. The facility implemented a room change and bariatric bed. While the facility implemented a new approach, they did not address other important information gleaned from the nursing notes and post fall assessment form. 04/02/18 11:48 a.m., Surveyor observed R28 seated in wheel chair. R28's legs were crossed. The foot of R28's leg not crossed was not firmly planted on the floor. 04/02/18 2:25 p.m., Surveyor observed R28 in bed laying on the side facing door. There were pillows in front of and behind R28. R28's bed was noted not in the lowest position closest to the floor. According to R28's care plan, R28's bed was to be in the lowest position. 04/03/18 2:02 p.m., Surveyor observed R28 in her wheel chair. Surveyor also noted R28's knees and hips were not at a 90 degree and are approximately at a 75 degree angle. Surveyor observed R28 cross her legs. When doing this, Surveyor noted the foot of the leg not crossed was not firmly planted on the floor but suspended slightly. Should R28 lean forward there would limited ability for R28 to stop the forward motion resulting in a face first fall from the wheel chair. On 4/4/18 at 7:77 a.m., Surveyor observed CNA-I (Certified Nursing Assistant) and CNA-K assist R28 with morning cares and to transfer into the wheel chair. Surveyor noted neither of R28's feet touched the floor while seated in the wheel chair. 04/05/18 at 9:01 a.m., Surveyor spoke with LPN-H (Licensed Practical Nurse) about the facility's fall prevention program. LPN-H indicated there were 3 components to their fall program which the nurses on the floor filled out. LPN-H stated they documented falls in the nursing notes, post fall assessment form and risk management form. LPN-H stated the nurses would then give a copy to the UM (Unit Manager) and DON (Director of Nursing). LPN-H indicated the UM determines the root cause and what interventions were to be placed based on the root cause of the fall. LPN-H indicated the nurses on the floor can and should put immediate interventions into place. Surveyor asked LPN-H about R28's falls. LPN-H indicated R28 had been falling for years. LPN-H indicated R28 was legally blind and had dementia. LPN-H indicated R28 reaches for things she thinks are there and then starts to grab. LPN-H indicated R28 was antsy when R28 needed to use the bathroom. 04/05/18 09:12 AM Surveyor spoke with UM-G. UM-G indicated she was the UM on the unit where R28 resides. Surveyor asked UM-G about the facility's fall prevention program. UM-G stated the nurses on the floor complete 3 separate documents component the nursing notes, post fall assessment, and risk management form. UM-G stated the nurses update management with any injury fall or any resident on [MEDICATION NAME]/blood thinner. UM-G stated during their daily morning report attended by all department heads, falls are talked about in conjunction with other facility issues. UM-H stated as a team, they look at all information from the fall reports and try to identify the reason the resident fell and put interventions into place based on what the team thought the cause of the fall was beyond the immediate ones put into place by the nurse. UM-G stated the nurses were responsible to investigate and identify root cause. UM-G stated she and the interdisciplinary team reviewed the investigation and root cause. Surveyor asked UM-G about R28's fall. UM-G indicated some falls were related to incontinence. UM-G stated if R28 was placed on the toilet she remained continent. UM-G indicated R28 scoots herself forward in the wheel chair and indicated R28 was very active even though blind. On 04/04/18 at 8:44 a.m., Surveyor spoke with COTA-L (Certified Occupational Therapy Assistant). COTA-L indicated occupational therapy had not seen or screened R28 for a long time. COTA-L indicated R28 was on hospice and therapy did not see anyone receiving hospice services. COTA-L also indicated R28 had been seen for wheel chair positioning historically. COTA-L stated there was no record of any therapy or screening done for R28 over the last year. Surveyor asked COTA-L what she looks for when determining appropriate wheel chair positioning. COTA-L indicated a resident's feet needed to be firmly planted on the floor so the resident was grounded. The resident needed to be seated with knees and hips at a 90 degree angle, and the depth of the wheel chair should be long enough that the seat itself rested at the back of a residents knee. Surveyor asked COTA-L about R28's wheel chair. COTA-L indicated she felt R28 was in the wrong type of chair. On 04/05/18 at 11:57 a.m., Surveyor spoke with the CCN and DON. The CCN indicated when a fall occurred, the nurse was responsible to investigate the cause of the fall at the time of the fall including assessing the residents environment and then place new approaches based on the cause of the fall. The CCN indicated in (MONTH) he identified issues with the facility's documentation of falls. The CCN stated he implemented a process improvement program on 2/21/18 which the facility has just started.

Based on observation, interview, and record review the facility did not ensure 1 of 3 residents reviewed (R20)for UTIs (Urinary Tract Infections) received the necessary care and treatment to prevent a UTI from occurring. R20 had historical UTIs. On 4/2/18 R20 was noted to have had an incontinent episode. Observations of 2 CNA's (Certified Nursing Assistants) performing care reveled there was no peri care completed after the incontinent episode to remove all urine from R20's skin. This is evidenced by: R20 has a [DIAGNOSES REDACTED]. R20's most current MDS (Minimum Data Set) was dated 1/25/18 and indicated R20 required extensive to total assistance of 1 to 2 staff persons for all aspects of care and was always incontinent of both bowel and bladder. On 04/02/18 at 12:59 p.m., Surveyor observed CNA-I and CNA-J assist R20 to the bathroom. Both CNA-I and CNA-J assisted R20 into the bathroom and onto the toilet using a sit-to-stand lift. CNA-J removed R20's adult brief and indicated it was soiled with urine. R20 also voided on the toilet. CNA-I and CNA-J assisted R20 into a standing position using the lift. CNA-J obtained toilet paper wiped R20's buttock with toilet paper. Both CNA-I and CNA-J applied a clean adult brief. There was no frontal or posterior peri care done. Family-M was in R20's room during the observation. Family-M asked CNA-I if she needed the wipes to cleanse R20's skin. CNA-I responded she didn't as R20 did not have a bowel movement. Surveyor spoke with Family-M. Family-M indicated R20 has been listless, had decreased appetite, and occasional behaviors the last couple of days. Family-M wondered if R20 had a bladder infection. R20 was seen in the emergency room the evening of 4/2/18 and diagnosed with [REDACTED]. On 04/04/18 at 12:30 p.m., Surveyor asked CNA-I when peri care was completed. CNA-I said toilet paper is used unless the resident had a bowel movement, then wipes should be used. Surveyor questioned CNA-I's practice. CNA-I then indicated peri care should be done using wipes or a washcloth after any incontinent episode including both stool and urine. On 04/05/18 at 09:28 AM Surveyor spoke with UM-G (Unit Manager). UM-G indicated all residents should receive anterior and posterior peri care after any incontinent episode.

Based on interview and record review the facility did not ensure 3 of 13 residents (R46, R53, and R67) reviewed for hydration status received the appropriate amounts of fluid to maintain proper health. R46 was on a 1500 cc (cubic centimeter) fluid restriction due to end stage [MEDICAL CONDITION]. There was no process in place to tally the 24 hours totals of fluid intake. R53 was on a 1500 cc fluid restriction due to [MEDICAL CONDITION]. Despite that, there was no process in place to tally and monitor R53's 24 hour totals of fluid intake. R67 was on a 1500 cc fluid restriction due to [MEDICAL CONDITION]. There was no process in place to tally and monitor R67's 24 hour totals of fluid intake. This is evidenced by: It was the facility's practice to document intake in 2 separate formats, the CNA (Certified Nursing Assistant) charting when documenting fluids consumed during meals, and MAR (Medication Administration Record) where fluids were documented with medications. There was no process in place to document intakes of snacks or other fluids consumed. Example 1: R46 has [DIAGNOSES REDACTED]. On 4/25/17 the physician ordered a 1500 cc fluid restriction. Surveyor requested R46's total fluid intake over a 24 hour period for the last 30 days. Surveyor received 2 separate entries of fluid intake; CNA documentation of fluids during meals and the MAR. There was no place in which the 2 documented intakes were tallied. Additionally there was no process in which other fluids R46 may receive were documented. Surveyor completed a review of both the CNA documentation of intake and the MAR indicated [REDACTED]. ~14 of the 14 days received had incomplete CNA documentation of fluids at meals. ~5 of the 14 days received had incomplete documentation of fluids given with medications. ~4 of the 14 days received indicated R46 had greater than 1500 cc's of fluids. It was critical to have accurate intake and for all fluids consumed over a 24 hour period to be tallied. This was necessary in order to inform R46 physician and [MEDICAL TREATMENT] provider in order to determine treatment in order for R46 to maintain proper health. Example 2: R53 has current [DIAGNOSES REDACTED]. On 1/17/18 a physician ordered a 1500 cc fluid restriction. Surveyor requested R53's total fluid intake over a 24 hour period for the last 30 days. Surveyor received the CNA documentation of fluids during meals and the MAR. There was no place in which the 2 documented intakes were tallied. Additionally there was no process in which other fluids R53 may receive were documented. Surveyor completed a review of both the CNA documentation of intake and the MAR indicated [REDACTED]. ~ 17 of the 26 days had incomplete CNA documentation of fluid intake during meals. ~ 1 day of 26 had incomplete documentation fluid given during medication administration. ~ 12 of the 26 days R53 had greater than 1500 cc's of fluid. Example 3: R67 has a current [DIAGNOSES REDACTED]. On 10/14/17 R67 had a physician ordered a 1500 cc fluid restriction. Surveyor requested R67's total fluid intake over a 24 hour period for the last 30 days. Surveyor received CNA documentation of fluids during meals and the MAR. There was no place in which the 2 documented intakes were tallied. Additionally there was no process in which other fluids R67 may receive were documented. Surveyor completed a review of both the CNA documentation of intake and the MAR indicated [REDACTED]. ~ 3 of the 25 days received had incomplete documentation of fluids consumed during meals. ~ 2 of the 25 days received had incomplete documentation of fluids consumed during medication administration. ~ 23 of the 25 days received R67 had greater than 1500 cc's of fluid. On 04/04/18 at 10:00 a.m., Surveyor spoke with the CCN (Corporate Clinical Nurse) about the facility's practice for monitoring fluid restrictions. The CCN indicated fluids noted on the CNA documentation was intake from meals only and not what is taken during medication administration or snacks. The CCN indicated a 24 hour tally would need to be manually completed by either the UM (Unit Manager) or dietary. On 04/04/18 at 10:11 a.m., Surveyor spoke with LPN-H (Licensed Practical Nurse) about the facility's practice for documenting and tallying 24 hours fluid restrictions. LPN-H indicated the nurses document in the MAR indicated [REDACTED]. LPN-H indicated she was not sure but thought the UM did. On 04/05/18 at 09:25 a.m., Surveyor spoke with UM-G about the facility's practice for documenting and monitoring fluid restrictions. UM-G indicated she did not tally 24 hour totals every day. UM-G stated she was not sure who did. On 04/05/18 at 11:45 a.m., Surveyor spoke with the CCN and DON (Director of Nursing). The CCN indicated the facility did not have a system in place to tally intakes. The CCN indicated this was overlooked when the facility added new elements to their electronic charting system.

Based on interview and record review, the facility did not provide residents with a written bed hold notice, to those residents who were transferred from the facility. This occurred for 3 of 5 residents (R14, R3 and R10) reviewed for transfers and discharges. This is evidenced by: On 03/23/17, Surveyor received and reviewed part of the facility's admission paperwork. The section entitled, 'Bed Holds' and Readmissions states the following, in part: .If you will be temporarily absent from the (Facility) for hospitalization or therapeutic leave, you may request the (Facility) to hold your bed during this time (called a 'bed hold') .We will notify you and/or your Legal Representative of the option to pay the applicable daily rate for each day we hold your bed open. You and your representative have 24 hours after receiving this notice to let us now whether you want us to hold your bed for you . 1. On 03/22/17, Surveyor reviewed R14's medical record. The resident has a legal guardian. The medical record indicates the resident transferred from the facility to a hospital on [DATE], 06/28/16, and 03/07/17 R14's medical record does not include documentation the resident's legal guardian was provided with a bed hold notice upon discharge or within 24 hours of each transfer to the hospital. 2. On 03/21/17, Surveyor reviewed R3's medical record. The resident has an activated Power of Attorney for Healthcare (POAHC). The medical record indicates the resident transferred from the facility to a hospital on [DATE], and 02/24/17. R3's medical record does not include documentation, the resident or the POAHC, was provided with a bed hold notice upon discharge or within 24 hours of each transfer to the hospital. 3. On 03/22/17, Surveyor reviewed R10's medical record. The resident has an activated POAHC. The medical record indicates the resident transferred from the facility to a hospital on [DATE]. R10's medical record does not include documentation the resident's POAHC was provided with a bed hold notice upon discharge from the facility; on or within 24 hours of 09/29/16. On 03/22/17 at 2:50 p.m., the Director of Nursing stated the facility does not complete written bed hold notices when a resident is transferred out of the facility.

Based on observation, record review and interview, the facility did not develop and implement a comprehensive person centered care plan for all residents. A psychosocial care plan was not developed for 1 of 15 sampled resident care plans reviewed. R8 did not have a care plan related to psychosocial coping or situational depression. This is evidenced by: R8 [DIAGNOSES REDACTED]. On 03/21/17, at 02:15 p.m., Surveyor interviewed R8. R8 stated It's so hard being dependant on other people .you know I've been doing things for myself my whole life. I farmed with my family, and that was a lot of hard work I know my life has changed, and it is hard to get used to I can remember everything about that day I have to figure out a way that I'm going to be able to do things for myself and I don't know how I am going to do it, even with therapy. I am worried, of course I'm worried I'm supposed to have the fingers removed from both hands in April, then come back here for therapy .I'm so used to living alone and doing my own thing I hate the fact that now I have to ask other people .my life has changed . On 03/21/17, at 01:00 p.m., Surveyor reviewed R8s' comprehensive care plan. The care plan did not include psychosocial measures to assist R8 to cope with pending amputations of bilateral fingers. Surveyor reviewed R8s' progress notes. A note, dated 03/13/17, read: PHQ9 (an interview tool used to measure depression)completed with resident this afternoon .Resident was told that he would loose most of his fingers .Resident scored a 12 on PHQ-9 (indicating moderate depression) and stated that he feels bad about himself, hopeless, and has trouble concentrating on things and that he has no interest or pleasure in doing things. Resident stated everything I used to be able to do before, I need to figure out a way to do it. I can't do the things that I used to enjoy doing because of this. PHQ-9 placed in physician book. Will continue to follow and support resident. A nurses note, dated 03/14/17, read: Resident appears to be handling news about losing most fingers well. Resident stated he did not want to be asked all the time about his situation Another note stated: PA (Physicians' Assistant) rounding in facility today updated that resident uses [MEDICATION NAME] and [MEDICATION NAME] (pain medications) prior and after dressing changes .PA in agreement and gave OK to schedule . There was no documented discussion of R8s' PHQ-9 score, or update to the PA, regarding R8s' coping skills related to the pending loss of his fingers. On 03/20/17, a progress note stated, in part, that: Resident screamed and hollered at the CNA (Certified Nursing Assistant) about the cares and the loss of his digits .appeared to calm down. On 03/23/17, Surveyor interviewed the DON. The above documentation was reviewed with the DON. The DON agreed that a psychosocial care plan should have been developed, with interventions designed to assist R8 with coping with the pending loss of his bilateral digits.

Based on record review and interview, the facility did not provide necessary care and services regarding consistent wound care to 1 of 2 residents reviewed for wound treatment. R8 did not receive wound care as ordered on [DATE] and 02/22/17. This is evidenced by: R8 [DIAGNOSES REDACTED]. A review of Physician order [REDACTED]. Place find mesh gauze over the open wound making sure to completely cover, secure with kerlix and burn netting every day and evening shift for frost bite TX (treatment). R8's progress notes on 02/18/17 indicated R8 did not receive wound care as ordered, Dressings to hands and feet only changed tonight due to shortage of supplies. Progress note on 02/22/17 states, Only able to change dressing to right foot as out of [MEDICATION NAME]. Received call from Alixa (pharmacy) regarding [MEDICATION NAME]. Reported they will not be able to obtain another tub of cream until tomorrow to their facility; we will receive cream the following day. Surveyor interviewed ADON (Assistant Director of Nursing) A who functions as the facility's wound care nurse. ADON A stated If the staff run out of supplies or medications are not available in the facility, all they have to do is call Walgreens (the local pharmacy), and they will deliver the supplies. ADON A also stated the facility performs audits regarding R8's wound care supplies, so there should have been no reason that the wound care was not completed. ADON A stated if the supplies had not been available, the staff should have notified the on call pharmacy to obtain supplies.

Based on record review and interview, the facility did not ensure 1 of 15 residents (R5) records reviewed had a complete and accurate medical record. As evidenced by: On 03/21/17 at 2:20 p.m., Surveyor reviewed the medical record for R5 and noted the following: - Minimum Date Set (MDS), dated [DATE], states R5 is severely cognitively impaired and requires maximum assistance for all activities of daily living. - R5 has a [DIAGNOSES REDACTED]. - Comprehensive nursing care plan, received 03/21/17, states R5 has a tube feeding in place for medications due to [MEDICAL CONDITIONS], subarachnoid hemorrhage, [MEDICAL CONDITIONS], difficulty in swallowing and administration of medications. WEEKLY SUMMARY CHARTING On 03/21/17 at 2:30 p.m., Surveyor reviewed nursing notes for R5 from 01/13/17 - 03/21/17 and noted no weekly summaries were documented. Surveyor noted no nursing documentation from 02/14/17 - 03/05/17. On 03/22/17 at 9:00 a.m., Surveyor interviewed the Director of Nursing (DON) in regard to the above noted nursing notes for R5. The DON stated he was unable to identify any nursing documentation from 02/14/17 - 03/05/17 and was unable to identify weekly summaries for the above noted time frame. The DON stated nursing staff should be documenting weekly assessments on R5 and would ensure immediate staff education be done. RANGE OF MOTION CHARTING On 03/21/17 at 2:20 p.m., Surveyor reviewed ROM documentation for R5 and noted the following: - R5 is to have a palm protector to right hand when up during the day and off when napping and at bedtime. Surveyor noted, during the month of February, 2017, ROM was initialed as being done 3 times out of 28 times for when the palm protector is to be on during the day and is initialed as being done 22 times out of 28 times for when the palm protector is to be removed at bedtime. - R5 is to have ROM care to ankles and toes with knees bent for 10 reps twice daily. Surveyor noted, during the month of February, 2017, morning reps were only initialed as being done 3 times out of 28 times. - R5 is to have ROM cares to al extremities every day with cares. Surveyor noted, during the month of December, 2016, ROM to all extremities was only initialed as being completed 14 times out of 31 times. On 03/22/17 at 9:00 a.m., Surveyor interviewed the DON in regard to the above noted ROM documentation. The DON stated staff should have been documenting all ROM and ensured education would immediately be done to all required staff.

Based on record review and interview, the facility did not ensure it had an effective infection control program consisting of recognizing and preventing outbreaks (including appropriate precautions and timely use of [MEDICATION NAME]), tracking and monitoring during an outbreak and proper hand hygiene per current standards of practice. This had the potential to affect all 25 residents within the facility dementia unit. 1. The facility did not recognize and take immediate preventive measures when an acute respiratory illness (ARI) symptoms were discovered within the Alzheimer Care Unit (ACU) or when the facility had a confirmed case of influenza A in the facility on that same ACU. -Resident #15 developed signs and symptoms of ARI within the facility on 01/19/15 and was not placed on droplet precautions. Resident #15 was hosptalized on [DATE] and diagnosed with [REDACTED]. -Resident #11 developed signs and symptoms of influenza on 01/25/15 and tested positive for influenza A while in the facility. -Resident #13 developed signs and symptoms of ARI on 01/26/15. Resident #13 was not placed on droplet precautions and did not receive anti-viral medication until 02/02/15. Resident #13 was hosptalized on [DATE]. -Resident #15 returned to facility on 01/26/15 with a physician order [REDACTED].#15 was not placed on isolation precautions. On 01/30/15, Resident #15 was readmitted to the hospital diagnosed with [REDACTED]. -On 01/27/15, Resident #20 developed signs and symptoms of an ARI and was not placed on droplet precautions and was not treated with antiviral medication. On 01/31/15, Resident #20 developed worsening respiratory signs and symptoms and had a fever. Resident #20 was sent to the emergency room (ER) where Resident #20 was admitted with a [DIAGNOSES REDACTED]. -On 01/30/15, Resident #1 developed signs and symptoms of an ARI and was not placed on droplet precautions. Resident #1 did not receive antiviral medication until 02/03/15. -On 01/30/15, Resident #12 developed signs and symptoms of an ARI and tested positive for influenza A. Resident #12 was placed on droplet precautions and treated with [MEDICATION NAME]. On 02/02/15, the facility's Medical Director (MD) was notified of positive influenza in the ACU and the MD ordered [MEDICATION NAME] to all other residents in the ACU as a [MEDICATION NAME] measure. On 02/02/15, Resident #13 was diagnosed with [REDACTED].#13 was not placed on droplet precautions upon return to the facility. On 02/04/15, Resident #13 tested positive for influenza A and was placed on droplet precautions. On 02/06/15, Resident #13 was admitted to hospital due to influenza signs and symptoms. Failure to implement immediate measures to prevent the spread of an infection placed all residents with the ACU at risk. The facility's failure to: -Assure that all residents with signs and symptoms of influenza were placed on droplet precautions. -Inform the medical director in a timely manner -Offer [MEDICATION NAME] to those residents on the infected unit in a timely manner -Isolate residents that were showing signs and symptoms of illness -Maintain an accurate line lists during the outbreak to include all interventions to prevent the spread of infection and all [MEDICATION NAME] treatment -Ensure that facility staff were not floated to or from the infected unit, and staff who had signs and symptoms of respiratory illness stayed home within policy recommendation. This created a finding of immediate jeopardy. The immediate jeopardy began on 01/26/15. The Nursing Home Administrator (NHA) was informed on 02/10/15 at 3:00 p.m., that immediate jeopardy existed. The immediate jeopardy was removed on 02/10/15. The deficient practice continues at a scope/severity level of an E (potential for more than minimal harm that is not immediate jeopardy/pattern) until all components of the facility's plan of correction have been fully implemented, including ongoing monitoring for effectiveness. Additional examples of noncompliance at severity level 2 include: Residents #3, #6, #7, and #2 received personal cares from caregivers who did not wash or sanitize their hands according to accepted professional practice. This is evidenced by: Facility Policy titled, Influenza Outbreak Guideline, dated 12/01/14, states, When is influenza in your facility an outbreak? If you see even one case of influenza in your facility, you have an outbreak and should place outbreak management procedures into place immediately. Regular surveillance and communication between line staff and administration MUST be done in order to identify any possible cases within your facility . - What are the symptoms of the influenza? fever - usually quick onset and high (over 100 degrees Fahrenheit), headache, tiredness-lethargy, non-productive cough, sore throat, runny or stuffy nose and body aches . - How do you know that you have influenza? Obtain only nasopharyngeal swabs for influenza and send to the lab for identification. Do not perform throat swabs for this purpose. Get this within the first 24 hours of symptoms to ensure you have fresh high concentrations of the virus for easier identification. Do viral cultures on 3-5 ill residents, if possible. You should try to collect swabs only on residents with fever >100F. If their fever is not >100F at the time, the viral load will be lower and the test will be much less sensitive. If no one spikes a fever >100F and multiple people have respiratory tract infections at the same time, it is advisable to err on the side of it being the flu . - What should you do if you suspect influenza? Do not wait to confirm the [DIAGNOSES REDACTED]. (Emphasis added.) All the following should be done as soon as influenza is suspected: Inform Administration at your facility .Call and inform your Medical Director - request order for [MEDICATION NAME] anti-viral medications for residents according to current recommendations. Consider medicating staff also .Inform all departments in your building and re-educate them on standard and droplet precautions .Place signs on all entrances of your building informing visitor/families/staff that you have influenza-like illness in your building .Draw the curtain between beds to help segregate residents .Initiate line listing of all residents with symptoms and keep updated with current and new cases on each station .Complete employee reports/line listing for all employees with symptoms .Do not move your staff around the buildings. Designated staff should stay on their regularly scheduled area and should not go from floor to floor .Do not allow ill staff to work - exclude them from care of the residents until 5 days from the onset of their symptoms .Educate all staff on hand washing/hand hygiene and use of proper barriers - document this education .Have masks available .Have gowns available .wear eye protection when caring for potentially infected patients .segregate ill residents from asymptomatic residents .restrict residents from common areas and serve their meals in their rooms .Make sure other departments do not bring ill residents to activities or therapies etc .All departments must check at nursing desk prior to taking residents out of their rooms Cancel all activities/serve all meals in rooms if several residents have influenza on a particular wing. Facility Policy titled, Infections - Clinical Protocol, dated October 2013, states: - Infection may be suspected based on clinical signs and symptoms and/or temperature . - The physician and staff will identify individuals with infections that may represent infection transmission risks and (in conjunction with the Infection Preventionist) will implement relevant precautions. Facility Standard of Practice titled, State of Wisconsin Department of Health Services memo dated 10/16/13 titled, Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities states the following: - 2.0 DEFINITION OF TERMS USED: 2.1 Acute respiratory illness (ARI) is defined as illness characterized by any two (2) of the following: fever, cough (new or worsening, productive or non-productive), Rhinorrhea (runny nose) or nasal congestion, sore throat, myalgia (muscle aches) great than the resident's norm. - 2.3 A respiratory disease outbreak in a LTCF (Long Term Care Facility) is defined by CDC (Center of Disease Control) and DPH (Department of Public Health) as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have: pneumonia, or ARI, or laboratory-confirmed viral or bacterial infection (including influenza). - 3.2 Laboratory Testing: 3.2.3: Due to possible false positive results when using rapid influenza tests, particularly when testing does not occur during the influenza season, confirmatory testing using RT-PCR or viral culture should be performed .3.2.6: If test results confirm influenza within a facility no further testing will be performed unless the resident has an atypical presentation of illness or is not responding to treatment .3.2.7: A negative test result does not rule out infection nor the existence of an outbreak. - 3.3 Antiviral [MEDICATION NAME] and treatment for [REDACTED]. shorten the illness duration. - 4.0 INFECTION CONTROL; 4.1 Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. In contrast to contact transmission, respiratory droplets carrying and transmit infectious pathogens when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances. - 4.4 Duration of Contact and Droplet Precautions: 4.4.1: When a resident has confirmed or suspected influenza, the resident should remain on droplet precautions for seven days or until 24 hours after the resolution of fever and respiratory symptoms, which ever is longer, after the onset of their illness.- 4.8 Exclusion of Staff with ARI: 4.8.1: Staff should be excluded from work until at least 24 hours after they no longer have a fever (without the use of fever-reducing medicines such as [MEDICATION NAME] or [MEDICATION NAME] 4.8.2: If symptoms such as cough and sneezing are still present, staff should wear a surgical mask during resident care activities. On 02/09/15 at approximately 9:45 a.m., Surveyor interviewed the Director of Nursing (DON) during the entrance conference at the start of the recertification survey. Surveyor asked the DON if the facility had had any infection outbreaks in the facility. The DON stated the facility currently had residents in the ACU who had tested positive for influenza but did not consider it an outbreak due to not having three residents test positive for influenza within 72 hours of each other. The DON stated the cases of influenza were only in the ACU and no cases were noted on other units of the facility. On 02/09/15 at approximately 1:00 p.m., Surveyor interviewed both the DON and the Assistant Director of Nursing (ADON) about the facility's infection control program. The DON stated the facility did have influenza in the ACU but did not consider it an outbreak due to there being a 72 hours break between cases. The DON stated they did contact the county health nurse to update them on residents in the facility that tested positive for influenza. The DON stated he was directed by both the county health nurse and by the facility's MD that it is only considered an outbreak if the there are three or more positive influenza cases within a 72 hour period. The DON stated the facility was currently nearing the end of the illness. The DON stated that no formal education on proper infection control measures was done by staff, but stated the staff were encouraged to use proper infection control hygiene while working on the ACU. Surveyor asked the DON what standards of practice the facility used for infection control. The DON stated the facility used McGeers to define an infection and utilized the infection control guidelines outlined in the State of Wisconsin Department of Health Services memo dated 10/16/13 titled, Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities. The DON stated if the facility did have an infection outbreak that they would use the state protocol, call the county health nurse, complete a timeline, implement precautions, provide education to both residents, family and staff, provide daily monitoring, discuss at quality assurance (QA) meetings and possibly close the unit and/or stop admissions. Surveyor asked the DON and ADON if a timeline had been created for those residents in the ACU unit when signs and symptoms of an ARI had developed and they both said, Yes. The ADON provided a copy of the timeline to this surveyor. Timeline Received on 02/09/15 On 02/09/15 at approximately 1:30 p.m., Surveyor received the facility's timeline for the influenza infection on the ACU. The facility's timeline indicated the following: - 01/19/15: Resident #15 developed respiratory signs and symptoms that included a cough and congestion. Resident #15 remained afebrile (no fever) and was swabbed for influenza. The swab results were negative. Chest X-ray completed and was negative. No further information provided on the timeline for this date. - 01/22/15: Resident #15's respiratory signs and symptoms had worsened and now a fever had developed. Resident #15 was sent to the ER where she was admitted and diagnosed with [REDACTED].#15's roommate at the facility was isolated to her room for 24 hours and monitored for signs and symptoms and was also started on [MEDICATION NAME] antiviral medication [MEDICATION NAME] per the facility's MD. Droplet precaution was initiated and the facility housekeeping were asked to increase bleach cleaning in the ACU. ACU staff were verbally educated on handwashing and sanitizing and droplet precautions. ACU staff to perform daily living task of table preparation prior to meals until further notice (table preparation is conducted by the residents within the ACU). The Department of Health nurse was notified of the confirmed positive influenza. - 01/25/15: Resident #11 developed signs and symptoms of lethargy and had a mild temperature. Resident #11 was swabbed for influenza A and test results were positive for influenza A. Resident #11 was provided antiviral medication [MEDICATION NAME] and was placed on droplet precautions. Resident #11's roommate was also started on [MEDICATION NAME]. Visitors were discouraged from visiting ACU, masks to be worn by visitors and the Department of Health Nurse was notified of the confirmed positive influenza. Housekeeping deep cleaning on ACU continues and verbal education of handwashing to ACU was completed. - 01/26/15: Resident #13 developed signs and symptoms of a cough, congestion and a temperature. Resident #13 was swabbed for influenza and the results were negative. The timeline indicated Resident #13 was placed on droplet precautions and was give antiviral medication [MEDICATION NAME]. (Surveyor reviewed physician order [REDACTED].#13 did not receive the antiviral medication [MEDICATION NAME] until 02/02/15. Surveyor also interviewed facility staff and was told there was an error to the timeline due to Resident #13 not being placed on droplet precautions (note interviews below). Surveyor reviewed nursing notes for Resident #13 dated 01/26/15 and it was noted that rapid influenza A & B swabs were negative and no new orders or changes in medication were needed. Nursing notes did not indicate Resident #13 was placed on droplet precautions.) - 01/26/15: Resident #15 was readmitted to facility from hospital (reference above date of 01/22/15) afebrile and symptomatic. Resident #15 was being treated with antiviral medication [MEDICATION NAME]. No other information provided on timeline for this date. - 01/27/15: Resident #20, Resident #13's roommate, developed signs and symptoms of congestion and was afebrile. Resident #20 received a rapid swab for influenza A and results were negative. Timeline did not indicate if Resident #20 was placed on droplet precautions or received the antiviral medication [MEDICATION NAME]. No further information was provided on the timeline for this date. This was the third resident with signs and symtoms of influenza in a 72 hour period - per above interviews at this point there would be an outbreak. - 01/29/15: Timeline states that Resident #20's panel results returned negative. No other information provided on the timeline for this date. - 01/30/15: Resident #15 had a chest X-ray and received a rapid swab for influenza which came back negative. Resident #15 was sent to the ER and was then admitted to the hospital with [REDACTED]. Resident #1 developed signs and symptoms of a fever, cough and congestion. Resident #1 was swabbed for influenza and results were negative. The timeline does not indicate if Resident #1 was placed on droplet precautions or received the antiviral medication [MEDICATION NAME]. Resident #12 developed signs and symptoms of a cough, congestion and was afebrile. Resident #12 was swabbed for influenza A and test results were positive. Timeline indicated Resident #12 was placed on droplet precautions. No other information was provided on the timeline for this date. - 01/31/15: Resident #20 developed a fever and worsening respiratory signs and symptoms. Resident #20 was sent to emergency room and admitted with pneumonia and influenza A. No other information was provided on the timeline for this date. - 02/01/15: The timeline states Resident #15's respiratory panel results were positive for influenza A and that Resident #15 was currently in the hospital. No further information was provided on the timeline for this date. - 02/02/15: Timeline states the MD was notified of new respiratory signs and symptoms and confirmed influenza A within the ACU. The MD ordered the antiviral medical [MEDICATION NAME] to be given to all the non-signs and symptom residents residing on the ACU. The public health nurse was notified of the positive influenza case and did not request a copy of the facility's timeline until three residents within 72 hours met. Timeline stated Resident #13's respiratory signs and symptoms continued. Resident #13 was swabbed for influenza A and results were negative. Resident #13 did have a chest X-ray which indicated Resident #13 had pneumonia. No other information was provided on the timeline for this date. - 02/03/15: Resident #20 was readmitted to the facility afebrile for 24 hours and continued to be treated with the antiviral medication [MEDICATION NAME] along with an antibiotic. No further information was provided on the timeline for this date. - 02/04/15: Resident #13's respiratory panel was positive for influenza and [MEDICATION NAME] antiviral medication [MEDICATION NAME] dosage was changed. No further information was provided on the timeline for this date. - 02/06/15: Resident #13 was sent to the ER with worsening of signs and symptoms and was admitted to the hospital. No further information was provided on the timeline for this date. No further information was provided on the above noted timeline. Review of Nurses' Notes: Resident #11 Resident #11's nurse's note, written on 01/25/15, documents that she was having difficulty walking to the dining room, was very lethargic, flushed, her nose was dripping and her temperature was 100.1 degrees. A nasal swab was sent to the lab, which was positive for influenza A. Resident #11 started receiving [MEDICATION NAME] at 4:00 p.m. The facility set up an IMMEDIATE PLAN OF CARE dated 01/25/15 for influenza A. The interventions checked were, 1. Evaluate need for isolation. Do use universal precaution techniques with resident and 10. [MEDICATION NAME] 75 mg Bid (twice a day) X5 days. This temporary care plan did not stipulate droplet precautions. Subsequent nurses' notes state, in part: -01/26/15: Res. (resident) up and about hard to keep in room this shift. Ambulating well, some weakness noted . -01/27/15: Resident alert and trying to wander from room several times. Continue to monitor. -01/28/15: Resident continues to be in room with isolation precautions -01/29/15: Still very lethargic. Would not eat this shift (day shift) but drank 360 ccs (cubic centimeters). -01/30/15: Has started to ambulate independently stating .I think I feel better. -01/31/15: Remained in room with isolation precautions this AM shift. Ate 50% of meals, staff encouraging fluids. -02/01/15: Res. up in room with isolation precautions .Continues to have congestion and cough. -02/02/15: 1:13 p.m. .continues to have cough . -02/02/15: Writer was called to dining room at 4:25 p.m. where resident was sitting became unresponsive and slumped over in her chair .transferred into her wheelchair and laid down in her bed with her feel elevated. Resident's coloring began to go back into her face and resident began talking . A Physician's Assistant was in the building and assessed Resident #11 and stated that it was a vaso-vagal response. Resident has a history of this condition. Resident #11's symptoms resolved, and she continued to go to the dining room for meals, as it had been more than seven days since the start of her symptoms. Although, as noted above, she was allowed to go to the dining room on 02/02, despite having a cough that day and cough with congestion the previous day. Resident #15: Review of Resident #15's medical record identified [DIAGNOSES REDACTED]. Review of the nurses' notes: 01/19/15 at 10:18 a.m., Resident noted to be having chest congestion, non-productive cough, states that she feels very tired. T. (temperature) 99.0, O2 (oxygen) 93% RA (room air). Call placed to PA D. H., new order for CB with Diff, CMP, Chest x-ray PA & Lat x 2 views (congestion) and an influenza swab. -01/19/15 1:43 p.m., Resident test results received. Influenza A&B = Negative . -01/19/15 4:13 p.m., [MEDICATION NAME] (100 MG/5 ML) 2 tsp syrup by mouth two tsp (10 ml) q 4h-prn as needed for cough, administered for cough. -01/19/15 8:00 p.m., [MEDICATION NAME] (100 MG/5 ML) 2 tsp syrup by mouth two tsp (10 ml) q 4h-prn as needed for cough, administered for cough. -01/19/15 at 9:09 p.m., Resident is alert and oriented per usual able to verbalize needs to staff . Unproductive cough present. Cough syrup administered at 4:00 p.m. and 8:00 p.m. prn . -01/20/15 1:28 p.m., .Resident was coughing this morning. Gave her 10 ml [MEDICATION NAME] and was effective. No other s/sx of cold noted . -01/20/15 at 8:38 p.m., Resident is alert and oriented per usual able to verbalize needs to staff . Unproductive cough present. Cough syrup administered at 4:00 pm and 8:00 pm. prn, with good effect . -01/20/15 8:42 p.m., SMDC lab results for molecular testing are as follows: Influenza A and B and subtype H1 and H3, RSV A and RSV B, Human Metapnemoovirus, Rhinovirus, Parainfluenze, Adenovirus, all results are negative. -01/22/15 9:10 p.m., Call placed to Essentia Duluth 3E. Spoke with RN Micheal regarding resident. Resident admitted d/t (do/to) positive influenza A and possible UTI. DNS (Director of Nursing Services), ADNS (Assistant Director of Nursing Services), ED, ACD and PA D. H. updated regarding residents condition. -01/26/15 at 2:27 p.m., Resident returned from the hospital at 1:58 p.m. via hospital transport. She is alert and orientated to staff Resident denies any discomfort of any type. she has a non-productive cough . -01/26/15 at 8:57 p.m., .Some cough noted. no temp . -01/28/15 at 2:00 p.m., Resident up and about per usual this AM shift. Worked with OT, ate 75% of lunch. Noted non productive cough . -01/28/15 at 8:52 p.m., .Ate 100% of supper meal with others in the dining room. Noted non productive cough . -01/29/15 3:46 a.m., [MEDICATION NAME] Solution 0.5-2.5 (3) MG/3ML 1 dose inhale orally every 6 hours as needed for congestion. -01/29/15 6:37 a.m., Resident had 2 sm emesis and 1 lg emesis on NOC shift. Return from hospital on 01/26 with Dx of influenza A. Has been afebrile since return. Coughing fits preceded each emesis. Resident had 2 small pinkish emesis following a coughing spell at 11:00 p.m LS crackles throughout . -01/29/15 2:07 p.m., Resident is very lethargic this shift. Emesis x 1 after coughing episode . -01/29/15 10:13 p.m., .Small emesis after coughing episode. Temp-99.9. -01/30/15 10:07 a.m., Resident c/o pain when breathing this AM, VS: 110/80, 99.4, 80, 16, 93% RA. Resident SOB, Increase WBC, Decreased breath sounds, PA D. H. assessed resident, new orders Chest x-ray PA/LAT 2-views and repeat Influenza swab . -01/30/15 12:56 p.m., Resident continues to have SOB, T. 99.6, 87% RA. PA D. H. updated, new orders to send resident to Essentia Superior for treatment of [REDACTED]. -02/01/15 1:24 p.m., Resident Respiratory Viral Panel, PCR results received today from the Influenza swab done on 01/30/15. Influenza A is positive at this time . -02/10/15 2:25 p.m., Responsible party called writer to state that resident would not be returning to facility but would be entering palliative care . Review of the medical record did not identify if isolation was implemented, type of precautions in place, cessation of group activities and community dining, while Resident #15 had a cough, chest congestion, and a temperature. It is noted that Resident #15 participated in OT and ate in the dining room while experiencing cough and congestion. Resident #13 On 02/11/15, Surveyor reviewed the medical record for Resident #13 and noted that Resident #13 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Nursing notes, dated 02/07/15, stated, Acute kidney injury caused by stated mild dehydration. Resident #13 was receiving antibiotics for pneumonia and [MEDICATION NAME] for influenza A. Resident #20 On 02/11/15, Surveyor reviewed the medical record for Resident #20 and noted that Resident #20 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #20 was treated with antibiotics and [MEDICATION NAME]. On 02/09/15, Surveyor interviewed both Registered Nurse (RN)/Unit Manager (UM) A and Director of Alzheimer Care (DAC) P in regard to the above noted timeline. Both RN/UM A and DAC P stated the above noted timeline had an error in regard to droplet isolation. RN/UM A stated that on 01/26/15, Resident #13 was not on droplet isolation because residents on the ACU were not placed on droplet precautions unless they were confirmed positive for influenza. Both RN/UM A and DAC P stated Resident #13 had signs and symptoms but were not positive for influenza so therefore Resident #13 was not placed on droplet precautions. RN/UM A stated when Resident #15 was readmitted to the facility on [DATE], no precautions were implemented due to being afrebile. RN/UM A stated when Resident #20 returned to the facility on [DATE], no precautions were implemented due to being afrebile for 24 hours. On 02/09/15 at 4:00 p.m., Surveyor along with Surveyors , and , interviewed the DON in regard to the above noted timeline received on 02/09/15. The DON stated that residents on the ACU, who showed signs and symptoms of respiratory illness but received a negative rapid swab test, were not put on droplet precautions. The DON confirmed the timeline included an error on 01/26/15 in regard to droplet precautions. The DON stated Resident #13 was not placed on droplet precautions because she did not test positive for influenza. The DON stated the timeline should not have reflected that information. The DON stated Resident #13 also did not receive [MEDICATION NAME] on 01/26/15. The DON stated he did not know the exact date the [MEDICATION NAME] started for Resident #13 but would have to look into the medical record. The DON stated residents were not put on droplet precaution unless they tested positive for influenza A regardless if they had signs and symptoms of a ARI. Surveyor reviewed the timeline received on 02/09/15 with the DON. The DON stated the first confirmed case of influenza was on 01/22/15 but that the resident (Resident #15) was diagnosed in the hospital. The DON stated Resident #15 did have signs and symptoms of an ARI on 01/19/15 and no isolation or droplet precautions had been implemented. The DON stated Resident #13 had a cough, congestion and a fever and was swabbed for influenza on 01/26/15, but because the swab showed negative results, the facility did not feel she needed to be on droplet precautions. Surveyor reviewed the State of Wisconsin Department of Health Services memo dated 10/16/2013 titled, Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities with the DON. The DON confirmed the facility did use this memo as their standard of practice for infection control guidance. Surveyor discussed the memo section 3.3 Antiviral [MEDICATION NAME] and treatment for [REDACTED]. The DON stated he was told by both the county health nurse and the facility's MD to not treat residents [MEDICATION NAME] with [MEDICATION NAME] even with a confirmed case of influenza. Surveyor asked the DON if he felt the facility was following the standards of practice in which the facility was using and the DON stated, No .not according to this memo. On 02/11/15, Surveyor 0 received a listing of all residents currently residing on the ACU and the dates that [MEDICATION NAME] was provided. Surveyor noted that 18 residents started [MEDICATION NAME] on 02/02/15, 2 residents started [MEDICATION NAME] on 01/25/15 and 2 residents started [MEDICATION NAME] on 01/30/15. Resident #13 was noted to have started [MEDICATION NAME] on 02/02/15. Floating Activity Staff On 02/09/15, Surveyor received a copy of the facility staff infection timeline for the month of December, January and February 2015 and noted the following: - DAC P called in to work sick with symptoms of a cough, sore throat and congestion on 01/15/15 and outcome date was 01/16/15. - Registered Nurse Charge Nurse (RN/CN) U called in sick on 02/04/15 with signs and symptoms of fever, sore throat and congestions and outcome date was 02/06/15. Surveyor interviewed the DON who stated the outcome date was considered the date the facility staff member was allowed to return to work. Surveyor discussed concerns of RN/CN U having symptoms of a fever, sore throat and congestion and only being out of work for two days, asking the DON if RN/CN U was required to wear a mask upon returning to work on 02/06/15. The DON said no and felt that staff are allowed to return to work 24 hours after the onset of the illness. On 02/10/15, Surveyor received from the DON a copy of all facility staff who had floated onto the ACU from another unit within the facility between the dates of 01/19/15 and 02/11/15. Surveyor reviewed the list with the DON. It was noted that during this time frame, 15 staff members floated into the ACU from other units in the facility. Surveyor asked the DON if staff were restricted to t

Based on interview and record review, the facility did not ensure each resident receives adequate supervision, monitoring for medication side effects, and assistive devices to prevent accidents, for 1 of 8 residents reviewed for problematic behaviors (Resident #15). Resident #15 was physically abusive to three residents, on four different occasions, between 11/02/13 and 01/13/14. Resident #15 was an identified wanderer, and was observed wandering into the rooms of other residents on several occasions. The resident also was an identified hoarder of dining utensils, which the resident kept on his person or in his room. Resident #15, at times, also threatened to "kill" other residents and staff. This is evidenced by: On 01/30/14 at 8:15 a.m., Surveyor received and reviewed a copy of the facility's "Behavior Management Guideline" policy, last revised in 2013. The policy states, in part: "Purpose: To develop behavior plans and medication regimes, when appropriate, to optimize the functional abilities of residents while monitoring for adverse side effects and improved behaviors. Pre-Admission: A resident's history of behaviors impacting functioning and any previous or current use of psychotropic medications are considered in the inquiry process. Assessment/Care Planning: Antipsychotic drug use is evaluated by the prescriber and the behavior management team within 7 days drug initiation or admission with drug order... Licensed nursing staff completes the Plan of Care following identification of antipsychotic medication usage or behavioral concerns. Licensed nursing staff refer to Behavior Tip Sheets as indicated to help with interventions for current residents who exhibit new behaviors. The Antecedent Behavior Monitoring Log is utilized for new residents with behaviors and current residents who exhibit new behaviors that negatively impact functioning or quality of life...Non-pharmacological interventions and implemented and assessed for effectiveness, PRIOR to considering initiation of any psychoactive medications. Based on a review of the tracking log, a determination will be made if the resident is a danger to self or others and if so, a plan of care is developed to ensure safety and determine if the center can meet the resident/patient's needs on an ongoing basis. Medications: The use of any medication to control behaviors should always be considered a last resort to assist with managing a resident's behavior..." Example On 01/29/14 at 9:35 a.m., Surveyor reviewed Resident #15's medical record. Resident #15 was originally admitted to the facility's locked Alzheimer's/dementia unit. The resident has [DIAGNOSES REDACTED]. Resident #15 currently receives scheduled Depakote Sprinkles (used for the [DIAGNOSES REDACTED]. Nurses' notes indicate Resident #15 hoards dining utensils, including butter knives, and at times will take objects from the rooms of other residents. A review of Resident #15's Minimum Data Set (MDS), dated [DATE], indicates the resident's Brief Interview for Mental Status (BIMS) assessment is a 6 out of 15 possible points. A score of 6 indicates the resident has severe cognitive deficits. On 01/29/14, Surveyor also reviewed Resident #15's incident reports, which involved resident-to-resident physical altercations. The four incident reports, along with various nurses' notes from Resident #15's medical record, revealed the following information: -11/02/13 at 4:00 p.m: Resident #15 used the open palm of his hand to hit Resident #22's head, and then used a closed fist to hit Resident #22 in the lip. Staff report this incident was unprovoked by Resident #22, and the residents were sitting next to each other during an activity at the time, as they were "friends." Resident #22 sustained a small purple bruise to his left lower lip. When Resident #15 was asked why he hit the other resident, Resident #15 stated Resident #22 "was making noise." The incident report indicates Resident #15 has a cognitive assessment score of 06. Interventions after this incident included having the two residents separated to different ends of the table for all meals and activities. Staff provided one-to-one supervision for Resident #15 for 48-hours after this incident, and provided 15-minute safety checks at night. On 11/04/13, Resident #15 was started on Namenda 10 milligrams (mg) for his behaviors. 11/15/13 at 12:20 p.m: During brunch, Resident #15 stood up from his wheelchair, walked over to Resident #22 and poured cold coffee on Resident #22's head. Resident #15 then hit Resident #22, with a closed fist, in the cheek. Staff report this incident was also unprovoked. Resident #22 sustained a small reddened area to the left cheek. When Resident #15 was asked why he hit the other resident, Resident #15 stated, "He (Resident #22) just keeps getting bigger and bigger. I haven't liked him for years. I punched him and I know I shouldn't have." The incident report indicates Resident #15 has a cognitive assessment score of 6. Interventions after this incident included a medication review, one-to-one supervision for Resident #15 throughout the daytime and 15-minute safety checks at night for 72-hours, and a reminder for staff to offer the Animal Channel or old western movies for Resident #15 to watch if agitated. On 11/16/13, Resident #15 was moved out of the locked dementia unit and relocated to the general living area of the facility with a roommate. A Wanderguard band was also placed on Resident #15's wrist, as he was an identified wanderer. 11/18/13: Nurses' notes from this date indicate Resident became agitated and confrontational with kitchen staff when some dirty dishes were placed out of the resident's reach. Resident #15 was redirected away from the dining room, and the behavior was reported to the facility Social Worker (SW) and Director of Nursing (DON). Resident #15 was also started on Depakote Sprinkles 125 mg, everyday for three days; then the frequency was increased to twice a day for "exit seeking behaviors with agitation." It is documented Resident #15 also had a previous order for Ativan, given as needed. On 01/29/14 at 12:15 p.m., Surveyor interviewed the Director of Nursing (DON) regarding the above incident with staff on 11/18/13. The DON indicated he was not aware of this incident, no investigation or incident report was completed, and there was no follow-up by the Social Worker or DON after this incident. -11/30/13: Nurses' notes from this date indicate a nurse had asked Resident #15 to turn over a pen for safekeeping. Resident #15 responded to the nurse by saying, "Who do you think you are? Get the hell outta (sic) here. I'm gonna (sic) kick your ass." At this time, Resident #15 was also attempting to stand up from the wheelchair. -12/1/13: Nurses' notes from this date indicate Resident #15 was found using the toilet in another resident's bathroom. It is also documented Resident #15 was found to have a stuffed animal which belonged to another resident. Resident #15 did allow staff to take the stuffed animal, but shortly thereafter, requested the object back and stated, "I'll hit you if you don't give it back to me." -12/2/13: A hand-written physician's visit progress note, states the following, in part, "HPI (History of Present Illness): Patient was transferred out of the ACU (Alzheimer's Care Unit) because of aggressive behavior. He threatened his roommate with a knife over one weekend. It was a butter knife and he (Resident #15) said, 'I will kill you.' He is still hoarding..." The physician increased Resident #15's Depakote Sprinkles to 250 mg, twice a day. On 01/29/14 at 12:15 p.m., Surveyor interviewed the DON regarding the above physician's progress note from 12/2/13. The DON indicated he was not aware of an incident of Resident #15's roommate being threatened with a knife, while in the locked dementia unit. The DON stated no investigation or incident report was completed. -12/8/13: Nurses' notes from this date indicate Resident #15 continues to enter the rooms of other residents, as he continues to take items from these rooms. -12/10/13: Documentation from an MDS progress note indicate Resident #15 is independent with bed mobility, and often self-transfers. -12/18/13 at 8:10 a.m. (but not documented until 11:22 p.m.): Resident #15 went into the room of Resident #23, just as Resident #23 was exiting the bathroom. Resident #15 hit Resident #23 on the right cheek/chin area, after Resident #23 told the resident he was in the wrong room. After the incident, Resident #23 informed staff she had previously watched Resident #15 go by her room "frequently." Staff reports Resident #15 was unable to remember this incident, and was unable to be interviewed. The incident report indicates Resident #15 has a cognitive assessment score of 6. Interventions after this incident included a medication review, a review of a facility "Wandering Toolkit," redirection as needed, one-to-one supervision for Resident #15 throughout the daytime for the rest of the shift and 15-minute safety checks at night, and a care conference with Resident #15's family was scheduled. Surveyor notes documentation of the details which were discussed during Resident #15's care conference were not documented. 12/18/13: Nurses' notes on this date, documented at 10:30 p.m., indicate Resident #15 "threatened" a Certified Nursing Assistant (CNA) at bedtime. Resident #15 had grabbed the CNA's arm, shook his fist at the CNA and then reached into his pocket stating he "was going to kill" the CNA. On 01/29/14 at 12:15 p.m., Surveyor interviewed the DON regarding the above incident with staff on 12/18/13. The DON indicated he was not aware of this incident, no investigation or incident report was completed, and there was no follow-up by the Social Worker or DON after this incident. 12/19/13: A hand-written physician's visit progress note, states the following, in part, "HPI: Pt (patient) has been increasingly agitated. Normal lab, urine and stools. Pulled a knife out and threatened a resident. He punched another resident in the face...Family, POA, wants him medicated to help with safety, behavior, redirection unsuccessful as he is very impulsive and being proactive rather than reactive." The physician added a [DIAGNOSES REDACTED].#15's Depakote Sprinkles to 250 mg, three times a day and added Seroquel 25 mg, everyday. During the above interview with the DON, on 01/29/14, Surveyor asked how long the facility had Resident #15 on one-to-one supervision after the resident-to-resident altercation which occurred on 12/18/13. The DON replied he was not sure when the one-to-one supervision was removed, but the supervision was removed after the half-life (the average length of time a person's body to process half of the drugs active ingredient) of the Seroquel medication. The DON thought the half-life of the Seroquel medication would be two to four days. According to the Food and Drug Administration (FDA), the half-life for Seroquel medication is approximately six hours (www.accessdata.fda.gov). Surveyor asked the DON to provide the date of when the facility removed Resident #15 from one-to-one supervision. This information was never provided to the Surveyor. 12/20/13: Nurses' notes indicate the facility received new orders for Resident #15 to have a neuropsychological evaluation. It is documented the Certified Nurse Practitioner (CNP) stated Resident #15 would not tolerate the evaluation, and did not want staff to make an appointment for the evaluation. 12/23/13: Nurses' notes state Resident #15 has been on one-to-one supervision throughout the weekend, but there is no documentation as to the reason. On 01/29/14 at 12:15 p.m., Surveyor interviewed the DON regarding the above nurse's note, indicating Resident #15 required one-to-one supervision. The DON indicated he was not aware of this and was not sure why the resident was placed on one-to-one supervision. There was no investigation or incident report completed as well. 01/13/14 at 10:00 a.m: Resident #15 went into the room of Resident #12, self-propelling his wheelchair. Resident #15 shut the room door after entering the room, and approached Resident #12, who was on the opposite side of the room (by the window). Resident #15 grabbed the arm of Resident #12, and with his other hand, used a package of personal wipes to hit Resident #12 on the side of the head. Resident #15 also threatened to "kill" Resident #12 during the incident. Resident #15 was unable to remember this incident and was unable to be interviewed. The incident report indicates Resident #15 has a cognitive assessment score of 6. After this incident, the facility implemented continuous one-to-one supervision of Resident #15 during the daytime, and 15-minute safety checks during the night. On 01/28/14, Resident #15 was temporarily discharged from the facility to a psychiatric unit. On 01/29/14, Surveyor also reviewed Resident #15's care plan. Resident #15's care plan does not list any behaviors of threatening to "kill" others, having been physically abusive to staff and other residents, or addressing Resident #15's need for psychotropic medications as an intervention for his mood and behaviors. On 01/30/14, at 8:00 a.m., Surveyor received and reviewed a copy of Resident #15's December 2013 and January 2014 "Daily Behavior Documentation" sheets. The DON reports there was no behavior monitoring for the month of November 2013, as the behavior "program" was recently implemented. The "Target Behavior," for Resident #15, listed on each form states, "A. Agitation, B. Anxiety." There are several blanks on the behavior documentation sheet for the month of December 2013 and January 2014. The dates with blanks on each form are listed below: December 2013: -Night Shift: 6, 10, 12-31. -Day (A.M.) Shift: 17-23, 30. -Evening (P.M) Shift: 4-7, 10, 14, 15, 17, 19-23, 25. January 2014 -Night Shift: 1-18, 20-21, 24. -Day (A.M) Shift: 15-17, 20-22, 24-27. -Evening (P.M.) Shift: 1, 5, 6, 8, 9, 13-16, 19-20, 22, 27. Interviews On 01/28/14 at 3:30 p.m., Surveyor interviewed Resident #12. Resident #12 indicated on 01/13/14, Resident #15 had come into her room and closed the door. Resident #12 stated Resident #15 then "had me in the corner" of her room, as Resident #15 grabbed the right arm of Resident #12, and started hitting Resident #12 on the right temple with a package of "butt" wipes. Resident #12 also stated Resident #15 "said he was going to kill me." Resident #12 stated her eye glasses were knocked on the ground, and she had a red mark on her head after this incident. During the continued interview with Resident #12, the resident stated, "I try to avoid him (Resident #15) now. He wouldn't remember (the incident) anyways...They (staff) have someone with him all the time during the day, but who watches him at night? They told me he (Resident #15) can't get out of bed on his own, but I don't know." On 01/29/14 at 7:55 a.m., Surveyor interviewed CNA R, who removed Resident #15 from Resident #12's room on 01/13/14. CNA R confirmed the events on the incident report, dated 01/13/14. CNA R further stated Resident #12 was "a bit upset" after the incident involving Resident #15, and Resident #12 told CNA R, "I don't know what I would've done if you wouldn't have come in here (Resident #12's room)." During the continued interview, CNA R explained Resident #15 wanders throughout the facility, and stated, "The littlest things set him off." On 01/29/14 at 12:15 p.m., Surveyors and interviewed the DON, Assistant Director of Nursing (ADON), as well as the Nursing Home Administrator (NHA) regarding these four resident-to-resident altercations, as well as the nursing notes, as written above. Each resident-to-resident altercation was discussed, as well as the facility interventions, which were implemented after each incident, as written above. The DON confirmed the events of each of the incident reports, along with the interventions implemented by the facility. During the continued interview with the DON, Surveyor asked the DON if a cognitive assessment was completed on Resident #15 after each of the resident-to-resident altercations. The DON replied a cognitive assessment was given to Resident #15 after the incident on 11/02/13, but no cognitive assessments were provided to Resident #15 following the incidents from 11/15/13, 12/18/13 and 01/13/14. The DON indicated Resident #15's cognitive assessment after the first resident-to-resident incident was a 6. On 01/29/14 at approximately 3:30 p.m., during a daily meeting with the DON, ADON, and NHA, Surveyor discussed the behavior monitoring sheets for Resident #15. Surveyor discussed no targeted behaviors are being monitored for Resident #15, especially after the resident has had four resident-to-resident altercations with three other residents since November 2013. Surveyor also asked about the facility's behavior monitoring program, to which the DON indicated the facility has been working on a "pilot" behavior program since November 2013, which was implemented on 12/01/13. The DON indicated the nursing notes "just aren't detailed enough" to explain each resident's behaviors, so the behavior monitoring plan was started. The DON indicated the facility is still in the works with the behavior monitoring policy and procedure. Cross reference F 225, F 279 and F 329

Based on medical record review and staff and family interview, the facility did not ensure that supervision to prevent accidents was provided for 1 of 17 sampled residents. Resident #14 was assisted to the floor from the toilet by a Certified Nursing Assistant (CNA) on 06/30/11 when Resident #14 experienced an unresponsive spell. The facility did not update the plan of care to guide staff in the safe care of Resident #14. On 07/03/11, Resident #14 had another unresponsive spell on the toilet. Resident #14's blood pressure was 65/32, then 68/42 and her pulse was 32. Resident #14 was sent to the Emergency Department (ED) and was diagnosed with [REDACTED]. After returning to the facility, Resident #14's daughter made a request to facility staff that her mother not be left alone on the toilet. On 07/05/11, Resident #14 was left alone on the toilet, fainted and fell on to the floor, sustaining a gash on her nose and another on her head and bruising on her upper body. Resident #14 was again sent to the ED and was admitted to the hospital, where she had a pacemaker implanted and remained hospitalized through the end of the survey, for nine days. This is evidenced by: Resident #14's medical record states she was admitted to the facility on [DATE] after experiencing a gastrointestinal bleed requiring eight units of blood and hypovolemic shock. She was admitted with [DIAGNOSES REDACTED]." She rolled off her bed four hours after her admission and then had no falls for 3? months. Resident #14 had a poor appetite, had lost weight and had occasional emeses (episodes of vomiting). According to Resident #14's nurses' notes and an incident report, on 06/30/11 at 9:57 p.m., Resident #14 was on the toilet in her room and a CNA was washing her up while the resident was urinating. Resident #14 grabbed her own stomach and "the CNA reached to get the garbage pail in case the resident had an emesis. Resident was tipping off the toilet and CNA assisted resident to the floor. CNA stated resident was breathing heavy, pupils fixed, tongue protruding and drooling." The CNA notified the nurse, who documented that when she arrived, the resident was alert and oriented, but did not remember the incident. Her blood pressure was 142/58 and pulse was 62. The physician was consulted and an order was received for "two upper grab bars to promote bed mobility and assisted transfers secondary to [DIAGNOSES REDACTED]. After this episode, the facility did not update the care plan to instruct staff to not leave Resident #14 alone on the toilet. The follow up recommendations documented on the incident report states, "Continue to monitor for change of condition." On 07/03/11, nurses' notes charted at 2:48 p.m. state, "Resident has (had) a period of unresponsiveness while on toilet, resident had a large loose stool, emesis consisting of phlegm, blood pressure 65/32 heart rate 32 respirations 8...Resident leaning to right side while on toilet, skin dusky color, blood pressure 68/42 heart rate 32 respirations 8. Resident did respond after one minute. More alert after helped back to bed." Resident #14 was sent to the ED where she was diagnosed with [REDACTED]. On 07/05/11, nurses' notes state the nurse "was called to resident's bathroom by another resident. Writer found resident lying on her back with a bleeding gash above her left eye and a bleeding gash on the left side of her nose. Resident stated she had past (sic) out while sitting on the toilet and fell forward hitting her face...Wounds to left side of nose and left forehead above left eye were cleansed and pressure applied. Resident kept comfortable and flat to the floor until ambulance arrived." During the facility's investigation of the incident, it was determined, "The resident had used her call light and had been assisted to the bathroom using a gait belt and walker by a cna." The incident report stated, "...the CNA went to assist another resident when resident fell . Resident stated she passed out and fell on her face to the floor." Surveyor interviewed Resident #14's daughter, Family Member (FM) F, on 07/14/11 at 10:10 a.m. by telephone. FM F stated her mother was still in the hospital and she had a pacemaker placed in her chest. FM F stated that after the second episode of being unresponsive on the toilet, she spoke to a nurse, whose name she cannot remember, and expressed concern, asking that her mother not be left alone on the toilet. FM F stated she was assured not leaving her mother alone would be documented on Resident #14's chart, "but I suppose they got busy." However, there was no documentation of this and the care plan was not updated at this time. In the above telephone interview, FM F stated her mother had trouble with orthostatic hypotension in the hospital, where her blood drops when she stands. Surveyor asked FM F to describe her mother's injuries from the fall of 07/05/11. FM F stated, besides the gashes mentioned above, Resident #14 also had "black and blue eyes, bruises on her arms and shoulder and a big bump above her left eye." FM F stated her mother told her that after the CNA put her in the bathroom, another resident was heard yelling. The CNA asked Resident #14 if she was ok and the resident said she was all right and the CNA left her to attend to the other resident. Resident #14 stated it seemed like a long time that the CNA was gone and began hitting her walker against the door to get her attention. After a while, she stood up and immediately passed out and fell to the floor. Surveyor interviewed the Director of Nursing (DON) on 07/14/11 at 9:45 a.m., who stated that according to the investigation, after Resident #14 fell on [DATE], the resident who shares the bathroom with Resident #14 came out into the hallway and told the nurse there was a resident who had fallen and there was "blood all over the place." When the nurse found her, Resident #14 was lying on her back and had hit her face. On 07/14/11 at 11:00 a.m., the DON told Surveyor he had interviewed the CNA by telephone (who was on vacation) who verified the above, but stated she thought she was only gone approximately two minutes before Resident #14 fell . The DON also told Surveyor , "The day before she was supposed to come back to us, she passed out in the elevator" at the hospital. After the above third incident, the facility updated Resident #14's care plan so she is not to be left alone on the toilet when she returns to the facility.