Every finding on record at United Pioneer Home

Based on observation and interview, the facility did not ensure food was stored and prepared in a sanitary manner that prevents foodborne illness to the residents. This practice had the potential to affect all 40 residents within the facility.*Open food noted in cold storage, not labeled and dated.*Cook D did not have a hair net on mustache. Findings:Labeling open foods:The 2022 FDS Food Code documents at 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food: Disposition .A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.On 09/22/2025 at 8:33 AM, during initial tour of the kitchen, Dietary Director (DD) C provided Surveyor with a tour of the cold storage items. In the refrigerator was an open gallon of milk without an opened date written on it. In the frozen storage Surveyor showed DD C an open bag of hashbrowns, frozen peas and peas and carrots with no opened date written on them. DD C replied, That should have a date on them; we will discard these unmarked items.On 09/23/2025 at 11:35 AM, Surveyor observed [NAME] D obtaining temperatures on hot food items before serving lunch on the Harmony unit. [NAME] D was noted to have black facial hair greater than one quarter inch for both his beard and mustache. [NAME] D had a hair restraint on the top of his head and a beard restraint on his chin, but the restraint did not cover his mustache.On 09/23/2025 at 11:40 AM, Surveyor noted that [NAME] D was now temping foods on the Butternut unit. [NAME] E did not have his mustache covered on that unit either.On 09/24/2025 at 9:10 AM, Surveyor interviewed Dietary Director (DD) E regarding the observations made of [NAME] D temping food with a beard restraint not covering his mustache. DDE replied, All facial hair must have a hair restraint when serving food to the residents.

Based on record review and interview, the facility did not ensure residents/representatives were notified of the rate to reserve the resident's bed in the bed hold notice. This has the potential to affect 2 of 5 residents R9 received bed hold notices with no daily rate documented and no information on resident appeal rights. R5 received bed hold notices with no daily rate documented and no information on resident appeal rights. R3's bed hold notices did not have daily rate documented and no information on resident appeal rights. R15 received a verbal bed hold notice, but facility did not have any documentation that R15 received the daily rate or information on resident appeal rights. R16 received a bed hold notice but it did not have the daily rate documented nor information on resident appeal rights. Findings: Example 1 R9 was admitted to the facility on [DATE], with a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated that R9 was cognitively intact. R9 had diagnoses of dementia, chronic obstructive pulmonary disease (COPD,) and history of urinary tract infection (UTI.) R9 had a care plan for confusion due to dementia, hypoxia related to COPD and UTI symptoms dated 3/13/25. R9 had a Minimum Data Set (MDS), dated [DATE], titled Discharge Return Anticipated. On 05/23/25, progress note revealed R9 became confused and unresponsive. R9 left the facility by ambulance and went to the emergency room. On 09/23/2025 at 12:13 PM, Surveyor interviewed Director of Nursing (DON) B and requested bed hold notices for R9's hospitalization. On 09/23/2025 at 2:28 PM, DON B provided Surveyor with bed hold notice and indicated they do not have a dollar amount on them informing R9 of the exact amount R9 would be charged. Surveyor reviewed bed hold notices and noted there is no statement of resident's appeal rights. On 09/23/2025 at 2:52 PM, Surveyor informed DON B and Nursing Home Administrator (NHA) A that there is no dollar amount on R9's bed hold form and the bed hold has no appeal rights for the residents. DON B responded that facility will update form to include that information Example 2 R5 was admitted to the facility on [DATE], with a Brief Interview of Mental Status (BIMS) score of 10/15, which indicated that R5 was cognitively intact. R5 had diagnoses of vascular dementia, Parkinson's disease, congestive heart failure, atrial fibrillation, and history of urinary tract infection. R5 had a care plan for quality of life care dated 5/5/25. R5 had an MDS, dated [DATE], titled Discharge Return Anticipated. On 05/15/25, progress note revealed R5's breathing was labored and reported chest discomfort with symptoms of pneumonia. R5 left the facility by ambulance and went to the emergency room. On 09/23/2025 at 12:13 PM, Surveyor interviewed DON B and requested bed hold notices for R5's hospitalization. On 09/23/2025 at 2:28 PM, DON B provided Surveyor with a bed hold notice and indicated they do not have a dollar amount on them informing R5 of the exact amount R5 would be charged. Surveyor reviewed bed hold notices and noted there is no statement of resident's appeal rights. On 09/23/2025 at 2:52 PM, Surveyor informed DON B and NHA A that there is no dollar amount on R5's bed hold and the bed hold has no appeal rights for the residents. DON B responded that facility will update form to include that information Example 3 Resident (R) 3 was admitted to the facility on [DATE]. R3 had Minimum Data Set (MDS) discharge return anticipated, dated 06/12/25, 08/29/25, and 09/14/25. On 09/23/2025 at 12:13 PM, Surveyor requested from Director of Nursing (DON) B bed hold notices for all three of these hospitalizations. On 09/23/2025 at 2:28 PM, DON B provided Surveyor with bed hold notices and indicated they do not have a dollar amount on them informing R3 of the exact amount R3 would be charged. Surveyor reviewed bed hold notices and noted there is no statement of resident's appeal rights. On 09/23/2025 at 2:52 PM, Surveyor informed DON B and NHA A that there is no dollar amount on the bed hold and the bed hold has no appeal rights for the residents. DON B replied, We will fix that. Example 4 On 09/22/25 at 1:46 PM, Surveyor reviewed R15's two hospitalizations, dated 04/25/25 and 08/19/25. Surveyor did not find documentation that R15 received written notification of a bed hold or was informed in writing of the daily bed hold rate until R15 returns to facility. On 09/23/25 at 2:16 PM, Surveyor interviewed DON B and asked DON B if R15 had a bed hold given to them. DON B reported back to Surveyor that R15 was told verbally about bed hold. DON B provided Surveyor with progress note stating that bed would be held but Surveyor did not see that the progress note stated how much the daily rate was for bed hold or inform resident or representative in writing of resident's rights pertaining to bed hold. Example 5 On 09/22/25 at 1:53 PM, Surveyor reviewed R16's hospitalization dated 04/25/25. Surveyor found documentation that R16 received written notification of a bed hold but was not informed of the daily bed hold rate or R16's resident rights that should be stated on the bed hold form. On 09/23/25 at 2:16 PM, Surveyor interviewed DON B and asked DON B if R16 had a bed hold given to them. DON B reported back to Surveyor that R16 was given a bed hold form. DON B provided Surveyor with bed hold form, but Surveyor did not see that the bed hold form stated how much the daily rate was for bed hold or inform resident or representative in writing of resident's rights.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This affected residents (R) R29, R41, R17, R16, R21, and R15. Certified Nursing Assistant (CNA) G did not perform hand hygiene when passing water pitchers to R29, R41, R17, R16, and R21. CNA H did not perform hand hygiene when providing peri cares to R15. Maintenance F entered R16's droplet precaution room without donning PPE when cleaning R16's room. Findings include: The facility policy titled Transmission Based Precautions dated last review March 2025, in part reads: .Contact Precautions: #2. Wear gloves when entering room. Wear gown when contact with the resident or potentially contaminated surfaces in their environment will occur.Droplet Precautions: #2. In addition to contact precaution measures, a mask shall be donned when entering the room for contact within 6 feet for the resident. Surveyor requested and reviewed the facility policy titled Hand Hygiene dated March 2025. The policy in part reads: .#8. Use alcohol-based hand rub containing at least 62% alcohol, or alternately, soap and water for the following situations: h. Before moving from a contaminated body site to a clean body site during resident care. J. After contact with bodily fluids.Example 1On 09/23/2025 at 10:41 AM, Surveyor observed CNA G passing water pitchers to residents. Surveyor observed CNA G enter R29's room. CNA G placed clean water pitcher on R29's bedside table. Surveyor observed CNA G take R29's dirty water pitcher and place it on the clean water cart. Surveyor did not observe CNA G sanitize hands when exiting R29's room. Surveyor observed CNA G grab a clean pitcher with contaminated hands and enter R41's room. CNA G placed the clean water pitcher on R41's bedside table. Surveyor observed CNA G take R41's dirty water pitcher and place it on the clean water cart. Surveyor did not observe CNA G sanitize hands when exiting R41's room. Surveyor observed CNA G grab a clean pitcher with contaminated hands and enter R17 's room. CNA G placed clean water pitcher on R17's bedside table. Surveyor observed CNA G take R17's dirty water pitcher and place it on the clean water cart. Surveyor did not observe CNA G sanitize hands when exiting R17's room. Surveyor observed CNA G grab a clean pitcher with contaminated hands and entered R16's droplet precaution room. CNA G placed clean water pitcher on R16's bedside table. Surveyor observed CNA G take R16's dirty water pitcher and place it on the clean water cart. Surveyor did not observe CNA G wearing Personal Protective Equipment (PPE) when entering or sanitizing hands when exiting R16's precaution room. Surveyor observed CNA G ambulate down hallway to kitchen and drop off dirty water pitchers. Surveyor observed a call light going off in R21's room. CNA G sanitized hands then and entered R21's room. On 09/23/25 at 10:52 AM, Surveyor interviewed CNA G and asked what CNA G's process is when passing water pitchers to residents to practice infection control and prevent the spread of infections. CNA G reported that CNA G should have sanitized hands in between residents' rooms and understands that CNA G did not. On 09/23/25 at 3:32 pm, Surveyor interviewed Director of Nursing (DON) B and asked DON B what DON B's expectations are for sanitizing hands during water pass and grabbing used dirty water pitchers from residents' rooms. DON B reported to Surveyor that DON B expects CNA G to sanitize hands in between each resident's room before grabbing clean pitchers and delivering them. DON B reported to Surveyor that all staff should be sanitizing hands before entering residents' rooms and after leaving residents' rooms. Example 2On 09/22/2025 at 10:53 AM, Surveyor entered R15's room and observed R15 on toilet in bathroom with call light going off. Surveyor observed CNA H enter R15's room and place gloves on. CNA H walked over to toilet and began wiping R15 with wipes. Surveyor observed CNA H finish cleaning R15's bowel movement (BM) off R15's bottom. CNA H then proceeded to pull R15's brief and pants up with contaminated gloves. CNA H then assisted R15 to walker and walked out of bathroom with contaminated gloves. Surveyor observed CNA H grab R15's wheelchair and began transferring R15 to the wheelchair with contaminated gloves. Surveyor observed CNA H rearrange oxygen tubing from underneath wheelchair wheels with contaminated gloves. Surveyor observed CNA H grab nasal cannula with contaminated gloves and placed into R15's nose. Surveyor observed CNA H place R15's jacket over R15's shoulders with contaminated gloves. Once CNA H was done assisting R15 in R15's room, CNA H doffed contaminated gloves in trash and continued to push R15 out of R15's room to the reading activity in lounge. Surveyor did not observe CNA H sanitize contaminated hands. Surveyor observed CNA H park R15 in wheelchair in the lounge and then walked over to a resident and touched her back to say hello with contaminated hands. On 09/22/2025 at 10:59 AM, Surveyor interviewed CNA H and asked what CNA H's process is for sanitizing hands and changing contaminated gloves. CNA H reported that CNA H should have taken off contaminated gloves after wiping BM off R15 before touching any other surfaces. CNA H apologized to Surveyor. On 09/23/25 at 3:35 pm, Surveyor interviewed DON B and asked what DON B's expectations are for doffing contaminated gloves and sanitizing hands before and after toileting R15 before providing other cares. DON B reported to Surveyor that DON B expects CNA H to doff contaminated gloves after providing peri cares and sanitize hands before providing any other cares to R15 per facility policy. Example 3On 09/23/25 at 11:02 AM, Surveyor observed Maintenance F enter R16's droplet precaution room without donning gown. Maintenance F started cleaning R16's surfaces in droplet precaution room. Maintenance F cleaned bathroom, bedside table surfaces, and floors while in R16's room without PPE gown on. On 09/23/25 at 11:10 AM, Surveyor interviewed Maintenance F and asked what Maintenance F's process is for cleaning transmission-based rooms. Maintenance F reported to Surveyor that Maintenance F reviews the sign on door before entering and makes sure to don appropriate PPE per the isolation requirements. Surveyor asked Maintenance F what PPE is to be utilized in R16's droplet precaution room. Maintenance F reported to Surveyor that he wore gloves and mask. Surveyor asked Maintenance F why Maintenance F did not also don a gown for droplet precautions. Maintenance F reported that if R16 is not in room then Maintenance F does not have to wear gown while cleaning R16's surfaces. On 09/23/25 at 3:37 PM, Surveyor interviewed DON B and asked DON B's expectations for Maintenance F donning PPE in droplet precaution room for R16. DON B reported that all staff need to be following the isolation signs outside the door. DON B reported droplet precautions act like contact precautions and when any staff are within 6 feet from R16 or near high contact surfaces, that all PPE is to be utilized such as mask, gloves, and gown.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not use appropriate assist devices during transfer when needed to prevent accidents which affected resident (R) (R6).Certified Nurse Assistant (CNA) H did not use gait belt while transferring R6 from toilet to wheelchair.Findings include:Facility policy titled, Fall Protocol, dated reviewed in February 2025, states in part: .Definition: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. Facility policy titled, Safe Resident Handling, dated reviewed in September 2017, states in part: .#5. Direct resident care staff will avoid manually lifting residents except for medical emergencies.#7. Suggested patient/resident handling aids: Minimal assist: The resident is ambulatory, able to assist, has a steady gait, and will follow directions, but may have some periods of confusion. Use transfer aids and gait belt.R6 was admitted to the facility on [DATE], with following diagnoses, in part, osteoarthritis left knee, polymyalgia rheumatica, muscle wasting, bursitis of left knee, weakness, atrial fibrillation, anemia, and adult failure to thrive.R6's Activities of Daily Living (ADL)s care plan states:-TRANSFER: Independent in the facility with FWW [four-wheeled walker] revised on 09/26/24.-AMBULATION: Independent in facility with FWW revised on 09/26/24.-AMBULATION: CGA [contact guard assist] x1 in facility with FWW revised on 12/30/24.AMBULATION: CGA x1 with gait belt in facility with FWW revised on 03/27/25.R1's fall care plan states:-Ambulation: Does not ambulate. Power w/c [wheelchair] to all destinations.-Bed mobility: Assist of one. -Transfer: Pivot contact guard assist of one with gait belt. EZ-Stand as needed with assist of one.On 09/23/25 at 10:15 AM, Surveyor observed R6 wanted to lay down in bed after using the toilet. CNA H assisted R6 with getting off the bathroom toilet. Surveyor observed R6 stand at the toilet using the assist bars to help stand. Surveyor did not observe CNA H place a gait belt on R6. CNA H was cleaning R6's bottom with wipes when R6 screamed, I can't stand long. Surveyor observed R6's legs give out and R6 plopped on the toilet seat hard falling backwards into toilet railing. Surveyor observed CNA H try to grab R6 but couldn't grab onto anything. R6 reported that her left leg is giving her pain still and it hurts bad. CNA H instructed R6 to try and stand again. Surveyor did not observe CNA H place gait belt on R6 at this time. R6 attempted to stand again allowing CNA H to finish cleaning R6 and pulling pants up. R6 then quickly pivoted and plopped herself in wheelchair landing on the edge of R6's wheelchair seat. R6 raised R6's voice and stated to CNA H, I need my wheelchair foot plate pushed down fast. I am slipping out of the wheelchair. CNA H told R6 to calm down and proceeded to move R6's feet to place foot plate down. R6 yelled that R6 was going to slip out of the wheelchair as R6 is on the edge if CNA H continues to do that. R6 then stated, Hurry, I need the foot plate down soon. CNA H adjusted the foot plate and R6 was able to boost self in wheelchair. CNA H propelled R6 over to the bed and stand pivoted R6 from wheelchair to bed without gait belt in place. Surveyor observed CNA H finish with R6 and exit R6's room. On 09/23/25 at 10:23 AM, Surveyor interviewed CNA H and asked CNA H what CNA H's process is for safe transfers with R6 when R6 is feeling weak. CNA H reported to Surveyor that CNA H should have been using a gait belt but sometimes R6 is in a rush to get going on whatever R6 is doing. On 09/23/25 at 3:31 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what expectations are for transferring R6 from wheelchair to toilet and from toilet to wheelchair. DON B reported that R6 is an assist of one and needs help in bathroom. Surveyor asked DON B if it is the expectation that CNA H uses a gait belt when transferring R6 as one assist from wheelchair to toilet and toilet to wheelchair. DON B reported to Surveyor that usually staff follow whatever the care plan is, but facility policy states anyone who is independent with transfers does not need a gait belt but all other transfers including assist of one and above need gait belts for safety.

Based on observation, interview and record review, the facility failed to ensure standards of practice were followed for providing respiratory services for 1 of 1 resident (R) reviewed for oxygen therapy (R15). Certified Nurse Assistant (CNA) H did not check portable oxygen tank before taking R15 to lounge for an activity according to facility policy. The facility did not implement new respiratory interventions after each episode of R15 found with no oxygen on. Findings include:Surveyor reviewed the facility protocol titled Oxygen Therapy, last reviewed in April 2019, states in part, .initiating oxygen: 2. Turn on the oxygen to the prescribed flow rate. 3. Place appropriate oxygen to device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 5. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. 6. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. R15 was re-admitted to the facility on [DATE], with following diagnoses, in part, unspecified fracture of lower end of right humerus, respiratory failure with hypoxia, pan lobular emphysema, heart failure, atherosclerosis of coronary artery bypass graft, atrial fibrillation, cardiac pacemaker, and muscle weakness. R15's oxygen therapy related to congestive heart failure care plan initiated on 04/24/25 and revised 05/08/25 states: The resident will have no signs and symptoms of poor oxygen absorption through the review date. -Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated to approximately 30 degrees revised on 05/15/25.-Oxygen settings: O2 [oxygen] via nasal cannula at 2-4L [liters]. May titrate to keep O2 above 89%. Update provider for need to titrate in O2 requirement above 4L revised on 08/13/25.-Ensure nasal canula is properly in nares throughout shift, as it is known to shift out of place initiated on 09/22/25. Surveyor reviewed R15's progress notes, which state in part: .-On 05/28/25 at 11:49 PM, Administration note: Apply O2 continuously via nasal cannula to keep O2 saturations 90% or greater; 1-2L during the day, 3-4L at night. Notify Nurse Practitioner (NP) if change in O2 requirement. Nasal cannula was on the ground when I came to check on her at 11:30 PM, O2 was 91%, will recheck shortly with O2 applied.-On 07/07/2025 at 2:56 PM, Administration note: Apply O2 continuously via nasal cannula to keep O2 saturations 90% or greater; 1-2L during the day, 3-4L at night. Notify NP if change in O2 requirement. Resident's nasal cannula was out of nose.-On 8/18/2025 at 11:26 AM, Nurse note: Resident went to therapy right after breakfast, therapist noted confusion and brought resident to Registered Nurse (RN). RN noted resident's O2 was not turned on. O2sat was 56 %. Turned O2 on at 4L/M [minute] and within 1-2 minutes O2 saturation was 94% at 4L/M. Resident was also more alert and oriented. Resident wished to go back to therapy. When returned O2sat was still 94% with 4L/M.-On 08/18/25 at 9:09 AM, Physician/NP Update: NP updated on resident having O2 turned off while in dining room at breakfast and drop in O2 sat. Family updated as well. Director of Nursing (DON) updated. -On 8/19/2025 at 1:58 PM, Nurse's Note: Writer went in to speak with resident. Resident was having a hard time finding words. Upon assessment, resident was 86% on 3L. Resident stated she was feeling SOB [short of breath]. Instructed resident to take a couple deep breaths, O2 increased to 90%, then resident was breathing normal and O2 dropped to 81%, O2 increased to 4L. Saturation came back up above 90. Resident stated she would like to be evaluated in the ED. Lung sounds diminished throughout. NP updated, family updated and all in agreement to go to Emergency Department (ED). Vital Signs (VS) Blood Pressure (BP) 130/58, Temp 98.5, Respirations (R) 20, Pulse (P) 85, O2 93% on 4L. Emergency Medical Services (EMS) called at 1:37 PM, Report given to ED. EMS came at 1:47 PM.-On 8/19/2025 at 2:43 PM, administration note: Sent to ED.-On 8/19/2025 at 8:47 PM, Nurse's Note: Received call from hospital with update, resident was admitted due to inability to stabilize O2 level and trouble diuresing as well as lower than normal hemoglobin. she will be seen by hospitalist in the morning to determine if she will need a transfusion.-On 9/22/2025 at 1:38 PM, Physician/NP Update: NP updated on resident oxygen being out of her nares after lunch and resident appearing unaware. Oxygen at 89% via nasal cannula (NC) @4LPM when writer checked. Increased to 92% when resident not speaking. Care plan and treatment made to ensure nasal cannula is properly in nares throughout shift.Surveyor reviewed a resident/family concern note, dated 07/28/25, which states in part, In nurse report on 07/26/25 it was discussed that Saturday in the morning [R15] was found to have oxygen off for about 30 minutes before turned back on. Coaching was completed to both CNAs assigned to work with [R15] .Surveyor reviewed Employee Coaching form, dated 08/05/25, which states in part, On 07/26/25 [R15] was left without [R15's[ oxygen on. [R15's] O2 dropped substantially and put [R15] at risk. Education provided to both CNAs that O2 must always be applied when ordered by a provider. Please ensure you double check all residents with O2 need prior to leaving their room . On 09/22/25 at 1:25 PM, Surveyor observed R15 with nasal cannula for oxygen out of nose and off on right cheek. R15 had requested to have help to room as R15 felt short of breath. Licensed Practical Nurse (LPN) J observed this as well, stopped, placed nasal cannula in nose and educated resident to keep oxygen nasal cannula in nose. LPN J gathered O2 which stated 89% and waited until O2 rose to 92% then contacted primary of the event. On 09/22/2025 at 10:53 AM, Surveyor entered R15's room and observed R15 on toilet in bathroom with call light going off. Surveyor observed CNA H enter R15's room. CNA H then assisted R15 to walker and walked out of bathroom. Surveyor observed CNA H grab R15's wheelchair and began transferring R15 to the wheelchair. Surveyor observed CNA H rearrange oxygen tubing from underneath wheelchair wheels. R15 asked CNA H if there was enough oxygen in the portable tank for R15 before R15 went to a reading activity in the lounge area as R15 had walked with physical therapy earlier this morning and was worried about portable tank being low. CNA H responded to R15 that R15's oxygen tank was fine and that it was filled this morning. Surveyor did not observe CNA H check portable oxygen tank before hooking R15 to the portable tank from R15's concentrator in R15's room. Surveyor observed CNA H grab nasal cannula and place into R15's nose. CNA H went to start pushing R15 out of the room and Surveyor went ahead and asked if CNA H checked portable tank and how much oxygen was left. CNA H reported to Surveyor that CNA H was unsure how much was in portable tank and continued to push R15 out of R15's room to the reading activity in lounge. Surveyor observed CNA H park R15 in wheelchair in the lounge. Surveyor observed CNA H speak to another resident and then left the lounge leaving R15 alone with other resident. On 09/22/2025 at 11:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B could check R15's portable oxygen tank as Surveyor thought tank was low. DON B walked over to R15 and grabbed portable oxygen tank to check the status of the tank. DON B reported to Surveyor at first that R15's portable tank appeared to be empty, but then DON B stated, Sometimes these tanks are finicky, and you need to grab at this angle of the strap. [R15's] tank appears to be really low and [R15] will need a refill before lunchtime. Surveyor asked DON B what DON B's expectation is of checking portable oxygen tank before R15 is brought out of room to an activity or meals. DON B reported that CNA H should have checked the portable oxygen tank before R15 was brought out. DON B reported that all staff are to check the proper placement of oxygen tubing and how much is in portable tanks before taking out of room off oxygen concentrators. On 09/23/25 at 3:31 PM, Surveyor interviewed DON B and asked DON B's expectations for CNA H to check portable oxygen tanks before R15 was leaving R15's room for activity. DON B reported that all staff should be checking portable oxygen tanks regularly and CNA H should have checked R15's portable tank thoroughly since R15 was concerned. On 09/24/2025 at 12:11 PM, Surveyor interviewed RN K and LPN J and asked once LPN J observed R15 with R15's NC out of nose and on right cheek on 09/22/25, what interventions did LPN J put into place. LPN J reported to Surveyor that LPN J immediately called provider for any new orders, and it was suggested to update care plan. Surveyor asked LPN J and RN K why care plan interventions were not put into place before this event when progress notes show this has happened before. RN K reported to Surveyor that RN K was unaware this had occurred previously. RN K reported to Surveyor that once there is an event like this nursing staff know to update appropriate interventions to decrease the potential of problems. On 09/24/2025 at 12:49 PM, Surveyor interviewed DON B and asked why R15 did not have an intervention placed sooner than Monday 09/22/25 with frequent progress notes stating that R15 was found with nasal cannula out of nose. DON B reported that DON B would have to look at R15's record and review the chart as DON B does not know why there wasn't an intervention placed. Surveyor asked if DON B could correlate R15 being found with not being on concentrator with having to send R15 to the ED on 08/19/25. DON B reported to Surveyor that DON B did not correlate it as hospital reported back that R15 was full of fluid and then diuresis in hospital. Surveyor asked DON B why all staff were not educated about proper use of oxygen use. DON B reported to Surveyor that DON B figured this was an isolated event and only educated one staff member. On 09/24/2025 at 12:57 PM, DON B came to Surveyor and handed an employee coaching form to Surveyor stating that on 08/19/25 the staff member was educated on importance of the responsibility to applying oxygen and turning it on the concentrator.

Based on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 12 residents (R12) reviewed for medication errors. R12 has a type 2 diabetes mellitus diagnosis. Facility staff administered short acting insulin 4 hours after Blood Glucose (BG) was taken. Facility staff did not follow standards of practice for insulin administration. Findings include:Surveyor reviewed the policy titled, Insulin Administration, dated reviewed in January 2017, which stated in part, .Insulin Pen: #2. Check blood glucose per physician order or facility protocol.On 09/23/25 at 9:34 AM, Surveyor observed Registered Nurse (RN) I administer Humalog KwikPen 33 units subcutaneous in R12's left abdomen. RN I read out loud to Surveyor that R12's BG (blood glucose) was 173 and completed at 4:12 AM earlier this morning from night shift. RN I reported to Surveyor that R12 will receive sliding scale insulin as well. Surveyor observed RN I give Humalog insulin 33 units and head back to the medication cart. On 09/23/25 at 1:19 PM, Surveyor interviewed RN I and asked what RN I's normal process is for checking BG before giving insulin. RN I reported that sometimes facility has too many BG checks so night shift helps in completing this task for day shift. RN I reported that RN I will use whatever BG night shift obtains to prep for administration of insulins. Surveyor asked RN I if RN I will gather another BG closer to mealtimes for R12. RN I reported that R12 usually fluctuates in the morning and is low so RN I was not concerned with BG taken at 4:12 AM, four hours before insulin was given. On 09/23/25 at 1:22 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for checking BG and administering insulins to insulin dependent residents. DON B reported that DON B's expectation for gathering BG should be performed around mealtimes and no earlier than an hour before administering insulins. DON B reported that RN I should have gathered another BG from R12 as using the BG from 4 hours earlier was not acceptable practice.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not implement new interventions and increase supervision when needed to prevent accidents for 2 of 3 residents (R) (R1, R2) reviewed.-R1 is at risk for falls and fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, and the facility did not place new interventions or increase supervision to prevent further fall incidents. On 08/06/25, x-ray results revealed a left humeral head fracture. On 08/08/25, additional x-rays of left knee related to complaints of pain, revealed an acute transverse non-displaced fracture of the mid portion of the left patella. The facility failure to place new interventions and increase supervision for R1 led to harm, when R1 suffered a left humeral head fracture and an acute transverse non-displaced fracture of the mid portion of the left patella. This example is cited at a scope/severity level of G.-R2 was at risk for falls. R2 has had a fall resulting in a fractured right ankle on 6/29/25. On 8/26/25 and 08/27/25, R2 continues to self-transfer without assist increasing risk for a fall. No new interventions were put into place to prevent further fall incidents. The failure of the facility to implement interventions to prevent future fall incidents due to R2 self-transferring will be a deficient practice cited at a scope/level severity of D.Findings include:Facility policy titled, Fall Protocol, dated reviewed in February 2025, states in part:.Definition: A fall refers to unintentionally coming to rest on the ground, floor, or other lower level.An episode where resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall.Procedure: After a fall:-If a resident has fallen or is observed on the floor without a witness to the event, nursing staff will evaluate for possible injuries to the head, neck, spine, and extremities.-Nursing staff will notify the resident's Attending Physician/Nurse Practitioner for injuries or alteration in function. If the residents Attending Physician/Nurse Practitioner is not available, or the fall occurs outside normal business hours the nurse may notify the on-call physician to update him/her about the fall and obtain any necessary orders/treatments. A provider will be notified of the fall and resulting injuries at the time of the fall of significant injuries occur including: any injury to the head or face, open cuts or skin tears, new onset or change in pain, any change in condition or functional ability, or any other injury deemed significant by the nurse on duty or Registered Nurse (RN) on call. If there are no significant injuries or changes in function, the Medical Doctor/Nurse Practitioner (MD/NP) may be notified via fax or on the next business day.-Nursing staff will observe for delayed complications of a fall each shift for approximately seventy-two hours after an observed or suspected fall. Findings will be documented in the resident's medical record.-Documentation will include any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, changes in level of responsiveness/consciousness and overall function.-An incident report will be completed for all falls whether witnessed or not. Nurse on duty and nurse managers will work collaboratively to make sure all notifications are completed. Nursing management team will ensure completion of the Interdisciplinary Review portion of the incident.Identifying causes of a fall or fall risk:-Within 24 hours of a fall, the nursing staff will begin to identify possible or likely causes of the incident.-Nursing management will review the resident's history of falls for any identifiable patterns.-IDT meets weekly to review falls and discuss patterns or trends.Documentation: When a resident falls, the following information should be recorded in the resident's medical record:-Vital signs-Injuries-Any first aid or treatment rendered.-Notification of physician and family.-Completion of the Incident Report.-New interventions to minimize risk for further falls .Example 1R1 was re-admitted to the facility on [DATE], readmitted on [DATE], with following diagnosis, in part, Parkinson's disease, insomnia, weakness, idiopathic progressive neuropathy, atherosclerotic heart disease, chronic kidney disease stage 3, primary osteoarthritis, gout, dysphagia, dementia, major depression, essential primary hypertension, hypothyroidism, and unsteadiness.R1's Minimum Data Set (MDS) assessment, completed on 06/09/25, confirmed R1 scored 13/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R1 was at risk for falls. R1 requires minimal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear.R1's MDS dated [DATE] confirmed R1 requires substantial to maximal assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. R1's Activities of Daily Living (ADL)s care plan states:-TRANSFER: Independent in the facility with Four-wheeled walker (FWW) revised on 09/26/24.-AMBULATION: Independent in facility with FWW revised on 09/26/24.-AMBULATION: Contact Guard Assist (CGA) x1 in facility with FWW revised on 12/30/24.-AMBULATION: CGA x1 with gait belt in facility with FWW revised on 03/27/25. R1's fall care plan states:-Physical Therapy (PT) evaluate and treat as ordered initiated on 08/14/20.-Educate resident about safety reminders. Initiated on 08/15/20.-Encourage resident to seek assist with transfer initiated on 06/29/23.-Ensure call light in reach and encourage resident to use for assistance. Initiated on 05/30/24.-Ensure walker is within reach in recliner. Initiated on 05/30/24.-Dycem cushion in recliner per resident. Initiated on 06/17/24.-Signage in room for assistance with moving items created 09/24/24.-Signage in room to ring for assistance with moving items and to ring for assist prior to transferring. Revised 01/14/25.-Ensure walker is within reach when in recliner and when in wheelchair in room. Initiated on 08/05/25.On 08/29/25 at 10:34 AM, Surveyor reviewed nurse progress notes for R1's falls:Falls on 12/24/24, 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, 08/20/25, and 08/21/25.On 12/24/24 at 2:53 PM, Note Text: At 1:20pm CNA found res [R1] on her floor and called RN to room. Res [R1] was lying on her back with head up against the armoire. Noted skin tear right hand. Res [R1] stated she did hit her head. Res [R1] denied hurting anywhere else. Res [R1] stated she was in her w/c and had gotten up and was going for her walker and fell. She said it happened fast, but she thinks she landed on her knees then fell over on her side and then rolled on her back. She was assisted to standing with 2 assists, no marks noted on her head, back or shoulders. Skin tear right hand 1.5cm, cleansed with normal normal saline (NS) and flap of skin put in place and steri-strips use for wound closure. Band-Aid on for protection. Blood Pressue (BP):133/75 Pulse (P):79 beats per minute (bpm), Respirations (R):16 per minute Temperature: 97.5, Oxygen (O2) saturation (sat):98% room air. Neurological (Neuro's) assessments within normal limits (WNL), strong equal hand grasp, able to raise arms as previous, as left arm does not go up as high. Able to kick out legs and stood well. Pupils Equal, Round, Reactive to Light (PERRL). After res [R1] had been up in chair for a few minutes, she complained of (c/o) left shoulder pain, then a bit later c/o right knee pain and a little while after that c/o right hip pain. No marks had been found, and range of motion (ROM) remained unchanged. Offered ice packs but she denied these. Then at 2 PM, res [R1] walked with 1 assist and walker out to dining room (DR), followed with wheelchair (w/c) and played bingo.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 12/30/24 at 10:32 AM, Note Text: At 9:45am, CNA called RN to room, res [R1] was found on floor. Res [R1] was lying on her back with walker near her. She was alert and oriented as usual. Stated she was going to the bathroom and just fell down. ROM as previous. Continues with sore right hip but had good ROM. PERRL. Assisted to standing, no redness or marks to head, back or buttocks. Assisted into w/c. Vital Signs Stable (VSS) and neuro's WNL, see sheet. Res [R1] taken to the bathroom then laid down. Nurse Prctitioner (NP) and son notified.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 01/01/25 at 12:55 PM, Note Text: 12:40 PM, res [R1] was lowered to the floor during a staff assisted transfer. res [R1] did not hit her head, c/o rt knee discomfort, already has a bruise there from previous fall. BP 92/46, P 81, R 18, T 97.6, and notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 01/02/25 Bactrim started after R1 had UTI.On 01/09/25 at 10:57 PM, Note Text: Unwitnessed fall at 7:20 p.m.; [R1] found sitting with back partially against her armoire. Resident [R1] did report she hit her head; no bump or red mark seen. Neuro check started and WNLs; vital signs stable. ROM without difficulty or pain. Assisted into standing position and into wheelchair. Stood on feet without difficulty. Update sent via fax to [name of hospital].Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 05/13/25 AT 10:34 AM, Note Text: Res [R1] was lowered to the floor in her room with assist of one when walking with the walker. did not hit head or knees. had fainting spell which lasted a few seconds assisted back into w/c with assist of two. No injuries. B/P 103/63, P 74, R 18. Notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 06/06/25 at 12:58 PM, Note Text: Resident [R1] in her bathroom with CNA and she needed to be lowered to the floor due to (d/t) weakness. No injury noted at this time. Staff assisted resident [R1] to her bed and is resting. B/P 145/97, P 73, R 18, O2 sats 97% room air.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 06/06/25 at 2:20 PM, Late entry charted on 06/10/25 at 9:21 AM, Late Entry:Note Text: Fax sent to Dr. [name] to notify of resident being lowered to the floor without injury.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/04/25 at 9:37 PM, Note Text: Found lying on left side on the floor in her room at 1855. ROM assessed before getting resident [R1] off floor and is within normal limits. Three assist to help her off floor and into wheelchair. She had gotten up to go in her closet, did not ask for assistance. Skin tear noted on left elbow, Mepilex applied. She reports hitting her head and small lump noted, no redness or bruising to area. At first reported back pain, within 15 minutes denied having any pain.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/05/25 at 1:35 PM, Note Text: found res [R1] on floor by staff member, states she was reaching for her walker and fell. c/o back pain left shoulder and elbow pain, also knee pain. assisted with gait belt and 3 to standing and into w/c, wants to stay in w/c to go to bingo. VSS. notifications done.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling.On 08/06/25 at 4:01 PM, Note Text: Received call from NP [name] that x-ray results showed a probable non-displaced intra-articular fracture of the radial head to left arm. To set-up an ortho appt for further f/u. R1 and R1's son updated on results and follow-up.Facility did not implement new interventions for R1 to decrease or prevent R1 from falling after injury of radial head of left arm resulted on x-ray. On 08/06/25 at 4:56 PM, Note Text: NP [name] updated on resident c/o knee pain and swelling/bruising noted upon writer looking at knee. New order for x-ray to left knee. Also new order for sling to left arm as tolerated. Discussed new orders with resident [R1].Facility did not implement new interventions for R1 to decrease injury or prevent R1 from falling.On 08/07/25 at 1:10 PM, Late Entry:Note Text: CNA showed RN light bruising to the back of resident's [R1] head which resident reports is from recent fall with hitting head. Will monitor until resolved.On 08/08/25 at 12:20 PM, NP notified facility of left knee x-ray results. X-rays reveal an acute transverse non-displaced fracture of the mid portion of the left patella.On 08/29/25 at 9:41 AM, Surveyor interviewed R1's Family Member (FM) C and asked FM C to describe what FM C knows about R1's falls. FM C stated the facility should be doing more for R1's confusion. FM C stated it's getting to be an everyday occurrence. FM C stated R1 would be walking with staff and get these dizziness and blackout spells and fall. Staff would have to catch her. FM C said R1 had a fall on 08/04/25 in the evening and the facility called her and said that R1 had fallen but no concerns at this time other than a little scrape on the elbow. FM C stated that on the next day, they called again and her that R1 fell on [DATE] in the daytime. Then a couple days after that R1 fell again. FM C stated the facility has done nothing to prevent R1 from falling. FM C stated it wasn't until 7 or 8 days later that R1 had staples placed in the elbow. FM C stated that while R1 was seeing the doctor he refused to look at the x-rays for R1's knee because the nursing home did not let the doctor know of the knee issue. So, then it was a separate visit days later that the review of knee x-rays took place to see that R1 had broken her left leg from one of the falls. Surveyor asked FM C if there were any interventions put into place to prevent R1 from falling. FM C reported to Surveyor that FM C did not feel facility did anything to manage R1 from falling. FM C reported to Surveyor that R1 was up walking around and now is not transferring independently in facility. FM C reported that R1 needs assistance.On 08/29/25 at 10:15 AM, Surveyor interviewed R1 and asked R1 if R1 had significant pain anywhere after falling. R1 reported that R1 had elbow pain. Surveyor asked R1 how R1 is feeling now. R1 reported they just took out staples yesterday and so elbow feels a lot better, Surveyor asked if R1 had surgery on elbow. R1 stated, No I did not have surgery. Facility told me I had a skin tear, but I couldn't see it. They placed staples in elbow. On 08/29/25 at 2:31 PM, Surveyor interviewed Resident Manager D and asked Resident Manager D to review R1's falls on 12/24/24, 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, 08/05/25, 08/20/25, and 08/21/25 with Surveyor. Surveyor asked Resident Manager D why interventions were not placed after R1 fell on [DATE], 12/30/24, 01/01/25, 01/09/25, 05/13/25, 06/06/25, 08/04/25, and 08/05/25. Resident Manager D reported that Resident Manager D is unsure why fall interventions were not placed after R1's falls. Resident Manager D reported that DON B is working with providing education to staff on nurses implementing interventions for residents that fall right away instead of waiting for other staff responsible for reviewing care plans to implement interventions on business days. Resident Manager D reported that all nurses need to be implementing new interventions after every fall within 24 hours of resident falling instead of waiting until staff are in the business office to review and implement.On 08/29/25 at 3:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked what LPN E's process is after a resident fall. LPN E reported that after a fall event occurs LPN E would assess resident from head to toe to make sure resident is ok. LPN E then notifies provider of the resident's falls right away with assessment conclusion and ask for any orders needed to treat resident. Surveyor asked LPN E to explain the event that occurred with R1 on 08/21/25 when R1 was transferred to the ER. LPN E reported to Surveyor that LPN E took R1's vitals twice before R1 was taken by EMS. LPN E then documented R1's prognosis before being transferred out to the hospital on report sheet that then gets entered by Director of Nursing (DON) B into the record. LPN E could not find documentation in R1's record. Surveyor requested LPN E gather a copy of the report sheet LPN E documented on R1's vitals and assessment from 08/21/25. LPN E provided Surveyor with report sheet documentation. Surveyor found minimal information from LPN E's documentation. Surveyor could not find the pertinent information on R1's fall on 08/21/25. LPN E reported that LPN E must have not documented any other information pertaining to R1's fall on 08/21/25.Surveyor could not find valid education regarding correct process for implementing new interventions per resident falls as indicated during the interview with Resident Manager D. No other documentation was given to Surveyor at this time.Example 2 R2 was admitted to the facility on [DATE], with following diagnoses including cerebral infarction, hemiplegia affecting right dominant side, weakness, difficulty in walking, fusion of spine cervical region, constipation, Parkinson's disease, insomnia, weakness, depression, and essential primary hypertension. R2's Minimum Data Set (MDS) assessment, completed on 08/20/25, confirmed R2 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R2 was at risk for falls. R2 requires partial to moderate assistance from staff for toileting, sit to stand, transferring, dressing lower body, and putting on/taking off footwear. R2's Activities of Daily Living (ADL)s care plan dated 06/02/25 states:Ambulation: Not currently. Wheelchair to all destinations, initiated on 06/02/25 and revised on 07/01/25. Ensure call light is within reach and encourage resident to use it to seek assistance when needed, initiated on 06/02/25. Bed mobility: Assist of one, initiated on 06/02/25.Transfer EZ-stand assist of one, initiated on 06/02/25 revised on 08/11/25. R2's fall care plan initiated on 06/02/25 and revised on 06/02/25:Anticipate and meet the residents needs initiated on 06/02/25.Follow facility fall protocol initiated on 06/02/25.PT evaluate and treat as ordered initiated on 06/02/25.Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed, initiated on 06/03/25.Signage to ring for assistance prior to attempting to transfer initiated on 06/30/25. Keep grabber within reach when resident in her room, initiated on 07/01/25. Surveyor reviewed DON B's fall investigation for R2's fall, which states in part: On 06/29/25, [R2] had an unwitnessed fall. On 07/03/25, [R2] had x-rays ordered by provider for right ankle after complaints of it hurting and [R2's] husband unable to transport [R2] in his personal vehicle as she was having hard time with transferring. [R2] is using Hoyer for transfers at this time. On 07/07/25, facility was notified that [R2] had a fracture of the right ankle. ([R2] would complain about pain minimally between this time frame and staff were able to minimize occurring pain with use of interventions set in place. [R2] has now a Reacher to grab items from ground. [R2] frequently at times is forgets to use call light for assistance. [R2] is doing well and was upset with herself for falling.) Surveyor did not find documentation in DON B's investigation report for R2's second fall on 06/30/25. Surveyor reviewed R2's progress notes, On 06/03/25 at 5:28 AM, Note Text: She was assisted by 2 staff with the EZ stand to the bathroom. She is admitted due to some failure to thrive and inability to walk safely.On 06/29/25 at 9:54 PM, Note Text: Transcribed from incident report: Resident was found by staff lying flat on her back in the middle of her room. Resident states I was leaning over to grab my sock off the floor and I leaned too far and fell right on my face. Resident denies any pain. Resident denies any numbness or tingling in her extremities. Resident can move all extremities equally and against resistance. A small bruise is noted above resident's right eye as well as a red abrasion below resident's right eye. Initial vitals were bp - 137/88, pulse - 75, respirations - 19, temp - 97.2. Resident's pupils are equal, round and reactive to light and accommodation and resident is A and O x4. Resident would not like any family notified. No other injuries noted at this time. On call RN notified. On call provider called and updated on injuries.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 06/30/25 at 2:42 PM, Note Text: 1:30pm. found res [R2] sitting on the floor in front of her bed, had been laying down and sat up and was trying to reach her w/c and sat down on the floor. denies injury and denies hitting head. vss. notifications done.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling. On 08/21/25 at 10:29 AM, Note Text: Care conference held for resident [R2] for quarterly review. Husband in attendance along with Resident Care Manager (RCM), Social Service Director (SSD), and Activities Director (AD). Resident [R2] unable to attend, as she had a possible seizure in the bathroom (BR) just prior to care conference and getting sent to ER for eval. R2 has had 2 falls since her last assessment date. One fall resulting in a right tibia fracture. Denies any recent pain. Has a chronic indwelling urinary catheter. She is to see urology in September for further follow-up (f/u), as catheter has been recently placed due to d/t urinary retention. She is always continent of bowel. She will ring for assistance when needing to use the restroom. Participates in PT and Occupational Therapy (OT) to regain strength and mobility.Facility had no documentation of R2's event in the bathroom such as vital signs and assessments with the result of R2 being transferred to the ER. Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling. On 08/21/25 at 3:08 PM, Note Text: Received call from RN from hospital stating they will be sending resident [R2] back. ER thinks she had a vasovagal episode. Her delta troponin was negative, and Electrocardiogram (EKG) showed sinus bradycardia (slow heart rate). On 08/21/25 at 8:48 PM, Note Text: Resident [R2] returned from ER at 5:00 PM, came to the dining to eat supper, after supper writer witnessed resident attempt to self-transfer from wheelchair to recliner, writer reminded resident [R2] to push the call light and wait for help, resident verbalized understanding and pushed call light and waited for assistance to transfer.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 08/26/25 at 1:52 PM, Note Text: Increased attempts to self-transfer to toilet and bed. Son visiting today, and alerted staff to resident [R2] attempting to get onto toilet independently.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling On 08/27/25 at 2:58 PM, Note Text: Resident [R2] noted to have attempts to self-transfer. Also noted to be day 5 with no bowel movement (BM). It is possible these two things are related. NP to review bowel regimen and adjust as indicated.Facility did not implement new interventions for R2 to decrease injury or prevent R2 from falling.On 08/29/25 at 9:25 AM, Surveyor interviewed R2 and asked R2 how R2's fall happened on 06/29/25 and 06/30/25. R2 stated, I saw something on the ground and was trying to pick it up when I fell forward. I was admitted to the facility due to weakness and falls. My goal was to get stronger and get home. Sometimes I have been getting confused. Surveyor asked R2 if R2 received a nurse assessment from head to toe after R2 fell on floor in June. R2 reported that R2 does not remember an evaluation completed after R2 fell. Surveyor asked R2 if R2 was in pain after falling. R2 reported I wasn't in too much pain until later in the day. On 08/29/25 at 2:31 PM, Surveyor asked Resident Manager D why there was no documentation in R2's record pertaining to the fall on 06/30/25 and the last fall where R2 had to be transferred to ER for passing out and falling in bathroom when being transferred via EZ-Stand in bathroom. Resident Manager D reported that there should be documentation in the record, but the nurse did not complete the documentation electronically. Resident Manager D reported expectation is that all staff document in record the process of what led up to the event, if vitals were completed or not, results of the vitals, assessments, etc. and documentation when provider was notified, and what the orders were to support R2 during R2's event. Resident Manager D reported that LPN E should have documented this pertinent information in R2's record pertaining to the fall that led to the ER. Surveyor asked Resident Manager D if interventions should have been placed right away for R2 to not fall again on 06/29/25. Resident Manager D reported that fall interventions should have been placed on 06/29/25 right away or extra supervision to prevent the fall on 06/30/25. Resident Manager D reported to Surveyor that DON B is working with staff on making sure that fall interventions are put into place right away versus waiting for the next business day when office staff are in place. Surveyor could not find valid education regarding correct process for implementing new interventions per resident falls as indicated during the interview with Resident Manager D. No other documentation was given to Surveyor at this time.

Based on observation, interview and record review, the facility did not maintain an infection prevention program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. This has the potential to affect all 33 residents residing in the facility. The facility did not implement Standard of Practice (SOP) for documentation of Infection Control Surveillance and Monitoring with isolation precaution type, start date, and stop date. Staff did not perform appropriate hand hygiene with glove use during cares provided to R19 and R16. Findings: Example 1 The facility policy titled, Infection Prevention & Control Surveillance, with most recent review date 03/2024, states in part: The Infection Preventionist will conduct ongoing surveillance for HAIs and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. .the Infection Preventionist/designee will record actual and suspected infections noting date of symptom onset, location of resident, symptoms, any relevant labs, treatment and precautions initiated. Surveyor reviewed the facility's Infection Control Surveillance logs dated 01/2024-06/2024 including monthly infection rate and noted the following: January 2024: 01/02/24 R30 had date of symptom onset 1/02/24, symptoms hyperglycemia and advantageous lung sounds, diagnosis of Upper Respiratory Infection (URI), and treatment with ZPak (antibiotic). No isolation type, start or end date documented. 01/12/24 R30 had date of symptom onset 1/12/24, diagnosis of suspected respiratory infection, and treatment with ZPak. No isolation precaution type, start/stop date listed documented. 01/31/24 R195 had date of symptom onset 1/31/24, symptoms of cough, Shortness of Breath (SOB), isolation start date 2/1. No type or end date of isolation precautions documented. No diagnosis documented. February 2024: R30 had symptoms of SOB, lethargy, hyperglycemia, suspected URI, and treatment with Levaquin (antibiotic). No symptom onset date documented. No isolation precautions documented. 02/27/24 R6 had date symptom onset of 2/27/24, symptoms of cough, wheeze, fever, lab date 2/28/24, diagnosis of covid-19, isolation start date 2/28/24. No treatment documented. No end date of isolation precautions documented. Isolation precautions were not implemented with onset of symptoms. 02/28/24 R21 had date symptom onset 2/28/24, symptoms of cough, lab date 02/28/24, diagnosis of respiratory syncytial virus (RSV), isolation start date of 02/28/24. No end date of isolation noted. Type of isolation precaution not documented. 02/29/24 R191 had date symptom onset of 02/29/24, symptoms of cough and nasal congestion, lab date 02/28/24, isolation start date 02/29/24 and end date 03/02/24. No diagnosis documented. No treatment documented. Type of isolation precaution not documented. 04/02/24 R193 had symptoms of facial rash and burning pain, diagnosis of possible shingles, treatment Valacyclovir 500mg three times a day for 7 days, isolation start date 4/2/24. No isolation type or end date for precautions documented. 04/26/24 R28 had symptoms of decreased oxygen saturation, increased blood pressure, and shortness of breath, lab date 04/26/24 with negative 4plex and 04/26/24 chest x-ray (no result noted), diagnosis of possible pneumonia, treatment of Doxycycline 100mg twice a day for 5 days. No isolation precaution type, start/end date documented. No confirmed diagnosis documented. May and June 2024: All surveillance documentation did not include isolation precaution type, start and end dates. 46694 Example 2 The facility policy titled, Hand Hygiene revised 05/2020, states in part: .Policy Interpretation and Implementation . 8. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: . b. Before and after direct contact with residents; . h. Before moving from a contaminated body site to a clean body site during resident care. i. After contact with a resident's intact skin; . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. m. After removing gloves; . 9. Hand hygiene is the final step after removing and disposing of personal protective equipment . Procedure: . Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. R19 was admitted on [DATE] with diagnoses of Alzheimer's, dementia, and weakness. On 07/09/24 at 7:07 AM, Surveyor observed morning cares provided to R19 by Certified Nursing Assistant (CNA) L and CNA J. Both CNAs performed hand hygiene and glove use appropriately. After cleaning and drying R19's top half, the staff removed pillows from under R19's legs and between the knees. R19's legs were cleaned, dried and lotion applied. Compression socks were applied to both legs. Non-skid footwear placed to feet and pants put on and pulled to R19's knees. CNA J cleaned R19's front and peri area with wipes, wiping front to back. R19 was then rolled onto the left side and R19's buttocks were cleaned by CNA J using wipes and a new brief was placed. CNA J did not remove gloves and perform hand hygiene. With the contaminated gloves that CNA J was using to wipe R19's buttocks clean, R19 was then rolled onto back. CNA L washed R19's peri area with a clean washcloth and then dried. R19 was rolled onto the right side with CNA J holding R19 with the contaminated gloves and R19's bottom was washed with washcloth and dried by CNA L. New brief was pulled through and secured in the front. The remaining observations of care were appropriate. On 07/10/24 at 7:14 AM, Surveyor interviewed CNA J about the observations from the previous day and asked CNA J, What should you have done differently in this situation? CNA J replied, I should have removed the dirty gloves and cleaned my hands and put on new gloves. On 07/10/24 at 8:36 AM, Surveyor interviewed DON B about the observations of cares for R19 from the previous day and asked, What is the expectation in this case regarding hand hygiene? DON B replied, She should have removed the dirty gloves, performed hand hygiene, and put on new gloves to proceed with cares with this resident. R16 was admitted on [DATE] with diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting R16's left non-dominant side. Based on the quarterly Minimum Data Set (MDS) date 06/10/24, R16 had a Brief Interview of Mental Status (BIMS) score of 10 which indicates R16 had moderate cognitive impairment. On 07/09/24 at 7:40 AM, Surveyor observed morning cares provided to R16 by CNA N and CNA L. CNAs assisted R16 with socks, pants, left ankle brace, and shoes. Pillow was removed from R16's left arm pit and washcloths removed from both hands. R19 was taken to the toilet from the bed via the E-Z stand lift. Once on the toilet both CNAs put on gloves without performing any hand hygiene. On 07/10/24 at 7:42 AM, Surveyor interviewed CNA L about the observations made from the previous day and asked CNA L, What is the expectation of hand hygiene with glove use? CNA L replied, From what I can remember from CNA class is you need to at least use hand sanitizer or wash hands before and after glove use. On 07/10/24 at 8:36 AM, Surveyor interviewed DON B about the observations of care performed on R16 and asked DON B if this observation is OK? DON B replied, Yes, as long as they perform hand hygiene between gloves changes and when they remove the dirty gloves at the end of the care provided. Surveyor then asked for a copy of the facility's hand hygiene with glove use policy. On 07/10/24 at 10:55 AM, DON B provided policy titled Hand Hygiene and showed Surveyor under section M. After removing gloves, you are to perform hand hygiene but not when putting gloves on unless using sterile gloves. Surveyor reviewed the policy and under the procedure section titled Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. Surveyor showed this to DON B and DON B replied, It looks like we have conflicting guidelines for hand hygiene.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An antibiotic stewardship program that includes a system to monitor/review antibiotic use. This has the potential to affect all 33 residents residing in the facility. The facility did not follow a Standard of Practice (SOP) for antibiotic stewardship for antibiotic use for residents on the line list logs from January 2024 through June 2024 line lists. The facility did not implement a SOP for antibiotic stewardship to monitor/review antibiotic usage, outcome measures, and summarizing of antibiotic resistance. The facility did not outline and implement a SOP for antibiotic stewardship concerning mode and frequency of education for prescribing providers and nursing staff on antibiotic use and protocols. R6 was prescribed Keflex for wound infection. Culture and sensitivity results did not indicate sensitivity to Keflex. The facility did not communicate with R6's provider to ensure R6 was receiving an appropriate antibiotic. This is evidenced by: The facility policy titled, Antibiotic Stewardship, with most recent review date of 03/2024, states in part: .The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents . .Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community . .When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued . The facility policy titled, Infection Prevention & Control Surveillance, with most recent review date of 03/2024, states in part: .purpose of surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms .to guide appropriate interventions and to prevent future infections . Using the current suggested criteria for HAIs (McGeer, Loeb, etc.), determine if the resident has a HAI. Interpreting Surveillance Data .analyze the data to identify trends and reported to QAPI committee quarterly. Surveyor reviewed facility's guiding infection criteria dated 11/2017 titled, Interactions to Reduce Acute Care Transfers (INTERACT) Care Paths, which included McGeer Criteria dated 2012, and noted the following: The INTERACT Care Path provides an outline of the common criteria for infection surveillance and initiation of antibiotics (McGeer, Agency for Healthcare Research and Quality (AHRQ), and Loeb). INTERACT encourages facilities to select a specific criterion for infections and a criterion for when to notify the provider to maintain consistency. .purpose of INTERACT criteria is to provide a set of clinically sound criteria that is consistent with published guidelines about when to notify a clinician about a change in condition. The INTERACT criteria are not designed to define any specific infection or to indicate the need for antibiotic therapy. .antibiotic therapy should not be initiated unless a patient/resident meets criteria for an infection. Surveyor reviewed facility's Infection Control Surveillance logs dated 01/2024-06/2024 including monthly infection rate and noted the following: January 2024 01/01/24 R4 had no symptoms documented - stated diagnosed in emergency room with urinary tract infection (UTI), treatment with Bactrim DS twice a day for 5 days. 01/02/24 R30 had symptoms of hyperglycemia and advantageous lung sounds, diagnosis of upper respiratory infection (URI), and treatment with ZPak (antibiotic). No start date, dosage or duration of antibiotic documented. 01/03/24 R194 had symptoms of increased confusion decline with a diagnosis of UTI and treatment with Rocephin 1g. 01/12/24 R30 had no symptoms listed - stated diagnosed at appointment with suspected respiratory and treatment Zpak. 01/18/24 R236 had symptoms of hallucinations and increased weakness, diagnosed with UTI, and treated with Bactrim DS for 7 days. 01/20/24 R13 had symptoms of agitation, striking out, and increased confusion with a diagnosis of UTI and treatment with Bactrim DS twice daily for 5 days. 01/31/24 R186 had symptoms of confusion, hallucinations, anxiety diagnosed with UTI and treated with Bactrim DS twice daily for 5 days. The surveillance for R4, R30, R194, R30, R236, R13 and R186 had no start date or dosage of antibiotic documented. No documentation to indicate appropriate antibiotic is being used for a specific bacterium causing infection. Symptoms listed do not meet updated 2024 Revised McGeer Criteria for surveillance of UTI and respiratory infection. February 2024 R30 has symptoms of shortness of breath (SOB), lethargy, hyperglycemia with an undiagnosed URI and treatment with Levaquin 750mg every other day for 4 doses. No documentation of diagnostic confirming respiratory infection. Symptoms listed do not meet updated 2024 Revised McGeer Criteria for surveillance of URI. March 2024 03/07/24 R9 had symptoms of increased behaviors and cloudy urine with a diagnosis of UTI treated with Keflex three times daily for 7 days. 03/13/24 R5 had no symptoms documented - stated bypassing urine ordered by MD without rationale why urinalysis was bypassed. Listed diagnosis of UTI and treated with Bactrim DS twice a day for 5 days. 03/14/24 R35 had symptoms of increased confusion, diagnosis of UTI, and treatment of Cipro twice a day for 5 days. Under symptom column it states - ordered by nurse practitioner (NP). Line was crossed through stating no growth and Cipro was discontinued. Provider ordered antibiotics prior to receiving C&S. No documentation of when antibiotic was initiated or discontinued. Symptoms listed do not meet updated 2024 Revised McGeer Criteria for surveillance of UTI. 03/18/24 R21 had symptoms of increased confusion and stated - ordered by NP, diagnosis UTI and treated with Levaquin 750 every 48 for 4 days. The surveillance for R9, R5, R35 and R21 had no start date of antibiotic documented. No documentation to indicate appropriate antibiotic is being used for a specific bacterium causing infection. Symptoms listed do not meet updated 2024 Revised McGeer Criteria for surveillance of UTI. April 2024 04/17/24 R19 had symptoms of cough/choke, vomit, diarrhea, wet lungs, decreased oxygen saturation, diagnosis of suspected aspiration pneumonia, and treatment of Rocephin x2 then Levaquin 750 x3 days. No lab/diagnostic data documented for confirmation of aspiration pneumonia. No start date of antibiotic documented. No documentation to indicate appropriate antibiotic is being used for a specific bacterium causing infection. June 2024 06/06/24 R28 had symptoms of increased confusion since hospitalization - ordered by NP, diagnosis of UTI, and treated with Keflex 500 three times a day for 7 days. No start date of antibiotic documented. No documentation to indicate appropriate antibiotic is being used for a specific bacterium causing infection. Symptoms listed do not meet updated 2024 Revised McGeer Criteria for surveillance of UTI. Monthly infection rate: January monthly infection rate was 10.28 (Urinary 7.19, Respiratory 2.06, Skin 1.03). February monthly infection rate was 5.18 (Urinary 1.04, Respiratory 4.15). March monthly infection rate was 6.03 (Urinary 6.03). April monthly infection rate was 8.12 (Urinary 1.02, Respiratory 6.09, Skin 1.02). June monthly infection rate was 7.79 (Urinary 2.92, Respiratory 0.97, Skin 1.95, Other 1.95). No documentation of facility reviewing/monitoring prescribed antibiotic use for trends in infection rates related to specific bacteria. Incomplete documentation of infectious cause including bacteria identified through lab analysis, antibiotic start/end dates, and symptoms of illness. Surveyor reviewed facility's Antibiotic Stewardship policy which did not include the mode (e.g., verbal, written, online) and frequency of education for prescribers or nursing staff on antibiotic use protocols. Surveyor requested documentation of education provided to staff and no information was provided. On 07/10/24 at 7:50 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F regarding education for infection prevention and antibiotic stewardship. LPN F stated that infection prevention training is completed via Relias (an electronic-based education program for staff) annually, but unable to recall antibiotic stewardship education specifically. Surveyor asked LPN F the criteria used for determining if a resident had signs/symptoms of an infection. LPN F stated that staff use INTERACT Care Path and the standing orders for any labs. On 07/10/24 at 11:15 AM, Surveyor interviewed Director of Nursing (DON) B with dual role of Infection Preventionist (IP). Surveyor asked DON B for clarification of antibiotic stewardship policy regarding criteria used for infection surveillance. DON B stated that McGeer Criteria was used. Surveyor asked DON B what criteria the provider uses for prescribing antibiotics. DON B stated that they use whatever guideline the provider uses. Surveyor asked which guideline was used. DON B stated not knowing which particular one, but that whichever one the provider used was the most current guideline. Surveyor asked DON B how nursing staff determine when a provider should be notified. DON B stated they use INTERACT Care Paths, which are located at each nursing station. Surveyor asked for further explanation of INTERACT Care Paths. DON B stated it is a guidance for infection surveillance based on current standards of practice that are used in addition to the current standing orders from the provider to conduct a urinalysis if the Care Path says to do so. Surveyor asked DON B to explain the facility's policy for how antibiotic review was completed. DON B stated the pharmacy sends a report monthly stating what antibiotics were prescribed. Surveyor asked DON B how this information is reviewed. DON B stated it is compared to the surveillance log and it is reviewed as soon as it comes in, but sometimes so much stuff comes through the office, some can be missed - especially if not in the office for vacation. Surveyor asked DON B how education for infection control and antibiotic stewardship was completed. DON B stated that nursing staff complete training via Relias for infection control upon hire and annually. DON B stated that providers are not included in this education. No documentation for antibiotic stewardship education provided. On 07/10/24 at 1:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. Surveyor asked NHA A regarding frequency of the Quality Assurance and Performance Improvement (QAPI) committee and topics addressed. NHA A stated that QAPI meets quarterly and discusses resident/staff concerns and areas identified needing improvement. Surveyor asked NHA A if resident illness and antibiotics use/trends were reviewed. NHA A stated the infection rate numbers were reviewed, but no investigations as to causation or trends related to antibiotic use were reviewed, monitored, or investigated. NHA A further stated that the first time this was discussed was during the QAPI meeting held on 07/09/24 during survey. 44863 R6 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and osteomyelitis of right ankle and foot. Care plan: -Contact precautions d/t active wound infection. May resume enhanced barrier precautions after antibiotic treatment. Chronic enhanced barrier precautions related to chronic wounds to right foot and left hip. Date initiated 07/03/24, revised 07/09/24. Orders: -06/20/24, Keflex (cephalexin) for infection x 14 days. -07/02/24, Keflex (cephalexin) for infection, no end date. On 07/10/24, Surveyor reviewed R6's progress notes, and noted the following: -06/17/24, provider updated, two white pustules left hip. -06/19/24, left hip wound draining serous drainage, provider updated and ordered Keflex (antibiotic). -06/21/24, wound culture results staphylococcus and enterococcus faecalis-sensitivity completed and indicated Ampicillin, Linezoid, Vancomycin, Ampicillin/Sulbactam. -06/24/24, provider updated on darkening drainage and ordered to send to ER for evaluation of left hip wound. CT completed and indicated fluid around hip. Wound culture completed. Referral to orthopedics and continue Keflex. -06/27/24, culture results from the ER. Organism: enterococcus faecalis. Sensitivities to Ampicillin, Linezoid, Vancomycin, Ampicillin/Sulbactam. -07/01/24, request from provider to continue Keflex ordered to end on 07/04/24 or start a new one. -07/02, provider ordered to continue Keflex, no end date. On 07/10/24 at 10:47 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated per Antibiotic Stewardship program, R6's provider should have been updated on or around 06/21/24, to question if Keflex was appropriate based on culture and sensitivity results. DON B stated, This would be the expectation; however, I am unsure of the delay. I was off that week.

Based on interview and record review, the facility did not conduct a thorough investigation into the abuse or protect from future incidents through education for Resident (R) 16. The facility did not conduct a thorough investigation into the abuse as other residents were not interviewed to determine if other residents were affected. The facility did not protect residents from future incidents as education was not provided to staff after this incident occurred. Findings: The facility's policy titled, Resident Abuse Prevention and Reporting revised 01/2017, states in part: 7. Investigation/Reporting Procedures for actual or suspected abuse/neglect: . i) Plan for interviews of staff and residents as appropriate . k) Depending on the results of the investigation: Corrective actions will be taken to prevent abuse/neglect which may include discipline up to and including terminations, additional education, care plan or policy change. R16 was admitted on [DATE] with diagnoses of hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting R16's left non-dominate side. Traumatic subdural hemorrhage (type of bleeding near your brain that can happen after a head injury) with loss of consciousness greater than 24 hours without return to pre-existing conscious level with the patient surviving and muscle weakness. Based on the quarterly Minimum Data Set (MDS), dated [DATE], a Brief Interview of Mental Status (BIMS) of 10 indicates R16 had moderate cognitive impairment. The MDS also indicated the following: Functional Limitation in Range of Motion: Impairment on one side (left) upper and lower extremities. Mobility devices: wheelchair. Bowel/Bladder: urinary frequently incontinent, bowel always incontinent. Urinary toileting program: yes Bowel toileting program: no. Behaviors not exhibited. Review of the facility's investigation on 06/07/24 R16 requested assistance to the bathroom. Certified Nursing Assistant assisted R16 to the bathroom and said to R16, You better do something this time or I'm not going to help you if you call again for the bathroom tonight. The facility's investigation about the abuse did not include interviews with additional residents to determine if further abuse had occurred. There was no progress note in the medical chart specific to this abuse allegation. On 07/09/24 at 11:31 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H asking about the kind of education they receive for abuse. LPN H replied, We get computer training annually that has things that include abuse and neglect. Surveyor asked LPN H, Have you received this training in the last month? LPN H replied, No. On 07/09/24 at 2:32 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, asking if there were, as part of the abuse investigation, interviews of other residents and training that was provided to all staff about abuse and neglect to prevent abuse from happening in the future. NHA A replied, I don't know. We interview 10 random residents quarterly to ask if there are any abuse concerns, but I don't have anything since this happened. I don't think so, but I will check on that. As part of the staff employment, they do receive annual abuse training but not since this incident. On 07/10/24 at 6:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA) I asking what kind of education they receive for abuse. CNA I replied, A month or two ago on our computer program we had this education on abuse and neglect. On 07/10/24 at 7:06 AM, Surveyor interviewed both CNA J and CNA K asking what kind of education they receive for abuse. CNA J and CNA K replied, We get dementia and abuse training. On 07/10/24 at 9:25 AM, Surveyor interviewed NHA A asking if there was any further documentation regarding resident interviews and staff education provided since this abuse allegation was made. NHA A replied, No.

Based on observations, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was documented accurately related to tube feeding for 2 (R2 and R11) of 13 residents reviewed for MDS resident assessments. Findings include: Example 1: Review of R2's care plan, orders, diagnosis, and progress notes did not indicate R2 received tube feedings while a resident in the facility. Review of R2's electronic medical record (EMR) annual MDS comprehensive resident assessment with an Assessment Reference Date (ARD) of 06/27/24, documented in section K: Swallowing / Nutritional Status K0520 B, R2 was receiving tube feeding while a resident. The documentation indicated the response was locked and signed on 06/28/24 at 4:47 PM. On 07/08/24 at 6:45 PM, Surveyor completed initial tour of facility and observed R2 was not receiving tube feeding services. Example 2: A review of R11's care plan, orders, diagnosis, and progress notes did not indicate R11 received tube feedings while a resident in the facility. A review of R11's EMR annual MDS comprehensive resident assessment with an ARD of 06/04/24 documented in section K: Swallowing / Nutritional Status K0520 B, R11 was receiving tube feeding while a resident. The documentation indicated that the response was locked and signed on 06/04/24 at 11:01 AM. On 07/08/24 at 6:45 PM, Surveyor completed initial tour of facility and observed R11 was not receiving tube feeding services. On 07/09/24 at 11:55 AM, Surveyor interviewed Director of Nursing (DON) B regarding the MDS indications for tube feeding. Surveyor asked why R2 and R11 might be labeled for tube feeding on the MDS. DON B said that R2 and R11 were incorrectly labeled for tube feeding and they submitted a request to change them today when the issue was brought forward. On 07/10/24 at 11:52 AM, Surveyor interviewed Licensed Practical Nurse (LPN) M who completed the MDS assessment with the oversight of the DON. LPN M said they believe they just hit the wrong buttons and they are sorry they were not sure what exactly happened. On 07/10/24 at 1:23 PM, Surveyor interviewed DON B regarding expectations for MDS accuracy. DON B said they would have expected this to have been caught and the MDS should be coded accurately.

Based on observation, interview and record review, the facility did not ensure activities of daily living were maintained for 1 out of 2 sampled residents (R31). R31 was not ambulated per recommendation of Physical Therapy (PT). This is evidenced by: The facility's policy titled, Restorative Nursing Program (08/2015) states in part, To promote each Residents ability to adapt and adjust to living as independently and safely as possible .To focus on achieving and/or maintaining the Residents optimal physical functioning in activities of daily living. R31 was admitted to the facility on [DATE]. R31's diagnoses included compression fracture of vertebra, low back pain, unspecified, adult failure to thrive, weakness, and muscle weakness (generalized). R31's Minimum Data Set (MDS), dated [DATE], confirmed R31 scored 14 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R31 understands and is understood by others, and she is able to make her needs known. R31 is totally dependent on staff for all transfers and ambulation. On 05/29/24, Physical Therapy (PT) recommended R31 ambulate to all destinations with roller walker (RW) and Caregiver Assist of 1 (CGAx1) with gait belt including to and from meals in the dining room. On 05/29/24, R31's care plan and the Certified Nursing Assistant (CNA) Kardex indicated R31 is to ambulate to all destinations with RW and CGAx1 with gait belt including to and from meals, in the dining room. Surveyor reviewed documentation related to R31's ambulation. Surveyor noted documentation in minutes per day and evening shifts. Documentation does not indicate that R31 ambulated to and from dining room for all meals. Surveyor did not observe R31 ambulate or being offered to ambulate during survey period of 07/08/2024 - 07/10/2024. On 07/09/24 at 7:13 AM, Surveyor interviewed R31 as she was in her room and in her wheelchair (w/c), R31 reported she would like to have help walking more. That's what I'm here for, to get better. I need to get up and walk. I want to get better so I can go home. They don't walk me here like they did when I was in Eau [NAME]. On 07/09/24 at 8:04 AM, Surveyor observed R31 was taken to dining room in W/C; no ambulation or encouragement to ambulate was observed. After meal, R31 was not offered to ambulate back to room and was taken back to her room in her w/c. On 7/9/24 at 8:52 AM, Surveyor observed R31 in w/c repeatedly saying, Help me, help me get up. I cannot do it by myself. I want to get up and need help. R31 was not offered to ambulate and was wheeled to hall and news was turned on a laptop for her to watch. On 07/09/24 at 10:50 AM, R31 was observed being pushed outdoors in W/C then brought back in approximately 5 minutes later. R31 sat in W/C by nursing station. On 07/09/24 at 11:37 AM, Surveyor observed R31 in recliner in her room. CNA C was present in room and reported R31 transferred with assist of 1 and her walker. CNA C stated, We ambulate her to the dining room and back when she doesn't have back pain. On 07/10/24 at 8:19 AM, Surveyor observed R31 in dining room in w/c. Surveyor did not observe staff offer R31 to ambulate to or from dining room. On 07/10/24 at 8:50 AM, Surveyor interviewed CNA E regarding R31's ambulation expectations or routine. CNA E reported R31 has pain a lot and was offered to ambulate before going to the dining room for breakfast but refused. CNA E admitted that R31 was not offered to ambulate back from dining room. CNA E asked R31 if she had pain and R31 responded, I'm feeling better, and then CNA E transferred R31 from w/c into recliner chair. No observation that CNA E offered to assist R31 with ambulation. On 07/10/24 at 9:00 AM, Surveyor interviewed R31. R31 reported she would like to walk more. R31 stated, When I was in another facility, they walked me all the time, the doctor made sure of it. When asked if she refuses to walk when she has pain, she reports, When it is real bad, then I don't walk, but if I walk I have less pain, like when I was in the other facility, I have only been here three months but they do not walk me On 07/10/24 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported it is the expectation R31 is offered to ambulate to and from dining room and then to document if refused in the walking program record. DON reported when R31 was in therapy, Ambulation actually helped her pain.

Based on observation, record review and interview, the facility did not implement a restorative program in attempt to improve or maintain resident's functional abilities for 1 of 2 residents (R19) reviewed for limited Range of Motion (ROM). Findings: The facility's policy titled, Restorative Nursing Program revised 8/2015, states . Policy To promote each Residents ability to adapt and adjust to living as independently and safely as possible. One Restorative Aide (RA) will be scheduled each day. Purpose To focus on achieving and/or maintaining the Residents optimal physical functioning in activities of daily living. Procedure The director of Nursing or designee will supervise the Restorative Program. An RN will be the Restorative Nursing Coordinator. CNA's specially trained in Restorative procedures will implement, assist, and document the restorative activities for assigned Residents. In-service will be held as needed to train and update staff. R19 was admitted on [DATE] with diagnoses of Alzheimer's, dementia, difficulty in walking, weakness, contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of right and left ankle, osteoarthritis of knee, and age related osteoporosis. Care plan: The resident has an Activities of Daily Living (ADL) self-care performance deficit relate to decline in mobility, advanced age, contractures to right/left ankle, osteoarthritis, osteoporosis. Bathing and showering: The resident is able to: participate to fullest extent. Staff assist x1. Bed mobility: The resident is able to: participate to fullest extent. Assist x1, assist x2 as needed (PRN). Eating: The resident is able to: participate to fullest extent. Supervision/assistance as needed. Has plate guard. Pureed diet with honey thick liquids. Sippy cups for liquids at meals. Personal hygiene/oral care: The resident is able to: participate to fullest extent. Assist x1 with personal hygiene/oral care. Check and change q2h. Peri-care q AM and PM, when incontinent and as needed. Apply barrier cream with every incontinent episode. Toilet use: The resident is able to: Check and change every 2 hours. Assist x1 with peri-care with day and night cares, when incontinent, and as needed. Transfers: The resident is able to: transfers with Hoyer Lift-Assist x2. Encourage the resident to participate to the fullest extent possible with each interaction. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. Physical/Occupational evaluation and treatment as per doctor order. The resident has limited physical mobility related to limited ROM of right and left arms. Resident to be Hoyer lift assist of 2 with all transfers. Check and change q2h. The resident will remain free of complications related to immobility, including increased contractures, thrombus formation, skin-breakdown, fall related injury. Elevate lower extremities in recliner for prolonged knee extension stretch. Locomotion: The resident is totally dependent on (1) staff for locomotion using Broda Chair (specialize wheelchair that reclines). Minimum Data Sets (MDS) dated [DATE]: Functional abilities: upper extremity impairment on both sides. Mobility devices: wheelchair. On 07/08/24 at 8:03 PM, Surveyor observed R19 in bed. Resident had heels floated and washcloths in hands bilateral. Both of R19's arms were tight to her chest. On 07/09/24 at 7:07 AM, Surveyor observed Certified Nursing Assistant (CNA) L and CNA J providing AM cares to R19. Staff did not perform any ROM exercises to upper or lower extremities aside from putting on clothing and washing under R19's arms. On 07/10/24 at 8:09 AM, Surveyor interviewed CNA L asking if R19 is to be receiving restorative care for limited ROM. CNA L replied, Yes based on the care plan, but for some reason this month the resident is not on my restorative care schedule. I don't have this resident on my restorative care list. Maybe the Director of Nursing (DON) B would know more about this? On 07/10/24 at 9:30 AM, Surveyor interviewed Physical Therapist (PT) G asking what kind of therapy R19 is getting. PT G replied, I believe this resident is getting restorative care from the staff on the floor. This resident has been known to be combative and they may have discontinued that because of that. Surveyor requested documentation of restorative plan. On 07/10/24 at 9:37 AM, PT G provided Surveyor a therapy progress note dated 8/2/23. Surveyor asked if there is anything more recent. PT G replied, No this resident should be getting restorative cares by the nursing staff on the floor. On 07/10/24 at 10:14 AM, Surveyor interviewed CNA K, asking if any restorative cares are being provided for R19. CNA K replied, No, this resident had been getting stretching exercises but got sick and was placed on 'End of life care' and the restorative care stopped. Surveyor asked CNA K who decides to restart these therapies. CNA K replied, The order comes from our DON. The DON is the one that writes them. On 07/10/24 at 10:52 AM, Surveyor interviewed DON B, asking based on the care plan for limited ROM, does R19 have a restorative care program. DON B replied, That should be in the restorative care binder on the unit. Surveyor asked to review the binder. On 07/10/24 at 11:09 AM, DON B informed Surveyor, This resident went to palliative care in April and restorative care was discontinued. When R19 came off of palliative care it was never resumed. On 07/10/24 at 11:19 AM, Surveyor interviewed DON B, asking why there is no referral to therapy for restorative care. DON B replied, Because we have not seen a decline in care because R19 is not walking. Advanced directives provided by DON B shows this resident started palliative care on 04/30/24 and removed from palliative care on 05/28/24. Surveyor asked DON B, how do you maintain the resident's level of mobility, and what is your expectation for a timeline for when restorative care should be restarted. DON B replied, I don't know. But the girls are supposed to be doing some stretching with this resident's arms during cares. Surveyor explained observations of cares over the past 3 days during the survey and CNAs have not provided stretching to R19's arms. Surveyor reviewed with DON B the interview with restorative care staff stating R19 has not been on their schedule this month for any restorative care.

Based on interview and record review, the facility did not ensure 1 of 5 residents (R8) were free from unnecessary medications. -R8 was prescribed lorazepam (anti-anxiety) without a documented diagnosis. -R8 was prescribed lorazepam as needed (PRN), beyond the 14-day limit, without a documented rationale. -R8's record did not include interventions to reduce or eliminate the need for administration of medication. -R8's record did not indicate adequate monitoring of anti-anxiety medication, including signs or symptoms to warrant administration of medication, and side effects of the medication. Findings include: R8 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and heart failure. R8's record did not include a diagnosis of anxiety. R8's Minimum Data Set (MDS) assessment completed on 03/25/24, indicated a significant change related to hospice services. R8's most recent MDS assessment completed on 06/12/24 confirmed R8 scored 07/15 during Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R8's physician orders included lorazepam PRN every four hours as needed for anxiety or shortness of breath, dated 03/22/24-06/12/24 and 06/12/24-09/12/24. On 07/10/24, Surveyor reviewed R8's medication administration record (MAR), and noted PRN lorazepam was administered as follows: -April, administered five times. -May, administered 26 times. -June, administered 23 times. -July, administered six times. Progress notes confirmed need for administration of lorazepam was for, Anxiety, SOB for 3 months. Progress noted did not provide detail about signs or symptoms R8 was exhibiting to indicate use of medication. On 07/10/24, Surveyor reviewed R8's care plan and noted: -The resident uses antidepressant medication r/t depression. -The resident has a behavior problem verbally aggressive toward others at times. R8's record did not contain a care plan related to anti-anxiety medication, which would include non-pharmacological interventions, signs, or symptoms to indicate need for administration of medication, and adverse consequences related to medication. On 07/10/24, Surveyor reviewed monthly pharmacy reviews, which indicated no irregularities related to lorazepam. On 07/10/24 at 1:46 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated she will ask the doctor about rationale for PRN lorazepam, As he is here right now. This happens with a lot of hospice residents. DON B provided Surveyor with a printed progress note dated 06/12/24. Progress note reads, New order to extend Ativan end date x 3 months from [Dr. Name], see TO. The printed note included a handwritten note that read, On hospice. He has anxiety and likely will require more medication as he progresses through end of life. Signed by [Dr. Name] on 07/10/24. Surveyor was unable to find a documentation in R8's record to confirm a rationale was provided prior to 07/10/24.

Based on observation, record review and interview, the facility did not ensure drugs and biologicals used in the facility are labeled in accordance with current accepted professional principles for 1 of 26 medications reviewed during medication administration observation. This had the potential for harm to affect Resident (R)30. This is evidenced by: R30 was admitted to facility on 12/08/23 with a pertinent diagnosis of diabetes mellitus II. R30 has a prescription order for insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) inject 28 unit subcutaneously one time a day related to type 2 diabetes. On 07/10/24 at 7:50 AM, Surveyor observed Licensed Practical Nurse (LPN) F complete medication administration of insulin to R30. Surveyor observed R30's insulin glargine injection pen had a pharmacy label stating name, received date of 06/14/24, open date of 06/24/24, and dose to be administered of 22 units subcutaneously every AM. Surveyor reviewed physician order and Medication Administration Record (MAR) in R30's Electronic Medical Record (EMR) and noted as being to administer 28 units. Surveyor asked LPN F to verify this finding. LPN F verified that the current order was to administer 28 units. Surveyor asked LPN F why the medication label from pharmacy on the insulin pen was for 22 units. LPN F stated it must have been missed and corrected the dosage with a handwritten sticker stating the correct dose and placed it over this part of the label. On 07/10/24 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B regarding the facility policy of medication labeling. DON B stated the expectation for verifying medication labels would be completed when medication was received from pharmacy and when staff are administering the medication during verification of right resident, medication, dose, route, and frequency. DON B stated that if an error is observed, then the nurse would use a handwritten sticker to correct the date, apply to the current label, and notify the pharmacy. Surveyor asked what timeframe this would be expected to be completed. DON B stated immediately. Surveyor explained the finding of the incorrect dosage on the medication label. DON B stated that this should have been corrected when the insulin pen was first received on 06/14/24. No evidence was provided that the pharmacy had been notified of this error or was corrected.

Based on observation, interview and record review, the facility did not revise the care plan with accurate information for safety interventions when the call light was removed for 2 of 2 residents (R) reviewed. (R2 and R3). Findings include: Example 1 R2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia with severe mood disturbance, dysphagia, contracture of right and left knee, muscle weakness, and hypertension. R2's minimum data set (MDS) assessment, completed on 03/14/24, confirmed R2 scored 03 during a brief interview for mental status (BIMS), indicating severely impaired cognition. R2 requires partial/moderate assistance with eating. R2 requires total assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R2's care plan was initiated on 09/06/19, and included the following interventions: ADL SELF-CARE DEFICIT care plan: Encourage the resident to use bell to call for assistance implemented on 09/06/19. AT RISK FOR FALLS care plan: Be sure residents call light is within reach and encourage the resident to use it for assistance as needed. The resident need prompt response to all requests for assistance. On 05/07/24 at 9:29 AM, Surveyor observed R2 sitting in wheelchair in room sleeping. Surveyor did not observe call light in reach, or a call light connected to wall. Surveyor observed an orange dot sticker on the call light panel on wall. Surveyor did not observe any type of device R2 could use to alert staff. On 05/07/24 at 11:04 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G, CNA H, and Licensed Practical Nurse (LPN) E and asked why R2 does not have a call light in place. CNA H indicated that R2 was found with the call light cord around R2's neck a while back, so staff took call light away and placed an orange sticker on panel on wall. On 05/07/24 at 12:15 PM, Surveyor interviewed Social Worker (SW) C and asked why R2 had no call light. SW C indicated that SW C could retrieve the documentation that was investigated with R2's discontinuation of call light. On 05/07/24 at 12:27 PM, Surveyor observed R2 looking out to the hallway. Surveyor observed R2 asking housekeeping staff walking by if someone can change his TV channel to football. Staff member stopped and tried finding football on for R2. On 05/07/24 at 12:30 PM, Surveyor interviewed CNA H and asked how R2 asks for assistance with any needs R2 may have. CNA H indicated that staff just kind of checks on R2. CNA H indicated there is no set time R2 is checked on. Surveyor asked CNA H the specific time frame that CNA H checks on R2. CNA H indicated that R2 is kind of near the nurse's station so when we walk by, we check on R2. Surveyor explained that Surveyor observed no one near R2 when he asked for assistance with his TV channels while everyone was at lunch in the dining room. CNA H indicated there was no staff nearby during lunch time as R2 refused lunch today and does that sometimes. CNA H indicated that staff check on R2 before meals and after meals. CNA H indicated CNA H will be repositioning R2 after lunch. CNA H walked back to dining room. On 05/07/24 at 12:33 PM, Surveyor interviewed R2 and asked how R2 asks for assistance with no call light in room. R2 stated, Sometimes I have to yell out to the door when I see people walk by, or wait till staff come in. On 05/07/24 at 12:41 PM, SW C provided Surveyor with a progress note for R2's discontinuation of call light dated on 04/21/24 which stated in part, .resident had call light cord laying across his neck (not around) did take the call light out of his room, as he is in close proximity to the nurse's station and had has not been using it. Provider updated on resident's call light being across not around his neck . On 05/07/24 at 1:45 PM, Surveyor interviewed Director of Nursing (DON) B and asked about R2's call light usage and not having a call light in room. DON B indicated that R2's call light usage record was reviewed and R2 did not utilize call light recently after the incident with the call light being draped across R2's neck. DON B indicated that staff felt it was safer to remove call light out of R2's room. DON B indicated that for any residents that don't have a call light, safety interventions are added and checking on resident is individualized in the care plan to inform staff how often to check on residents. Surveyor asked DON B if R2 had safety interventions when staff are to check on R2 for R2's needs on the care plan. DON B reviewed R2's care plan and indicated R2's care plan was not updated with safety interventions or specifications on how often R2 should be checked on if R2 needs assistance. Example 2 R3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified dementia, right artificial hip joint, dysphagia, anxiety, restlessness, and agitation. R3's MDS assessment, completed on 02/27/24, confirmed R3 scored 02 during a BIMS, indicating severely impaired cognition. R3 requires partial/moderate assistance with eating. R3 requires partial/moderate assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R3's care plan was initiated on 04/10/24, and included the following interventions: ADL SELF-CARE DEFICIT care plan: Encourage the resident to use bell to call for assistance implemented on 06/22/21. COMMUNICATION PROBLEM R/T DEMENTIA care plan: Ensure/provide a safe environment: call light in reach, adequate low glare light, avoid isolation implemented on 03/17/22. FREQUENT FALLS care plan initiated on 06/22/21: Be sure the resident call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance. On 05/07/24 at 9:33 AM, Surveyor observed R3 sitting fidgeting in recliner with feet elevated and recliner plugged into wall. Surveyor did not observe R3 having a call light or a device R3 could use to alert staff. On 05/07/24 at 12:15 PM, Surveyor interviewed SW C and asked why R3 had no call light. SW C indicated SW C could retrieve the documentation that was investigated with R3's discontinuation of call light. On 05/07/24 at 12:30 PM, Surveyor interviewed CNA H and asked how R3 asks for assistance with any needs R3 may have. CNA H indicated that staff just kind of checks on R3. Surveyor asked CNA H the specific time frame that CNA H checks on R3. CNA H indicated that R3 is toileted before and after meals and at bedtime. CNA H indicated that staff just checks on R3 whenever staff walk by. On 05/07/24 at 12:41 PM, SW C could not provide Surveyor with a progress note for R3's discontinuation of call light. On 05/07/24 at 1:45 PM, Surveyor interviewed DON B and asked about R3's call light usage and not having a call light in room. DON B indicated that for any residents such as R3 that do not have a call light, safety interventions and checking on residents is individualized in care plan to inform staff how often to check on residents. Surveyor asked DON B if R3 had safety interventions on the care plan as to when staff are to check on R3 for R3's needs. DON B reviewed R3's care plan and indicated that R3 did not have any revised safety interventions or specifications on how often R3 should be checked on if R3 needs assistance. DON B indicated only safety intervention in place for R3 is 1/2-hour checks when R3 is in bed but that pertains to falls.

Based on observation, interview and record review, the facility did not ensure residents were safe in their environment to prevent the risk of falling. This occurred for 3 of 3 residents (R) reviewed for falls, (R1, R2, and R3). The facility staff did not ensure R1 had pressure alarm pad while R1 was sitting in recliner as care planned. The facility staff did not ensure brakes were locked on EZ-stand lift during R2's transfer from recliner to bathroom. The facility staff did not ensure R3's recliner leg rest was down, and recliner unplugged as care planned. Findings include: Example 1 R1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, non-ST elevation myocardial infarction, arthritis, congestive heart failure, muscle weakness, and hypertension. R1's minimum data set (MDS) assessment, completed on 04/10/24, confirmed R1 scored 09 during a brief interview for mental status (BIMS), indicating moderately impaired cognition. R1 requires partial/moderate assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R1's care plan AT RISK FOR FALLS was initiated on 04/10/24, and included the following interventions: Pressure alarm in bed, in wheelchair, and when in recliner implemented on 04/24/24. Surveyor reviewed physician orders dated 04/25/24 which state in part: Pressure alarms at all times. Surveyor reviewed progress notes dated 04/17/24 which state in part: R1 had a fall on 04/17/24 in the hallway outside his room. On 05/07/24 at 1:32 PM, Surveyor observed R1 sitting in recliner with no pressure alarm under R1. Surveyor observed pressure alarm pad lying in the wheelchair. Surveyor requested Certified Nursing Assistant (CNA) F to show Surveyor R1's pressure alarm in recliner. CNA F indicated there was not a pressure alarm pad under R1 in the recliner and the pressure alarm was on the wheelchair. Surveyor interviewed CNA F and asked what the expectation was for R1's pressure alarm pad. CNA F indicated that CNA F usually follows the care plan located on door in resident's room. CNA F showed Surveyor R1's specific care plan. CNA F stated, Pressure alarm in bed, in wheelchair, and when in recliner. CNA F indicated R1 should have the pressure alarm pad under R1 in recliner. On 05/07/24 at 1:45 PM, Surveyor interviewed Director of Nursing (DON) B and asked what expectation from staff is for applying pressure alarm pad when R1 is in recliner. DON B indicated that CNA F should follow R1's specific care plan. DON B indicated DON B would have to review R1's care plan to review the exact intervention it states per pressure alarm pad. Example 2 R2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia with severe mood disturbance, dysphagia, contracture of right and left knee, muscle weakness, and hypertension. R2's MDS assessment, completed on 03/14/24, confirmed R2 scored 03 during a BIMS, indicating severely impaired cognition. R2 requires total assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R2's care plan AT RISK FOR FALLS was initiated on 09/06/19, and included the following interventions: Lock brakes of EZ stand while attaching resident implemented on 03/23/23. Surveyor reviewed progress notes dated 02/17/24 state in part: CNA was attempting to transfer resident with the EZ stand, when resident kicked the stand away and she had to lower him to the floor, no injuries noted. On 05/07/24 at 12:55 PM, Surveyor observed CNA G and CNA H enter R2's room and hook R2 to EZ-stand machine to transfer from recliner to bathroom. Surveyor did not observe CNA G and CNA H lock EZ stand brakes before attaching harness and lifting R2 out of recliner. CNA G and CNA H wheeled R2 to bathroom and instructed R2 to ring light when done with bowel movement. CNA G and CNA H exited R2's room. On 05/07/24 at 1:27 PM, Surveyor interviewed CNA G and CNA H and asked about safety interventions with R2's transfer process with EZ stand. CNA G indicated that CNA G always locks brakes before attaching harness and lifting R2 out of recliner or bed. CNA G indicated that CNA G forgot to lock brakes when getting out of recliner. CNA H indicated that CNA H only locks the brakes when R2 is getting out of the bed as that is when R2 originally fell due to being up high and coming down to EZ stand lift. CNA G and CNA H indicated they both follow resident's individualized care plan. On 05/07/24 at 1:45 PM, Surveyor interviewed DON B and asked what expectations from staff are for transferring R2 from recliner with EZ stand and safety interventions to prevent falls. DON B indicated that staff should follow R2's specific care plan. DON B indicated that DON B would have to review R2's care plan to review the exact intervention it states per locking EZ stand brakes. Surveyor showed DON B R2's care plan. DON B confirmed that brakes should be locked on EZ stand before lifting R2 out of bed, recliner, and wheelchair. Example 3 R3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified dementia, right artificial hip joint, dysphagia, anxiety, restlessness, and agitation. R3's MDS assessment, completed on 02/27/24, confirmed R3 scored 02 during a BIMS, indicating severely impaired cognition. R3 requires partial/moderate assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R3's care plan FREQUENT FALLS care plan initiated on 06/22/21 and included the following interventions: Pressure alarm at all times. Pressure alarm to be set to no delay implemented on 07/29/21. Recliner unplugged and in the stationary position at all times implemented on 08/04/21. Only have folding chair in room for visitor's d/t attempts to self-transfer and chair falling on her implemented 02/14/24. Surveyor reviewed physician orders dated 08/04/21 which state in part: Pressure alarms at all times when in wheelchair and in recliner. Stationary recliner unplugged. Do not elevate footrests every shift. Surveyor reviewed fall incident reports and indicated R3 had fallen on 09/02/23, 09/26/23, 10/22/23, 10/26/23, 11/25/23, 12/04/23, 12/30/23, 01/15/24, and 02/11/24. On 05/07/24 at 9:33 AM, Surveyor observed R3 sitting fidgeting in recliner with feet elevated, and recliner plugged into wall. On 05/07/24 at 10:52 AM, Surveyor interviewed Registered Nurse (RN) D and asked if R3's recliner was supposed to be plugged into wall and R3's legs elevated. RN D and Surveyor walked into R3's room and RN D indicated that R3's recliner footrest was up, and recliner plugged into wall. RN D indicated that RN D doesn't usually work down hall 400 and RN D would need to check care plan located in R3's closet door. RN D looked at care plan and indicated that R3's feet are not supposed to be elevated and recliner was not supposed to be plugged in. RN D unplugged R3's recliner. Surveyor observed RN D leave R3's feet elevated and RN D exited R3's room. On 05/07/24 at 10:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked if R3's recliner was supposed to be plugged into wall and R3's legs elevated. LPN E indicated that R3's feet are not supposed to be elevated and recliner was not supposed to be plugged in. LPN E entered R3's room, plugged recliner into wall and lowered footrest to ground and unplugged R3's recliner. LPN E indicated that staff don't usually place R3 in recliner, but R3 must have been really tired after R3's bath performed earlier today. On 05/07/24 at 1:45 PM, Surveyor interviewed DON B and asked what expectations are for staff following R3's safety interventions per care plan. DON B indicated that staff are to follow R3's interventions as care plan states. DON B indicated that normally staff don't place R3 in recliner, but it was R3's bath day. DON B indicated that R3's recliner should not be plugged in, and footrest should not be elevated. DON B confirmed that R3 had fallen out of recliner previously in the past and that's why those safety interventions were in place.

Based on observations, interviews and kitchen temperature log review, the facility did not ensure the dishwashers were maintained and in safe operating condition. This has the potential to affect all 32 residents. The dishwasher did not reach manufacturer recommended temperatures to effectively sanitize dishes. Findings include: On 08/01/23 at 9:20 AM, Surveyor observed the dishwasher in kitchenette on Harmony House. The dishwasher had been running prior to Surveyor entering the area. Surveyor observed the wash temperature go up to 145 after Dietary Aide (DA) G restarted it 3 times. The dishwasher is a Champion hot water machine. For a high temperature dishwasher (heat sanitization) the wash temperature should be 150 - 165 degrees F. The rinse temperature must indicate a minimum of 180 - 190 degrees. Surveyor asked DA G if the wash cycle gets up to 150. DA G indicated that it has not been. Surveyor asked how long this has been going on. DA G indicated a while. Surveyor observed the dishwasher in the main kitchen; the temperature for the wash was 130. Surveyor then asked Dietary Director (DD) E for copies of temperature logs for the main kitchen and kitchenette for the past 3 months. Surveyor reviewed the logs for the main kitchen. For May, June and July 2023, the wash temperatures documented ranged from 120 to 141 degrees. Surveyor reviewed the logs for the kitchenette for May, June and July 2023. The wash temperatures documented ranged from 122 to 148 degrees with one day recorded at 150 degrees. The rinse temperatures documented ranged from 166 to 189 degrees. Surveyor interviewed DD E and asked if this has been reported to anyone. DD E indicated it had been reported several times but was unsure what happened to the work orders. Surveyor asked DD E if they had any emails or documentation of work orders submitted. DD E provided Surveyor with one work order with a number 243 that was submitted on November 15, 2022 for dishwasher leaking and not holding appropriate temperature. It was set to completed by maintenance staff on December 5, 2022. On 08/02/23 at 8:46 AM, Surveyor interviewed Maintenance Staff (MS) I and asked if they had any work orders for the dishwashers in the main kitchen or kitchenette. MS I indicated in April or May one of the dishwashers was overflowing and whenever he would repair anything in the dishwashers he always ran them to make sure they were up to temperature. MS I indicated the dishwashers were not that old, and they have had to repair them several times. MS I wasn't made aware of temps going down until yesterday after Surveyor requested temperature records.

Based on record review and interview, the facility did not consult with the resident's physician when the resident had a change in condition for 1 of 1 residents reviewed (R27). Physician was not notified of R27's increased pain after a fall with a resident that has a history of fractured cervical vertebra. This is evidenced by: R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. Surveyor reviewed nursing description of fall with injury that occurred on 05/08/23 at 3:10 PM that read in part: .[R27] was seen by [Licensed Practical Nurse (LPN) N] lying on floor in front of [R27] wheelchair in hallway between hall and dining room. [LPN N] evaluated [R27]. [LPN N] observed [R27's] glasses crooked to the side of resident's face, nose bleeding. [R27] was assisted back to wheelchair via hoyer lift and returned to room. RN called. Face cleaned and bridge of nose and left hand steri-stripped. Resident sustained skin tear to nose and left hand. Resident also has large contusion to forehead. The facility incident description indicated that Nurse Practitioner (NP) L was notified. On 05/09/23 at 12:30 AM, there is a nurse's note that reads in part: .complain of severe neck pain. Hollers out when we attempt to move her to be toileted. Attempted to call POA to get OK to send to hospital, went straight to voicemail, left voicemail to return call. Attempted to call second emergency contact, no voicemail available. No documentation in the medical record indicated that the physician was notified of the severe neck pain after the fall. On 5/9/2023 at 1:23 AM, Surveyor reviewed an incident note by LPN M that read in part: .[R27] was resting in recliner this shift. Awake at 12:00 AM med pass. Vitals and neurological assessment taken. Within normal limits (WNL). Upper eye lids have increased bruising and swelling. Unable to open them at this time. Increased back of neck pain. Tramadol given and ice applied. Resident stated that she would like to go to the hospital. Called RN on call. She recommended to call POA-Care for OK to send to hospital. Called POA-Care, went straight to voicemail, voicemail left. No call back yet. No documentation in the medical record indicated that the physician was notified at this time. On 05/09/23 at 3:25 AM, Nurse's note in file reads in part: .assessed [R27],[ R27] indicated neck pain is 9/10. Facial bruising, nose, and forehead abrasions. POA called by [DON B] and consent received to transport to hospital. No documentation in the medical record indicated that the physician was notified of pain levels 9 out of 10. On 05/09/23 at 12:14 PM, there is documentation in R27's chart that R27 was admitted for observation, pain control and to do an MRI tomorrow as R27 has a possible hairline fracture. Surveyor interviewed Director of Nursing (DON) B and asked if the physician was notified when R27 had increased neck pain with a history of a cervical fracture, during the night. DON B could not provide any evidence that the physician was notified.

Based on observations, interviews and record review, the facility did not ensure residents received care per professional standards of practice. The LPN moved R27 after a significant fall, who had a history of cervical fracture after a fall with injury before Registered Nurse (RN) assessment was completed. Facility did not ensure a resident with chronic wounds received care per professional standards of practice to include weekly wound assessments with description of wound and measurements. This affected 1 of 3 residents looked at for wounds. (R8) This is evidenced by: Example 1 The facility policy, entitled Falls Protocol, dated 05/2019, reads in part If a resident had fallen or is observed on the floor without a witness to the event, nursing staff will evaluate for possible injuries to the head, neck, spine and extrmidies [sic]. R27 was admitted to the facility on [DATE] and has diagnoses that include fracture of 6th cervical vertebra, anxiety, traumatic brain injury (TBI), fibromyalgia and major depressive disorder. R27 was admitted to the facility with orders to wear aspen vista collar at all times for 6 weeks. Collar was discontinued on 03/10/23. Surveyor reviewed nursing description of fall with injury that occurred on 05/08/23 at 3:10 PM that read in part: .[R27] was seen by [Licensed Practical Nurse (LPN) N] lying on floor in front of [R27] wheelchair in hallway between hall and dining room. [LPN N] evaluated [R27]. [LPN N] observed [R27's] glasses crooked to the side of resident's face, nose bleeding. [R27] was assisted back to wheelchair via hoyer lift and returned to room. No RN assessment was completed prior to LPN N transferring R27. RN was called after R27 was in their room. Director of Nursing (DON) B cleaned R27's face and bridge of nose and left hand steri-stripped. Resident sustained skin tear to nose and left hand. Resident also has large contusion to forehead. Surveyor reviewed a nurses note dated 05/09/23 at 12:30 AM, that read in part: .complain of severe neck pain. Hollers out when we attempt to move her to be toileted. Attempted to call POA to get OK to send to hospital, went straight to voicemail, left voicemail to return call. Attempted to call second emergency contact, no voicemail available. On 5/9/2023 at 1:23 AM, nurse's note by LPN M read in part: .[R27] was resting in recliner this shift. Awake at 12:00 AM med pass. Vitals and neurological assessment taken. Within normal limits (WNL). Upper eye lids have increased bruising and swelling. Unable to open them at this time. Increased back of neck pain. Tramadol given and ice applied. Resident stated that she would like to go to the hospital. Called RN on call. She recommended to call POA-Care for OK to send to hospital. Called POA-Care, went straight to voicemail, voicemail left. No call back yet. On 05/09/23 at 3:25 AM, nurse's note in file reads in part: .assessed [R27], [R27] indicated neck pain is 9/10. Facial bruising, nose, and forehead abrasions. POA called by [DON B] and consent received to transport to hospital. EMS called at 8:20 AM for transportation to the hospital. On 05/09/23 at 12:14 PM, there is documentation in R27's chart that R27 was admitted for observation, pain control and to do an MRI tomorrow as R27 has a possible hairline fracture. R27 returned from the hospital on 05/11/23. Hospital discharge notes read in part: .CT scan in the emergency room identified abnormality at C6 but difficult to discern old or new. MRI did have a minimal amount of marrow edema as well as concern for at least a partial anterior ligament damage. CT spine findings vertebra read in part no definite new cervical spine fracture identified. Redemonstrated small ununited chip fracture off of the anterior inferior aspect of the C6 vertebral body/inferior endplate, which now appears minimally displaced. Discharge note also read will need follow up appointment with spine surgery. On 08/02/23, Surveyor interviewed DON B and asked what the policy was if an LPN came upon a resident that had fallen. DON B indicated they should assess the resident and make sure stable, if injury then notify RN, MD and POA immediately, if no injury then report within 24 hours. Surveyor asked DON B if she was notified when R27 had a fall with injury. DON B indicated they were in the building. Surveyor asked DON B if staff waited to move R27 until DON B could assess R27 given the history of R27's cervical fracture. DON B indicated she was not there when they initially got R27 up. Surveyor asked DON B, given R27's history of a cervical fracture, if staff should have waited for DON B to assess R27 before moving the resident. DON B stated ideally they should have waited. 40181 Example 2 Findings include: According to woundsource.com, Inaccurate wound documentation can impact the ability to determine the best wound treatment options and the overall wound healing process. Overall, documentation should record the following elements: Wound etiology or cause (pressure, venous, arterial, surgical, etc.) Wound odor (strong, foul, pungent, etc.) Wound location, described with proper anatomical terms. Thickness characteristics for non-pressure wounds. Partial-thickness wounds - tissue destruction through the epidermis that extends into but not through the dermis. Full-thickness wounds - tissue destruction that extends through the dermis to involve subcutaneous tissue and possible bone or muscle. Wound size measured in centimeters to include length, width, and depth. Wound bed characteristics, including tissue amounts and types (granulation, slough, eschar, epithelialization) Indication of infection, including fever, erythema, increased drainage, odor, warmth, edema, elevated white blood cell count, induration, and pain . R8 was admitted to the facility on [DATE] with diagnoses including, in part, multiple sclerosis, chronic non-pressure ulcer of skin on right lower extremity, chronic venous hypertension with ulcer and inflammation of right lower extremity. On 07/31/23 at 10:44 AM, R8 informed Surveyor she had draining wounds on the right lower leg from lymph edema and the nurses change bandages twice a day. Surveyor identified the following wound care orders, dated 07/24/23, on R8's medical record : Wound care right lower extremity: 1. Remove all soiled dressing pieces 2. Cleanse with NS 3. Apply thin layer of hydrocortisone 2.5% to all areas with intact skin 4. Apply silvercel to open areas, cut to size 5. Apply non adhesive foam cut to slightly larger than silvercel 6. Wrap with rolled gauze 7. Apply Tubigrip. Surveyor identified the following care plan focus on R8's medical record: The resident has open areas to right lower leg and is at risk for further skin breakdown related to immobility, diabetes, and incontinence. The care plan included the following intervention, in part: .Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage . On 08/01/23 at 10:12 AM, Surveyor observed Registered Nurse (RN) F complete wound care on R8's right lower leg. Surveyor observed RN F did not measure the wound during the procedure. Immediately after leaving R8's room, Surveyor asked RN if she routinely measured R8's wound during wound care. RN F stated they did not usually measure R8's wound because it was not a pressure injury. On 08/01/23 at 11:35 AM, Surveyor interviewed Director of Nursing (DON) B and asked if they did weekly wound measurements and assessments of wound condition and document weekly wound summaries for R8's wounds. DON B stated because R8's wound was not a pressure injury they didn't routinely measure it weekly, but nurses should document a weekly synopsis of the wound condition in the weekly summary charting. On 08/01/23, Surveyor reviewed skin/wound notes related to R8's right leg wound and all weekly summary documentation on R8's medical record since admission on 01/12/23. Surveyor identified measurements of the right lower leg wound were only documented eight times in seven months. Surveyor identified there were four weeks, the weeks of 03/27/23, 04/24/23, 05/08/23, and 06/12/23, where there was no documentation of any kind about R8's right leg wound. Surveyor identified the following weekly summary documentation, dated 01/18/23, which stated in part: .has an open area on lower outer right ankle that has been open from when she had problems with lymph edema. The note did not contain any description of the wound condition or appearance. Surveyor identified the following weekly summary documentation, dated 01/25/23, which stated in part: .dressing changed to rt [right] lower leg daily . The note contained no description of the wound condition. Surveyor identified the following weekly summary documentation, dated 05/17/23, which stated in part: .dressing to rt [right] leg in progress . The note did not contain any description of the wound appearance or condition. Surveyor identified the following weekly summary documentation, dated 07/12/23, which stated in part: .trmt [treatment] to leg daily per order. The note did not contain any description of the wound appearance or condition. Surveyor identified the following Skin/Wound Note, dated 07/23/23, which indicated R8's wound was getting worse: Wound to lateral right lower leg is larger. Has the previous open area now 5cm x 2cm with white base. Above this has a 1.6cm x 1cm open area with red base. Below the previous area is now a 1cm x 0.6cm open area with red base. Noted drainage on old dressing. Continues with silver dressing. Leg is now pink rather than red. On 08/02/23 at 10:45 AM, Surveyor interviewed DON B after reviewing above documentation and asked facility policy for weekly wound assessment with measurements of wounds. DON B stated they did not require weekly wound assessments with measurements for non-pressure related wounds because there was no regulation that required that for non-pressure related wounds. Surveyor asked DON B how they could accurately determine if the wound was improving or deteriorating without assessments, measurements, and documentation of this on a regular basis. DON B stated she relied on nursing staff who completed the wound care to note any concerns about the wound on the daily report sheet so DON B would know to go and assess the wound. Surveyor asked if they had any other policy and procedure directing staff for care and assessment of chronic wounds. DON B stated the skin tear policy was the only policy directing staff on care and assessment of non-pressure related wounds and that policy did not require weekly wound measurements or assessments. Surveyor reviewed the weekly summary documentation noted above with DON B. Surveyor asked what should nursing staff include in their weekly synopsis of chronic wounds. DON B stated nursing staff should include a descriptive summary of what the wound condition was and whether it was getting better or worse. DON B stated the above examples did not meet expectations and should include more description of the wound condition.

Based on observation, interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for two of twelve residents (Resident #7 and 2) reviewed for pain. 1. Resident #7 experienced episodic pain after falling and sustaining a [MEDICAL CONDITION], and was receiving as needed Tylenol for pain. The facility did not notify the physician after the resident experienced episodes of excruciating leg pain, including when the resident dialed 911 because of the pain. The facility did not thoroughly assess for pain, did not change the pain medication, and did not monitor the effectiveness of the Tylenol, or monitor the pain itself. The facility did not develop a care plan related to the pain, or the potential pain, the resident was having after the [MEDICAL CONDITION]. 2. Resident #2 experienced pain during observed transfers. The pain assessment completed was not a thorough pain assessment and did not address assessing pain for the cognitively impaired resident. The facility had not made any changes to the pain medications since 11/19/15, and a [MEDICATION NAME] (muscle relaxant) addition on 12/22/15. This is evidenced by: On 01/13/16 at 4:00 p.m., Surveyor received and reviewed a facility policy, entitled, Pain Management. The policy, dated August 2014, states the following, in part: Policy: Pain will be assessed upon admission, quarterly, and with a significant change of condition or as needed by discussion with the resident, staff, family or therapists. The plan of care will denote nursing or therapy interventions to promote comfort and will be adjusted according to Resident's response. Procedure: 1. Non-pharmacological and pharmacological interventions can be used to manage or prevent pain. 2. For PRN (as needed) pain medications--nursing will determine the resident's pain range on a scale of 1-10 and document the resident's pain goal in the MAR (Medication Administration Record). Effectiveness of the PRN medication will be documented. 3. Weekly documentation of pain and pain management will be in the nurse' summary charting. 4. The pain management plan will be communicated to everyone involve (sic) in the residents care. EXAMPLES 1. On 01/12/16, Surveyor reviewed Resident #7's medical record. The resident has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], and had the following standing order for pain management: -Tylenol 325 milligrams (mg), two tablets (650 mg), every four hours as needed. Special Instructions: Not to exceed 3000mg in 24 hours. The resident's Brief Interview for Mental Status (BIMS) score, dated 10/23/15, was a 6 out of 15 possible points. According to the BIMS assessment, a score of 6 indicates the resident has severe cognitive impairment. Resident #7's Minimum Data Set (MDS), dated [DATE], indicates the resident does not have any pain. Resident #7's medical record identifies the resident had eleven falls in the facility, from 11/08/15 to 12/15/15. A fall, on 11/19/15, resulted in the resident sustaining a fractured right hip and required hospitalization , until 11/23/15. The resident was not a surgical candidate, therefore the hip was not repaired. Resident #7 had a stage II pressure ulcer present to the right buttock, upon readmission to the facility. The resident was changed to a mechanical hoyer (full body sling) lift. There is no comprehensive pain assessment, no pain care plan, or any pain management interventions after Resident #7 was readmitted to the facility with the stage II pressure ulcer, and the [MEDICAL CONDITION]. The resident remained on the 650 mg of as needed Tylenol, and no other pain medications were ordered upon the resident's discharge from the hospital. No other pain medications were requested by the facility. Surveyor reviewed the resident's nurses' notes, from 11/23/15 to 01/12/16. The notes state the following, in part: -11/24/15: .Resident crying at supper d/t (due to) pain in right hip, PRN APAP (Tylenol) given, which was somewhat effective . -11/25/15: Late entry for 11/24/2015. Resident had called 911 and an officer arrived on scene. Resident said he called 911 because his hip was hurting. Resident requested a helicopter to come and get him and fly him to Rochester (Minnesota) to have his hip taken care of. Writer explained the risks of surgery and that he could die as a result of the surgery. Resident stated 'I might just as well be dead if they don't fix this hip' . -11/27/15: [MEDICATION NAME] (an antipsychotic medication) 0.5 mg, twice a day, and [MEDICATION NAME] (an antianxiety medication) 0.5 mg, as needed were ordered; for restless behaviors, [MEDICAL CONDITION] and anxiety (these behaviors could have been related to pain). -11/29/15: .At times makes sense in what he says; other times I cannot understand what he is saying .Restless later in shift and given [MEDICATION NAME] ([MEDICATION NAME]) . -11/30/15: .Does have hip pain from fx (fracture) and chronic back pain. EXPRESSING PAIN: Verbal, Facial Expression. CURRENT medications: [REDACTED] -12/30/15: .EXPRESSING PAIN: Verbal, Facial Expression. CURRENT medications: [REDACTED] Surveyor reviewed Resident #7's MARs, from October 2015 to January 2016. The MARs identify the frequency in which the resident received as needed Tylenol: -October 2015: Three times from 10/16/15 to 10/30/15 -November 2015: Eleven times from 11/1/15 to 11/18/15, and seven times from 11/24/15 to 11/29/15 -December 2015: Ten times for the month -January 2016: Three times from 01/01/16 to 01/12/16 There are no pain rating scales, no documentation of the pain location, and no monitoring to determine if the Tylenol was effective in managing Resident #7's pain. There is no documentation if Resident #7 was requesting the Tylenol, or if the medication was provided based on non-verbal signs of pain. There is no documentation if Resident #7 was pre-medicated with Tylenol, prior to working with therapy services, or before transfers. There is no documentation in the resident's medical record, a physician was notified regarding the resident's significant pain, or the facility's request for scheduled or stronger pain medications. Surveyor reviewed the resident's comprehensive care plan. There is no care plan identifying Resident #7 has pain, the potential for having or expressing pain, along with any individualized interventions to help alleviate the resident's pain. On 01/13/16 at 9:43 a.m., Surveyor interviewed the Director of Nursing (DON), and the resident's pain, and potential for pain were discussed. The DON confirmed Resident #7 did not have a care plan identifying the potential for pain, or any pain management interventions. The DON indicated she would expect the resident to have a comprehensive pain care plan, after the resident sustained [REDACTED]. During the continued interview, the DON indicated the facility does not have an assessment tool to thoroughly assess the resident's pain. The DON indicated the facility only completes the pain questions on each resident's MDS. The DON confirmed Resident #7 has hip pain with movement, and stated the resident is very confused and was showing signs of [MEDICAL CONDITION] after the [MEDICAL CONDITION]. The DON stated the facility did not change or request any pain medications for the resident after the fracture. At 2:54 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C stated when the resident is being transferred, Resident #7 will show non-verbal signs of pain, such as facial grimacing. 2. Resident #2 was admitted [DATE]. The admission MDS documents a pain level of 6. The 60 day PPS (prospective payment system) MDS, dated [DATE], documents Resident #2 has severe constant pain. Resident #2's BIMS score was 7 on admission, and 5 on the 60 day PPS MDS, dated [DATE]. These scores mean Resident #2 has severe cognitive impairment. The care plan titled, Impaired physical mobility, potential for falls; related to left sided weakness and pain, frozen left shoulder with rigid left arm, chronic pain Narcotic agents used for pain management. Frequently has muscle spasms 11/10/15. Approaches: .administer pain meds. Goal: Safety maintained. Physical Therapy treatment notes in part: 10/27/15 .resident was calling out in pain . 11/30/15 .resident was shouting 'Ow, hip hurt', throughout entire PT session at rest and with activity- nursing informed .supine to sit edge of bed .resident was shouting 'ow, ow Owie', with all transitions . 12/02/15 .resident complains of pain stating, 'Ow for the first 2 minutes of Omnicycle rotations . 12/04/15 .resident was calling out 'ow!', with all activity . Physician orders [REDACTED].>10/22/15 Tylenol 500 mg, 2 tabs, po (by mouth) three times a day 10/26/15 Change Tylenol to 650 mg QID (four times a day) 10/27/15 [MEDICATION NAME] 20 mg/ml. 0.1 ml, (2 mg) po sub lingual every 1 hour prn pain left leg [MEDICATION NAME] 2 mg/ml [MEDICATION NAME] solution 0.2 mg po/SL every 4 hours prn anxiety muscle spasm 11/03/15 Continue [MEDICATION NAME] concentrate and [MEDICATION NAME] as prescribed. 11/10/15 Increase [MEDICATION NAME] 20 mg/ml 0.2 ml(4 mg) po qid, and 2 mg po every 1 hour prn leg pain/restlessness/generalized pain. 11/17/15 Increase [MEDICATION NAME] 20mg/ml 0.2 ml (4 mg_ po 6 am, 10 am, 2 pm, 6 pm, 10 pm and 2 mg every 1 hour prn pain/restlessness. [MEDICATION NAME] 50 mg po every 6 hours prn (as needed) pain 11/19/15 [MEDICATION NAME] 20 mg/cc, 10 mg po/SL every 2 hour prn pain. Left hip x ray. 12/22/15 Schedule [MEDICATION NAME] 5 mg tid (three times a day) Nurses' notes in part: 10/22/15 Location of pain mostly in left leg, mostly cramps about 8-9/10 at its worst. Neck pain started last Friday .about a 10/10.Left shoulder pain 10/10 10/25/15 .had had painful cramping in he LLE (left lower extremity) since admission . 10/25/15 6:50 p.m., .has been anxious this shift, calling out 'help me, help me', numerous c/o discomfort Prn [MEDICATION NAME] .APAP (Tylenol) at 5:30 p.m., .little if any relief . 11/11/15 Resident woke up c/o left left pain/spasm. Was given routine Tylenol at 7 am. and [MEDICATION NAME] gel to hip/thigh area. Given routine MS 0.2 ml at breakfast. After that resident started to moan. Resident went to therapy and continued to moan with pain all through therapy. PT reported cont pain at 11 am. and resident given prn [MEDICATION NAME] with her routine Tylenol. Resident then started to c/o neck pain .She quieted down just before dinner .was given routine MS .at noon . 11/18/15 .asked resident how she felt and she stated, 'hurt' .resident had routine MS at 6 am, 10 am, 2 p.m., and prn MS 1 ml at 8:45 a.m. and prn [MEDICATION NAME] at 12 noon .yet resident is still c/o pain and has had a warm pack on her neck during supper and still received routine MS 2 ml at 6 p.m., 11/19/15 Resident has been complaining of pain through out the day. Was seen by Dr. on rounds, and ordered a 10 mg MS stat dose .After dinner was saying ow, ow, ow . 11/30/15 Resident has leg pain and spasms mostly in left left. Pain is difficult to control. Receives [MEDICATION NAME] every 4 hours, [MEDICATION NAME] gel Bid, APAP Qid, (four times a day), also has a prn order for MS . 12/01/15 Resident yelling out 'help, owie, throughout the whole shift, prn [MEDICATION NAME] and MS given with ineffective results. Resident stopped yelling and calmed when her granddaughter came to visit her .12/08/15 Pain assessment: frequent pain in feet, legs, hip. 12/22/15 .reviewed use of prn [MEDICATION NAME], Order [MEDICATION NAME] 5 mg tid (three times a day). 12/30/15 Summary week 5 .Location of pain: Mainly in left hip/leg or right shoulder. Has routine Tylenol, and MS and [MEDICATION NAME], and prn MS. Sometimes prn MS does not seem to be effective. 01/01/15 Resident was yelling out 'help me, ouch! my leg!' Staff assisted resident to w/c where she could rock herself. Resident has been quiet and asleep since. 01/11/15 .Hollered out in pain during HS cares. Scheduled MS given with relief of pain . 01/13/15 3:15 a.m., MS given for pain -unable to rate 'OW, OH MY LEG! OH HELP ME! OH MY HEEL' 04:04 a.m., Med ineffective- continues to yell out 'Help! Oh, my leg!' 04:05 a.m., [MEDICATION NAME] given for anxiety/leg spasms - yelling 'Ow,! OH MY LEG! OH HELP! HELP! 05:39 a.m., Med effective . physician progress notes [REDACTED].>The patient is complaining of left hip pain and relatively speaking consistent about her complaints.she does have recurrent problems with her left hip pain. In reviewing her notes for prn use of medication she has had only intermittent use of prn medications so over the last week she has used a small amount of [MEDICATION NAME], seven time per week .it is unclear as to whether or not those measures are beneficial O: This well developed elderly female who is complaining of left hip pain 'owie, owie, owie' .she does have pain over the left grater trochanter. She has some pain with internal and external rotation of the hip while she is sitting and she does not like flexion of the hip either. A/P: Left hip pain.She did have an ultrasound of that leg to one paint because she was complaining of pain and that was negative for clot .she is getting scheduled meds and I am unsure if that has made that much of a difference either. Today since she was complaining of acute pain we gave her 10 mg of oral [MEDICATION NAME] .in any event over the course of almost 60 minutes it did not make her sedated. therefore we will plan on increasing the [MEDICATION NAME] prn dosing to 10 mg po or sublingual every two hours prn pain. We will get a left hip x-ray . X-ray results 11/24/15 Findings Femoroacetabular joints show some narrowing of the joint space on the left .some [MEDICAL CONDITION] of the acetabulum .no fractures .Impression: joint space narrowing, mild [MEDICAL CONDITION] developing left hip suspected. (Joint space narrowing means loss of cartilage in the hip joint showing worsening signs of [MEDICAL CONDITION], which can cause pain.) OBSERVATIONS: On 01/13/16 at 9:40 a.m., Surveyor observed CNA I and CNA J assist Resident #2 with a transfer using the EZ stand. As the CNAs moved the resident forward to put on the sling, Resident #2 yelled, Oh my hip, my leg, take the pain with you. The CNAs continued the transfer. As CNA I moved Resident #2's left foot onto the foot rest of the lift, Resident #2 yelled, Owie it hurts my hip, ow my hip, ow my hip! CNA I used the controls to lift the resident. When the resident was 3/4 of the way up in the air, she started to yell, Owie, owie, it hurts. The CNAs took Resident #2 to the bathroom. Resident #2 did not complain of pain while being lowered onto the toilet. As CNA I lifted the resident up off the toilet, Resident #2 started to yell again, Owie, Oh my! Can I sit down please! Resident #2 had facial grimacing. Resident #2 was then taken to her reclining chair and put in it. CNA J lifted Resident #2's left leg to put the brace on it. Resident #2 yelled, Owie, it is in my leg, real hurtful! It still hurts. CNA J finished putting the left boot in place. CNA I placed a blanket on Resident #2, and Resident #2 again yelled, Owie, my hip! When Resident #2 sat still in the relining chair, she no longer complained of any pain. The CNAs continued cares, and did not notify the nurse of the pain. Surveyor asked for the pain assessments for Resident #2, and was given an MDS worksheet dated 12/17/15, that includes in part: Cognitive sensory is left blank. Pain last 5 days, present: Yes. Frequency: Almost constantly Severity: Severe. Location is blank. Interfere with sleep? Yes Interfere with activity? Yes Scheduled pain meds? Yes Prn pain meds? Yes Non-med interventions? Yes Staff interview for non-verbal sounds, vocal c/o pain, facial expressions, protective body movements is left blank. INTERVIEWS: On 01/13/16 at 4:00 p.m., Surveyor interviewed the DON about the above concerns. The DON acknowledged the facility does not use a formal pain assessment, only the MDS questions. Surveyor asked if they have a pain assessment to use for the cognitively impaired. The DON stated, Not that we are currently using, but I am familiar with that. Surveyor shared that several medication changes were made until 11/19/15. The effectiveness of this change was not assessed to find out if additional pain management interventions were needed. The [MEDICATION NAME] was added, but no assessment was done to determine if that had been effective. The medical record, observations, and interviews all support that pain is still occurring and affecting Resident #2's highest practicable physical and psychosocial well being. On 01/14/16 at 7:35 a.m., Surveyor interviewed CNA J about the transfers for Resident #2. CNA J stated, We use the hoyer lift out of bed, and the EZ stand the other times, she is always in pain so the transfers are difficult. She generally has pain everywhere, so we try to go slow and be careful. When you move her it is worse, but she will yell out in pain when she is just sitting still. Surveyor asked if CNA J considers this a behavior or pain. CNA J said, This is real pain to the resident. Surveyor reviewed the MAR. 11/19 to 11/30/15 after the prn [MEDICATION NAME] (MS) dose was increased, Resident #2 received one dose on three days. -December, Resident #2 received prn dose of MS 14 of 31 days, 10 of the 17 days, Resident #2 received the prn dose one time, on 4 days she was given the MS two times. -January 1-12, Resident #2 received MS prn 6 days, having one dose 5 of the days, and two doses 1 day. On 01/13/16, Resident #2 was given prn MS at 9:59 a.m., after the observation of the painful transfer by Surveyor . On 01/14/16 at 8:00 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) H about Resident #2's pain. LPN H stated, We have tried a lot of things, she complains of pain a lot so it is hard to tell what really hurts. She will say wrong words that make no sense. Surveyor asked if Resident #2 could use a 1 - 10 pain scale. LPN H said, No, not accurately. Surveyor asked when the last time was that the pain medication was adjusted. LPN H said, Not very long ago. Surveyor reviewed the physician orders [REDACTED]. Surveyor asked how often LPN H gives the prn medication. LPN H stated, I know she has pain so I give it a few times while I am on duty. We did an x-ray and it was negative. Surveyor reviewed the MARs, and noted that several days Resident #2 was not given any of the prn dose of MS, and she did not receive any until after the transfer observation on 01/13/16. LPN H said, I was told about the pain after the CNAs transferred her, and gave her the prn dose. Surveyor asked about the dose of MS Resident #2 gets on a scheduled basis. LPN H stated, It is 4 mg. Surveyor asked what the normal dose was or the peak of the dose of the MS. LPN H was not sure. Surveyor referred to the Nursing Drug Handbook, by Lippincott, that states 10 mg is the normal dose, and the medication peaks in 1 hour, so the 6 a.m., dose is likely worn off before the cares are provided to the resident.

Based on observation, interview, record review and policy review, the facility did not ensure the resident's environment remained as free of accident hazards as possible, for four of thirteen residents (Resident #7, 1, 13, 2) reviewed for falls. 1. Resident #7 was a high fall risk upon admission, and had eleven falls, from 11/08/15 to 12/15/15, and sustained a hip fracture. After the fracture, the resident had a significant decline in overall physical functioning, mood, and now requires long-term nursing care. The facility did not always identify a root cause of the falls, and did not implement new safety interventions or supervision in order to prevent further falls and injury. The first example is cited at a level G, the other examples are a lower level. 2. Resident #1 had several falls where the facility did not thoroughly investigate to determine the root cause of the falls, implement effective interventions or provide adequate supervision to prevent further falls. 3. Resident #13 had experienced falls where the facility did not put interventions in place related to the root cause of the fall to prevent future falls. 4. Resident #2 was not served a pureed diet for breakfast as the physician had ordered, Resident #2 experienced coughing while eating the regular diet. This is evidenced by: On 01/13/16 at 4:00 p.m., Surveyor received and reviewed a facility policy, entitled, Falls Protocol. The policy, dated August 2015, states the following, in part: .General Guidelines: 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes .4. Falling may be related to underlying clinical conditions and functional decline, medication side effects, and/or environmental risk factors. 5. Residents must be assessed in a timely manner for potential caused (sic) of falls. 6. Relevant environmental issues should be addressed promptly .After an observed or probable fall, the staff will clarify the details of the falls, such as .what the individual was trying to do at the time the fall occurred . Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident using the FSI (Fall Scene Investigation Report) .if the resident continues to fall despite attempted interventions, the nursing staff will discuss the situation with the Attending Physician or Medical Director .Appropriate interventions taken to prevent future falls .Interventions will be added to the plan of care at the time of admission and reviewed as needed to prevent falls and injury . EXAMPLES 1. On 01/12/16, Surveyor reviewed Resident #7's medical record. The resident has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], after sustaining four falls at home; all occurred one month prior to being admitted to the facility. Resident #7 was admitted for short term rehab, and is a full code status. Surveyor reviewed a Physical Therapy (PT) assessment note, dated 10/16/15. The assessment states the following, in part, Pt (Patient) referred to therapy after hospitalization for increased confusion and falls at home .Pt has R (Right) side with a lot of black and blue marks due to fall .Tinetti balance test 9, gait 9 with overall score of 18/28 placing him at high fall risk . The facility completed a Henrich II Fall Risk Model assessment, dated 10/16/15. Resident #7's score was a 7, which according to the assessment, a score of five or higher indicates the resident is a high fall risk. The resident's Brief Interview for Mental Status (BIMS) score, dated 10/23/15, was a 6 out of 15 possible points. According to the BIMS assessment, a score of 6 indicates the resident has severe cognitive impairment. Resident #7's Minimum Data Set (MDS), dated [DATE], indicates the resident has no behaviors, no delusions, and needs assistance for ambulating, bed mobility, transfers, dressing, and personal hygiene. Resident #7 is able to eat independently, with some set up assistance from staff. The MDS indicates the resident is always continent of bowel function, and occasionally incontinent of bladder. The resident's Patient Health Questionnaire (PHQ-9) assessment score, dated 10/23/15, was a 01 on a scale of 27 points. According to the PHQ-9 assessment, a score of 01 indicates the resident has minimal symptoms of depression. A Certified Nursing Assistant (CNA) care plan, dated October 2015, states Resident #7 transfers independently with contact guard assist of one staff member, and uses a cane or a walker. The care plan further states, in part, Behavior Approach: remind to use call light and wait .Sundowns so is more confused evening/night. Is up several times (at) night. Leave the BR (Bathroom) light on (and) door partially open (at) night . Surveyor reviewed Resident #7's nurses' notes, dated 10/16/15 to 11/08/15. The notes state the following, in part: -10/16/15: .Was instructed in the use of the call light and this was pinned to his recliner. His wife feels he will not remember to call and wait for assistance to get up to use the toilet . -10/17/15: .Res (Resident) is cooperative, but doesn't like to wait for help. Was found up walking in his room. Staff told res. he should ring for help, and when he is transferring he should have a gait belt on. Later got up and walked over to the chair, got the belt and put it on and was sitting with it on, and said, 'he was trying to be safe' . Surveyor reviewed Resident #7's eleven Fall Scene Investigation reports, from 11/08/15 to 12/15/15. The reports state the following, in part: -11/08/15 at 5:55 a.m.--Resident #7 fell to the floor when attempting to grab his cane and needing to use the bathroom. The resident was confused at the time of the fall. The intervention implemented was for the physician to be updated regarding the resident's decline in cognitive and physical function. On 11/11/15, the facility sent a fax to the physician, with an update on the resident's decline in cognitive and physical functioning, as well as the fall on 11/08/15. The physician increased the resident's Aricept to 10 milligrams (mg), daily, and Namenda to 5 mg, twice a day (both medications are used to slow the effects of dementia). -11/12/15 at 1:20 p.m.--Resident #7 stated he blacked out, while walking from the bathroom back to the recliner. The resident was confused, and was using a cane at the time of the fall. The facility removed the resident's cane, and encouraged the resident to use the walker for stability. Nurses' notes, dated 11/14/15, states the following, in part, Resident walking around without cane/walker twice this shift . A nurse's note, dated 11/15/15, states the following, in part, Wandering halls without walker . The fall reports, continue, in part: -11/15/15 at 6:30 p.m.--Resident #7 slipped out of the recliner, as he was looking for a cell phone charger. The charger was located on the nightstand, next to the resident's recliner, and the resident was confused. Resident #7 sustained bruising to both knees. The facility placed a non-skid pad on the recliner. -11/16/15 at 7:20 p.m.--Resident #7 fell while walking out of the bathroom, and sustained sore knees. The resident was confused and not using the walker. Upon assessing the resident's vitals, it was discovered the resident had orthostatic hypotension (low blood pressure when going to a standing position). The facility documented fluids would be encouraged for the resident, to alleviate the low blood pressure. There is no documentation in the resident's medical record or care plan to indicate that the facility increased, encouraged or monitored Resident #7's fluid intake after this fall. The facility did not increase supervision, or frequently monitor the resident's blood pressure after 11/16/15. On 11/18/15, Resident #7 was started on Lasix (a diuretic medication), 40 mg, daily. The use of this medication can cause an increase in urinary frequency, which would place Resident #7 at an increased risk for falling. The Lasix can cause a resident to have lower blood pressures, since the medication pulls fluids out of the body. There is no documentation in the medical record if the facility increased Resident #7's toileting schedule, or monitored the resident's toileting frequency due to the new medication. There is no documentation the facility was checking Resident #7's blood pressure to determine if the resident was again having orthostatic hypotension. The use of the Lasix was not identified on the resident's care plan as a fall risk. The resident's fall reports, continue, in part: -11/19/15: Time of Fall: 11:20 (a.m.) .Heard noise and yell for help. Found res sitting on floor in BR on L side, holding Rt (right) hip up .pants partially down, floor wet, was using his walker .What did the resident say they were trying to do just before they fell ? Using the BR .Describe resident's mental status prior to fall: Confused as usual . Time last toileted .10:40 (a.m.) .Did the resident have any injuries? Rt hip pain, Rt leg outward rotation, Rt leg shorter. RE-Creation of last 3 hours prior to fall .Was started on Lasix yesterday so he has been voiding freq (frequently), was in a new (room) and was confused .Interventions: (left blank) .Interdisciplinary Team Review .Resident transferred to ER (emergency room ) . Resident #7 sustained a right hip fracture as a result of this fall, and the resident was hospitalized until 11/23/15. The resident was not a surgical candidate, in order to repair the fracture. The report does not identify why the bathroom floor was wet, or if the resident was incontinent at the time of the fall. There is no documentation in the resident's medical record of new interventions to prevent falls, or updates to the resident's fall care plan, when Resident #7 was readmitted to the facility. The Fall Scene Investigation Reports, continue, in part: -11/26/15: Time of Fall: 6:15 p.m .Res laying on floor-on L side next to his bed .was 'working under the bed' .Was transferred to bed (at) 6pm .Time last toileted: (left blank) .Did the resident have any injuries? No (A nurses note, written 11/26/15, states the resident sustained [REDACTED]. What appears to be the root cause of the fall? Confusion, agitation .Interventions: (left blank) .Interdisciplinary Team Review .Team is concerned about delirium. MD notified of symptoms . The facility did not implement any new interventions or supervision, to prevent future falls from occurring, and did not identify the root cause of the resident's fall out of bed. -11/26/15 at 11:50 p.m.--Resident #7 fell out of bed and was confused and anxious at the time. The facility added a body pillow to the outside of the resident's bed. -11/27/15: Time of Fall: 3 (a.m.) .found on knees .in front of bed. Body pillow still on bed (had climbed over it) .What did the resident say they were trying to do just before they fell ? (None)-could not understand, had previously stated he needed to leave . Time last toileted .2:30 a.m .Interventions: (one-to-one) staff as much as possible rest of shift .Interdisciplinary Team Review .(Team) concerned about delirium. MD updated about condition . A fax sent to the physician, on 11/27/15 at 1:26 p.m., states the following, in part: .On 11/19/15 he had a fall, which resulted in a right hip fracture .Since that time he has had more significant confusion. He has difficulty staying focused, is easily distracted, more disoriented than usual, rambling, calling out, insomnia, difficulty speaking clearly, difficulty understanding others, and unrelieved restlessness. He has had 3 falls in the past 24 hours. He is needing nearly (one-to-one) attention . At this time, the physician ordered Risperdal (an antipsychotic medication) 0.5 mg, twice a day, and Ativan 0.5 mg, as needed. The use of antianxiety and antipsychotic medication places an elderly patient at an increased risk of falls. The facility did not implement supervision or new safety interventions, as a result of starting on the Risperdal and Ativan. The fall reports, continue, in part: -11/27/15: Time of Fall: (11:15 p.m.) .Found down by writer .sitting with back against bed on knees .attempting to self-transfer .'Going somewhere. I can't walk' .Describe resident's mental status prior to fall: Confused per usual . Time last toileted .(left blank) .Did the resident have any injuries? Abrasion to left lateral knee. Re-Creation of last 3 hours .Was just checked on within previous 10 minutes and was sleeping .Interventions: Frequent safety checks .Interdisciplinary Team Review .Resident had just receive 1st dose of Risperdal. Also has Ativan to help manage restlessness. Now responding to new medication. Less confused (and) less restless . The facility did not identify the root cause of this fall, nor did the facility implement any interventions or supervision in order to prevent future falls from occurring. There is no documentation in the medical record if the facility did implement frequent safety checks, and how often staff were to be checking on the resident. On 12/02/15, the physician reduced Resident #7's Risperdal, to 0.25 mg, due to the resident being lethargic, and over sedated. The fall reports, continue, in part: -12/12/15 at 1:45 p.m.--Resident #7 slid to the floor from the recliner, and stated he was going for a walk. The fall report identifies the resident was last toileted at 10:00 a.m., almost four hours prior to the fall. The facility placed a sign in the resident's room, reminding the resident to not stand or walk unassisted. This was not updated on the resident's care plan. -12/15/15: Time of Fall: 5:50 p.m .Res found sitting on floor-next to bed .What did the resident say they were trying to do just before they fell ? He didn't know .confused per usual .Time last toileted .(left blank) .What appears to be the root cause of the fall? Confusion .Interventions: Freq (Frequent) checks .Interdisciplinary Team Review .Team reviewed falls-most occur from out of bed. Will add wide bed . The facility did not identify the root cause of Resident #7's fall on 12/15/15, and did not identify the last time the resident was toileted in order to determine if the resident needed to use the bathroom. Surveyor reviewed the resident's current comprehensive care plan. The care plan states, in part: 12/08/2015. PROBLEM: Impaired mobility, History of multiple falls, At risk for falls. RELATED TO: Dementia with behavior disturbance, Depression, Non-surgical Rt hip fx (fracture) with non-weight bearing status. MANIFESTED BY: Is bed/chair bound & total assist for all ADL (Activities of Daily Living) tasks .Has poor recall & is impulsive with poor safety awareness. APPROACH (no dates identified for the following): Nurses-Observe, record, and report all unsafe conditions and situations, Anticipate fall times, Observe for functional decline due to psychotropic use, Monitor for effectiveness and for (side effects) of psychotropics .Wide mattress to bed. Nurse Aide-Anticipate needs, Keep his room door open. The resident's medical record indicates Resident #7 now requires long-term nursing home care, and is not a candidate for short term rehab. Resident #7's most recent MDS, dated [DATE], identifies the resident now has delusions, is not able to walk and is using a mechanical hoyer (a full-body sling) mechanical lift, since the hip fracture. The resident now requires assistance with eating, is always incontinent of bowel function, and is now frequently incontinent of bladder. The resident's PHQ-9 assessment score, dated 11/30/15, was a 06 out of 27 points. At this time, Resident #7 stated he has spent several days, within the previous two weeks, with thoughts of being better off dead. According to the PHQ-9 assessment, a score of 06, along with having thoughts of being better off dead, may indicate the resident has a depressive disorder. On 01/13/16 at 9:43 a.m., Surveyor interviewed the Director of Nursing (DON), and the eleven falls were reviewed. Surveyor asked what interventions or supervision the facility implemented after Resident#7's fall, on 11/19/15. The DON replied no interventions or supervision were implemented, due to the resident not having the fracture surgically repaired. During the continued interview, the DON indicated there is no documentation or care plan updates, regarding the frequent check intervention, after the resident's fall on 11/27/15. Surveyor requested any additional information related to Resident #7's falls, including any safety interventions or supervision the facility may have implemented. No additional information was provided to the surveyor. On 01/14/16 at 9:15 a.m., Surveyor interviewed Resident #7's spouse, Family Member (FM) M. FM M indicated the resident was initially admitted to the facility for short term rehab, with the goal of returning home. FM M stated since the resident's hip fracture and subsequent falls, Resident #7 has declined physically and Resident #7 will no longer be able to return home. During the continued interview, FM M indicated since Resident #7 sustained the hip fracture, the resident is much more confused, is restless and antsy. 2. Resident #1 has [DIAGNOSES REDACTED]. Resident #1's BIMS was assessed by the facility staff to be an 11 out of 15 on Resident #1's 11/30/15 MDS assessment. Resident #1 BIMS was a 9 out of 15 on Resident #1's 12/28/15 MDS. Both scores indicate cognitive impairment. A Fall Assessment completed 11/06/15, identified Resident #1 was at high risk for falls. A Comprehensive Fall Assessment, completed 12/03/15, included the following RN (Registered Nurse) Analysis: Resident is at risk for falls d/t (due to) CVA (cardiovascular accident) c/ (with) L (left) sided weakness, cognitive deficits & anxiety. (Resident #1) has fallen x 3 since in NH (nursing home) & had a hx (history) of falls prior to NH admission All NH falls occurred between 9:25 p (p.m.) - 10:15 a.m. & were r/t (related to) self transfer x 2 & slid off bed x 1. Resident also has low Hgb (hemoglobin) and (elevated) INR & her Warfarin dosing has been adjusted. (Resident #1) has poor recall & safety awareness & attempts transfers I (independently) instead of calling for assist. Orthostatic BP (blood pressure) checks are set for q (every) month but have not been done yet. She is on 3 BP meds to control HTN (hypertension). Will continue to re-mind to call for assist. She also continues on caseload for PT (physical therapy) & OT (occupational therapy) to increase strength and self performance. Resident #1 was initially admitted to the facility on [DATE]. Resident #1's first fall at the facility was on 11/10/15 at 10:15 p.m. Resident #1 got up alone to go answer a phone she heard ringing. It was actually on her neighbor's television. The Fall Scene Investigation report identified Resident #1's mental status prior to the fall as Confused per usual. And Time last toileted read unknown, yet pm was circled, dry was checked and it read Toileted x 2 in past 8 hours. Resident #1's care plan at that time did not identify a toileting schedule or how often staff should offer to assist Resident #1 with walking to the bathroom. Resident #1's care plan identified Resident #1 is continent, to have contact guard assist of one and walk with her to and from the bathroom. On 11/10/15, Resident #1 was started on an increased dose of Lasix 20 mg (milligram), a diuretic medication, which increases urinary output and likely the frequency one would need to go to the bathroom. Surveyor noted Resident #1 had been placed on oxygen on 11/10/15. The section of the fall scene investigation report that asked What appears to be the root cause of the fall? was blank. The intervention implemented after Resident #1's 11/10/15 fall, was a sign placed in Resident #1's room stating Push red button & wait for help. Facility documentation had previously identified Resident #1 has poor recall & safety awareness & attempts transfers independently instead of calling for assistance. On 11/13/15 at 9:25 p.m., Resident #1 slid off the edge of her bed on to the floor. The fall scene investigation report identified Resident #1's call light was on. Interventions to prevent future falls Call light in reach-per usual- remind to call-freq (frequent checks). It was not specified how frequent the checks were to be, nor were these interventions on Resident #1's care plan. Reminding Resident #1 to call for assistance was not an effective intervention. Resident #1 was hospitalized later on the evening of 11/13/15. Resident #1 returned to the facility on [DATE]. On 11/18/15, Resident #1 exhibited symptoms of a stroke and was hospitalized [DATE]-11/23/15 for a CVA. Resident #1 fell on [DATE] at 6:40 a.m. Resident #1 had attempted to ambulate independently to the bathroom. The fall scene investigation report identified Resident #1 had been confused, anxious and restless during the night and had not slept much. The report identified Resident #1 had been toileted at 5:00 a.m. The fall scene investigation read in part What appears to be the root cause of the fall? Insomnia was wrote in. An intervention to prevent future fall was listed as If restless at night get up into recliner or wheelchair. This intervention was not on Resident #1's care plan. On 12/31/15 at 3:17 a.m., Resident #1 was found on the floor in her room. Resident #1 had ambulated unassisted to the bathroom and fell on her way back to her bed. The fall scene investigation form identified it was unknown the last time Resident #1 had been toileted. Resident #1 was checked on at 12:30 a.m., 1:30 a.m. and 2:30 a.m. and was sound asleep. The intervention after this fall was listed as Remind to use call light and wait for help. It was known Resident #1 would not always use her call light or wait for help. This was a previous intervention that had been ineffective. The interdisciplinary team (IDT) review dated 12/31/15 read Resident feels she can be more independent than she is capable of. Need to be more proactive at meeting needs. Additional Care Plan Changes: Toilet 1st & 3rd Rounds was added to Resident #1's care plan after this fall. Resident #1 fell on [DATE] at 2:10 p.m., Resident #1 reported she had to go to the bathroom quickly and didn't ring for help. The IDT review note of 01/05/16 read in part Resident currently on routine toileting. Was toileted 1 hour prior to fall. There is no routine toileting schedule on Resident #1's care plan, except for the first and third rounds during the night. Additional care plan changes listed Post reminder signs in room. This was an intervention that had been previously implemented and had proven ineffective. On 01/14/16 beginning at 9:10 a.m., Surveyor met with the DON and shared the above concerns with the DON. 3. Resident #13 was admitted on [DATE], with a BIMS score of 6, meaning Resident #13 has severe cognitive impairment. Resident #13 had a history of [REDACTED]. The care plan titled, Impaired physical mobility with potential for falls, related to chronic dislocation of right shoulder .periods of confusion, 09/15/15 Manifested by: Recent falls, impaired balance .orthostatic hypotension, episodes of confusion with poor decision making skills. Approaches in part: Observe, record and report all unsafe conditions and situations. Ensue adequate hydration .avoid elevation of footrest-ensure non slip foot wear are utilized .monitor orthostatic BPs .Goal: Will walk using a walker and CGA (caregiver assist) in his room. The care plan titled, Urinary frequency with incontinence related to Lasix doses, manifested by: .may void 15 times a day. Sometimes sits on the toilet feeling he has to go but does not. Cannot use urinal independently. Approaches: .Assist with toileting tasks . Nurses' notes in part: 07/11/15 Self transferred .remind to use call light (Resident #13 has a BIMS of 6). 08/01/15 Walked to dining room unassisted, .to wait for assist . 08/11/15 Found standing by closet, assisted to his recliner. 08/13/15 4:30 p.m., Incident type: Fall to knees in dining room . Fall investigation for 08/13/15 in part: Factors observed: Resident lost balance? possible dizziness goes back and forth denies dizziness, then says no dizziness .Orthostatic BP suggest the BP change may have contributed to the fall? No (The sitting BP is 166/90, the standing BP is 140/78, this is greater than 20 point drop which is considered an orthostatic BP change.) Interdisciplinary team review (IDT): Agreed with intervention. Rehab working on endurance. (There is no intervention on the falls scene investigation.) There is no documentation in the resident's medical record or care plan, the facility increased, encouraged or monitored Resident #13's fluid intake after this fall. The facility did not increase supervision, or frequently monitor the resident's blood pressure after 08/13/15. Nurse's note: 08/14/15 2:00 a.m., .took himself to the bathroom X 2, reminded to push the red button (call light) and wait for assistance both times. 2:26 p.m. .he has some dementia and does not always remember to call and wait for assistance to use the bathroom, especially during the night . 09/04/15 .new orders .Zaroxolyn 2.5 mg po (by mouth) every day x 3 days . (This medication causes orthostatic hypotension (drops in blood pressure upon standing), which can cause dizziness.) 09/06/15 Incident type: fall, 12:30 a.m., .effects:Hematoma to left posterior top of head measuring 2.7 cm X 3.4 cm with 1.4 cm red stripe through center left to right and further bruising from hematoma going posteriorly. medial left elbow skin tear measuring 1.3 cm x 3.4 cm with 0.75 cm open length of tear. Distal left elbow skin tear measuring 3 cm x 3.6 cm with outer distal edge open .found down by CNA .Neuro checks: began within 5 minutes of fall, PERL (pupils equal and reactive to light), WNL (within normal limits) at present time .comments: Resident states that he sat up on left side of bed to use the urinal, then got up to get his slippers . Physician orders [REDACTED].>08/09/15 Lasix 40 mg stat, then Lasix 20 mg daily 09/03/15 Lasix 40 mg daily 09/21/15 Resume Lasix 40 mg bid (twice a day) for edema 09/24/15 Lasix 40 mg 2 tablets (80) mg by mouth twice a day for edema. Fall investigation for 09/06/15 Give exact details: Found down with feet toward recliner on left side, lying on left arm, heat next to TV stand .alone and unattended .What did resident say he was trying to do prior to fall? Stated he was going to get his slippers so he could sit in his recliner. (This omits the documentation in the nurses' note that he had to use the urinal.) Mental status: Normal, confused. Footwear: barefeet .Orthostatic BP: sitting 132/76 Standing:116/68 .Hemoglobin level 10.9 on 07/09/15 .What appears to be the root cause: Resident did not call for assistance, lost balance. Describe initial interventions: Reminded to use call light each time staff left room. Left door open to easily check on resident. IDT review: Resident has acute medical condition, (increased edema, increased shortness of breath), he is working with PT/OT on mobility and balance. Start restorative balance training. The therapy was in place prior to the first fall on 08/13/15. There is no intervention to address the bare feet, or the need to void. Nurses' notes: 09/14/15 Time of incident: 12:10 p.m., Location: resident bathroom .he self transferred . Fall Scene investigation for 09/14/15 Staff witness who reported fall: 12:10 went to see if (resident name) was coming out for lunch. Heard someone say, 'Can someone help me?', .on his left side on the floor almost under the bathroom sink. the toilet riser was lying next to him. His pants and underwear were down below his knees and he was wet with urine and incontinent of BM .What was resident doing just prior to the fall? He felt the urge to have a BM and got up on his own because he forgot to ring did not have shoes or slippers on .What type of assistance was resident receiving at time of fall? He was attempting to toilet self .footwear at time of fall: .he was left reclined in his power lift chair with out shoes or slippers on .Last time toileted: 9:00 a.m .Orthostatic BPs: sitting: 126/68 Standing: 106/56. Did orthostatic BPs suggest the BP change may have contributed to the fall? Possibly. Describe initial interventions: Non slip footwear at all times- do not elevate feet in recliner .toilet riser removed . IDT review: Left blank. Nurses' notes: 09/17/15 .concerns about using the bathroom in a timely manner; he actually transferred himself to the bathroom independently once during the night because his call light was not answered fast enough. Resident was reminded to call and wait for staff assist . 10/01/15 .increase in confusion, increasing urinary frequency .could not stand with assist of 1 with gait belt this shift . 10/02/15 .found walking to bathroom per self. Reminded that he is to use call light and wait for help .confused by call light, instructed repeatedly to pull red string in bathroom when done, would pull immediately (while staff still in there) .staff checked him frequently. 10/05/15 Began c/o more right shoulder pain .PT looked at shoulder feels it is dislocated .sent to ER at 1:57 p.m., returned 7:15 p.m resident's right shoulder is considered chronically dislocated (The resident has a history of this prior to admission). 10/06/15 5:23 a.m., .signs of anxiety during night, mostly between 11 p.m. and 2 a.m., frequently calling staff .wants staff to stay with him . 06:21 a.m. .found standing in closet. Had used cane to get up .reminded to ring and wait for assist. 4:37 p.m. Fall at 4:15 p.m., resident's room, unwitnessed. Resident stated he was going to go to the bathroom and appears to have tried to self transfer from the recliner Fall scene investigation 10/06/15 Factors observed at time of fall: resident lost balance, resident slipped .give exact details .at time of fall: lying on left side leg straight out head resting on foot of recliner what was resident doing? attempting to self transfer .what did resident say they were trying to do just before the fall? stand up out of recliner to use bathroom .mental status: confused, baseline can be confused at times .footwear: slippers. Time last toileted: 3:30 p.m .orthostatic BP: sitting: 124/84 standing: 100/64. Did orthostatic BPs suggest the BP change may have contributed to the fall? Yes Does the resident have anemia? Yes hgb 9.4. Recreation of last 3 hours: 3:30 p.m. check on resident stated he had to use the bathroom I assisted him .took resident back to room after supper sat him in is recliner .got him ready for bed. Complained of dizziness. O.k. once in bed. Fall huddle: Resident recently moved, started Tramadol prn, grips on slippers do not work well and slip on carpet .describe initial interventions: reminded to use call light, frequent checks, new shoes or use gripper socks. (Non sl

Based on record review and interview, the facility did not ensure nutritional services were provided to meet the needs of each resident, in order to maintain acceptable parameters of body weight. This occurred for one of five residents reviewed for weight loss. Resident #7 lost 25.7% of his body weight in less than three months. The facility did not develop a care plan related to the resident's nutritional risk, significant weight loss, or interventions to maintain or increase the resident's body weight. The facility did not notify the physician, and no nutritional interventions, or supplements, were documented and implemented after the weight loss. This is evidenced by: On 01/13/16, Surveyor received and reviewed a facility policy, entitled, Weights Policy and Procedure. The policy, last revised October 2010, states the following, in part: Objective: Resident weights will be obtained to monitor nutritional status . Admission Weights: Obtain weight on the day of admission or within 24 hours, unless medically contraindicated, and record in medical record. Monthly Weights: All residents will be weighed monthly .The Dietary Manager will be notified for a monthly weight loss/gain of 5 pounds or more. Other Weights: The M.D. (Doctor of Medicine), DON (Director of Nursing), ADON (Assistant Director of Nursing), or Registered Dietician (RD) will determine weekly or more frequent weights. The dietary manager will be notified of significant weight change . The facility policy does not identify the procedure once a significant weight change has been identified. No other policies, related to weight management or monitoring, were provided to the surveyors. On 01/12/16, Surveyor reviewed Resident #7's medical record. The resident's Brief Interview for Mental Status (BIMS) score, dated 10/23/15, was a 06 out of 15 possible points, indicating severe cognitive impairment. Resident #7's Minimum Data Set (MDS), dated [DATE], identifies the resident's admission weight was 141 pounds. The MDS identifies the resident was independent with eating and only needs setup assistance for meals. Resident #7's medical record does not identify if the resident was receiving any types of nutritional supplements upon admission to the facility. A dietary progress note, written by Dietary Manager (DM) D on 10/28/15, states the following, in part: ORAL PROBLEMS: resident does not have chewing or swallowing problem(s) and does not appear to have any mouth pain. DIET .Regular-needs ground meats because he has a 'pocket' in his esophagus where pieces of meat get stuck .EATING PATTERN: 25-100% of meals .FOOD PREFERENCES: Likes: most foods. Does not eat corn, raw vegetables .EATING ABILITY: Independent . A dietary progress note, written by RD E on 10/30/15, states the following, in part: HEIGHT 68 .CURRENT WEIGHT: 141.2# .USUAL WEIGHT: 140# range .IBW (Ideal Body Weight): 132-166# .Weight goal: Maintain weight between 136-146# .CALORIES: 1600-1700 kcals/day .PROTEIN: 51-64 g (grams)/day .RELEVANT medications: [REDACTED].(an antidepressant medication): anorexia, decreased weight, [MEDICATION NAME] (a blood thinning medication) . Resident is at low nutrition risk as shown by regular diet (ground meats). Weight in the usual range for him and within IBW range .Resident's po (oral) intake seems adequate so no nutritional intervention at this time . The nurses' notes, dated 11/10/15, identify Resident #7 developed a stage II pressure ulcer on the inner right buttock. There is no new nutritional assessment, nutritional care plan, or nutritional interventions after the pressure ulcer was identified. A nurse's note, dated 11/17/15, identifies Resident #7 is having a frequent, wet cough, along with two-plus [MEDICAL CONDITION] in the feet and ankles. On 11/18/15, Resident #7 was started on [MEDICATION NAME] (a diuretic medication), 40 milligrams (mg), daily. There is no other documentation in the medical record of [MEDICAL CONDITION] being present after 11/18/15. There is no documentation of the resident's weight at, or around this time. A fall, on 11/19/15, resulted in the resident sustaining a fractured right hip and required hospitalization , until 11/23/15. The resident was not a surgical candidate, in order to repair the fracture. On 11/23/15, at the time of the resident's re-admission to the facility, Resident #7's weight was 137 pounds. There is no nutritional assessment, nutritional care plan, or nutritional interventions after Resident #7 was readmitted to the facility with the stage II pressure ulcer and the [MEDICAL CONDITION]. A nurse's note, dated 11/30/15, states in part, NUTRITION: Adequate-Eat(s) (greater than) 1/2 most meals .usually takes supplement. The note does not indicate what type of supplement is provided, the amount which is generally consumed, and the frequency in which the supplement is provided throughout the day. A nurse's note indicates the resident's pressure ulcer has healed, as of 11/30/15. On 12/07/15, the resident's medical record indicates Resident #7's weight is down to 115.5 pounds. Surveyor calculated this to be a loss of 25.5 pounds, or 18.08% since the resident's initial admission. A dietary progress note, written by DM D on 12/01/15, states the following, in part: ORAL PROBLEMS: has possible swallowing deficit from aspirating in hospital .DIET: Cardiac, thick liquids .leaves 25% of his/her food uneaten .EATING PATTERN: Is consuming 50-75 (percent) .APPETITE: fair-good .FOOD PREFERENCES: Likes: most foods .COMMENTS: Does not state food preferences .EATING ABILITY: set up, occasionally fed . SUMMARY: (Written by RD E) Resident is on a Cardiac, thickened liquids diet (nectar). Intakes of 50-100% meeting 72-142% of calculated nutrition needs. Resident's weight has dropped 23.6% (32.3#) since 11/23/15 .Resident's current weight is 104.7# .Resident does have a swallowing deficit (aspiration) hence the nectar thick liquids and mechanical altered diet. Resident doesn't state preferences .Noted four medications with anorexia side effects. Skin condition includes a pressure sore. Resident's po intake meeting calculated nutrition needs but due to weight loss and pressure sore recommendation continuation of milk shake + and pro mod TID (three times a day). Wife has requested ice cream at night for (Resident #7's first name) so nursing is checking with the doctor for a possible diet order change. Goals .Increase weight to usual weight but if unable stabilize weight +/- 5# of current weight of 104.7# . The facility did not develop a nutritional care plan, or identify the significant weight loss on the care plan. No nutritional interventions were documented, and there is no documentation in Resident #7's medical record when the resident began the milk shake plus and pro mod, as indicated in the above RD E's progress note. There is no documentation in Resident #7's medical record a physician was notified of the significant weight loss. A progress note, written by DM D on 12/08/15, states the following, in part: .WEIGHT: Wt (weight) is decreasing since hospital return .Under ideal weight. Notified of a significant wt. loss in less than 1 month. Resident has a fx (fracture) hip and it was not repaired due to risk. APPROACHES: Add: a nutritional supplement with meals. Will add Pro Mod to 1 food item per meal .Resident needs to be fed. Anticipate more wt. loss if resident doesn't consume supplement or greater than 50% of meals and fluids. A nurse's note, dated 12/30/15, states in part, NOURISHMENTS .supplement with meals . The note does not indicate what type of supplement is provided, the amount which is generally consumed, and the frequency in which the supplement is provided throughout the day. Surveyor reviewed Resident #7's Medication Administration Record [REDACTED]. There are no nutritional supplements or nutritional interventions, identified on the MARs or TARs. There is no current, or previous physician's orders [REDACTED]. The resident's most recent documented weight, as of 01/06/16, is 104.7 pounds. Surveyor calculated Resident #7's total weight loss, from 10/16/15 to 01/06/16, to be 36.3 pounds. This is a total weight loss of 25.7% in less than three months. OBSERVATIONS On 01/12/16 at 12:03 p.m., Surveyor observed Resident #7 eating the noon meal. At this time, the resident was eating a bowl of vegetable soup, a small Jello mold, and a half of a deli meat sandwich. The resident had a glass of thickened water and a glass of thickened white milk. The resident was able to eat independently, but needed verbal cueing from staff. There was no supplement given at this meal. INTERVIEWS On 01/13/16 at 9:43 a.m., Surveyor interviewed the DON, and the resident's weight loss was discussed. Surveyor asked if Resident #7 has a nutritional risk care plan, which identifies a significant weight loss. The DON confirmed the resident did not have a care plan identifying the resident's nutritional risk and/or the significant weight loss. The DON indicated Resident #7 has had a poor appetite. When Surveyor asked what interventions the facility has implemented in response to the resident's significant weight loss, the DON indicated the resident likes eating bananas, ice cream, root beer and root beer floats. The DON indicated the facility gives Resident #7 these items for additional calories and fat content. The DON indicated the nursing department did not notify the physician related to Resident #7's weight loss and that the dietary department may have notified the physician. At 1:00 p.m., Surveyor interviewed DM D. DM D indicated she does not update the resident's physician, and neither does RD E, regarding a resident's significant weight loss. DM D indicated the facility does not obtain physician's orders [REDACTED]. DM D indicated the dietary department does not document when the resident's supplements are added or changed. DM D stated she believes the Pro Mod supplement was added, as of 12/08/15, but there is no other documentation other than DM D's note. Surveyor discussed the food preferences with DM D. DM D stated none of the food preferences are on the resident's care plan. DM D further stated she was not aware of the resident's preferences, of root beer and ice cream, until 01/12/16.

Based on record review and interviews, the facility did not complete a thorough assessment to determine the root cause of decline in bowel function or offer appropriate interventions which would allow the residents to maintain or restore their bowel function for 3 of 12 residents (Resident # 7, #10, #6) reviewed for a decline in bowel function. These three examples are at Level G (actual harm). Examples at a lower lever include: the facility did not complete a thorough assessment to determine the root cause of bowel function or offer appropriate interventions which would allow the residents to maintain or restore their bowel function for 3 of 12 residents (Resident #5, #1, #3) reviewed who did not have a decline in bowel function but are incontinent. As evidenced by: Facility Policy titled, "Bowel and Bladder Assessment," dated 3/2014, states the following: "Policy. Residents bowel and bladder status will assessed at time of admission and the care plan will reflect their toileting needs. Bowel and bladder status will be reviewed quarterly and when a Resident's bowel or bladder status changes significantly. Procedure: Resident and or Family will be interviewed at time of admission to determine their bowel and bladder status. The care plan and ADL (activity of daily living) sheet will indicate their status and toileting needs. Residents will be toileted or changed routinely to promote continence and intact skin. The care plan will be reviewed quarterly if there is a significant change of condition." 1. Resident #7 On 03/19/14, Surveyor # reviewed the medical record for Resident #7. Resident #7 was originally admitted on [DATE] and has a [DIAGNOSES REDACTED]. The Initial MDS, dated [DATE], coded Resident #7 a 0 which indicated Resident #7 was always continent of bowel. This MDS also coded Resident #7 as having no bowel toileting program in place. The Quarterly MDS, dated [DATE], coded Resident #7 a 2 which indicated Resident #7 was frequently incontinent of bowel. This MDS also coded Resident #7 as having no bowel toileting program in place. The Comprehensive Care plan for Self-Care Deficit states: "Is incontinent of B&B (bowel and bladder) & often points to the bathroom for a BM (bowel movement)." No toileting schedule or program noted on the care plan. The care plan had no changes following a decline in bowel continence. The CNA Care Plan, dated 03/2014 - 06/2014, stated Resident #7 is mostly incontinent of bowel and that resident may point to the bathroom to indicate when he needs to have a bowel movement. The care plan states for the overnight shift to check and change on 2nd and 4th rounds and as needed and to use a purple medium size incontinent brief. The care plan had no changes following a decline in bowel continence. On 03/19/14 at 1:10 p.m., Surveyor # interviewed Spouse O of Resident #7. Spouse O stated she had noticed an increase in incontinence for Resident #7 but was unsure why. 2. Resident #10 On 03/19/14, Surveyor # reviewed the medical record for Resident #10. Resident #10 was originally admitted on [DATE] and has a [DIAGNOSES REDACTED]. The Annual MDS, dated [DATE], coded Resident #10 a 2 which indicated Resident #10 was frequently incontinent of bowel. This MDS also coded Resident #10 as having no bowel toileting program in place. The Quarterly MDS, dated [DATE], coded Resident #10 a 3 which indicated Resident #10 was always incontinent of bowel. This MDS also coded Resident #10 as having no bowel toileting program in place. No Comprehensive Care plan for Bowel incontinence or toileting program was found. The CNA Care Plan, dated 03/2014 - 06/2014, stated resident is incontinent of bowel and to check and change on rounds if incontinent. Care plan also states for staff, during night shift, to check and change when wet and to provide a medium purple incontinent brief at all times. The care plan had no changes following a decline in bowel continence. 3. Resident #6 On 03/19/14, Surveyor # reviewed the medical record for Resident #6. A Significant Change MDS, dated [DATE], coded Resident #6 a 1 which indicated Resident #6 was occasionally incontinent of bowel. This MDS also coded Resident #6 as having no bowel toileting program in place. The Quarterly MDS, dated [DATE], coded Resident #6 a 2 which indicated Resident #6 was frequently incontinent of bowel. This MDS also coded Resident #6 as having no bowel toileting program in place. The Self-Care Deficit Comprehensive Care Plan, dated 03/18/14, states Resident #6 usually leaves the table right after eating to use the toilet, likes bathroom door open when toileting and will walk to/from the bathroom. No toileting schedule noted on the care plan. The care plan had no changes following a decline in bowel continence. The CNA Care Plan, dated 03/2014 - 06/2014, states Resident #6 is occasionally incontinent of bowel. The care plan states that during the day shift the resident is able to notify staff of toileting needs and needs assist of two to the bathroom. The care plan states during the night shift the resident will ring when needing assistance to the bathroom. The care plan also states Resident #6 is to use a blue incontinence pad. On 03/19/14, Surveyor # requested all bowel assessments for the last year for Residents #7, #10 and #6 from the Assistant Director of Nursing (ADON) B. ADON B was unable to provide any bowel assessments for Residents #7, #10 and #6 and stated she had looked into each resident's chart and no assessments were available. ADON B told this surveyor she was unable to provide any further information in regard to bowel assessments and to speak with the Director of Nursing (DON) for further follow up. On 03/19/14, Surveyor # interviewed the DON. This surveyor reviewed the decline in bowel function, as seen on the MDS, for Residents #7, #10 and #6 and asked who was responsible for assessing the residents' bowel function. The DON stated there was no one certain individual in charge of bowel assessments and felt the nursing staff should be completing them. The DON stated all assessments, once completed, are placed in the resident's chart. This surveyor asked the DON when a bowel assessment should be completed and she stated upon admission, if incontinence is new, if incontinence has changed (declined) or if they (residents) start a restorative program which includes the facility's toileting program. This surveyor asked if Resident #7 was currently on the Restorative Toileting Program and she stated, "No." This surveyor asked if Resident #10 was currently on a restorative program which included the facility's toileting program and the DON stated, "No." This surveyor asked if Resident #6 was currently on a restorative program which included the facility's toileting program and the DON stated, "Yes." The DON confirmed the decline in bowel function according to the MDS dates listed above for Residents #7, #10 and #6 and confirmed there were no bowel assessments or toileting program in place for Resident #7, #10 and #6. On 03/20/14 at 9:35 a.m., Surveyor interviewed Registered Nurse (RN) A who is in charge of the restorative program. RN A stated the DON and the ADON complete the bowel assessments. RN A stated the facility has not incorporated bowel incontinence into the restorative program, just bladder incontinence. No further information as provided. 4. Resident #5's quarterly MDS, dated [DATE], and the significant change MDS, dated [DATE], document that Resident #5 is frequently incontinent of bowel. Surveyor reviewed the medical record 03/18 - 03/19/14 and was unable to locate any bowel assessments or documentation that determined a toileting program for Resident #5. On 03/18/14 at 1:10 p.m., Surveyor observed personal cares and noted that Resident #5 had been incontinent of bowel. The nursing care plan includes in part: Impaired Physical Mobility, dated 01/22/14...manifested by: Skin exposure to BB (bowel/bladder) incontinence. The Certified Nursing Assistant (CNA) care plan includes in part: Elimination: Bladder frequently incontinent. Bowel frequently incontinent, toilet with standing lift and 1 assist. Nights check and change every round and prn- offer bedpan or toilet. Incontinent products: Yellow brief. On 03/19/14 at 11:05 a.m., Surveyor interviewed RN B to ask for bowel/bladder assessments. RN B stated, "We do the assessments upon admission and if incontinence is new for the resident or a change in incontinence. We also do an assessment if they are on the restorative program for incontinence. Surveyor stated that the assessments were not located in the chart. RN B stated, "Then you should check the nurses' notes." The nurses' notes were reviewed and document that Resident #5 is frequently incontinent of bowel. The nurses' notes do not contain a comprehensive assessment or address toileting programs. On 03/20/14 at 8:50 a.m., Surveyor interviewed the DON about the bowel assessments. The DON stated, "We look at the MDS quarterly; if we see a decline we do an assessment." Surveyor asked if the DON knew the reason that Resident #5 is incontinent of bowel and not on a bowel program, when there was no assessment to make that determination. The DON stated she would look for more information. On 03/20/14 at 9:35 a.m., Surveyor interviewed RN A, who is in charge of the restorative bladder program. RN A said she does bladder assessments for only the residents on the restorative program. She went on to say that she does not do a bowel assessment; that has not been incorporated into their program. RN A suggested to ask the DON for further information on bowel assessments. On 03/20/14 at 10:20 a.m., Surveyor again interviewed the DON. Surveyor asked if she had any further information for bowel assessments. The DON stated, "We have not been doing a complete assessment; we need to improve in this area." 5. Resident #1's Significant Change MDS, dated [DATE], documents that she is frequently incontinent of bowel. The quarterly MDS, dated [DATE], documents that Resident #1 is frequently incontinent of bowel. Surveyor reviewed the medical record 03/18 - 03/19/14 and was unable to locate any bowel assessments. On 03/18/14 at 12:30 p.m., Surveyor observed personal cares for Resident #1, and noted she was incontinent of bowel and bladder. The nursing care plan includes in part: Self Care Deficit, dated 11/05/13, Manifested by:...She is still frequently incontinent of urine even with the RA toileting program....frequent incontinent of bowel. Will notify staff of BM (bowel movement) after she has been incontinent. The CNA care plan in part: Elimination: Bowel: Frequent incontinent, pericare after incontinence Nights: Toilet 2nd and 3rd rounds, encourage to use the toilet and assist upon arising, before and after meals, activities, hs (hour of sleep) and prn (as needed). The restorative care plan, dated 04/26/13, includes in part: Toileting, will be continent of urine 2 times per day. Approaches: 1. Encourage to use the toilet and assist, walk with walker upon arising, before and after meals, activities, HS and prn. 2. Peri care after each incontinence 3. Wears x-large brief. (There is no mention of bowel continence status or approaches.) On 03/19/14 at 11:05 a.m., Surveyor interviewed RN B, asking for bowel/bladder assessments for Resident #1. RN B stated, "We do the assessments upon admission and if incontinence is new for the resident or a change in incontinence. We also do an assessment if they are on the restorative program for incontinence. Surveyor stated that the assessments were not located in the chart. RN B stated, "Then you should check the nurses' notes." Surveyor reviewed the nurses' notes which included that Resident #1 was incontinent of bowel and needed assist to toilet. The nurses' notes did not contain a bowel assessment, or bowel tracking information. On 03/20/14 at 8:50 a.m., Surveyor interviewed the DON about the bowel assessments for Resident #1. The DON stated, "We look at the MDS quarterly; if we see a decline we do an assessment." Surveyor asked if the DON knew the reason that Resident #1 is incontinent of bowel and not on a bowel program, when there was no assessment to make that determination. The DON stated she would look for more information. On 03/20/14 at 9:35 a.m., Surveyor interviewed RN A, who is in charge of the restorative bladder program. RN A said she does bladder assessments for only the residents on the restorative program. She went on to say that she does not do a bowel assessment, that has not been incorporated into their program. RN A suggested to ask the DON for further information on bowel assessments. On 03/20/14 at 10:20 a.m., Surveyor again interviewed the DON. Surveyor stated that we have been asking for bowel assessments and nothing had been received. The DON stated, "We have not been doing a complete assessment; we need to improve in this area." 6. Resident #3 has a [DIAGNOSES REDACTED]. Resident #3's Minimum Data Sets (MDS's), dated 11/04/13 and 01/31/14, section H0400 scored the resident as a "3," always incontinent of bowels with no episodes of continent bowel movement in seven days. On 03/19/14 at 11:05 a.m., Surveyor requested from ADON B bowel assessments in the last year completed for Resident #3. The surveyor was provided with bowel assessments, dated 09/07/07 (over six years old) and 03/01/14. The bowel assessment dated [DATE] documented Resident #3 was incontinent of bowels more than three times a week and the bowel pattern is regular at least one movement every three days. The bowel assessment does not describe a bowel program to retrain the resident. Bowel assessments were not completed quarterly as per the facility policy. Review of the bowel records dated 01/01/14 - 03/18/14 documented Resident #3 had episodes of bowel incontinence. On 03/20/14 at 8:55 a.m., the DON told Surveyor , Resident #3 is totally incontinent and is on check and change every two hours. The DON stated the resident is not on a restorative program. On 03/20/14 at 9:35 a.m., Surveyor interviewed RN A who is in charge of the restorative program. RN A stated the DON and the ADON complete the bowel assessments. RN A stated Resident #3 is not on a restorative program due to dementia. RN A stated the facility has not incorporated bowel incontinence into the restorative, program just bladder incontinence. No further information as provided.

Based on record review and interviews, the facility did not complete a thorough assessment to determine the root cause of decline in bladder function or offer appropriate interventions which would allow the residents to maintain or restore their bladder function for 6 of 12 residents (Resident #10, #6, #7, #3, #5 and #1) reviewed for bladder incontinence. Resident #10 experienced a decline in bladder continence and was cited at a Level G (actual harm); the other examples (#6, #7, #3, #5 and #1) were cited at a lower level due to no decline in status. As evidenced by: Facility Policy titled, "Bowel and Bladder Assessment," dated 03/2014, states the following: - "Policy: Residents bowel and bladder status will assessed at time of admission and the care plan will reflect their toileting needs. Bowel and bladder status will be reviewed quarterly and when a Resident's Bowel or bladder status changes significantly. Procedure: Resident and or Family will be interviewed at time of admission to determine their Bowel and bladder status. The care plan and ADL (activity of daily living) sheet will indicate their status and toileting needs. Residents will be toileted or changed routinely to promote continence and intact skin. The care plan will be reviewed quarterly if there is a significant change of condition." Facility Policy titled, "Restorative Bladder Program," dated 04/2013, states the following: - "Policy: Residents with urinary incontinency will be evaluated for an RA (Restorative Aide) Program. Purpose: To maintain or achieve urinary continence. To maintain or achieve occasional urinary incontinence." - "Procedure: 1. Continence will be assessed on admission and at care conference, or when continence changes occur. 2. The Plan of Care will indicate the resident's toileting needs. 3. Residents with some contingency will be chosen and a voiding record will be completed to help detect urinary patterns and/or intervals between incontinence episodes. The record will be done between the time the Resident awakens and then goes to bed. Medical interventions will be used to treat causes of incontinence when applicable. 4. If it is determined that the Resident could benefit from a toileting program, a daytime toileting trial will be established. 5. The results of the toileting trial will be evaluated and if indicated, an individualized Resident centered daytime toileting program will be organized, planned, documented, monitored and evaluated." 1. On 03/19/14, Surveyor # reviewed the medical record for Resident #10. The following information was noted: - Resident #10 was originally admitted on [DATE] and has a [DIAGNOSES REDACTED]. - Annual Minimum Data Set (MDS), dated [DATE], coded Resident #10 a "2" which indicated Resident #10 was frequently incontinent of urine which indicates the resident had been incontinent greater than seven times but had at least one continent episode. This MDS also coded Resident #10 as having no bladder toileting program in place. - Quarterly MDS, dated [DATE], coded Resident #10 a "2" which indicated Resident #10 was frequently incontinent of bladder which indicates the resident had been incontinent greater than seven times but had at least one continent episode. This MDS also coded Resident #10 as having no bladder toileting program in place. - No Comprehensive Care plan for bladder incontinence or toileting program available. - CNA Care Plan, dated 03/2014 - 06/2014, stated resident is incontinent of bladder and to check and change on rounds if incontinent. Care plan also states for staff, during night shift, to check and change when wet and to provide a medium purple incontinent brief at all times. On 03/20/14, Surveyor # reviewed the bowel and bladder tracking records for Resident #10 and noted the following: - Bowel and bladder tracking records, dated 01/24/14 - 03/20/14 indicate resident is always incontinent of urine. No continent episodes charted. - Last known continent episode charted 01/23/14. - Resident #10 has now gone from frequently incontinent to always incontinent. On 03/20/14 at 9:30 a.m., Surveyor # interviewed Certified Nursing Assistant (CNA) N. CNA N stated Resident #10 is always incontinent of bowel and bladder and has been this way for a while. CNA N stated staff check and change resident regularly and the resident does not use the toilet or the bedpan. 2. On 03/19/14, Surveyor # reviewed the medical record for Resident #6. The following information was noted: - Resident #6 was originally admitted on [DATE] and has a [DIAGNOSES REDACTED]. - Significant Change MDS, dated [DATE], coded Resident #6 a 1 which indicated Resident #6 was occasionally incontinent of bladder. This MDS also coded Resident #6 as having no bladder toileting program in place. - Quarterly MDS, dated [DATE], coded Resident #6 a 1 which indicated Resident #6 was occasionally incontinent of bladder. This MDS also coded Resident #6 as having no bladder toileting program in place. - Self-Care Deficit Comprehensive Care Plan, dated 03/18/14, states Resident #6 usually leaves the table right after eating to toilet, likes bathroom door open when toileting and will walk to/from the bathroom. No toileting schedule noted on the care plan. - CNA Care Plan, dated 03/2014 - 06/2014, states Resident #6 is occasionally incontinent of bladder. The care plan states that during the day shift the resident is able to notify staff of toileting needs and needs assist of two to the bathroom. The care plan states during the night shift the resident will ring when needing assistance to the bathroom. The care plan also states Resident #6 is to use a blue incontinence pad. 3. On 03/19/14, Surveyor # reviewed the medical record for Resident #7. The following information was noted: - Resident #7 was originally admitted on [DATE] and has a [DIAGNOSES REDACTED]. - Initial MDS, dated [DATE], coded Resident #7 a 2 which indicated Resident #7 was frequently incontinent of bladder. This MDS also coded Resident #7 as having no bladder toileting program in place. - Quarterly MDS, dated [DATE], coded Resident #7 a 2 which indicated Resident #7 was frequently incontinent of bladder. This MDS also coded Resident #7 as having no bladder toileting program in place. - Comprehensive Care plan for Self-Care Deficit states: "Is incontinent of B&B (bowel and bladder) & often points to the bathroom for a BM (bowel movement)." No toileting schedule or program noted on the care plan. - CNA Care Plan, dated 03/2014 - 06/2014, stated Resident #7 is mostly incontinent of bladder and that resident may point to the bathroom to indicate when he needs to go. The care plan states for the overnight shift to check and change on 2nd and 4th rounds and as needed and to use a purple medium size incontinent brief. On 03/19/14 at 1:10 p.m., Surveyor # interviewed Spouse O of Resident #7. Spouse O stated she had noticed an increase in incontinence for Resident #7 but was unsure why. This surveyor asked Spouse O if she had spoken to the facility about this and Spouse O said no, but she was going to be speaking to nursing staff soon. On 03/19/14, Surveyor # requested all bladder assessments for the last year for Residents #7, #10 and #6 from the Assistant Director of Nursing (ADON) B. ADON B was unable to provide any bladder assessments for Residents #7, #10 and #6 and stated she had looked into each resident's chart and no assessments were available. ADON B told this surveyor she was unable to provide any further information in regard to bladder assessments and to speak with the Director of Nursing (DON) for further follow up. On 03/19/14, Surveyor # interviewed the DON. The DON stated there was no one certain individual in charge of bladder assessments and felt the nursing staff should be completing them. The DON stated all assessments, once completed, are placed in the resident's chart. This surveyor asked the DON when a bladder assessment should be completed and she stated upon admission, if incontinence is new, if incontinence has changed (declined) or if they (residents) start a restorative program which includes the facility's toileting program. This surveyor asked if Resident #7 was currently on the Restorative Toileting Program and she stated, "No." This surveyor asked if Resident #10 was currently on a restorative program which included the facility's toileting program and the DON stated, "No." This surveyor asked if Resident #6 was currently on a restorative program which included the facility's toileting program and the DON stated, "Yes." The DON confirmed Residents #7, #10 and #6 should have been thoroughly assessed for bladder incontinence and should be on a restorative bladder training program. No further information was provided. 4. Resident #3 has a [DIAGNOSES REDACTED].#3's Minimum Data Sets (MDS's), dated 11/04/13 and 01/31/14, section H0300 Urinary Incontinence scored the resident as a "3" always incontinent with no episodes of continent voiding in seven days. The MDS's stated no current toileting program. On 03/19/14 at 11:05 a.m., Surveyor requested from the ADON B bladder assessments in the last year completed for Resident #3. The surveyor was provided with bladder assessments dated 09/07/07 (over six years old) and 03/01/14. The bladder assessment dated [DATE] documented the resident was incontinent of bladder more than once a day. The bladder assessment does not describe the type of incontinence, [DIAGNOSES REDACTED]. Bladder assessments also were not completed quarterly as per the facility policy. Review of the bladder records dated 01/01/14 - 03/18/14 documented Resident #3 had episodes of bladder incontinence. On 03/20/14 at 8:55 a.m., the DON told Surveyor , Resident #3 is totally incontinent and is on check and change every two hours. The DON stated the resident is not on a restorative program. Surveyor requested additional bladder assessments that included the type of incontinence, medical reason for incontinence and medication that could affect incontinence. On 03/20/14 at 9:35 a.m., Surveyor interviewed Registered Nurse (RN) A who is in charge of the restorative program. RN A stated Resident #3 is not on a restorative program due to dementia. RN A stated no further bladder assessment have been completed. RN A stated she felt she could not determine the type of incontinence and would need a physician to determine. RN A states she only completes bladder assessments on residents who are on the restorative program. No further information as provided. Resident #5's quarterly MDS, dated [DATE], and the significant change MDS, dated [DATE], document that Resident #5 is frequently incontinent of bladder. Resident #5 has resided in the facility since 2010. Surveyor reviewed the medical record 03/18 - 03/19/14 and could not locate any bladder assessments or documentation that determined a toileting program for Resident #5. On 03/18/14 at 1:10 p.m., Surveyor observed personal cares and noted that Resident #5 had been incontinent of bladder. The nursing care plan includes in part: Impaired Physical Mobility, dated 01/22/14...manifested by: Skin exposure to BB (bowel/bladder) incontinence. The Certified Nursing Assistant (CNA) care plan includes in part: Elimination: Bladder frequently incontinent. Bowel frequently incontinent, toilet with standing lift and 1 assist. Nights check and change every round and prn- offer bedpan or toilet. Incontinent products: Yellow brief. On 03/19/14 at 11:05 a.m., Surveyor interviewed Registered Nurse (RN) B to ask for bowel/bladder assessments. RN B stated, "We do the assessments upon admission and if incontinence is new for the resident or a change in incontinence. We also do an assessment if they are on the restorative program for incontinence. Surveyor stated that the assessments were not located in the chart. RN B stated, "Then you should check the nurses' notes." On 03/20/14 at 8:50 a.m., Surveyor interviewed the DON about the bladder assessments. The DON stated, "We look at the MDS quarterly; if we see a decline we do an assessment. Surveyor asked if the DON knew the reason that Resident #5 is incontinent of bladder and not on a specific toileting program, when there was no assessment to make that determination. The DON stated she would look for more information. On 03/20/14 at 9:35 a.m., Surveyor interviewed RN A, who is in charge of the restorative bladder program. RN A said she does bladder assessments only for the residents on the restorative program. RN A informed Surveyor that Resident #5 is not on the restorative bladder program, so would not have one completed. On 03/20/14 at 10:20 a.m., Surveyor again interviewed the DON. Surveyor stated that we have been asking for bladder assessments and nothing had been received. The DON stated, "We have not been doing a complete assessment; we need to improve in this area." 5. Resident #1's Significant Change MDS, dated [DATE], documents that she is frequently incontinent of bladder; the quarterly MDS, dated [DATE], also documents that Resident #1 is frequently incontinent of bladder. Resident #1 has resided in the facility for five years. Surveyor reviewed the medical record on 03/18 - 03/19/14 and did not locate any bladder incontinence assessments. On 03/18/14 at 12:30 p.m., Surveyor observed personal cares for Resident #1, and noted she was incontinent of urine. The nursing care plan includes in part: Self Care Deficit, dated 11/05/13, Manifested by:...She is still frequently incontinent of urine even with the RA toileting program....frequent incontinent of bowel. Will notify staff of BM (bowel movement) after she has been incontinent. The CNA care plan in part: Elimination: Bowel: Frequent incontinent, pericare after incontinence Nights: Toilet 2nd and 3rd rounds, encourage to use the toilet and assist upon arising, before and after meals, activities, hs (hour of sleep) and prn (as needed). The restorative care plan, dated 04/26/13, includes in part: Toileting, will be continent of urine 2 times per day. Approaches: 1. Encourage to use the toilet and assist, walk with walker upon arising, before and after meals, activities, HS and prn. 2. Peri care after each incontinence 3. Wears x-large brief. On 03/19/14 at 11:05 a.m., Surveyor interviewed RN B to ask for bowel/bladder assessments. RN B stated, "We do the assessments upon admission and if incontinence is new for the resident or a change in incontinence. We also do an assessment if they are on the restorative program for incontinence." Surveyor stated that the assessments were not located in the chart. RN B stated, "Then you should check the nurses' notes." Surveyor reviewed the nurse's notes which included that the resident was incontinent of bladder and needed assist to toilet. The nurses' notes did not contain a complete urinary assessment, recent urinary incontinence tracking information, or toileting program needs. On 03/20/14 at 8:50 a.m., Surveyor interviewed the DON about the bladder assessments. The DON stated, "We look at the MDS quarterly; if we see a decline we do an assessment." The DON gave Surveyor a Bladder Elimination Pattern Assessment that was completed 04/29/13. Surveyor asked how they used this information to help restore or maintain bladder continence. The DON did not provide any further information. On 03/20/14 at 9:35 a.m., Surveyor interviewed RN A, who is in charge of the restorative bladder program. RN A said she does bladder assessments for only the residents on the restorative program. Surveyor reviewed the medical record with RN A. RN A could not locate a bladder assessment, but stated, "I try to do one for everyone on the program." On 03/20/14 at 10:20 a.m., Surveyor again interviewed the DON. Surveyor stated that we have been asking for comprehensive bladder assessments and nothing had been received. The DON stated, "We have not been doing a complete assessment on a regular basis; we need to improve in this area."

Based on interview, policy review and record review, the facility did not ensure the policy and procedures which prohibit mistreatment, abuse and neglect of residents were developed and implemented. Staff and residents were afraid to report abuse and incidents reported were not thoroughly investigated. This had the potential to affect all 45 residents. The facility policy was not developed to include all the components necessary to prevent abuse and protect residents. On 02/06/12 an allegation of abuse was reported to administration against CNA (Certified Nursing Assistant) A with Resident #7. Staff statements indicated CNA A is intimidating, residents are fearful CNA A will answer their call light when they turn it on, residents are intimidated by her and feel degraded by her. Staff statements also indicate staff are intimidated by CNA A and after they have reported things to administration, CNA A's behavior continues. The failure to implement facility policies by failing to immediately report observations of abuse allowed the abuse by CNA A to continue to mistreat residents over a twelve month period. Cross reference F 223. The facility did not implement their policy and did not immediately initiate an investigation. The facility did not protect residents from CNAs, did not self-report the incidents to the state agency and did not immediately retrain all staff regarding abuse prevention and protection of residents following allegations of abuse for 4 residents reviewed (#7, #3, #5 and #18). Cross reference F 223. The failure of the facility staff to implement the abuse policy and procedure led to the finding of Immediate Jeopardy. The Immediate Jeopardy began on 02/03/12. The NHA was notified of the Immediate Jeopardy on 02/14/13. The facility removed the immediate jeopardy on 02/15/13. The deficient practice continues at a scope/severity level of E (potential for harm/pattern) because not all staff have been retrained. This is evidenced by: On 02/13/13 Surveyor was provided with a copy of the facility's Abuse and Resident Protection Policy with the most recent revision date of: 4/05. 1. Policy: The United Pioneer Home's policy on Abuse and Resident Prevention is to protect all residents from neglect, verbal or physical abuse, involuntary seclusion and misappropriation of funds or personal property by any employee, volunteer, visitor, or family member. 2. Definitions: (read in part) PHYSICAL ABUSE: Any inappropriate physical contact with the resident which harms or could harm the resident (i.e. pinching, hitting, punching, pushing, etc.) or an intentional act of aggression on one person's part, toward any resident. VERBAL ABUSE: Any improper speech which is directed at or about a resident. Any conversation that is crude, vulgar or generally unacceptable. Derogatory remarks about resident's age, religion and national origin, physical or mental handicap or condition. Any threat of harm or making statements to intentionally frighten a resident. MENTAL ABUSE: Any contact, physical, verbal or sexual in nature, which would disturb the mental and/or emotional peace of mind of the resident, including teasing and harassing statements or gestures. This includes statements or actions that cause a resident to experience feelings of humiliation, intimidation, abandonment, and powerlessness or depriving a resident of possessions. 3. Procedure: (read in part) United Pioneer Home will take the following measures to ensure residents are protected from physical, verbal, sexual or mental abuse, neglect and misappropriation of funds. a. Prevention: i. A copy of the complaint procedure and Resident Protection Policy will be given to each resident or responsible party at the time of admission. A copy will also be posted in the main lobby and break room. Complaint procedure will be reviewed with resident at Resident Council Annually. ii. Equipment and environment will be monitored through the maintenance department. c. Training: i. All new employees are trained on identifying abuse and potential abuse situations, stress and stress reduction, procedure for reporting abuse and abuse prevention at the time of orientation. ii. In-services will be held yearly to identify what constitutes abuse and potential abuse situations, stress and stress reduction, procedure for reporting abuse and abuse prevention at the time of orientation. iii. In-service training will include interventions to deal appropriately with aggressive and or catastrophic reactions of residents. iv. Recognizing signs of stress that could lead to inappropriate or harmful behavior will be reviewed through annual in-service or as needed. d. Monitoring: i. Reports are promptly investigated. ii. Incident and Accident reports are reviewed after their completion. Trends or patterns in staff involvement, nature of injuries, suspicious circumstances and unexplained bruises are considered in the review process. iii. Administrator, DON, ADON and Social Worker will make regular rounds of resident areas to observe for preservation of dignity and respect for residents. iv. Care plan team will regularly assess and monitor residents with needs and behaviors that may lead to conflict with or neglect by staff. e. Investigation: i. All complaints by residents, family, visitor or staff are investigated by Administrator, DON, Social Worker or designee within 5 working days of receipt of complaint. ii. Rapid Report Investigatory worksheet will be initiated by the person receiving the complaint. iii. Charge Nurse will immediately investigate any bruise, skin tear or injury that does not have a documented cause. Charge Nurse will be responsible for keeping resident protected from further harm if injury is abuse. Charge Nurse will notify Administrator immediately of alleged incident. f. Reporting: i. All individuals have the responsibility to immediately report any knowledge of abuse or neglect of a resident when there is a reasonable cause to suspect abuse or neglect. This report can be made to the charge nurse, DON, Social Worker or Administrator. ii. Rapid Response worksheet will be initiated immediately. iii. Administrator or designee will be contacted immediately of alleged incident. iv. Alleged violations and substantiated incidents will be reported to the Bureau of Quality assurance within 5 days of receipt of the complaint. Administrator or designee will make determination based on decision tree flow sheet. v. Quality Assurance Committee will review alleged and substantiated incidents to determine if and what charges are needed to prevent further occurrences. g. Protection: i. Residents will be protected from further occurrences by immediate action. Options include: 1. relieve of duty of any staff that pose a danger to residents 2. call law enforcement 3. move resident to a different room 4. secure items of value for resident 5. gather information/evidence to assist with investigation The facility policy does not identify ways to prevent abuse (what to look for), it does not address the need to report suspicions of abuse to state agency immediately and it does not address removing accused abusers from their duties during an investigation (this is listed as an option). The facility did not have a means to monitor employees' interactions with residents following an allegation of abuse. Many staff and resident expressed to surveyors concerns with CNA A. These concerns were not always reported or if reported were not investigated. Staff and residents stated they were intimidated by CNA A. The failure to implement facility policies by failing to immediately report observations of abuse allowed the abuse by CNA A to continue to mistreat residents over a twelve month period. On 02/06/12 an allegation of abuse was brought to the NHA's (Nursing Home Administrator's) attention that CNA (certified nursing assistant) A had verbally abused Resident #7 on 02/03/12. A handwritten statement by LPN (Licensed Practical Nurse) E indicated she interviewed Resident #7 on 02/03/12 after 4:30 p.m.. Resident #7 told her after CNA A could not find a co-worker to give Resident #7 her bath, she returned to Resident #7's room and said to her "no breakfast for you" when she realized she had to give Resident #7 the bath herself. LPN E reported the abuse to the DON (Director of Nursing) on 02/06/12 who then reported it to the NHA on the same date. The NHA investigation included a note from LPN E to report the incident and an interview with Resident #7. The NHA determined through this information that although Resident #7 did not like the way CNA A gave her a bath it was not abuse. The NHA stated in the report that CNA A is "a little rough around the edges." No other residents or staff were interviewed regarding CNA A. No retraining or monitoring was done to prevent further abuse. On 02/14/13 at 8:25 a.m. Surveyors and met with the NHA to discuss any further information that may be available related to the investigations with CNA A and Resident #7. The NHA stated, "I have nothing more to offer you. There is no more documentation." The NHA added, "We have had an ongoing attitude problem with this employee (CNA A). The NHA was asked who makes the final decision in what gets reported to the State Agency. The NHA responded, "I make the final decision and I felt it did not rise to the level of reporting." CNA M stated to Surveyor that CNA A's bad attitude has been reported many times and "nothing ever happens." CNA M stated she encourages residents to report any mistreatment but they are afraid that CNA A will still have to take care of them and she will be mean to them. On 02/13/13 at 12:30 Surveyor conducted an interview with CNA (certified nursing assistant) L who requested to stay anonymous related to fear of retaliation. CNA L was asked if she was aware of any residents having difficulties with any CNA's. CNA L responded there is a certain resident that has a problem with one of the CNA's. CNA L went on to say, "I have heard rumors about this resident and the CNA, something that happened in January." CNA L was asked by Surveyor if she thought the rumors were true. CNA L responded, "yes I believe the rumors are true." Surveyor asked CNA L if she works with this certain CNA and certain resident. CNA L responded, "Yes I work with them." CNA L was asked if she felt comfortable elaborating on the issues. CNA L responded, "A couple of weeks ago Resident #5 had her call light on and when I answered it I overheard her tell her roommate, "I am scared every time I turn my call light on that CNA A will answer it." CNA L stated, "I told the resident I would try to answer her call light every time she turned it on." CNA L was asked by Surveyor if she had ever witnessed abuse with any of the residents or any of her coworkers. CNA L responded, "I have never witnessed abuse but I have witnessed CNA A's attitude with residents." CNA L was asked if she could elaborate on "CNA A's attitude." CNA L responded, "When CNA A gets overwhelmed she complains about being overworked and stomps around here. Other CNAs are afraid of her and lots of the girls don't like to work with her." Surveyor asked CNA L if she had reported to anyone the conversation she overheard Resident #5 tell her roommate. CNA L responded, "No they investigated it and administration doesn't address issues with CNA A anyways." On 02/14/13 at 9:10 a.m. Surveyor interviewed CNA U regarding any issues she may be aware of regarding treatment of [REDACTED]. CNA U responded, "some days CNA A is good, some days she is not." CNA U went on to say, "Some days she is a little grumpier than others." Surveyor asked CNA U if she could elaborate on that. CNA U responded, "You kind of get to know if she's having a bad day, you help her answer lights so you can keep the peace." Surveyor asked CNA U if she is intimidated by CNA A. CNA U responded, "No." CNA U was then asked if she felt any of the residents are intimidated by CNA A to which CNA U responded, "Yes." Surveyor asked CNA U if it was related to things CNA A has said to residents. CNA U responded, "It is a particular resident. This resident becomes very nervous when CNA A is in her room. This resident has told me she feels degraded when CNA A talks to her and she feels she is a bother to CNA A when CNA A answers her call light because CNA A complains so much about call lights being on." CNA U went on to say, "I hugged the resident when she said that and I told her she is not a bother to us." Surveyor asked CNA U if this happened recently. CNA U responded, "It was a couple of weeks ago." CNA U was asked if she would be willing to share the residents name with the surveyor. CNA U reported, "It is (Resident #5's name)." CNA U was asked if she reported this to anyone. CNA U responded, "No they already knew about it, it had been reported by CNA T to the DON." On 02/14/13 at 9:35 a.m. Surveyors and interviewed CNA T related to the incident that occurred on 01/24/13 she had reported to RN S. CNA T responded, "I have reported it to the DON a couple of times." CNA T went on to explain, "Resident #5 only feels comfortable telling certain people things." Surveyor asked CNA T if she could go over the incident Resident #5 had reported to her. CNA T explained, "I was in Resident #5's room painting her nails when she told me CNA A had been in her room earlier in the day and was ranting and raving about being so busy. Resident #5 told me she was scared when it happened and she was trying to make a joke by making a statement about Christmas lights to see if CNA A would calm down." CNA T went on to say, "Resident #5 said she was so upset about it she couldn't go to the bathroom and had an upset stomach all day." CNA T also reported, "Resident #5 told me she feels threatened and scared when CNA A comes in to her room, I went straight to the DON when she told me that." Surveyor asked CNA T if there were any other residents she was aware of that had issues with CNA A. CNA T responded, "Resident #18 has also told me she feels rushed and scared by CNA A." CNA T went on to say, "Resident #5 told me CNA A is rude to us and I told Resident #5 no one should feel afraid in their own home." Surveyor and CNA T discussed CNA A's "mood" at times when she is working with the residents. CNA T stated, "She (CNA A) seems to always be in a mood." CNA T was asked if it is reported to the nurses when CNA A is "in one of her moods." CNA T responded, "They usually already know when she is having a bad day or upset about something." CNA T also stated, "The DON had me and CNA A go sit in her office recently with SW K because CNA A said I don't like her. I like everyone, we all have problems at home but we don't bring them to work. CNA A brings all of her problems to work. We all hear about it." CNA T was asked if she feels comfortable reporting things to administration. CNA T responded, "Yes, they do stuff about it then it goes right back to the way it was before." CNA T was asked if there was any other information she felt we should know? CNA T responded, "my worry is what happens when CNA A is working with residents who cannot speak up." CNA T was asked if CNA A does work with those residents. CNA T responded, "Yes." CNA T was asked, "Is CNA A ever alone with residents?" CNA T responded, "Yes." No other information was offered. Surveyor asked Resident #20 what she would do if she was mistreated or if she saw another resident be mistreated. Resident #20 said, "I don't know what I'd do - I sure wouldn't dare say anything because I'd get myself in trouble. On 02/14/13 at 12:30 p.m., Surveyor was interviewing Resident #7 who reported, "approximately 2 weeks ago a newer CNA with red hair was getting me ready for bed, when she washed my buttocks she went in too deep and it hurt. I told the CNA to stop because it hurt but she did it four more times." Resident #7 stated, "I reported it to RN (Registered Nurse) R after it happened." On 02/14/13 at 1:30 p.m., Surveyors and met with the NHA to discuss the above incident and requested a copy of the investigation related to this incident. The NHA responded, "I do not know anything about this incident, but I can see if I can find something on the DON's computer she may have written." Surveyor requested a copy of any documentation he finds. On 02/14/13 at 2:10 p.m., Surveyors and interviewed RN R related to the above incident. Surveyor discussed with RN R if the incident had been reported to her by Resident #7. RN R responded, "I do remember hearing about it from the DON but it was never reported to me." Surveyor went on to discuss with RN R what information she heard about from the DON. RN R responded, "The DON told me Resident #7 had reported to her CNA P had washed her and it hurt and she had already talked to CNA P." Surveyor asked RN R if she had been instructed to monitor CNA P on her shift. RN R responded, "No." On 02/14/13 at 3:30 p.m., Surveyor was notified by the NHA he had not found any documentation on the DON's computer related to the incident with Resident #7 and CNA P. On 02/18/13 at 7:30 a.m., Surveyor interviewed the DON regarding the above incident reported by Resident #7. Surveyor asked the DON who reported the incident to her. The DON responded, "The resident did." The DON went on to say, "Resident #7 was in the Wellness room one day a couple weeks ago and when I went in there, the resident asked to talk to me in private." The DON continued, "I went to her room and that is when she told me what happened...She (Resident #7) told me the new girl with the red hair had been rough when she washed her." Surveyor asked the DON if she had interviewed anyone else related to the incident. The DON responded, "I also talked with CNA P." Surveyor asked the DON if she had any written statements. The DON replied, "No I talked to CNA P and she said she didn't think she was being rough, she (CNA P) stated she wasn't trying to hurt her." Surveyor requested a copy of the investigation completed after the incident was reported to her. The DON replied, "I don't believe I wrote anything down but I will look." The DON then stated, "Maybe I should have written something down when I talked to the CNA and resident." On 02/18/13 at 11:00 a.m., Surveyor met with the DON and the NHA regarding information related to the extended survey. During this meeting the DON stated, "I did tell the NHA about the incident with Resident #7 and CNA P when it was reported to me." The NHA verified he had been notified by the DON but had forgotten when the surveyor had asked him about it on 02/14/13. No written documentation was provided to Surveyor related to the incident or an investigation. No further documentation was provided. Resident #3, who is [AGE] years old, was resistive to getting out of bed for a bath on 06/04/12. A Certified Nursing Assistant (CNA) forced Resident #3 out of bed, despite her yelling and hanging on to the other side of the bed. CNAs who witnessed the incident did not protect Resident #3 and did not immediately report the mistreatment. When Resident #3's hand and arm were bruised the next day, the CNAs attributed the bruises to the incident and told the nurse. The facility did not conduct a thorough investigation, (did not interview other residents who are cared for by the CNA) and did not protect residents from the CNA (allowed her to continue to work unsupervised with residents with dementia), did not self-report the incident to the Office of Caregiver Quality and did not immediately retrain all staff regarding abuse prevention and protection of residents. Surveyor also discussed the incident with Resident #3 and CNA B with the NHA at this meeting. The NHA responded, "I did not think it was intentional so I did not report that either because I did not feel it was a reportable event." Resident #18 stated to the surveyor she was intimidated by CNA A. She stated CNA A was not nice, was abrupt, doesn't like to talk and she wished she could tell CNA A to slow down during cares. Resident #18 told the surveyor CNA A "knows when she is pushing my buttons." The facility did not supervise CNA A to see how she treats the residents. Cross Reference 223 and 225.

Based on resident and staff interview, record review and investigation review, the facility did not ensure each resident was free from physical, verbal and mental abuse for 5 examples with 4 of 22 sampled residents. 1. Resident #3, who is [AGE] years old, was resistive to getting out of bed for a bath on 06/04/12. A Certified Nursing Assistant (CNA) forced Resident #3 out of bed, despite her yelling and hanging on to the other side of the bed. CNAs who witnessed the incident did not protect Resident #3 and did not immediately report the mistreatment. When Resident #3's hand and arm were bruised the next day, the CNAs attributed the bruises to the incident and told the nurse. The facility did not conduct a thorough investigation, (did not interview other residents who are cared for by the CNA) and did not protect residents from the CNA (allowed her to continue to work unsupervised with residents with dementia), did not self-report the incident to the Office of Caregiver Quality and did not immediately retrain all staff regarding abuse prevention and protection of residents. 2. Resident #7, a [AGE] year-old female, who enjoys taking a bath versus a shower, reported to LPN (Licensed Practical Nurse) E on 02/03/12, CNA A could not find anyone else to give her a bath and when CNA A returned to her room she (CNA A) stated, "come on let's go, no breakfast for you today." The incident was reported to the DON (Director of Nursing) on 02/06/12. The facility did not conduct a thorough investigation, (did not interview all staff who work with CNA A and did not interview residents who are cared for by the CNA A). The facility did not protect residents from the CNA, did not self-report the incident to the state agency and did not immediately retrain all staff regarding abuse prevention and protection of residents. 3. Resident #7 stated to Surveyor , during an interview "I don't know if I should tell you about this." Surveyor gently encouraged Resident #7 she could share anything with the surveyor and she wouldn't get in trouble for doing so. Resident #7 reported to Surveyor , "About 2 weeks ago a newer CNA with red hair was getting me ready for bed and she washed my buttocks and she went in too deep and it hurt. I told her (the CNA) to stop because it hurt but she did it four more times." The incident was reported to the DON. The facility did not conduct a thorough investigation and did not interview any other residents who were cared for by this CNA. The facility did not protect residents from the CNA, did not self-report the incident to the state agency and did not immediately retrain all staff regarding abuse prevention and protection of residents. 4. Resident #5 was not protected from the willful infliction of intimidation and mental abuse by a caretaker. Resident #5 suffered depression and intimidation resulting from CNA A's treatment. The facility did not conduct a thorough investigation, (did not interview other residents who are cared for by the CNA) and did not protect residents from the CNA (allowed her to continue to work unsupervised with residents with dementia), did not self-report the incident to the Office of Caregiver Quality and did not immediately retrain all staff regarding abuse prevention and protection of residents and the requirement to investigate thoroughly and report immediately. 5. Resident #18 was not protected from intimidation by CNA A. Resident #18 stated to the surveyor she was intimidated by CNA A. She stated CNA A was not nice, was abrupt, doesn't like to talk and she wished she could tell CNA A to slow down during cares. Resident #18 told the surveyor CNA A "knows when she is pushing my buttons." The facility did not supervise CNA A to see how she treats the residents. These deficient practices resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 02/03/12 when Resident #7 was verbally abused by CNA A (example #2). The same staff member returned to work and continued to work with residents at high risk for abuse (residents with dementia) without supervisory monitoring. After this incident, the facility failed to provide adequate training for all staff members in the identification, reporting and response of caregiver stress to protect residents from abuse. Caregivers continued to mistreat residents as evidenced by examples #1, 3, 4 and 5. The Immediate Jeopardy was identified on 02/14/13. The Facility Administrator was notified of the Immediate Jeopardy at 3:30 p.m. on 02/14/13. The Immediate Jeopardy was removed on 02/15/13. The deficient practice continues at a scope/severity level of E (potential for harm/pattern) because not all staff have been adequately trained in abuse prevention. This is evidenced by: 1. Resident #3 is a [AGE] year-old female whose medical record states she has resided at the facility since July of 2010. She has a history of being resistive to cares. Her CNA care plan instructs staff to use a "calm, gentle approach" and the ' Behavior approach ' section of the CNA care plan instructs staff to, "Reassure, TLC (tender loving care)." During the facility's recertification survey, Surveyor reviewed a facility investigation of an incident which happened on 06/04/12. The Nursing Home Administrator (NHA) wrote in his synopsis it was reported to him by the Director of Nursing (DON) on 06/05/12 CNA B "was observed by two witnesses to get (Resident #3), a [AGE] year-old woman who suffers from dementia, forcefully out of bed at approximately 6 am on June 4th 2012. This resident can be resistive to cares and it was not unusual for this to occur. One approach is to have another staff member attempt to get her to bathe. CNA B was asked to try for the bath aides. According to the two witnesses, CNA B threw the covering off the resident while at the same time announcing she is going to take a bath. According to the witnesses, CNA B then forcefully got the resident out of bed despite the resident refusing and yelling for help. Another aide came into the room to see what was going on and redirected the staff and resident. Both the witnesses say they felt very uncomfortable about CNA B's approach. A review of the investigation report revealed "This incident came to light when the next day, the same bath aides gave the resident a bath and noted bruising on the resident's left thumb area and upper inside arm. The aides asked the nurse, LPN (Licensed Practical Nurse) E to look at it. During this time, CNAs C and D wondered if the bruise was from the incident the day before. While these bruises appear to be fresh we really don't have any evidence they were a result of the incident on June 4th. The resident does ambulate freely around her room and facility." "Does this incident rise to the level of reportable? DHS 13.03(1) (b) - Based on my investigation while these incidents are unpleasant and do not meet our expectations of care, it was not something intentional on the part of CNA B to harm the resident. The aides who witnessed this felt very uncomfortable at what they saw and thought CNA B went too far. It appears to be an isolated incident with this one resident and not other residents evidenced by interviews with staff but not residents. I believe this to be a lack of judgment as to when CNA B should have stopped her attempt at getting the resident into the bath. CNA B will be counseled on this incident." The bruising is described in the nurse's notes on 06/05/12 by the DON. "The bruise at the base of her left thumb is dark bluish purple, 4.5 cm (centimeters) long by 5.0 cm wide." The bruise on the left inner upper arm was blue and measured 1.0 cm long by 2.0 cm wide. A statement written by CNA C confirmed the above note. CNA C also wrote Resident #3 did not want to get up when she went in to care for her, so she performed morning cares on another resident. She again approached Resident #3 at 6:00 a.m. "about a half hour later than the first time. CNA D was with me and (Resident #3) still didn't want to get out of bed. I told CNA D we can do a different bath and then (Resident #3) tomorrow. CNA D said maybe we should get CNA B to try and went out and got her. When CNA B was going into (Resident #3's) room she said 'Just do what I do yell at her.' She went into the room and yelled '(Resident #3's name) it's time to get up and have a bath.' She pulled the covers off and (Resident #3) said she wasn't going to take a bath. CNA B said 'you are taking a bath' and began pulling (Resident #3) out of bed - (Resident #3) was holding on to the other side of the bed with her right hand while CNA B was pulling her up with her left arm and (Resident #3) began screaming 'Help' extremely loud - She got (Resident #3) to a standing point but she wasn't steady and looked like she was going to fall. I stepped over there and boosted (Resident #3) back into bed by going under her legs and CNA B was up by her arm. CNA B said 'wow you are strong' I said 'I don't want (Resident #3) to fall, she was going to fall. CNA F had heard (Resident #3) screaming and came in to see what was going on. At this point CNA D had gotten (Resident #3) into the bathroom and CNA B said she was ready for her bath now. I told her I was just going to try her tomorrow because she is very mad now. CNA F got some clothes out for (Resident #3) and she would see if she could help her get dressed. CNA B left. CNA D and I went to do a different bath while CNA F helped (Resident #3). "On Tuesday morning June 5th CNA G and I got (Resident #3) in for her bath and noticed bruises on (Resident #3's) left hand and upper arm. I told CNA G I thought they were from yesterday and told her what happened. She told me she had something happen when (Resident #3) didn't want to get ready for bed and CNA B came in. We talked about how intimidating CNA B is and we were worried about saying something. I went and got LPN E and LPN H to look at (Resident #3's) bruises while she was getting done with her bath and said it might be from the way CNA B handled her yesterday. I reported this to the DON." CNA F's statement verifies CNA C's, as well as states when Resident #3 was yelling at CNA B, she also yelled "You can't force me" and CNA B was holding Resident #3's arm and her walker. "Then (Resident #3) sat on her bed and screamed again. CNA B again told Resident #3 she had to take her bath and Resident #3 yelled again, "you can't force me." After the other 3 CNAs left the room, Resident #3 settled down and allowed CNA F to assist her to get dressed and to sit in her recliner. Additional notes in the investigation state CNA B stated once to a resident the words, "pissed your pants" and the "General idea" is CNA B "is a bully with staff." Surveyors and interviewed the NHA on 02/14/13 at 3:30 p.m. The NHA stated no other residents had been interviewed regarding CNA B's treatment of [REDACTED]. He stated he felt CNA B was just doing her job with trying to get Resident #3 to take her bath, (although she fully intended to yell at Resident #3 and intended to manhandle her out of bed despite her protests) and he did not initially feel the incident needed to be reported to the Office of Caregiver Quality. He stated he now realizes he made a judgment in error. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/13/13, during the facility's recertification survey Surveyor reviewed a facility investigation of an incident which had occurred on 02/03/12. The Director of Nursing (DON) wrote in her statement, "It was reported to me on 02/06/12 a resident had complained of how (CNA A) talked to her and treated her on 02/03/12. She said it was obvious (CNA A) did not want to give her a bath day by how she touched her. She said (CNA A) was in such a hurry. She (CNA A) talks loud and the Resident said she talks very soft in hopes (CNA A) will 'get the hint'." Attached to the DON's statement was a handwritten note identified Resident #7 as the resident had complained of how CNA A had treated her. The handwritten note was signed by LPN (Licensed Practical Nurse) E. The note read in part as follows: "(Resident #7's name) c/o (complaint of) a.m. bath: "CNA A couldn't find anyone to give me my bath. Then she came back and said "come on let's go, no breakfast for you today...Then (she) wanted to give me a shower and she knows I don't take showers, it's either too hot or too cold...Brought me to my room and then she left, wouldn't help me with my hair, she knows I can't do it myself and she just left me...She just didn't want to do it." (Had told (CNA Y) earlier she was "cold and mean" and was crying). "She wasn't gentle; she just didn't want to do it...I was in tears when she was done, most girls are so good." On 02/14/13 at 12:25 p.m. Surveyor interviewed Resident #7 related to the incident she had reported on 02/03/12. Resident #7 relayed she remembered the incident, even though it was last year and remembered crying about it. Surveyor asked Resident #7 if she remembered receiving a bath or a shower that morning from CNA A. Resident #7 responded, "CNA A did give me a bath that morning but she didn't want to. She wanted to give me a shower but I am too short to fit in the shower chair." Resident #7 went on to say, "She used a very cold plastic belt around my waist that morning, when she put me in the bath and she was in a bad mood." Surveyor asked Resident #7 if CNA A still takes care of her. Resident #7 responded, "Yes she does, but she cannot do my bath anymore." Surveyor asked Resident #7, if she is afraid of CNA A. Resident #7 responded, "No she is a little louder than others." Resident #7 went on to say, "when she takes care of me she comes in and turns on all the lights and is so loud it makes you just want to get out of bed so she is (will be) quiet!" Resident #7 also reported, "CNA A bought me a new blanket last week, it's folded up on the chair there. It looks warm." Surveyor noted a white sheepskin blanket folded up and laying on a chair in the Resident #7's room. On 02/18/13 at 7:30 a.m. the NHA (Nursing Home Administrator) provided Surveyor with a typed statement dated 02/02/12. The NHA stated, " I interviewed Resident #7 after the incident on 02/03/12 and this is what I wrote up." The statement read in part as follows: "Investigation of report of possible rude treatment of [REDACTED]. The DON reported to (me) she found a note from LPN E under her door this morning. The note said that it was reported to OA (Other Administration) employee Q at 4:30 p.m. on Friday, February 3rd, 2012. I had just left the facility for the day. I interviewed Resident #7 and she related to me she told CNA Y about the how she had her bath by CNA A that morning. The statement went on and read in part as follows: ~"She told me she is not allowed to use her shampoo. The reason for this is the shampoo is not UV light compliant in the Apollo bather." ~"She told me she could tell that CNA A did not want to do her bath. She told me she was not fearful, it was just that CNA A had an attitude. The resident told me she likes to sleep in and does so often. Sleeping in means almost lunch time." ~"CNA A is known to be a little "rough around the edges" in her style of care giving. Sometimes it has created some misunderstanding." The NHA concluded the typed statement with: ~"Based on my interviews with the DON, the resident and LPN E, knowing CNA A and the resident, I do not believe that this incident rises to the level of abuse. While the resident did not care for the way CNA A performed her bath, she did not relate to me she was ever fearful of her. She related to me she just knew CNA A did not enjoy giving her a bath." Review of Resident #7's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated the following: BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating no cognitive impairment. Surveyor interviewed CNA M (time and date omitted to protect anonymity) who wished to remain anonymous for fear of retaliation from CNA A and from administration. CNA M appeared afraid to be seen talking to Surveyor and CNA M and Surveyor went into an empty room and closed the door. CNA M stated she did not understand why CNA A could treat the residents so mean and get away with it. She stated, "I think she was suspended once but nothing ever changes. We report she has a bad attitude and she still works here. If any of us ever acted like her we'd be fired." CNA M stated she encourages residents to report any mistreatment, but they're also afraid that CNA A will still have to take care of them and be mean to them. CNA M stated CNA A "has preferential treatment by administration - she is awful to work with. I care about these residents and its terrible how she treats them." 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/13 at 12:40 p.m. Surveyor was interviewing Resident #7 regarding an incident that occurred on 02/03/12. At the end of the interview Surveyor asked Resident #7 if there was any further information she thought the surveyor should know about. Resident #7 responded (quietly), "I don't know if I should tell you about this." Surveyor gently encouraged Resident #7 she could share anything with the surveyor and she wouldn't get in trouble for doing so. Resident #7 reported to Surveyor , "About 2 weeks ago a newer CNA with red hair was getting me ready for bed and she washed my buttocks and she went in too deep and it hurt." Resident #7 went on to say, "I told her to stop because it hurt but she did it four more times." Surveyor discussed with Resident #7 if she had reported this incident to anyone. Resident #7 responded, "I think I told RN (Registered Nurse) R." Resident #7 also stated, "I told the nurse about it and then the CNA came back in and said, "Oh I was just fooling around and smiled. She didn't apologize to me." Surveyor asked Resident #7 if any staff member had followed up with her at any time related to the incident. Resident #7 responded, "No one ever talked to me. The days have gone by and the nurse hasn't said anything about it." On 02/14/13 at 1:30 p.m. Surveyors and met with the NHA to discuss the above incident and requested a copy of the investigation related to this incident. The NHA responded, "I do not know anything about this incident, but I can see if I can find something on the DON's computer she may have written." Surveyor requested a copy of any documentation he finds. On 02/14/13 at 2:10 p.m. Surveyors and interviewed RN R related to the above incident. Surveyor asked RN R if the incident had been reported to her by Resident #7. RN R responded, "I do remember hearing about it from the DON but it was never reported to me." Surveyor went on to discuss with RN R what information she heard about from the DON. RN R responded, "The DON told me Resident #7 had reported to her CNA P had washed her and it hurt and she had already talked to CNA P." Surveyor asked RN R if she had been instructed to monitor CNA P on her shift. RN R responded, "No." On 02/14/13 at 3:30 p.m. Surveyor was notified by the NHA he had not found any documentation on the DON's computer related to the incident with Resident #7 and CNA P. On 02/18/13 at 7:30 a.m. Surveyor interviewed the DON regarding the above incident reported by Resident #7. Surveyor asked the DON who reported the incident to her. The DON responded, "The resident did." The DON went on to say, "Resident #7 was in the Wellness room one day a couple weeks ago and when I went in there, the resident asked to talk to me in private." The DON continued, "I went to her room and that is when she told me what happened...She (Resident #7) told me the new girl with the red hair had been rough when she washed her." Surveyor asked the DON if she had interviewed anyone else related to the incident? The DON responded, "I also talked with CNA P." Surveyor asked the DON if she had any written statements. The DON replied, "No I talked to CNA P and she said she didn't think she was being rough, she (CNA P) stated she wasn't trying to hurt her." Surveyor requested a copy of the investigation completed after the incident was reported to her. The DON replied, "I don't believe I wrote anything down but I will look." The DON then stated, "Maybe I should have written something down when I talked to the CNA and resident." No further documentation was provided. 4. Resident #5 has a history of diabetes mellitus, [MEDICAL CONDITIONS], right above knee amputation with prosthetic, atonic bladder, transient ischemic accident and [MEDICAL CONDITION] pain. Resident #5 is alert and oriented. On 02/13/13 at 12:30 p.m., Surveyor interviewed Resident #5 about an incident which took place on 01/24/13. Resident #5 told Surveyor she had her light on one morning because she had to go to the bathroom. CNA (Certified Nursing Assistant) A came into her room and stated "Everybody has their lights on!" Resident #5 stated she tried to make light of the situation by saying "Maybe they think its Christmas." CNA A stared at Resident #5 and stated "Your light is one of them." Resident #5 told Surveyor she thought about the exchange with CNA A later and it made her sad and depressed because CNA A was in a bad mood. Resident #5 stated to Surveyor because of CNA A's comment, she felt belittled and "not as important as all the other people who had their lights on." Resident #5 told Surveyor the DON talked to her and told her CNA A would not be complaining to her any more. Resident #5 stated CNA A continues to be assigned to assist her with her cares, but added "she does not complain to me anymore." On 02/13/13, Surveyor interviewed CNA L. CNA L told Surveyor she noticed Resident #5 was upset on 01/24/13. Resident #5 told CNA L she was upset with CNA A and was fearful CNA A would answer her call light. CNA L told the Resident she would answer her call light so CNA A would not have contact with her. On 02/13/13, Surveyor and Surveyor reviewed CNA A's employee file. An unsigned, handwritten document addressed to the DON, confirmed the exchange with CNA A on 01/24/13. In addition, Resident #5 told the writer the above exchange with CNA A had so upset her she was unable to have a bowel movement, which caused her stomach to hurt. Resident #5 told the writer this exchange caused her to be "upset and depressed all day. " Another untitled document, authored and signed by the DON in CNA A's employee file, was reviewed by Surveyors and . Dated 01/24/13, it is noted in the document Resident #5 stated to the DON she did not understand why CNA A "takes her frustrations out on her." Resident #5 also stated CNA A was "in one of her moods" on 01/24/13. Resident #5 told the DON she was upset and sick to her stomach the rest of the day because of the exchange with CNA A. The document stated the resident's concerns were discussed with the Social Worker and the Nursing Home Administrator (NHA). Social Worker K was assigned to interview the resident. An untitled document dated 01/24/13 and signed by SW (Social Worker) K revealed CNA A did assist Resident #5 to the toilet, but Resident #5 told SW K she was so nervous she couldn't have a bowel movement. SW K noted Resident #5 stated she wished CNA A "wouldn't complain so much." Resident #5 told SW K "when CNA A comes in and is singing then I am fine but when she comes in to answer my call light and she is not smiling, she makes me so nervous." On 02/13/13 Surveyor interviewed SW J. SW J stated she did not follow-up on the investigation into this incident since her co-worker, SW K, had conducted the interview. SW J told Surveyor the facility investigates allegations of abuse by talking to the residents, families and CNAs. SW J stated if a Resident complains of mistreatment, they review it with the NHA. SW J told Surveyor in services were conducted monthly with the CNAs. Various topics were discussed, including caregiver stress, dementia and home management (managing work/home life). SW J stated there is no record of these discussions. SW J stated the facility conducts a yearly all-staff meeting covering abuse. The DON contacted CNA A on 01/24/13 and told her a Resident had complained about her so she should not come to work as scheduled in the morning because an investigation was being done. The DON told CNA A to come in the next day (01/25/13) at 11:30 a.m. to discuss the investigation. A notation at the bottom of the document, handwritten by the DON says "...it was offered to CNA A to change households or change shifts if Butternut Place (the household where CNA A was assigned) is getting too stressful for her. The previous problems with CNA's attitude and demeanor with staff and Residents reviewed (sic). Any further problem (sic) will result in discharge." CNA A has a history of being rude and/or flippant with residents, as noted in her employee file. CNA A returned to her regular assignment after the suspension. On 02/13/13 at 01:55 p.m., Surveyor and Surveyor interviewed CNA A. CNA A told Surveyor and Surveyor she feels overwhelmed at times because of the demands of her job and the stress of answering call lights. CNA A stated she hurt her shoulder "a while back" and although she had cut back her working hours, "the pain sometimes makes me edgy." CNA A stated she did not know why Resident #5 complained about her, except she knows Resident #5s' family. CNA stated she thought she was not unkind to Resident #5 on 01/24/13 when she answered her call light, but acknowledged she complained to the Resident "everybody had their call lights on." CNA A stated she didn't mean to make Resident #5 feel bad, but she was rushed and "maybe it was my body language." CNA A stated "If I am not singing and happy go lucky then they (the residents) think there is something wrong. Well, I don't feel like singing and being happy-go-lucky every day!" 5. Resident #18 has [DIAGNOSES REDACTED]. She is alert and oriented. On 02/14/13, Surveyor interviewed Resident #18. Resident #18 stated CNA A stated to Surveyor that CNA A is "straight and to the point." She also stated CNA A is "not too nice." Asked to be more specific, Resident #18 stated CNA is "abrupt" and does not talk to her. Resident #18 stated if she needs assistance with transport and CNA A assists her, she "gets dropped off and doesn't fool around." Resident #18 stated CNA A "doesn't like to talk. She just repositions me in the wheelchair, takes me somewhere (like the chapel) and drops me off." Resident #18 told Surveyor that CNA A "knows when she is pushing my buttons." Resident #18 stated she hasn't said anything to CNA A about her treatment of [REDACTED]." Resident #18 told Surveyor she felt that CNA A "has been here so long she just goes with the flow. If I need some help from her, it has to be right now."

Based on interview and record review the facility did not ensure all allegations involving mistreatment and abuse of Residents #7, #5, #18 and #3 were reported immediately to the administrator of the facility so steps could be taken to prevent further potential abuse while an investigation was in progress. 1. Resident #3, who is [AGE] years old, was resistive to getting out of bed for a bath on 06/04/12. A Certified Nursing Assistant (CNA) forced Resident #3 out of bed, despite her yelling and hanging on to the other side of the bed. CNAs who witnessed the incident did not immediately report the mistreatment. When Resident #3's hand and arm were bruised the next day, the CNAs then attributed the bruises to the above incident and told the nurse. The facility did not conduct a thorough investigation, (did not interview residents who are cared for by the CNA) and did not protect residents from the CNA (allowed her to continue to work unsupervised with residents with dementia), did not self-report the incident to the Office of Caregiver Quality and did not immediately retrain all staff regarding abuse prevention and protection of residents and the requirement to investigate thoroughly and report immediately. 2. On 02/06/12 an allegation of abuse was brought to the NHA's (Nursing Home Administrator's) attention CNA (certified nursing assistant) A had verbally abused Resident #7 on 02/03/12. A handwritten statement by LPN (Licensed Practical Nurse) E indicated Resident #7 had reported to her CNA A had told her "no breakfast for you" after she couldn't find another CNA to give Resident #7 a bath and she had to give Resident #7 the bath herself. The staff reported the abuse to the DON (Director of Nursing) on 02/06/12 who then reported it to the NHA on the same date. The facility did not protect residents from the CNA, did not self-report the incident to the state agency and did not immediately retrain all staff regarding abuse prevention and protection of residents. The facility did not meet the requirements of a thorough investigation and report it immediately. In addition this same resident stated to Surveyor , during an interview "I don't know if I should tell you about this." Surveyor gently encouraged Resident #7 she could share anything with the surveyor and she wouldn't get in trouble for doing so. Resident #7 reported to Surveyor , "About 2 weeks ago a newer CNA with red hair was getting me ready for bed and she washed my buttocks and she went in too deep and it hurt. I told her (the CNA) to stop because it hurt but she did it four more times." The incident was reported to the DON. The facility did not conduct a thorough investigation and did not interview any other residents who were cared for by this CNA. The facility did not protect residents from the CNA, did not self-report the incident to the state agency and did not immediately retrain all staff regarding abuse prevention and protection of residents. 3&4. The facility did not produce evidence to ensure alleged violations of mistreatment alleged by Residents #5 and #18 were thoroughly investigated. The facility did not ensure alleged allegations were reported to the State Office of Caregiver Quality within 5 working days of the incident and did not ensure appropriate corrective action was taken to prevent further violations. The failure to have a system in place in which allegations were immediately reported and acted upon to prevent further abuse from occurring created an Immediate Jeopardy situation. The Immediate Jeopardy began on 02/06/12. The facility was notified of the Immediate Jeopardy on 02/14/13. The facility removed the Immediate Jeopardy on 02/15/13. The deficient practice continues at a scope/severity level of E (potential for harm/pattern) because not all staff have been retrained. This is evidenced by: On 02/13/13 Surveyor was provided with a copy of the facility's Abuse and Resident Protection Policy with the most recent revision date of: 4/05. Section 3. Procedure reads: United Pioneer Home will take the following measures to ensure residents are protected from physical, verbal, sexual or mental abuse, neglect and misappropriation of funds. f. Reporting: i. All individuals have the responsibility to immediately report any knowledge of abuse or neglect of a resident when there is a reasonable cause to suspect abuse or neglect. This report can be made to the charge nurse, DON, Social Worker or Administrator. ii. Rapid Response worksheet will be initiated immediately. iii. Administrator or designee will be contacted immediately of alleged incident. iv. Alleged violations and substantiated incidents will be reported to the Bureau of Quality assurance within 5 days of receipt of the complaint. Administrator or designee will make determination based on decision tree flow sheet. v. Quality Assurance Committee will review alleged and substantiated incidents to determine if and what charges are needed to prevent further occurrences. g. Protection: i. Residents will be protected from further occurrences by immediate action. Options include: 1. relieve of duty of any staff who pose a danger to residents 2. call law enforcement 3. move resident to a different room 4. secure items of value for resident 5. gather information/evidence to assist with investigation 1. Resident #3 is a [AGE] year-old female whose medical record states she has resided at the facility since July of 2010. She has a history of being resistive to cares. Her care plan instructs staff to use a "calm, gentle approach" and the ' Behavior approach ' section of the CNA care plan instructs staff to, "Reassure, TLC (tender loving care)." During the facility's recertification survey, Surveyor reviewed a facility investigation of an incident which happened on 06/04/12. The Nursing Home Administrator (NHA) wrote in his synopsis it was reported to him by the Director of Nursing (DON) on 06/05/12 CNA B "was observed by two witnesses to get (Resident #3), a [AGE] year-old woman who suffers from dementia, forcefully out of bed at approximately 6 am on June 4th 2012. This resident can be resistive to cares and it was not unusual for this to occur. One approach is to have another staff member attempt to get her to bathe. CNA B was asked to try for the bath aides. According to the two witnesses, CNA B threw the covering off the resident while at the same time announcing she is going to take a bath. According to the witnesses, CNA B then forcefully got the resident out of bed despite the resident refusing and yelling for help. Another aide came into the room to see what was going on and redirected the staff and resident. Both the witnesses say they felt very uncomfortable about CNA B's approach. " "This incident came to light the next day when the same bath aides gave the resident a bath and noted bruising on the resident's left thumb area and upper inside arm. The aides asked the nurse, LPN (Licensed Practical Nurse) E to look at it. During this time, CNAs C and D wondered if the bruise was from the incident the day before. While these bruises appear to be fresh we really don't have any evidence they were a result of the incident on June 4th. The resident does ambulate freely around her room and facility. " "Does this incident rise to the level of reportable? DHS 13.03(1) (b) - Based on my investigation while these incidents are unpleasant and do not meet our expectations of care, it was not something intentional on the part of CNA B to harm the resident. The aides who witnessed this felt very uncomfortable at what they saw and thought CNA B went too far. It appears to be an isolated incident with this one resident and not other residents evidenced by interviews with staff but not residents. I believe this to be a lack of judgment as to when CNA B should have stopped her attempt at getting the resident into the bath. CNA B will be counseled on this incident. "Reviewed above with CNA B June 6th 2012 in my office with (DON). 1. The aides that reported this incident are doing what they are instructed to do. If CNA B had witnessed this incident I would expect her to do/make the same report. Any reports of retaliation against any staff member for reporting allegation of abuse, etc. will result in termination of any staff member. 2. While CNA B may be considered the 'go to person' for problems with residents, she needs to recognize when to back off with residents. In this case staff was able to bathe the resident the following day. 3. During the course of the investigation, it was learned that some people find CNA B intimidating. This may be because of her expectations that other staff should get their work done timely and before they go home. CNA B needs to be aware of this. 4. Any further problems with CNA B's job performance will lead to disciplinary action up to and including discharge." The above note was signed by the NHA, the DON and CNA B and placed in CNA B's personnel file. Although CNA B is on medical leave, she continues to be an employee of the facility, with no plan to monitor her treatment of [REDACTED]. A statement written by CNA C confirmed the above note. CNA C also wrote Resident #3 did not want to get up when she went in to care for her, so she performed morning cares on another resident. She again approached Resident #3 at 6:00 a.m. "about a half hour later than the first time. CNA D was with me and Resident #3 still didn't want to get out of bed. I told CNA D we can do a different bath and then Resident #3 tomorrow. CNA D said maybe we should get CNA B to try and went out and got her. When CNA B was going into Resident #3's room she said 'Just do what I do yell at her.' She went into the room and yelled 'Resident #3's name it's time to get up and have a bath.' She pulled the covers off and Resident #3 said she wasn't going to take a bath. CNA B said 'you are taking a bath' and began pulling Resident #3 out of bed - Resident #3 was holding on to the other side of the bed with her right hand while CNA B was pulling her up with her left arm and Resident #3 began screaming 'Help' extremely loud - She got Resident #3 to a standing point but she wasn't steady and looked like she was going to fall. I stepped over there and boosted Resident #3 back into bed by going under her legs and CNA B was up by her arm. CNA B said 'wow you are strong' I said 'I don't want Resident #3 to fall, " she was going to fall. CNA F had heard Resident #3 screaming and came in to see what was going on. At this point CNA D had gotten Resident #3 into the bathroom and CNA B said she was ready for her bath now. I told her I was just going to try her tomorrow because she is very mad now. CNA F got some clothes out for Resident #3 and she would see if she could help her get dressed. CNA B left. CNA D and I went to do a different bath while CNA F helped Resident #3. " "On Tuesday morning June 5th CNA G and I got Resident #3 in for her bath and noticed bruises on Resident #3's left hand and upper arm. I told CNA G I thought they were from yesterday and told her what happened. She told me she had something happen when Resident #3 didn't want to get ready for bed and CNA B came in. We talked about how intimidating CNA B is and we were worried about saying something. I went and got LPN E and LPN H to look at Resident #3's bruises while she was getting done with her bath and said it might be from the way CNA B handled her yesterday. I reported this to the DON." CNA F's statement verifies CNA C's, as well as states when Resident #3 was yelling at CNA B, she also yelled "You can't force me" and that CNA B was holding Resident #3's arm and her walker. "Then Resident #3 sat on her bed and screamed again. CNA B again told Resident #3 she had to take her bath and Resident #3 "yelled again, 'you can't force me.'" After the other 3 CNAs left the room, Resident #3 settled down and allowed CNA F to assist her to get dressed and to sit in her recliner. As stated above, Resident #3 did allow the CNAs to bathe her the next morning. Additional notes in the investigation state CNA B stated once to a resident the words, "pissed your pants" and the "General idea" is that CNA B "is a bully with staff. Makes them stay until they finish rounds." LPN E wrote in Resident #3's nurse's notes on 06/04/12 at 7:14 a.m., "resident is uncooperative, resident is verbally abusive, resident is resistive to all adls (activities of daily living) this am." An investigation was not launched on this day regarding the above incident. Resident #3's nurse's notes written by LPN E at 3:32 p.m. on 06/05/12 state at 6:15 a.m., a CNA reported bruising on Resident #3's upper inner arm and top of left hand near her thumb. The LPN stated she had notified the family, the Nurse Practitioner and administration (the note did not state what time administration was notified). The bruising is described in the nurse's notes on 06/05/12 by the DON. "The bruise at the base of her left thumb is dark bluish purple, 4.5 cm (centimeters) long by 5.0 cm wide." The bruise on the left inner upper arm was blue and measured 1.0 cm long by 2.0 cm wide. The DON stated in the note she was notified at 9:20 a.m., approximately 2 hours after the incident and that it was a CNA who reported it to her. This corroborates with CNA C's above statement she "reported this to the DON. " The note stated Resident #3 "denied anyone hurting her when I asked her" but Resident #3 has dementia and was not interviewed until a day after the incident because it was not reported and investigated immediately. Surveyors and interviewed the NHA on 02/14/13 at 3:30 p.m. The NHA stated no other residents had been interviewed during the investigation regarding CNA B's treatment of [REDACTED]. He stated he felt that CNA B was just doing her job with trying to get Resident #3 to take her bath and did not initially feel the incident needed to be reported to the Office of Caregiver Quality. He stated he now realizes he made that judgment in error. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/13/13, during the facility's recertification survey Surveyor reviewed a facility investigation of an incident which had occurred on 02/03/12. The DON wrote in her statement, "It was reported to me on 02/06/12 a resident had complained of how CNA A talked to her and treated her on 02/03/12. She said it was obvious CNA A did not want to give her a bath that day by how she touched her. She said CNA A was in such a hurry. She CNA A talks loud and the Resident said she talks very soft in hopes CNA A will 'get the hint'." Attached to the DON's statement was a handwritten note that identified Resident #7 as the resident that had complained of how CNA A had treated her. The handwritten note was signed by LPN (Licensed Practical Nurse) E. The note read in part as follows: "Resident #7's name c/o (complaint of) a.m. bath: "CNA A couldn't find anyone to give me my bath. Then she came back and said " come on let's go, no breakfast for you today....Then (she) wanted to give me a shower and "she knows I don't take showers, it's either too hot or too cold....Brought me to my room and then she left, wouldn't help me with my hair, she knows I can't do it myself and she just left me." "She just didn't want to do it." (Had told CNA Y earlier she was "cold and mean" and was crying). "She wasn't gentle; she just didn't want to do it." "I was in tears when she was done, most girls are so good. " In addition, on 02/14/13 at 12:40 p.m. Surveyor interviewed Resident #7 regarding an incident that occurred on 02/03/12. At the end of the interview Surveyor asked Resident #7 if there was any further information she thought the surveyor should know about. Resident #7 responded (quietly), "I don't know if I should tell you about this." Surveyor gently encouraged Resident #7 she could share anything with the surveyor and she wouldn't get in trouble for doing so." Resident #7 reported to Surveyor , "About 2 weeks ago a newer CNA with red hair was getting me ready for bed and she washed my buttocks and she went in too deep and it hurt." Resident #7 went on to say, "I told her to stop because it hurt but she did it four more times." Surveyor discussed with Resident #7 if she had reported this incident to anyone? Resident #7 responded, "I think I told RN (Registered Nurse) R." Resident #7 also stated, "I told the nurse about it and then the CNA came back in and said, Oh I was just fooling around and smiled. She didn't apologize to me." Surveyor asked Resident #7 if any staff member had followed up with her at any time related to the incident. Resident #7 responded, "No one ever talked to me. The days have gone by and the nurses haven ' t said anything about it." See F223 for cross reference. 3. Resident #5 has a history of Diabetes Mellitus I, [MEDICAL CONDITIONS], R (Right) Above Knee Amputation with Prosthetic, Atonic Bladder, Transient Ischemic Accident and [MEDICAL CONDITION] Pain. Resident #5 is alert and oriented. On 02/13/13 at 12:30 p.m., Surveyor interviewed Resident #5. Resident #5 told Surveyor she had her light on one morning because she had to go to the bathroom. CNA (Certified Nursing Assistant) A came into her room and stated "Everybody has their lights on!" Resident #5 stated she tried to make light of the situation by saying "Maybe they think it ' s Christmas." CNA A stared at Resident #5 and stated "Your light is one of them." Resident #5 told Surveyor she thought about the exchange with CNA A later and it made her sad and depressed because CNA A was in a bad mood. Resident #5 stated to Surveyor because of CNA A's comment, she felt belittled and "not as important as all the other people who had their lights on." Resident #5 told Surveyor the DON talked to her that day and told her that CNA A would not be complaining to her any more. Resident #5 stated CNA A continues to be assigned to assist her with her cares, but added that "she does not complain to me anymore." On 02/13/13, Surveyor interviewed CNA L. CNA L told Surveyor she noticed Resident #5 was upset on 01/24/13. Resident #5 told CNA L she was upset with CNA A. CNA L told the resident she would answer her call light so CNA A would not have contact with her. There is no evidence that CNA L reported the incident. On 02/13/13, Surveyor and Surveyor reviewed CNA A ' s employee file. An unsigned, handwritten document addressed to the DON, confirmed the exchange with CNA A on 01/24/13. In addition, Resident #5 told the writer the above exchange with CNA A had so upset her she was unable to have a bowel movement, which caused her stomach to hurt. Resident #5 told the writer this exchange caused her to be upset and depressed all day. Another untitled document, authored and signed by the DON in CNA A's employee file, was reviewed by Surveyors and . Dated 01/24/13, it is noted in the document Resident #5 stated to the DON she did not understand why CNA A "takes her frustrations out on her." Resident #5 also stated CNA A was "in one of her moods" on 01/24/13. Resident #5 told the DON she was upset and sick to her stomach the rest of the day because of the exchange with CNA A. The document stated the resident's concerns were discussed with the Social Worker and the Administrator. Social Worker K was assigned to interview the resident. An untitled document dated 01/24/13 and signed by SW (Social Worker) K revealed CNA A did assist Resident #5 to the toilet and Resident #5 told SW K she was so nervous she couldn't have a bowel movement. SW K noted Resident #5 stated she wished CNA A "wouldn't complain so much." Resident #5 told SW K that "when CNA A comes in and is singing then I am fine but when she comes in to answer my call light and she is not smiling, she makes me so nervous." The DON contacted CNA A on 01/24/13 and told her a Resident had complained about her so she should not come to work as scheduled in the morning because an investigation was being done. The DON told CNA A to come in the next day (01/25/13) at 11:30 a.m. to discuss the investigation. A notation at the bottom of the document, handwritten and signed by the DON says that "...it was offered to CNA A to change households or change shifts if Butternut Place (the household where CNA A was assigned) is getting too stressful for her. The previous problems with CAN ' s attitude and demeanor with staff and Residents reviewed (sic). Any further problem (sic) will result in discharge." On 02/13/13, Surveyor interviewed LPN (Licensed Practical Nurse) H who is the charge nurse on the unit. LPN H told Surveyor she does not preform audits or observe specific interactions between the CNAs' and the Residents. She stated to Surveyor she investigates possible abuse if there is an obvious injury or behavioral change displayed by a Resident. On 02/13/13 Surveyor interviewed SW J. SW J stated she did not follow-up on the investigation into this incident since her co-worker, SW K, had conducted the interview. SW J told Surveyor the facility investigates allegations of abuse by talking to the residents, families and CNAs. SW J stated if a Resident complains of mistreatment, they review it with the Administrator. SW J told Surveyor in-services were conducted monthly with the CNAs. Various topics were discussed, including caregiver stress, dementia and home management (managing work/home life). SW J stated there is no record of these discussions. SW J stated the facility conducts a yearly all staff meeting covering abuse. There is no evidence of further investigation or follow-up by SW J or SW K or evidence the NHA reported the incident to the State Agency. The facility could not produce additional staff training following this incident on abuse recognition, reporting or prevention. CNA A has a history of being rude and/or flippant with Residents, as noted in her employee file (04/01/08, 02/07/12 and 12/07/11). CNA A returned to her regular assignment after the one day suspension on 01/25/13. The facility did not conduct interviews with other Residents or staff about possible mistreatment from CNA A. The facility did not monitor or audit CNA A's interactions with residents and staff. The facility did not provide additional staff training regarding abuse, after the above incident, for CNA A or any other staff members. The facility did not prevent CNA A from having contact with Resident #5 or other residents in the facility. CNA A often worked with residents with dementia with no other caregiver in the room. The facility did not report the allegation or investigative findings to the State Survey and Certification Agency. 4. Resident #18 has [DIAGNOSES REDACTED]. On 02/14/13, Surveyor interviewed Resident #18. Resident #18 stated CNA A stated to Surveyor that CNA A is "straight and to the point." She also stated CNA A is "not too nice." Asked to be more specific, Resident #18 stated CNA is abrupt and does not talk to her. Resident #18 stated if she needs assistance with transport and CNA A assists her, she "gets dropped off and doesn't fool around." Resident #18 stated CNA A "doesn't like to talk. She just repositions me in the wheelchair, takes me somewhere (like the Chapel) and drops me off." Resident #18 told Surveyor that CNA A "knows when she is pushing my buttons." Resident #18 stated she hasn't said anything to CNA A about her treatment of [REDACTED]." Resident #18 told Surveyor she felt that CNA A "has been here so long she just goes with the flow. If I need some help from her, it has to be right now." On 02/14/12, Surveyor interviewed LPN (Licensed Practical Nurse) E. LPN E told Surveyor she monitors the residents for abuse by asking about unexplained injuries, if observed. LPN E stated she will ask a resident about mental abuse if she notices a change in the resident's behavior. LPN E told Surveyor she has not audited or provided direct supervision of cares for CNA A. LPN E stated she does help the CNAs if they need help. ADDITIONAL INTERVIEWS: 1. On 02/13/13 at 12:30 Surveyor conducted an interview with CNA (certified nursing assistant) L who requested to stay anonymous related to fear of retaliation. CNA L was asked if she was aware of any residents having difficulties with any CNA's. CNA L responded there is a certain resident that has a problem with one of the CNA's. CNA L went on to say, "I have heard rumors about this resident and the CNA, something that happened in January." CNA L was asked by Surveyor if she thought the rumors were true. CNA L responded, "Yes I believe the rumors are true." Surveyor asked CNA L if she works with this certain CNA and certain resident. CNA L responded, "Yes I work with them." CNA L was asked if she felt comfortable elaborating on the issues. CNA L responded, "A couple of weeks ago Resident #5 had her call light on and when I answered it I overheard her tell her roommate, "I am scared every time I turn my call light on that CNA A will answer it." CNA L stated, "I told the resident I would try to answer her call light every time she turned it on." CNA L was asked by Surveyor if she had ever witnessed abuse with any of the residents or any of her coworkers. CNA L responded, "I have never witnessed abuse but I have witnessed CNA A's attitude with residents." CNA L was asked if she could elaborate on "CNA A's attitude." CNA L responded, "When CNA A gets overwhelmed she complains about being overworked and stomps around here. Other CNAs are afraid of her and lots of the girls don't like to work with her." Surveyor asked CNA L if she had reported to anyone the conversation she overheard Resident #5 tell her roommate. CNA L responded, "No they investigated it and administration doesn't address issues with CNA A anyways." 2. On 02/13/13 at 1:55 p.m. Surveyors and interviewed CNA A. Surveyor asked CNA A if she likes her job, to which CNA A responded, "I love my job." Surveyor went on to say, "We have some concerns and we are looking at your personal file." CNA A responded, "I know what you are talking about." Surveyor discussed treating residents with dignity and respect using examples of: not rolling our eyes, body language, tone of voice, going to work thinking I am going to make someone's life better. CNA A verbalized understanding. Surveyor shared with CNA A there were some reports of her not always being as patient with the residents as she should be. CNA A responded, "I am not patient sometimes. For example some residents have to go to the bathroom all at the same time and I have to decide which one do I get first. So many lights are on at once." CNA A was asked by the surveyor if she had abuse prevention training? CNA A responded, "Yes we get it once a year." CNA A went on to explain, "I took a week off not too long ago and then cut back on my hours from 10 days every 2 weeks to 9 days every 2 weeks because I am a little edgier since I hurt my shoulder. Sometimes it's overwhelming." Surveyor asked, "Is it all hands-on deck here?" CNA A responded, "No it's mostly just the CNA's that do the work." Surveyor asked CNA A if she recalled an incident in January she was involved in and if she would be willing to share what happened. CNA A responded, "That was with Resident #5. I went into her room because she had her call light on. I rushed in to get her into the bathroom because there were 4 or 5 call lights on. I said to the resident, whew it's busy everyone needs to get to the restroom. I explained to her to turn her call light on when she was done in the bathroom. The resident thought I was anxious. Sometimes I don't feel like singing - today I am quieter." Surveyor then asked CNA A if they could discuss the incident from February 2012 with Resident #7. CNA A stated, "I don't remember that incident." Surveyor stated, " The incident with her bath." CNA A stated, "Oh her bath. There was no bath aide that day and we all had to give our own baths." CNA A went on to say, " Resident #7 is a putzer, she wanted her own time and she is moody." CNA A was asked if she remembered if she gave Resident #7 a bath that day or a shower and if there was a statement regarding "no breakfast for you" made. CNA A responded, "I never told her she couldn't have breakfast and I did give her a bath." Surveyor asked if the resident had cried on that morning. CNA A responded, "No she never cried." CNA A was able to answer the abuse prevention questions appropriately when Surveyor asked them. 3. On 02/14/13 at 8:25 a.m. Surveyors and met with the NHA to discuss any further information that may be available related to the investigations with CNA A and Resident #7. The NHA stated, "I have nothing more to offer you. There is no more documentation." The NHA added, "We have had an ongoing attitude problem with this employee (CNA A). The NHA was asked who makes the final decision in what gets reported to the State Agency. The NHA responded, "I make the final decision and I felt it did not rise to the level of reporting." Surveyor also discussed the incident with Resident #3 and CNA B with the NHA at this meeting. The NHA responded, "I did not think it was intentional so I did not report that either because I did not feel it was a reportable event." 4. On 02/14/13 at 8:40 a.m. Surveyors and interviewed SW (Social Worker) K regarding the incident that occurred on 01/24/13 with Resident #5 and CNA A. SW K was asked if she was involved in the investigation of the incident? SW K responded, "I talked to Resident #5 after it was reported." SW K was asked by Surveyor if she interviewed any other residents during the investigation. SW K responded, "No I did not." SW K was then asked if she interviewed any other staff during her investigation. SW K responded, "No I did not." Surveyor asked SW K if she could go through how the incident was reported to her and by whom and how she proceeded with the investigation. SW K responded, "The incident was reported by RN S to me at the change of shift on 01/24/13. I then talked to the DON and the NHA about the incident before I talked to the resident about it." SW K went on to explain, "The DON spoke to CNA A and set up a meeting to be held on 01/25/13 at 11:30 a.m. to include CNA A, SW K and the DON. CNA A came in the next day and when we talked to her she said she didn't realize the resident felt bad." SW K also stated, "The DON and I talked to CNA A about body language, being a caregiver is a hard job and how things get hectic." SW K also talked about, "CNA A can get in to one of her moods, but for the most part she is in a good mood." Surveyor asked SW K, if all staff were in-serviced on abuse training after the incident. SW K responded, "No there was not an in-service done after the incident." SW K was asked if she does training with staff regarding abuse prevention. SW K responded, "I am not usually involved in that. SW J does the in-servicing." Surveyor asked SW K if someone monitors CNA A when she gets into one of her moods. SW K responded, "I do not know." 5. On 02/14/13 at 9:00 a.m. Surveyor interviewed LPN H regarding any issues she may be aware of regarding treatment of [REDACTED]. LPN H responded, "Yes I have worked with her on numerous occasions." LPN H and Surveyor discussed abuse prevention questions and if LPN H had ever witnessed any incidents involving CNA A. LPN H responded, "I have never witnessed CNA A being mean or abusive physically with a resident." LPN H went on to explain, "CNA A has a very strong voice, she comes from the era of...come on we need to get the job done, let's get to the bathroom, but nothing physical. I have never seen her be mean to a resident." LPN H did say, "CNA A seems to enjoy working with more of the alert a