Every finding on record at Wi Veterans Home at Chippewa Falls

Based on observations, interviews, and record review, the facility did not ensure a resident at risk of Pressure Injury (PI) development received the necessary treatment and services to prevent pressure injuries for 1 of 2 sampled residents (R) (R3).- R3 has a history of pressure injuries to their heels. Staff did not offload R3's heels with pressure-relieving devices per the plan of care. Findings include:According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage .The facility's policy titled Pressure Injury/Skin Integrity, read in part, It is the policy of this facility to enable nursing staff to manage wounds and select appropriate interventions according to the National Pressure Injury Advisory Panel (NPUAP).Interventions will be implemented to mitigate the risk for skin breakdown based on the individual risk factors, and may include, but are not limited to:The use of pressure redistribution devices such as mattresses or cushions; devices to eliminate or reduce friction and shearing; or the implementation of individualized turning or repositing schedules.Interventions should be documented in the resident's medical record, including in the resident's individualized resident-centered plan of care.R3 admitted to the facility on [DATE], with diagnoses including dementia, poor circulation to extremities, history of stroke, and type 2 diabetes with neuropathy.R3's most recent Brief Interview for Mental Status (BIMS) confirmed R3 scored 07/15, indicating severely impaired cognition.R3's care plan included:I am at risk for pressure and skin injury related to diagnoses of CKD, DM2, depression, and dementia. I require assistance with ADL needs and am incontinent of urine. I have a history of venous/arterial injury on my bilateral lower extremities. Initiated on 05/20/19, revised 05/29/26.Enhanced Barrier Precautions: I am on EBP r/t wounds on left heel and left lateral great toe. Initiated on 04/05/24, revised 06/30/26.ADL deficit: I have an ADL self-care deficit r/t dementia, head trauma, a-fib, diabetes, HTN, CKD III, constipation, and impaired mobility, initiated on 05/13/19, revised 07/15/26.Interventions as they relate to the deficient practice:-Bed mobility, head of bed elevated, float heels on wedge and place prevalon boots on member, initiated 05/13/19, revised 07/10/26.R3's physician orders included:-Heel protection wedge under both feet while in bed/chair. Place prevalon boots on as well. No pressure on heels, 06/01/26.-Left heel: cleanse with hypochlorous wound wash or equivalent, apply xeroform to left heel and wrap with kerlix. (OK to add foam or telfa if needed for additional padding/drainage). One time a day, every Tuesday, Friday, Sunday and as needed, 07/09/26.On 07/14/26, Surveyor reviewed R3's medical record and noted R3 recently had a deep tissue injury (DTI) to his left heel. Documentation indicated this may have been acquired after an emergency room visit and had healed on 06/18/26.R3's Braden Scale assessment and noted:-07/15/26, 13 moderate risk-05/21/26, 12 high risk-04/15/26, 12 high riskOn 07/14/26 at 2:01 PM, Surveyor observed R3 in their bed, lying on their back, with the head of the bed slightly elevated. R3 appeared to be sleeping. Surveyor observed R3's heels were resting on the bed and were not offloaded with wedge cushion or prevalon boots. Surveyor observed prevalon boots on counter next to the television.On 07/14/26 at 3:39 PM, Surveyor observed R3 in the same position with heels resting on the bed and not offloaded with wedge cushion or prevalon boots. R3 was awake at this time. Surveyor asked R3 if staff place boots on their feet. R3 did not answer and stated there are black holes in chest. Surveyor asked R3 if staff treat them well, and R3 reported staff treat them well. Surveyor observed prevalon boots on the counter next to the television, where the boots had been during the previous observation.On 07/15/26 at 7:22 AM, Surveyor observed R3 in their bed, lying on their back with the head of the bed slightly elevated. Surveyor observed a cushion under R3's knees, with heels resting on the bed and not wearing prevalon boots. Surveyor observed prevalon boots on the counter next to the television, where they had been the previous day.On 07/15/26 at 7:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. Surveyor asked CNA C if R3 had interventions to prevent pressure injuries. CNA C stated we reposition and change every two hours. They have a cushion in recliner and wheelchair. It is on the Kardex. Surveyor asked if R3 has prevalon boots. CNA C stated yes, but they have the option to wear them. Surveyor asked if it is documented if they refuse. CNA C stated yes, the nurses can see our charting. Surveyor reviewed R3's Kardex and noted: -Bed mobility: HOB elevated, sleeps in bed, float heels on wedge and place prevalon boots on member.On 07/14/26 at 7:46 AM, Surveyor interviewed Trained Medication Assistant (TMA) D. Surveyor asked TMA D what R3's interventions are to prevent PIs. TMA D stated, they have a float device under their feet when in recliner and in bed. Surveyor asked TMA D if R3 has boots they need to wear due to having a PI or preventing a PI. TMA D stated, they would have to look in the care plan. TMA D looked in R3's physician orders and stated, there is only an order for heel wedge. TMA D did not look in R3's care plan or Kardex.On 07/14/26 at 7:51 AM, Surveyor interviewed Assistant Director of Nursing (ADON) E. Surveyor asked ADON E if R3 had pressure reducing devices. ADON E stated R3 has posey boots, a foam pad under feet/calves, and repositioning every two hours. ADON E reported R3 wears boots when in bed and when in chair, if they allow. Surveyor asked ADON E if R3 refuses any devices. ADON E stated R3 does not typically refuse. ADON E stated if a resident refused, would CNAs would tell the nurses, and would the nurses document the refusal in the resident's record.On 07/15/2026 at 10:45 AM, Surveyor interviewed DON B. DON B stated, yes R3 should be floating heels off the bed and wearing boots. If R3 refuses staff should try again. DON B stated R3 doesn't really refuse and is pretty easy going. DON B reported that the nurse should document any refusals. DON B stated this may be an area of re-education for the staff. Surveyor was unable to find any documentation of R3 refusing to wear prevalon boots or float heels.

Based on interview and record review, the facility did not ensure that a resident who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 resident (R7) reviewed for dialysis.The facility failed to provide ongoing assessment of R7's condition and monitoring for complications before and after dialysis treatments. This is evidenced by:Facility's policy titled Dialysis with the revised date of 04/2026 documented, It is the policy of this community to provide coordination of care with the resident's dialysis provider.R7 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, and type 2 diabetes mellitus. R7's Minimum Data Set (MDS) assessment completed on 04/15/26 confirmed R7 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R7's care plan included: DIALYSIS: I need hemodialysis r/t renal failure on Tuesday, Thursday, Saturday at [Name] in [City] [Address] [Phone number] Uses [Name] for transportationto/from dialysis. Date Initiated: 09/25/2025 Revision on: 06/16/2026Interventions: Obtain vital signs and weight per protocol. Report significant changes in pulse,respirations and BP immediately. Date Initiated: 09/25/2025 If weight is noted to be 3-pound weight gain in 24 hours or 5 pounds in 7 days and accuracy is confirmed; MD notification needs to occur after appropriate assessments are completed. MD should be notified even if a reweigh was unable to be obtained. Reweigh member per nursing discretion. Date Initiated: 10/12/2025R7's physician orders included: 04/14/26 Vitals and dry weight Post Dialysis every evening shift every Tue, Thu, Sat.R7's Care Plan read in part, DIALYSIS: I need hemodialysis r/t renalfailure on Tuesday, Thursday, Saturday.Interventions: . Monitor/document/report to MD PRN for signs/symptoms (s/sx) of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Date Initiated: 09/25/2025. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Date Initiated: 09/25/2025 I am at risk for nutritional problem or potential nutritional problem r/t dietRestrictions Date Initiated: 10/12/2025 Revision on: 01/15/2026Interventions: If weight is noted to be 3-pound weight gain in 24 hours or 5 pounds in 7 days and accuracy is confirmed; MD notification needs to occur after appropriate assessments are completed. MD should be notified even if a reweigh was unable to be obtained. Reweigh member per nursing discretion. Date Initiated: 10/12/2025Review of vitals and weights documented in R7's medical record:06/07/26 and 06/08/26 no weights obtained.06/09/26 no weight obtained prior to dialysis. Post dialysis vitals entered at 8:35 PM were blood pressure (b/p) 149/54 and at 9:45 PM blood pressure (b/p) 156/64 and pulse of 94 were the same as documented on post dialysis communication sheet. 06/10/26 no weight obtained.06/11/26 no weight obtained prior to dialysis. Post dialysis vitals entered at 11:09 PM were b/p 170/70 and dry weight of 192.5 were the same as documented on post dialysis communication sheet. 06/12/26 no weight obtained. 06/13/26 no weight obtained prior to dialysis.06/14/26 and 06/15/26 no weights were obtained. 06/16/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals entered at 10:34 AM were b/p 187/72, pulse 94, and dry weight of 193.6 were the same as documented on post dialysis communication sheet. 06/17/26 no weights were obtained.06/18/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals entered at 11:25 PM were b/p 170/61 and weight of 197.5 were the same as documented on post dialysis communication sheet.06/19/26 no weight obtained.06/20/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals of b/p 149/55 and pulse of 101 were the same as documented on post dialysis communication sheet.06/21/26, 06/22/26, 06/23/26, 06/24/26 weights were not obtained.06/25/26 weight and vitals were not obtained prior to dialysis. 06/26/26 no weight obtained.06/27/26 weight and vitals were not obtained prior to dialysis.06/28/26 and 06/29/26 no weight obtained.06/30/26 weight and vitals were not obtained prior to dialysis. Dialysis communication documented R7 had hypotension at the end of treatment requiring intravenous fluids. 07/01/26 no weight obtained.07/02/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals of b/p 131/54, pulse of 109, and weight 194.7 were the same as documented on post dialysis communication sheet. 07/03/26 no weight obtained.07/04/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals of b/p 129/54 and pulse of 96 were the same as documented on post dialysis communication sheet. 07/05/26 and 07/06/26 no weights obtained.07/07/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals of b/p 184/67, pulse of 96, and dry weight 194.7 were the same as documented on post dialysis communication sheet. 07/08/26 no weight obtained.07/09/26 weight and vitals were not obtained prior to dialysis. Post dialysis vitals of b/p 138/46 and pulse no pulse taken and no pulse listed on dialysis sheet were the same as documented on post dialysis communication sheet. 07/10/26 documented no vitals taken. R7 received dialysis on this day. 07/11/26, 07/12/26, 07/13/26 weights and vitals were not obtained.07/14/26 weight and vitals were not obtained prior to dialysis.Review of dialysis communication sheets did not document vitals taken at the facility prior to arriving at dialysis.On 07/14/26 at 3:06 PM, Surveyor interviewed Registered Nurse (RN) G about the procedure for pre and post dialysis. RN G stated communication is sent to dialysis of the medications that were given that morning, vitals, meal intake, and blood sugar level. When the resident returns their vitals are taken, check for bruit or thrill, and check the dressing for any bleeding and only take the dressing off as ordered. The communication sheet from dialysis is entered in the progress notes and the sheet is sent to be scanned into the computer. Surveyor asked to verify when R7's last vitals were taken. RN G stated the last vitals were from 7/9/26 and were not taken today prior to dialysis. RN G showed that vitals are scheduled to be taken this evening and R7 had just returned from dialysis. Surveyor asked if the vitals on the dialysis communication sheet are to be the vitals entered in the computer as the facility's vitals. RN G stated no, we are to take vitals when the resident returns to the facility.On 07/15/26 at 8:35 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H about what communication and assessments are to be completed before and after dialysis. LPN H stated a sandwich, cookies and drinks are packed, and noon medications are given to the resident for dialysis. Paperwork is sent with the resident of vitals before leaving for dialysis and if any medical changes. Usually, vitals are done before and did not do them yesterday. LPN H was told when the resident returns, we can enter in the computer the vitals from dialysis. On 07/15/26 at 10:43 AM, Surveyor interviewed Director of Nursing (DON) B about communication sent to dialysis. DON B stated there is a packet of information of the face sheet and MD orders. Communication sheet returns from dialysis with any changes and with weights and vitals. Surveyor asked if vitals are taken before and after dialysis. DON B stated not necessarily we would do vitals before. We follow what dialysis has directed the facility to do. DON B believes R7's orders are to enter dialysis dry weight as this will fluctuate. Believe the orders are to get blood pressure after dialysis. Surveyor asked if staff could enter in blood pressure from the dialysis communication. DON B stated the staff should be obtaining blood pressure. On 07/15/26 at 12:48 PM, Surveyor interviewed DON B about the vitals taken pre and post dialysis. DON B stated they saw that the vitals were not obtained after dialysis and were taken from the dialysis sheet. They have changed the Treatment Administration Record (TAR) to state a new set of vitals upon return. Surveyor asked about pre dialysis assessments being completed. DON B stated they had reviewed the critical element pathway and identified that pre and post dialysis assessments to be completed and we are updating the communication sheets and education has already been started. Surveyor asked if there is a policy that speaks to assessments of a dialysis resident. DON B stated the dialysis policy was just updated but did not include assessments and this will be updated as well. DON B had asked corporate if there was another policy stating this and corporate told DON B there is no other policy.

Based on observation, interview and record review the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 72 residents sampled. (R271) The facility did not follow provider recommendations to taper gabapentin (anticonvulsant medication) and to monitor speech for R271. Findings include: R271 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, chronic obstructive pulmonary disorder, Parkinsonism, neuralgia and neuritis, and dysarthria following cerebral infarction. R271's most recent annual Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13 indicating cognition is intact. R271's care plan, dated 12/28/21, with a target date of 03/09/25, states: [R271] has .neuropathy and uses an anticonvulsant with interventions to monitor/document for side effects .slow reflexes, slurred speech, confusion and disorientation . R271's physician orders include: 07/03/24 gabapentin oral capsule 100 mg twice a day for neuropathy; 200 mg once a day at bedtime for neuropathy; and 100 mg every 24 hours as needed for anxiety. R271's psychiatric provider visit summary, dated 12/27/24, noted: [R271's] son-in-law mentioned that since being on gabapentin, [R271's] speech is slurred and didn't used to be prior to being on gabapentin. I would recommend considering a slow taper to monitor speech to see if gabapentin is affecting speech. R271's outpatient clinic communication tool note, dated 12/27/24, noted: Orders: Possible slow decrease of gabapentin if possible and monitor speech. Documentation on note has verification signatures by 3 facility staff acknowledging orders and updating primary care provider (PCP) on 12/30/24. R271's nurse progress notes: 12/30/24 Fax placed in provider's facility bin regarding outpatient provider's concern of R271 experiencing slurred speech and would recommend slowly titrating gabapentin dose. (Previously received an order on 12/19/24 for a neurology appointment.). Would you like to address this or have this information included in his neurology appointment? 01/02/25 Provider responded .address this at neurology appointment. R271's physician notes: 02/12/25 [R271] states he has not seen a new psychiatrist and did not get appointment for second opinion with neurology. It is true that I do not see any notes or appointments in the chart .follows with psychiatry, per records was supposed to meet with a new provider on 02/06/25 but [R271] states this appointment did not occur .defer future medication management to his office given complexity and challenges of the patient. Of note: Neurology follow-up occurred on 02/28/25. Documentation of visit did not include evaluation of tapering gabapentin dosing. No further documentation was noted for evaluation by psychiatry or neurology. Surveyor reviewed R271's assessments and was unable to locate focused speech assessments completed after 12/27/24. On 06/10/25 at 12:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding gabapentin tapering and monitoring speech. DON B stated the gabapentin dosing was to be handled by the psychiatrist per the PCP, but the 2 appointments that were scheduled were canceled by the provider and R271 was never seen prior to discharge in April. Surveyor asked DON B if the PCP's request to have the psychiatrist handle the gabapentin tapering was communicated to the psychiatrist. DON B stated no, it would have been stated during the appointment. Surveyor asked DON B if this should have been communicated considering the concern for slurred speech. DON B stated, yes, this should have been better communicated. Surveyor asked DON B if speech assessments had been completed per the psychiatrist's recommendations. DON B stated that staff had not noticed any changes in speech. DON B acknowledged that in hindsight this should have been assessed and documented. On 06/11/25 at 11:20 AM, Surveyor interviewed Medical Director (MD) E regarding gabapentin tapering. MD E stated that she felt it was best that psychiatry handle this and the need for tapering should have been better communicated to the psychiatrist when the appointments fell through.

Based on observations, interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received equipment to maintain or prevent further reduction in ROM for 1 of 2 residents (R) R29 reviewed. This is evidenced by: R29 was readmitted to the facility on [DATE] with diagnoses including, in part, spinal stenosis, atrial fibrillation, osteo arthritis, peripheral venous insufficiency, polyneuropathy, hypertension, dysphagia, and localized edema. R29's Minimum Data Sheet (MDS) dated on 03/24/25 indicates that R29 is totally dependent with all cares. R29's Activities of Daily Living (ADL) care plan and Certified Nurse Assistant (CNA) Kardex states, in part: -Dressing/Grooming: Adaptive clothing for upper body. Right hand splint and apply palm protector with foam piece to right hand in the AM. Wash and dry palm of right hand and in between fingers two times a day. Lightly stretch right middle finger at middle joint five times with each washing. R29's Occupational Therapy (OT) discharge recommendation note dated 05/21/25 states, in part: -R29 is to have palm protector on days and off at nights. Observations: On 06/09/25 at 11:02 AM, Surveyor observed R29 sitting in Broda chair in R29's room. Surveyor did not see right hand splint on R29 as stated in care plan. Surveyor observed right hand brace lying on bedside table. On 06/09/25 at 2:44 PM, Surveyor observed R29 resting in bed in R29's room. Surveyor did not see right hand splint on R29 as stated in care plan. Surveyor observed right hand brace lying on bedside table. On 06/10/25 at 9:01 AM, Surveyor observed R29 sitting in Broda chair at dining room table finished with breakfast. Surveyor did not see right hand splint on R29 as stated in care plan. On 06/10/25 at 9:04 AM, Surveyor walked to R29's room and observed R29's right hand brace lying on bedside table. On 06/10/25 at 10:50 AM, Surveyor observed CNA J and CNA I enter R29's room. Surveyor observed cares being performed. Surveyor observed CNA J and CNA I exit R29's room. Surveyor did not observe R29's right hand brace on at this time. Surveyor observed right hand brace lying on bedside table. On 06/10/25 at 12:09 PM, Surveyor observed CNA J and CNA I enter R29's room to transfer R29 up for lunch. Surveyor did not observe R29's right hand brace on. Surveyor observed R29's right hand brace located on bedside table in R29's room. On 06/11/25 at 9:20 AM, Surveyor interviewed CNA I and asked CNA I if R29 receives ROM exercises daily now that R29 has been discharged from Occupational Therapy (OT) services. CNA I indicated that CNA I is unsure and would need to verify with OT. CNA I indicated that since R29 went to hospital in March, R29 has declined and not able to use both hands anymore. Surveyor asked CNA I if R29 is supposed to have the right-hand palm protector on daily. CNA I checked CNA Kardex and stated, Oops she is supposed to have palm protector on right hand in the AM and off at night. I will go place R29's hand splint on. On 06/11/25 at 9:56 AM, Surveyor interviewed Certified Occupational Therapist Assistant (COTA) K and asked if COTA K is working with R29. COTA K reported that R29 was discharged from OT end of April. COTA K reported that recommendations is for staff to apply right hand palm splint daily in the AM and take off at night. COTA K reported staff are to stretch fingers twice a day during cleaning of the palm and fingers with palm protector on. On 06/11/25 at 11:39 AM, Surveyor interviewed Director of Nursing (DON) B and requested information pertaining to R29's right hand splint. Surveyor reported to DON B that Surveyor observed R29 without right hand palm splint for last 3 days 06/09-06/11/25. DON B indicated that if OT notes and care plan state that R29 is to have right hand splint applied in the morning and taken off at night then that is what staff should be completing.

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (R19) reviewed. R19 did not have fall intervention in place of leaving wheelchair at side of bed to prevent falls. This is evidenced by: The facility policy titled Accident/Falls last revised on 12/24, states: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. Under section titled Procedure states in part: 10. The resident's individualized care plan is to be updated with any changes or new interventions post fall/incident/accident, communicated to appropriate staff, and implemented. R19's Quarterly MDS, dated [DATE], indicates R19 has a BIMS of 0, meaning R19 has severe cognitive impairment, has had 2 or more falls since previous MDS and is independent with bed mobility, including going from a lying to sitting position on side of bed. R19's diagnoses include neurocognitive disorder with Lewy bodies, cognitive communication deficit, and dementia of unspecified severity with mood disturbance. R19's care plan last revised on 01/03/25 with a target date of 07/06/25 states in part, I am at risk for falls r/t Gait/balance problems, unaware of safety needs, . I have a history of falls, with an intervention initiated on 01/21/25 that states, Leave wheelchair next to bed when member is in bed due to self-transferring. On 06/09/25 at 9:36 AM, Surveyor observed R19 lying in bed with wheelchair at foot of bed and not positioned at bedside. On 06/10/25 at 8:07 AM, Surveyor observed R19 lying in bed with wheelchair at foot of bed and not positioned at bedside. On 06/10/25 at 8:57 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding fall interventions in place for R19. CNA confirmed R19's intervention to have wheelchair next to bed. On 06/10/25 at 9:05 AM, Surveyor shared observation with CNA C of wheelchair placed at foot of bed and not at bedside. CNA C stated being aware that wheelchair was at foot of bed and then moved wheelchair to side of bed, stating, It needs to be at bedside at all times as [R19] will attempt to self-transfer. On 06/11/25 at 1:44 PM, Surveyor interviewed Director of Nursing (DON) B and shared observations of R19 not having care plan intervention of wheelchair beside bed for fall prevention. DON B stated the expectation would be for staff to follow and implement the plan of care interventions.

Based on observation, record review and interview, the facility did not ensure a medication error rate of 5% or less for 1 of 7 residents (R) observed for medication administration. The facility had 25 opportunities and 9 medication errors resulting in a 36% error rate. Registered Nurse (RN) G crushed 9 different medications in applesauce and spilled a portion of the medications. RN G administered remaining medications in cup to R17. This is evidenced by: On 06/10/25 at 7:32 AM, Surveyor observed RN G prepping R17's medications. RN G placed Tylenol 325mg 2 tabs, Allopurinol 100 mg 1 tab, Depakote sprinkles 125mg 2 capsules, Donepezil 10mg 1 tab, Ziprasidone 40mg 1 tab, Losartan 25 mg 1 tab, Rexutil 2mg 1 tab, Sertraline 25 mg 2 tabs, Sertraline 100mg 1 tab, and Furosemide 20 mg 1 tab, and 10mg 1/2 tab into a medicine cup. RN G opened Depakote capsules and sprinkled into medicine cup. Then RN G crushed medications and added applesauce to R17's medications. While RN G was mixing medications with applesauce, RN G spilled a big spoonful of applesauce and crushed medications onto medication cart. Surveyor observed RN G clean medications and applesauce off the cart with Kleenex, place this in the garbage and go to R17's room. On 06/10/25 at 7:52 AM, Surveyor observed RN G administer R17's medications from applesauce cup. On 06/10/25 at 7:56 AM, Surveyor interviewed RN G and asked what is the normal process that RN G would do if RN G dropped some of R17's medications on medication cart. RN G stated that RN G should have disposed of all R17's medications and re-prepped new medications as RN G does not know how much of each medication R17 received. RN G did not prep new medications. On 06/10/25 at 2:56 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation of RN G prepping medications and then dropping a spoonful of medications with applesauce. DON B reported that DON B's expectation is RN G should have re-prepped medications for R17 and disposed of the current medications that RN G administered to R17.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 2 of the 17 residents (R) reviewed, R29 and R42. -Certified Nurse Assistant (CNA) J did not perform hand hygiene when providing peri cares for R29 or clean BM off R29's Broda chair. -Assistant Director of Nursing (ADON) H did not provide a protective barrier during wound dressing change for R29. -CNA J did not perform hand hygiene after providing catheter care for R42. Findings include: The facility policy titled Handwashing, dated April 2025, states in part: Alcohol based hand sanitizer should be used: -Before moving from work on a soiled body site to a clean body site on the same patient. -After contact with contaminated surfaces -Immediately after glove removal . Example 1 On 06/10/25 at 10:50 AM, Surveyor observed Certified Nurse Assistant (CNA) J and CNA I enter R29's room. Surveyor observed cares being performed. Surveyor observed CNA J and CNA I sanitize hands and then apply gloves. Surveyor observed Bowel Movement (BM) on bottom of R29's brief seeping out the sides. Surveyor observed BM on R29's Broda chair cushion. Surveyor observed CNA J and CNA I take off R29's brief and begin to clean R29's peri area. CNA J rolled R29 to the right side, began cleaning gluteal folds and cleaned BM off R29's bottom. Surveyor observed CNA J roll R29 to R29's left side and CNA I pull the Hoyer sling out and throw on top of the wet BM in Broda chair. Surveyor observed CNA J and CNA I roll R29 back to R29's back. Surveyor observed CNA J grab zinc oxide cream and used contaminated BM gloves to apply zinc oxide cream to R29's peri folds near vagina. R29 stated, That is very painful. Surveyor observed R29's majora labia and peri area folds very red and tender to touch. CNA I indicated to R29 that the zinc oxide should help alleviate the pain. Surveyor did not observe CNA J doff gloves, sanitize, and apply new gloves before applying zinc oxide. Surveyor observed CNA J and CNA I lower R29's bed and place Broda wheelchair in the corner of R29's room, take garbage and leave R29's room. Surveyor did not observe CNA J and CNA I sanitize R29's Broda chair or sling that had BM on it. On 06/10/25 at 12:09 PM, Surveyor observed CNA J and CNA I enter R29's room to transfer R29 up for lunch. CNA J and CNA I placed contaminated sling under R29 and hooked R29 to Hoyer lift. Surveyor interrupted CNA J and CNA I and asked CNA J and CNA I if CNA J and CNA I were going to transfer R29 to the contaminated Broda chair. CNA I stated that CNA I did not realize Broda chair was dirty. CNA J did not say anything but grabbed a wipe and proceeded to wipe down Broda chair. CNA J and CNA I transferred R29 to [NAME] chair and wheeled R29 to dining room with contaminated sling underneath R29. On 06/10/25 at 12:13 PM, Surveyor interviewed CNA J and asked if CNA J should have changed gloves and sanitized hands after cleansing R29's bottom that had BM before applying zinc oxide cream to R29's peri folds in the front vaginal area. CNA J reported that CNA J should have not used same gloves after cleaning BM off of R29. CNA J reported that CNA J should have doffed gloves and sanitized hands before applying a new pair of gloves. Example 2 On 06/11/25 at 9:28 AM, Surveyor observed ADON H perform wound dressing change on R29. ADON H sanitized hands before entering and then donned PPE. ADON H lifted R29's leg and undressed R29's wound dressing. ADON H stated, I am just going to fold the ABD pad in half and lay [R29's] leg back down while I prep supplies. ADON H lowered R29's right leg back down with open contaminated wound on right lateral leg area unto contaminated old ABD dressing pad. ADON H then lifted R29's leg and cleansed open wound with saline. ADON H then lowered R29's right lateral leg back onto contaminated ABD pad. ADON H lifted R29's leg again so wound doctor could begin debriding R29's wound. Once wound doctor was done debriding, ADON H lowered R29's right lateral leg on contaminated ABD pad. ADON H grabbed xeroform and wound doctor lifted R29's right lateral leg. ADON H applied xeroform to R29's wound, covered with clean ABD pad and then wrapped with kerlix. Surveyor did not observe ADON H clean R29's open wound with saline before applying new wound dressing. On 06/11/25 at 2:44 PM, Surveyor interviewed ADON H and asked ADON H to walk through wound care process when taking old, contaminated dressings off and then applying new dressings to an open wound. Surveyor stated to ADON H during R29's wound care dressing, ADON H placed contaminated ABD pad and folded the contaminated ABD pad in half and laid R29's open wound back on contaminated dressing after washing with saline. ADON H then placed R29's open wound back down on contaminated old ABD pad and then dressed R29's contaminated wound with a new wound dressing. ADON H reported that ADON H usually puts clean barrier down, but R29 is usually in R29's wheelchair so the process is different. ADON H indicated that ADON H should have placed protective barrier down first and not used contaminated ABD pad to lay R29's open wound on. Example 3 On 06/10/25 at 11:25 AM, Surveyor observed CNA J sanitize hands and empty catheter bag into gradual. CNA J drained graduate in toilet. On 06/10/25 at 11:27 AM, while observing CNA J emptying R42's graduate, R42 requested CNA J to adjust towels under arms to position for comfort. CNA J doffed gloves. CNA J walked towards R42 and began adjusting R42's towels under R42's arms. Surveyor did not observe CNA J sanitize hands after doffing gloves before touching R42's upper half in repositioning. On 06/10/25 at 12:13 PM, Surveyor interviewed CNA J and asked if CNA J should have sanitized hands after doffing contaminated gloves after emptying the catheter, and before assisting R42 with repositioning and placing towels under R42's arms. CNA J reported that CNA J should have sanitized hands after doffing gloves before assisting R42 with position change and propping arm towels for comfort. On 06/11/25 at 3:01 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for hand hygiene practices during peri cares, catheter care, and correct process for wound care. Surveyor reported to DON B that Surveyor observed CNA J used same gloves after cleaning BM off R29's bottom and then moving to the front of R29 and applied zinc oxide to R29's vaginal area. DON B stated that CNA J should have doffed gloves, washed hands, and applied new gloves before applying zinc oxide. Surveyor reported to DON B that CNA J did not sanitize hands after doffing gloves after catheter care for R42. CNA J repositioned R42's upper body with towels without sanitizing in between. DON B stated that CNA J should have doffed gloves and sanitized hands before helping R42 with a clean part of body. Surveyor reported to DON B through observation Surveyor observed ADON H place R29's open wound on contaminated ABD pad consecutively without proper cleaning of R29's wound before applying new dressing. DON B stated that all wound dressing changes need to have a protective barrier under the wound so that wounds do not become infected.

Based on observation, record review and interview, the facility did not ensure proper hand hygiene was conducted to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections during wound care for 1 of 1 residents (R) R28. This is evidenced by: The facility policy, entitled Handwashing revised on 11/2022 states in part that alcohol-based hand sanitizer should be used after contact with blood, body fluids or contaminated surfaces .immediately after glove removal. R28 returned to facility on 02/19/2024 with a pressure ulcer on left heel following hospitalization and placed on Enhanced Barrier Precautions (EBP). R28's comprehensive care plan states: Follow facility policies/protocols for the prevention/treatment of skin breakdown. On 04/10/24 at 11:17 AM, Surveyor observed Registered Nurse (RN) E don personal protective equipment (PPE) prior to conducting wound care on R28's left heel. RN E conducted hand hygiene, donned a clean pair of gloves, removed contaminated wound dressing, removed contaminated gloves, and donned a clean pair of gloves. RN E cleansed wound area, removed gloves, and donned a pair of clean gloves. RN E measured wound area, applied moisturizer on R28's foot, removed gloves, donned clean gloves, placed dressing as ordered and wrapped heel with Kerlix. No hand hygiene was observed between glove changes during the above procedure. On 04/10/24 at 11:30 AM, Surveyor interviewed RN E regarding no observation of hand hygiene between glove changes during wound care. RN E stated receiving education to conduct hand hygiene between gloves changes. RN E confirmed hand hygiene was not conducted during wound care. On 04/10/24 at 1:50 PM, Surveyor shared observation of RN E not conducting hand hygiene between glove changes during wound care with Director of Nursing (DON) B. DON B stated the expectation would be to conduct hand hygiene after removing soiled gloves and putting on a new pair of gloves per policy.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 6 residents reviewed (R32 and R53) for pressure injuries (PI) received necessary treatment and services, consistent with professional standards of practice to prevent new ulcers from developing. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (WCEI) 2018, for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high-risk status. The facility's policy titled Pressure Ulcer/Skin Integrity last revised on 04/02/22 states in part, Based on the comprehensive assessment of a resident. Health Dimensions Group (HDG) Communities will ensure: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Example 1 R32 is under the care of hospice and has medical diagnoses that include but are not limited to, non-traumatic brain dysfunction and Alzheimer's disease. According to the most recent Minimum Data Set assessment (MDS), which was a significant change assessment with the assessment reference date of 02/23/24, R32 is dependent on staff for basic daily tasks which includes toilet use and transfers with a mechanical lift. R32 sits in a Broda chair and is non-ambulatory. R32 is frequently incontinent of bowel and bladder function. R32 has short-term and long-term memory impairment and has severely impaired daily decision-making abilities. Surveyor reviewed R32's recent Braden Risk Assessment, dated 02/18/24, in which R32 was scored 11. A score of 10-12 indicated a high risk for the development of a PI. On 04/10/24 at 6:35 AM, Surveyor observed R32 sitting up in a Broda chair in the TV room. On 04/10/24 at 7:21 AM, Surveyor observed R32 sleeping in Broda Chair being brought to beauty shop for a haircut. On 04/10/24 at 8:34 AM, Surveyor observed R32 being brought back to TV room after breakfast. On 04/10/24 at 9:36 AM, Surveyor continued to observe R32 in the TV room. R32 opened eyes but fell back to sleep immediately after 2 separate visits from visitors. On 04/10/24 at 10:29 AM, Surveyor observed Certified Nursing Assistant (CNA) D bring R32 to room and returned to TV room at 10:31 AM. On 04/10/24 at 11:54 AM, Surveyor observed R32 taken to dining table by CNA C. On 04/10/24 at 12:47 PM, Surveyor observed R32 sitting at dining table. On 04/10/24 at 12:55 PM, Surveyor observed R32 brought to room to lie down by CNA C and CNA D. Note: This was an observation of 6 hours 20 minutes sitting in a Broda chair without staff providing offloading. Surveyor reviewed the comprehensive care plan the facility devised for R32. Included were the following: The resident has a skin impairment, at risk care plan related to (r/t) cognitive impairment, immobility. Interventions for this plan include: I need monitoring/reminding/assistance) to turn/reposition at least every 2 hours, more often as needed or requested. The care plan does not direct staff on R32's repositioning while seated in the Broda chair. On 04/10/24 at 1:19 PM, Surveyor interviewed both CNA C and CNA D who confirmed no offloading was conducted on R32 since getting out of bed in am. On 04/10/24 at 1:50 PM, Surveyor interviewed Director of Nursing (DON) B regarding observations of R32 sitting up in Broda chair for 6 hours and 20 minutes without offloading. DON B stated staff are expected to follow the care plan. DON B was unable to state what standard of practice they follow. On 04/11/24 at 8:08 AM, Surveyor received information from Nursing Home Administrator (NHA) A that the facility utilizes the NPIAP as their standard of practice. 30570 Example 2 R53's Minimum Data Set (MDS) was reviewed by Surveyor with the following noted: Most recent Significant Change in Status MDS dated [DATE] notes R53 sometimes understands and sometimes is understood with severely impaired cognition. R53 has no behavioral concerns, no range of motion impairments and no significant weight loss. R53 is dependent on staff for toileting, bathing, dressing, hygiene, rolling left to right and transfers. R53 is incontinent of bowel of bladder, is at risk for pressure ulcers and is on hospice services. Surveyor reviewed R53's most recent Braden Scale Tool completed on 03/07/24. Summary of Assessment: Member is at moderate risk for skin breakdown. Member is incontinent of bowel of bladder. Member is totally dependent for all cares. Surveyor reviewed R53's care plan. The care plan noted: Pressure ulcer: At risk: I have the potential for pressure ulcer development r/t (related to) Disease process, Hx (history) of ulcers, Immobility. I will have intact skin, free of redness, blisters or discoloration by/through review date: 06/12/24. Approaches: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer treatments as ordered and monitor for effectiveness. Apply barrier cream to buttock with cares. Follow facility policies/protocols for the prevention/treatment of skin break down. I need to turn/reposition at least every 2 hours, more often as needed or requested. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Roho cushion in wheelchair, air mattress overlay in bed. On 4/10/24 at 6:07 AM, Surveyor observed R53 up in his wheelchair in the lounge on household C. R53 remained in the lounge until 7:22 AM when R53 was taken to the dining room from the lounge in his wheelchair. R53 remained in the dining room until 8:25 AM when he was taken from the dining room back to the lounge. R53 was taken to his room from the lounge by CNA G at 8:52 AM. CNA G was joined by DON B at 8:54 AM. R53 was transferred to his bed from his chair for position change at 8:56 AM. CNA G indicated R53 had been incontinent of bowel and bladder and performed peri-care. CNA G informed DON B R53's butt was red. Following peri-care CNA G applied barrier cream to R53's buttocks, provided R53 his call light, placed a pillow under his head and covered R53 with blankets. R53 was up in his wheelchair without repositioning for 2 hours and 49 minutes placing him at risk for the redevelopment of pressure injuries. On 04/10/24 at 6:11 AM, Surveyor interviewed CNA F about R53's routine for repositioning and incontinence care. CNA F explained R53's care is done on night shift, and he is gotten up by night shift before 6:00 AM. R53 is laid back down after breakfast, usually around 10:00 AM and changed. Depending on activities he may get back up or stay in bed for about an hour. Today he will lay down for an hour then get up for lunch. After lunch R53 will be laid down and changed and get back up for bingo with his wife at 2:00 pm. On 4/10/24 at 9:07 AM, Surveyor interviewed DON B about the observation and staff expectations regarding R53's repositioning and risk for pressure injury. DON B expressed she would expect staff to follow R53's care plan and provide him repositioning every 2 hours. The plan of care is in place to prevent skin breakdown. DON B further expressed she believes R53 has a history of pressure injuries but would need to verify in R53's record his history of pressure injury. On 4/10/24 at 10:19 AM, DON B informed Surveyor of R53's history of pressure injury was prior to his admission to the facility in July 2023. R53 remains at risk for the redevelopment of pressure injuries.

Based on observation, interviews and record reviews, the facility did not ensure 2 of 5 residents (R) reviewed for bowel and bladder incontinence (R32 and R53) received appropriate treatment and services to prevent Urinary Tract Infections (UTI). This is evidenced by: Acello, [NAME] RN MSN. The Long-Term Care Nursing Desk Reference. Chapter 13, pages ,d+[DATE] offer the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Incontinence in long-term care facilities can often be linked to the facility's staff. Over time, staff become insensitive to incontinence . the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom . Effective urinary management is assessment-based and individualized to the resident . It involves toileting the resident at times in which he or she is most likely to eliminate . The facility policy titled Bowel and Bladder Management revised on ,d+[DATE] states in part, A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections. Example 1 R32 is under the care of hospice and has medical diagnoses that include but are not limited to, non-traumatic brain dysfunction and Alzheimer's disease. According to the most recent Minimum Data Set assessment (MDS), which was a significant change assessment with the assessment reference date of [DATE], R32 is dependent on staff for basic daily tasks which includes toilet use and transfers with a mechanical lift. R32 sits in a Broda chair and is non-ambulatory. R32 is frequently incontinent of bowel and bladder function. R32 has short-term and long-term memory impairment and has severely impaired daily decision-making abilities. On [DATE], the facility completed Full Function Screen Tool on R32 which indicates: Section K: Toileting Self Performance - member requires total assistance. Section L: Incontinence type - functional (deceased mental awareness, decreased or loss of mobility or personal unwillingness). Surveyor reviewed the comprehensive care plan the facility devised for R32. Included were the following: Bowel/Bladder incontinence r/t activity intolerance, Alzheimer's, confusion, impaired mobility, physical limitations, prostate enlargement. Interventions for this plan include: check me every ,d+[DATE] hours and as required for incontinence. Wash, rinse, and dry perineum. Monitor/document for signs and symptoms of UTI. On [DATE] at 6:35 AM, Surveyor observed R32 sitting up in a Broda chair in the TV room. On [DATE] at 7:21 AM, Surveyor observed R32 sleeping in Broda Chair being brought to beauty shop for a haircut. On [DATE] at 8:34 AM, Surveyor observed R32 being brought back to TV room after breakfast. On [DATE] at 9:36 AM, Surveyor continued to observe R32 in the TV Room. R32 opened eyes but fell back to sleep immediately after 2 separate visits from visitors. On [DATE] at 10:29 AM, Surveyor observed Certified Nursing Assistant (CNA) D bring R32 to room and returned to TV room at 10:31 AM. On [DATE] at 11:54 AM, Surveyor observed R32 taken to dining table by CNA C. On [DATE] at 12:47 PM, Surveyor observed R32 sitting at dining table. On [DATE] at 12:55 PM, Surveyor observed R32 brought to room to lay down by CNA C and CNA D. Note: This was an observation of 6 hours 20 minutes in which R32 was not provided incontinence care. On [DATE] at 1:19 PM, Surveyor interviewed both CNA C and CNA D who confirmed no incontinence care was conducted on R32 since getting out of bed in am. On [DATE] at 1:50 PM, Surveyor interviewed Director of Nursing (DON) B regarding observations of R32 sitting up in Broda chair for 6 hours and 20 minutes without receiving incontinence care. DON B stated staff are expected to follow the policy and care plan. 30570 Example 2 R53's diagnoses include non-traumatic brain dysfunction, non-Alzheimer's dementia and benign prostatic hyperplasia (enlarged prostrate). With this condition, the urinary stream may be weak or stop and start and lead to infection. Surveyor reviewed R53's record and noted the following: R53 Minimum Data Set (MDS) was reviewed by Surveyor with the following noted: Most recent Significant Change in Status MDS dated [DATE] notes R53 sometimes understands and sometimes is understood with severely impaired cognition. R53 has no behavioral concerns, no range of motion impairments and no significant weight loss. R53 is dependent on staff for toileting, bathing, dressing, hygiene, rolling left to right and transfers. R53 is incontinent of bowel of bladder, is at risk for pressure ulcers and is on hospice services. Surveyor reviewed Bowel and Bladder Functional Screen Tool most recently completed on [DATE] for R53. The tool in part read: The member is continent of urine: No The member is continent of bowel: No Elimination History: Member is incontinent of bowel and bladder at night. Member is changed q2 hours. Adequate fluid intake: Yes Current Elimination Symptoms Choose all that apply: Functionally disabled. Cognitive Status The member displays: Long-term memory loss The member is able to identify the need to void/defecate: No The member is able to use the nurse call light: No The member is able to ask to go to the bathroom: No The member is UNABLE to sit on the toilet: Yes The member is ABLE to sit on the toilet: No Perineum Visually inspect perineum. Describe any abnormalities noted or write 'none' if none observed. none Diagnoses Please choose all that apply: Cancer CVA Dementia/Alzheimer's Depression Prostate problems Medications Please check all that apply: Antihistamines Narcotics Psychoactive/Hypnotics Mobility Status Choose all that apply: Requires mechanical lift. Chairfast Pain Status Member has or is being treated for pain: Yes. Pain affects resident's ability to void/defecate: No Comment on any items involving pain or meds being used. acetaminophen TID (three times a day), morphine PRN (as needed) Toileting Self Performance How resident uses toilet, bedpan, and transfers on/off bed pan, toilet, cleanses, changes pads, adjusts clothes): Member requires total assistance. Incontinence Type Functional (decreased mental awareness, decreased or loss of mobility or personal unwillingness) Answer the following regarding environmental barriers that may impede toileting: 1. Bathroom: No 2. Bedroom: No 3. Bed: No 4. Wheelchair/chair: No 5. Lighting: No Retraining Member is a candidate for retraining? No Summary Summary of Assessment: Member is incontinent of bowel and bladder r/t loss of functional abilities. Member is on q2 hr and prn check and repositioning. Member has regular bowel schedule. Care plan: BOWEL/BLADDER INCONTINENCE: I have functional bladder incontinence r/t (related to) activity Intolerance, confusion, dementia, Impaired mobility, physical limitations, prostate enlargement. I will remain free from skin breakdown due to incontinence and brief use through the review date. [DATE]. Approaches: ACTIVITIES: notify nursing if incontinent during activities. Encourage fluids during the day to promote prompted voiding responses. Monitor and document intake and output as per facility policy. Monitor fluid intake to determine if natural diuretics such as coffee, tea, or cola is contributing to increased urination and incontinence. Monitor/document for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Monitor/document/report to MD PRN (as needed) possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Refer to ADL (activities of daily living) POC (plan of care) ADL's: Member has limited physical mobility r/t major neurocognitive disorder, chronic leukemia, and osteoarthrosis. Member will maintain current level of mobility through review date. BATHING: TD (total dependence), Shower Wed/Sun AM, use shower chair BED MOBILITY: A2 (assist of 2), float heels, sleeps with 2 pillows. BEHAVIORS: B: Irritability, I: ensure comfort, ask about pain, positive interaction, B: Hallucinations, I: reassure, ensure safety DRESSING: TD-A2, glasses (often times does not wear) EATING: TD, Regular diet, mech soft texture, nectar thick liquids. Prefers Chocolate milk and Juice. MOBILITY: TD broda chair POA prefers member to attend activities and HS (hour of sleep) around 8:30pm, use sheet only in bed/has night sweats. TOILETING: TD Incontinent, L brief (blue) check and change q 2 hrs, check between meals, barrier cream TRANSFER: TD Hoyer. Sling sz L, #500252, leave sling under member in broda, ensure sling is properly tucked. On [DATE] at 6:07 AM, Surveyor observed R53 up in his wheelchair in the lounge on household C. R53 remained in the lounge until 7:22 AM when R53 was taken to the dining room from the lounge in his wheelchair. R53 remained in the dining room until 8:25 AM when he was taken from the dining room back to the lounge. R53 was taken to his room from the lounge by CNA G at 8:52 AM. CNA G was joined by DON B at 8:54 AM. R53 was transferred to bed from his chair for position change and incontinence care at 8:56 am. CNA G obtained a clean brief and DON B obtained wet wipes after performing hand hygiene and donning gloves. CNA G lowered R53's pants and brief and indicated R53 had been incontinent of bowel and bladder. CNA G performed peri-care and informed DON B R53's butt was red. Following peri-care CNA G applied barrier cream to R53's buttocks, provided R53 his call light, placed a pillow under his head and covered R53 with blankets. R53 was observed by Surveyor up in wheelchair without incontinence care for 2 hours and 49 minutes. On [DATE] at 6:11 AM, Surveyor interviewed CNA F about R53's routine for repositioning and incontinence care. CNA F explained R53's care is done on night shift, and he is gotten up by night shift before 6:00 am. R53 is laid back down after breakfast, usually around 10:00 AM and changed. Depending on activities he may get back up or stay in bed for about an hour. Today he will lay down for an hour then get up for lunch. After lunch he will be laid down and changed and get back up for bingo with his wife at 2:00 pm. On [DATE] at 9:07 AM, Surveyor interviewed DON B about the observation and staff expectations regarding R53's incontinence care and potential risk for urinary tract infections (UTI). DON B expressed she would expect staff to follow R53's care plan and provide him incontinence care every 2 hours. The plan of care is in place to prevent skin breakdown, promote his comfort and to prevent UTIs.

Based on observations, interviews and record reviews, the facility did not ensure residents received timely pressure injury assessments, physician consult, and pressure relief interventions consistent with professional standards of practice to prevent and promote healing of pressure injuries for 1 of 3 residents (R4) reviewed for pressure injuries. Findings include: R4 was admitted to the facility on [DATE], and has diagnoses that include chronic kidney disease, hypertension, muscle weakness and osteoarthritis. R4's Minimum Data Set (MDS) admission 14-day assessment, dated 01/30/24, indicated that R4 has a brief interview for mental status of 09, which indicates that R4's cognition is moderately impaired. Section M of the MDS indicates R4 is at risk for pressure ulcers/injuries and has two unhealed stage 2 pressure injuries. Braden Scale dated on 01/24/24 number 7 indicated member is at risk for skin breakdown due to being wheelchair bound. R4's care plan, dated 01/25/24, under skin interventions tasks reads in part, Educate of causative factors and measurements to prevent skin injury - encourage good skin nutrition - follow facility protocols for treatment of injury - keep skin clean and dry, use lotion on dry skin, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surfaces - on 01/31/24 Juven added to help with wound healing. R4's care plan indicates wounds open area to right and left buttocks with a date initiated of 01/25/24. The care plan did not provide pressure relief interventions. There was no wound documentation for 01/25/24. On 02/14/24 at 7:30 am, Surveyor reviewed R4's medical record for doctor orders for wound care orders. Surveyor did not see any orders in R4's medical record for wound care. Surveyor requested a copy of R4's doctor orders from the Nursing Home Administrator (NHA) A at that time. Surveyor reviewed R4's weekly wound documentation. On 01/24/24 on admission, in the skin integrity documentation it was noted R4 had excoriation on sacrum that measures .5 cm. On 01/25/24, no wound assessments for right and left buttocks were completed. 01/31/24 weekly wound round documentation, wound #1 with a date of onset of 01/30/24 indicated right buttocks 25% epithelial length 2.5 width 2.5, stage II. In section 7a. describe current treatment plan it is noted: Awaiting wound orders from NP (Nurse Practitioner), cream applied. 01/31/24 weekly wound round documentation, wound #2 with a date of onset of 01/30/24 indicated left buttocks length 1.5 width 1.5, stage II. In section 7a. describe current treatment plan it is noted: Awaiting wound orders from NP, cream applied. The facility did not initiate pressure relief interventions to promote healing. The facility did not follow-up with a consult with a physician when R4's pressure injuries opened and NP did not provide treatment orders. 02/07/24 weekly wound round documentation, wound #1 right buttocks 25% epithelial, length 1.3, width .3, stage II, current treatment plan mepilex or equivalent. 02/07/24 weekly wound round documentation, wound #2 left buttocks 25% epithelial, length .3, width .2, stage II, current treatment plan mepilex or equivalent. On 02/14/24 at 9:11 AM, Surveyor went back into R4's electronic medical chart to review doctors' orders. The top entry was orders for wound care that read, Cleanse wound with saline and pat dry. Apply 4 x 4 bordered foam dressing to bilateral buttock wounds in the afternoon every Monday, Wednesday, and Friday, Order date was 02/14/24 at 8:08 AM. This order was obtained after Surveyor requested the physician orders for pressure injury treatment. On 02/14/24 at 11:29 AM, Surveyor received a copy of R4's doctors' orders from NHA A. Surveyor asked NHA A if the orders were added today. NHA A indicated that they got clarification from the NP today. On 02/14/24 at 12:52 PM, Surveyor interviewed Assistant Director of Nursing (ADON) D, who is also the wound care nurse and asked how often they do wound rounds. ADON D indicated every Wednesday they look at wounds and measure them. Surveyor asked ADON D what treatment they were doing for R4. ADON D indicated they were following standing orders until an order was received from the doctor. Surveyor asked if the orders were just received today. ADON D indicated yes. ADON D indicated that on rounds today the wounds are closed, and an air mattress was added to R4's bed today.

Based on interview and record review, the facility did not utilize staff with the appropriate competencies and skill sets to provide safe, two person staff assistance during transfer of residents with the use of a mechanical lift for six residents who utilize a mechanical lift. This is evidenced by: The facility policy, entitled Lift-Total Body/Maxi Lift, dated [DATE], states: .Refer to instructions for the facility equipment to be used. Staff must be trained in lift use and safety precautions .Transfer according to manufacture directions/guideline. The facility provided the operator's instructions for the EZ Way Smart Lift, dated [DATE], states: .The EZ Way Smart Lift was designed to be operated safely by one person. However, with some patients it is best to use two people. On [DATE], Surveyor reviewed the facility's staffing sheets that showed on [DATE], Human Resource Director (HR) S and Quality Director (QD) T, both ancillary staff, were scheduled to be float staff for households C and D. On [DATE] at 8:40 a.m., Surveyor interviewed the scheduling and certified nursing assistant (CNA) Manager U. Manager U stated if shorthanded with staff on the households, leadership will come in to do ancillary tasks such as two person transfer of residents. The ancillary staff were trained on two person transfers of residents during COVID, but the training had since expired last summer. Manager U said recently the ancillary staff had been used with Manager U to perform two person Hoyer lift resident transfers. The ancillary staff only watched and did not have any physical help with this. No injuries resulted from this situation. Manager U was aware of need for two people to physically help during a Hoyer transfer to prevent injuries. On [DATE] at 10:40 a.m., Surveyor interviewed the nursing home administrator (NHA) A concerning what the role of the ancillary staff was when utilized on the households. NHA A stated ancillary staff do not help with cares and do not help with transfers. They may be in the area during the cares or transfers. Survyor asked NHA A if they considered the ancillary staff as the second person for transfers of a two person assist transfer with a mechanical lift. NHA A did not know the answer to this question. Surveyor asked about training for HR S who was on the schedule on [DATE]. NHA A provided nursing assistant clinical skills checklist and competency eval for HR S dated on [DATE] for the skill of transfer with the Hoyer lift. NHA A asked if HR S was a CNA or medical trained otherwise and she said no. The competency checklist/eval was during COVID when ancillary staff could do this. On [DATE] at 3:40 p.m., Surveyor interviewed HR S who said during COVID, she was trained how to use the Hoyer lift. HR S said in the last couple of months this year she was utilized as a second person for a two person Hoyer transfer of residents. HR S said she only watched the transfer and did not physically touch anything. HR S said she was never needed to assist the trained staff during this time and no bad outcomes from the transfers. HR S said she last worked on households C and D on [DATE]. On [DATE] at 3:50 p.m., Surveyor interviewed QD T about being used as ancillary staff on the households. QD T said around the beginning of this year she was utilized as a second person for a two person Hoyer transfer of residents. QD T said she only watched and did not physically touch anything. No bad outcomes from the transfers. QD T said she last worked with HR S the middle of the month in March. On [DATE] at 4:00 p.m., Surveyor asked NHA A for a list of all residents who were needing a two person transfer assist with mechanical lifts. The NHA A provided the list with 12 residents. 6 of the residents resided on the C/D household. 5 of the 6 residents on the C/D household had on their minimum data set (MDS) assessment for transfer status total dependance with 2+ person physical assist and their care plan stated under transfer: A2 Hoyer lift. The other resident MDS assessment for transfer status was extensive assist with 2+ person physical assist and their care plan stated under transfer: A2 sit to stand. Below is the list of residents mentioned as the 6 residents on C/D household: R6 MDS dated [DATE]. Transfer status = total dependance with 2+ person physical assist. Care Plan = A2 (assist of 2) hoyer. R21 MDS dated [DATE]. Transfer status = total dependance with 2+ person physical assist. Care Plan = A2 overhead hoyer. R22 MDS dated [DATE]. Transfer status = total dependance with 2+ person physical assist. Care Plan = A2 total assist hoyer. R23 MDS dated [DATE]. Transfer status = total dependance with 2+ person physical assist. Care Plan = A2 hoyer. R24 MDS dated [DATE]. Transfer status = total dependance with 2+ person physical assist. Care Plan = A2 hoyer. R25 MDS dated [DATE]. Transfer status = extensive assist with 2+ person physical assist. Care Plan = A2 with sit to stand.

Based on record review and interview, the facility did not ensure that residents with pressure injuries receive the necessary treatment and services to promote healing, prevent infection, and prevent reoccurrence of pressure injuries for 3 of 3 residents reviewed (R2, R6, and R9). *R2 had no weekly wound documentation in the medical record. *R6 had no weekly wound documentation in the medical record. *R9 had no weekly wound documentation in the medical record. This is evidenced by: The facility's policy titled Pressure Ulcer/Skin Integrity with revision date of 04/2022, includes in part: Policy: Based on the comprehensive assessment of a resident, Health Dimensions Group Communities will ensure: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Procedure: Skin Inspection-Routine skin inspections will be completed and documented in the resident's EMR (electronic medical record). Wound identification: It is important that each pressure ulcer, or non-pressure wound be identified. Identification of factors that may have influenced development of the wound, the potential for development of additional wounds, or for the deterioration of the pressure ulcer(s) should be recognized, and may include: i. Differentiate the type of wound (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of wound. ii. Determine the wounds stage (pressure wounds only). iii. Describe and monitor the wounds characteristics. iv. Monitor the progress toward healing and for potential complications. v. Determine if infection is present. vi. Assess, treat, and monitor pain, if present, and vii. Monitor dressing and treatments. According to the www.NPUAP.com <http://www.NPUAP.com> the National Pressure Ulcer Advisory Panel (NPUAP) defines pressure ulcers (PU's) in the following categories: Category/Stage I: Non-blanchable erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage II: Partial thickness - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Suspected Deep Tissue Injury - depth unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Example 1 On 04/03/23, Surveyor reviewed R2's medical record. R2 was admitted to the facility on [DATE]. R2's diagnoses include but are not limited to pressure ulcer of sacral region-stage 4, COPD, chronic respiratory failure with hypoxia, Alzheimer's disease with late onset, type 2 diabetes mellitus with foot ulcer, pressure ulcer of left buttock-stage 4, type 2 diabetes mellitus with diabetic neuropathy, polyneuropathy and peripheral angiopathy without gangrene, type 2 diabetes mellitus with outer circulatory complications, hypertensive heat disease with heart failure, paroxysmal atrial fibrillation, nonrheumatic tricuspid valve insufficiency, presence of coronary angioplasty implant and graft. R2 receives Hospice Services. R2's Minimum Data Set (MDS) assessment dated [DATE] documents R2 requires extensive assist with bed mobility, dressing, eating, toilet use, and personal hygiene, total dependence with transfers, and locomotion on and off unit. R2's BIMS (Brief Interview for Mental Status) score is 0 out of 15, which indicates severe cognitive impairment. R2's orders include but are not limited to cleansing wound with Vashe. Dakin's 0.5% moistened gauze to left ischium. Change daily. R2's documentation states R2 is well known to the wound clinic. On 01/18/23, R2 attended the wound clinic for his stage 4 wounds. The left ischium was full-thickness and 9.5cm x 6cm x 8.4cm. Wound had strong odor with serosanguinous drainage. Wound was cleansed; irrigation with hydrofera blue and foam border adhesive; microfiber applied. Left buttocks wound full thickness with slough, 4.3cm x 3cm x 0.1cm small amount of serosanguinous drainage. Wound cleansed and dressed with hydrofiber, silver impregnated, foam border adhesive. Right buttocks: full thickness with slough, size: 8.3cm x 2.2cm x 0.1cm small serous drainage, wound cleansed and dressed with hydrofiber, silver impregnated; foam border adhesive. Left ischium, left and right buttock were debrided. R2's documentation R2 returned to the wound clinic on 02/01/23. The left ischium wound size was 10.4cm x 6cm x 11cm. Wound was cleansed; irrigation with hydrofera blue and foam border adhesive; microfiber applied. Left buttocks size was 3.5cm x 0.5cm x 0.1cm. Wound cleansed and dressed with hydrofiber, silver impregnated; foam border adhesive. Right buttocks wound size: 2.9cm x 1.8cm x 0.1cm. Wound cleansed and dressed with hydrofiber, silver impregnated; foam border adhesive. Left ischium, left and right buttock were debrided. R2's documentation stated follow-up with wound clinic on 03/01/23. Wound clinic note on 03/01/23 documented wounds have not made improvement or progression to healing. Documentation states R2 is not a surgical candidate and has a very poor prognosis without being able to definitively treat and long-term antibiotics are not recommended by Mayo Clinic Infectious Disease for this type of infection. He is around the clock Morphine. Wound clinic documented the left ischium wound was full thickness eschar partial coverage, slough. Size was 10cm x 7.8cm x 11cm. Copious drainage, purulent serosanguinous. Wound was cleansed; irrigation with hydrofera blue and foam border adhesive; microfiber applied. Left buttocks size was 3.5cm x 0.5cm x 0.1cm. Wound cleansed: irrigation, foam border adhesive; Dakin's full-strength. Coccyx full thickness, slough, size: 1.6cm x 0.5cm x 0.1cm. Wound had scant amount of serosanguinous drainage. Dressing: barrier cream, foam border adhesive. Right buttocks wound size: 1.8cm x 1.1cm x 0.1cm. Scant amount of serosanguinous drainage. Wound cleansed and dressed with hydrofiber, silver impregnated, foam border adhesive. Left ischium was debrided. R2's next wound clinic appointment which was to be in 4 weeks was not in R2's medical record and facility unable to provide Surveyor with documentation. Surveyor reviewed facility documentation on R2's wounds. Weekly skin assessments were completed but none of the weekly skin assessments included any mention of pressure injuries, size, or treatment. R2's medical record did not have weekly wound documentation completed by the facility. Example 2 On 04/03/23, Surveyor reviewed R6's medical record. R6 has diagnoses which include pressure injury both buttocks, multiple sclerosis, hypertension, renal failure, neurogenic bladder, dementia, atherosclerosis, cognitive communication deficit, hypothyroidism, and osteoporosis. R2's MDS assessment dated [DATE] documents R2 requires extensive assist with bed mobility, personal hygiene, and dressing; total dependence with transfers, toilet use; independent with locomotion in wheelchair and eating. R2's BIMS score is 9 out of 15, which indicates moderate cognitive impairment. R2's documentation states weekly skin assessment completed, but weekly skin assessments do not have any wound measurements, size, or treatment on them. R2's progress wound documentation was not completed weekly. R2 has MASD (Moisture-Associated Skin Damage) to both buttocks and there are small open areas. Nurse's progress notes state MASD both buttocks with reoccurrence 03/23/23. No weekly wound documentation completed. Example 3 On 04/03/23, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE]. R9's diagnoses include but are not limited to anemia, CAD, heart failure, renal insufficiency, neurogenic bladder, obstructive uropathy, type 2 diabetes mellitus, COPD, other cognitive functions and awareness, obesity, paroxysmal atrial fibrillation, and GERD. R9's MDS assessment dated [DATE] documents R9 requires limited assist with bed mobility, transfers, extensive assist with dressing and toileting. R9 is independent with locomotion in wheelchair. R9's BIMS score is 15 out of 15, which indicates intact cognitive response. R9's medical record documents onset of MASD to coccyx on 03/19/23. Weekly skin assessments completed but no indication of skin issues. No weekly wound documentation found in R9's records. On 04/03/23 at 12:25 p.m., Surveyor asked RN (Registered Nurse) E if the assessments, such as wounds, are completed weekly. RN E stated they probably are not. On 04/04/23 at 9:30 a.m., Surveyor interviewed RN O and asked about assessments and if they are completed as ordered, especially wound assessments. RN O stated assessments are not done all the time because the nurses are too busy helping the CNAs. On 04/04/23 at 1:50 p.m., Surveyor interviewed Nursing Home Administrator (NHA) and asked about the wound assessments and that the medical records reviewed do not show weekly wound documentation, other than if the residents attend the wound clinic. NHA A unaware weekly wound assessments were not completed.

Based on observation, interview and record review, the facility did not provide proper treatment for a skin condition for 1 of 18 sampled residents (R5). R5 had an open area which was not assessed, physician wasn't notified, and treatment was not ordered. This was evidenced by: R5 was admitted to the facility on [DATE]. R5 has diagnoses of aortic valve stenosis, osteoporosis, major depressive disorder, anxiety disorder, and long-term use of anticoagulants. MDS quarterly of 07/20/22 Section C gives R5 a BIMS score of 13 meaning they were cognitively intact. R5 requires the use of a gait belt with transfers, and reminders to toilet with incontinence cares scheduled every 2 to 3 hours. R5 was admitted to hospice services on 09/09/22. R5 is up for meals and in room and is alert. On 02/27/23 at approximately 10:25 AM, Surveyor observed R5 up in recliner in room. Surveyor noted a 1 cm open area to the right side of R5's nose. This was not covered. On 02/28/23 at approximately 12:45 PM, Surveyor observed R5 up in recliner in room, continues with open area to right side of nose that is uncovered continues to be approximately 1 cm in size with reddened edges. On 03/01/23 at approximately 8:30 AM, Surveyor observed R5 in the beauty shop. The open area to right side of nose remains with increased redness surrounding it. There is no dressing to the area. On 02/27/23 at approximately 10:25 AM, Surveyor interviewed R5. Surveyor asked R5 how they got the sore on the side of their nose. R5 stated they did not know what happened or why it was there. On 02/28/23 at 12:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C who was the nurse on the unit. Surveyor asked how R5 got the sore on the side of her nose. LPN C stated it might be on Alert Charting or a risk assessment, but when LPN C looked, they could not find. Surveyor asked how you get on the Alert Charting so that it could be monitored. LPN C stated they did not know. LPN C said R5 picks at the bridge of her nose. R5 has an itch pill she can take but she doesn't take it usually. Surveyor informed LPN C that the area of about 1 cm that Surveyor had noted was on the right side of the nose, not on the bridge. LPN C stated she had not seen this, so LPN C and Surveyor walked together to R5's room. There Surveyor pointed out the lesion. LPN C said they had not seen that. Surveyor asked why they did not know about it; wouldn't the CNAs notify the nurse. LPN C stated they had been working as the CNA that morning and they did not notice it. LPN C then did offer a pill for itching but R5 refused. On 02/28/23 at 1:37 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked what the expectations were if a resident would have an open area. DON B stated they would put in weekly skin notes, dressing changes, let MD and DON know of any changes. Surveyor asked what would you do if you first notice an open area. DON B stated you would do a Risk Management, and this should trigger the nurse to then put them on Alert Charting. Surveyor asked if any nurse can do this. DON B stated yes. Surveyor asked if they would expect all nurses to know this. DON B stated yes. Surveyor asked what are your expectations if a CNA would notice a new skin opening. DON B stated they should notify the nurse. Surveyor asked since this nurse was working as a CNA, should she have notified the nurse if she would have noticed it. DON B replied, Yes, the MD and hospice should also be notified. On 03/01/23 at 10:16 AM, Surveyor again spoke with DON B. Surveyor asked what alert charting means. DON B stated that it means we chart on it and look at it. Surveyor asked if this is every shift. DON B stated no, it can be once a day depending on what it is. Surveyor asked if this would show up in the progress notes. DON stated yes it would. Surveyor informed DON B that there had been no further charting on R5's nose since yesterday, and that a skin assessment had been done but it did not include description or measurements. DON B said they thought they sent out a fax for an antibiotic ointment last night. Surveyor asked if this would be in the progress notes. DON B stated yes, it would be. Surveyor stated it was not there. On 02/28/23, Surveyor reviewed R5's comprehensive medical record. Surveyor noted that there was no entry in the progress notes regarding the open area to R5's nose. Surveyor then reviewed the Physician Orders for R5. Noted was an order for Hydroxyzine 25mg every six hours as needed for pruritus (itching). There were no other treatment orders present. Surveyor reviewed R5's care plan. There it stated that R5 had risk for pressure injury but there was no mention of R5's habit of picking skin and what should be done about these should they occur. The Kardex that the CNA staff use to give care to R5 did not mentions R5's propensity to pick skin until it is open nor what actions to take should they notice it. On 03/01/23, Surveyor reviewed R5's progress notes. It was noted that after the Surveyor's conversation with DON B, DON B entered a note at 1:46PM on at 02/28/23 that the POA was notified, and that the MD was faxed for orders. Also, of note on 03/01/23 is a note done on 03/01/23 as a late entry for 02/28/23 by LPN C, that R5 had an open area on the right side of their nose that was measured at 1.1 cm in length and 1.3 cm in width. That there was no drainage, and that a physician was faxed to apply Bacitracin daily. Surveyor notes in the Physician orders an order dated 03/01/23 for Bacitracin to nose daily x 7 days. On 02/28/23, Surveyor reviewed the Hospice RN note for the visit that day there is no mention of any open area on the skin or any issues. On 03/01/23, Surveyor reviewed the facility policy that was titled Pressure Ulcer/Skin Integrity. Under Procedure number 4 Wound Identification: It is important that each pressure ulcer, or non-pressure wound be identified. Identification of factors that may have influenced development of the wound, the potential for development of additional wounds or for the deterioration of the pressure ulcer should be recognized and may include: Differentiate the type of wound (pressure vs non pressure) because intervention may vary, describe and monitor the wounds characteristics, monitor progress towards healing and for potential complications, determine if infection is present, assess and treat, monitor for pain if present and monitor dressings and treatments.

Based on record review and interview, the facility failed to issue a CMS (NOMNC), informing residents of changes to their Medicare coverage, for 2 of 2 residents whose Medicare Part A services ended when benefit days were not exhausted. Resident (R) 71 and R26's Medicare Part A services ended prior to them being exhausted, and were not issued a CMS (NOMNC). The facility stated they went to a training and were told this practice had ended, so they stopped issuing the CMS , some time ago. This has the ability to affect all residents who experience changes to their Medicare coverage. This is evidenced by: On 02/07/19 at 8:12 AM, Surveyor reviewed information provided by the facility. R71's Medicare Part A services started on 01/04/19. R71's last covered day was 01/28/19. A CMS was not provided to R71. R26's Medicare Part A services started on 11/12/18. R26's last covered day was 12/05/18. A CMS was not provided to R26. Interview on 02/07/19 at 10:47 AM with the Nursing Home Administrator (NHA) revealed the following information. The NHA stated they had gone to a training some time ago and were told that they don't have to do a CMS anymore, so they stopped issuing them. The NHA stated the Social Worker (SW) issues letters like that if needed. Interview on 02/07/19 at 11:46 AM with SW A. SW A stated she and a few other facility staff went to a training, in which they were told that effective (MONTH) 7, (YEAR), did not need to issue a NOMNC (CMS ) any longer. So they stopped doing it at that time.

Based upon observation, interview, record review and policy review, the facility did not provide assistance with ambulation and restorative programs for residents with limited mobility as scheduled and did not evaluate resident progress in the programs to ensure the residents maintained their mobility for 6 of 9 sampled residents (R2, R4, R10, R12, R3 and R13). R2, R4, R10 and R12 have ambulation and restorative programs that were not completed. The residents' progress in the programs was not evaluated on a regular basis. The facility did not ensure that a resident with a limited range of motion or mobility received restorative services to maintain range of motion and mobility for R3 and R13. This is evidenced by: The facility policy titled, Restorative Program, origination date April 1, 2008, includes in part: Policy: While in this facility, all residents are supported to maintain or attain their hightest level of functioning.Restorative programs are individualized to meet resident needs with short and long term achievable goals documented . 1. R2 has a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], documents R2 needs extensive assistance with transfers, and one assist for ambulation. Walking in the corridors did not occur any days in the seven day look back period. The care plan, .is on a nursing restorative program r/t (related to) [MEDICAL CONDITION] Passive ROM (range of motion) bilateral Passive shoulder flexion, external rotation x 10 reps .Walk to dine one meal per day . Surveyor observed R2 during three days of survey. R2 was not observed ambulating to meals, and was transferred with a sit to stand lift. The restorative documentation was reviewed and includes: Walk to dine 12/28 - 01/11/16, not applicable was charted all days, except 3 days that had 0 minutes of walking provided. The restorative notes by the Certified Nursing Assistants (CNA) document in November the program was not completed, 11/06 - 11/15, and then not done 11/17 - 11/30/16. The December CNA charting documents the program was not completed any days in December. On 01/11/17 at 1:00 p.m., Surveyor interviewed Registered Nurse (RN) C to ask what not applicable means. RN C stated not applicable would only apply if the resident was in therapy. Surveyor asked if R2 was in therapy. RN C replied, No. 2. R4 has a [DIAGNOSES REDACTED]. The ambulation section is documented as did not occur in the seven day look back period. The care plan, .on a Nursing Restorative program: ambulation .Walking, walk to and from meals with staff assist of 2 . Surveyor observed R4 for three meal observations. R4 was not walked to or from meals. Surveyor observed a transfer with R4 who used a sit to stand lift for the transfer. Surveyor reviewed the ambulation documentation from 12/28/16 to 01/09/17, which is assigned to be done three times each day. The ambulation was refused eight times, completed one time, and charted as not applicable 30 times out of a possible 39 times. Surveyor interviewed RN C to ask about all of the not applicable charting. RN C stated the resident is not on therapy services and should not have been documented by the CNAs. The care should have been provided or refused. 3. R10 has [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documents R10 ambulates with extensive assistance of two persons. The care plan, .nursing restorative program r/t deconditioning and weakness .assist member to ambulate 100-200 ft daily using FWW (front wheeled walker) with assist of 1 . Surveyor reviewed the ambulation documentation that includes in part: October - The ambulation was not documented for 7 days November - A total of 7 days the ambulation was not completed. December - The ambulation program was not completed a total of 7 days. 4. R12 has a [DIAGNOSES REDACTED]. The most recent quarterly MDS documents R12 needs extensive assistance of one for transfers, assist of one for ambulation and has limited mobility. The care plan, .is on a restorative program AROM r/t weakness and deconditioning Walk to dine x 1 meal per day with w/c (wheelchair) to follow . Surveyor reviewed the walk to dine documentation that includes in part: October: Seven days of the month not applicable is charted, meaning R12 was not ambulated. November: Nine days of the month not applicable is charted, meaning R12 was not ambulated. December: Five days of the month has not applicable charted, and one day of zero minutes, meaning R12 was not ambulated on six days of the month. Surveyor interviewed RN C, who is in charge of the restorative program. RN C stated the CNAs are not to chart not applicable unless the resident is in therapy, and that R12 was not in therapy. On 01/10/17 at 10:00 a.m., Surveyor interviewed CNA E and CNA I about how the restorative programs are carried out. CNA E stated the restorative aide has not been scheduled consistently making it difficult to get all the exercises done. CNA I added that the float has not always been scheduled lately. This has made it hard to carry out all of the walking and exercise programs. The CNAs stated they do what they can with the time they have. On 01/11/17 at 9:10 a.m., Surveyor interviewed RN H, who helps manage the household the above residents reside on. Surveyor shared the concern that the restorative and walk to dine programs have not been completed and asked if there have been changes in the restorative assignments. RN H stated that the restorative aide is not scheduled consistently, and the float is scheduled some days but not all days. RN H agreed it is difficult for two CNAs to complete all of the restorative assignments. 5. R3's [DIAGNOSES REDACTED]. On 01/10/16 at 8:25 a.m., Surveyor observed CNA J assist R3 to the breakfast table. CNA J did not ask R3 to ambulate or attempt to ambulate to the meal. After breakfast, CNA J assisted R3 back to his room. CNA J did not ask R3 to attempt to ambulate back to the room. On 01/11/17, Surveyor observed R3 as R3 was wheeled in a wheelchair into the dining room for breakfast. Staff did not attempt to assist R3 with ambulation to the dining area, or ask R3 if he wished to ambulate to the meal. Surveyor reviewed R3's clinical record. The current Care Area Assessment (CAA), dated 03/02/16, identified that the resident required a restorative program to slow or minimize a decline in function. Surveyor reviewed R3's care plan. The care plan stated, in part, Resident is walk to dine every meal with 4WW (4 wheeled walker) The care plan also stated, in part, Resident is to continue with current ADL (activities of daily living) ability through next review period. Active ROM (Range of Motion) NuStep (a type of stationary bike) level 6-8 x 15 minutes. There was no frequency listed; however, RN C told Surveyor the resident was to receive these services Tuesdays, Thursdays and Saturdays. Surveyor reviewed a document entitled Restorative program notes. The notes document that in January 2017, R3 had received the restorative services one time. There is one notation R3 was out with wife on 01/01/17. There were no other restorative notes for the current month. There was no evidence the facility attempted the restorative treatment when R3 returned from the outing. Surveyor reviewed restorative notes for December 2016. On December 1, 2016, a notation read: Out of the facility. There was no evidence that the facility attempted the restorative treatment when R3 returned from the outing. The notes stated R3 was out from 12/06/16 to 12/16/16. This was confirmed by the nurses' notes. The next restorative note, dated 12/18/16, read: Great. The notes are blank until 12/22/16 which stated Refused. The notes were again blank until 12/29/16, which stated Refused-busy. There was no evidence the facility attempted the restorative treatment when R3 was not busy. After 12/29/16, the restorative notes are blank for the remainder of the month. The notes showed R3 had received the restorative services one time for the month of December. Surveyor reviewed the restorative notes for November 2016. The notes were blank until 11/03/16. 11/03/16, Refused said was going out. 11/04/16, blank 11/05/16, Out with wife. 11/06-07/16, blank 11/08/16, Out appt. 11/17-19/16, blank 11/20/16, Good. 11/21-23/16, blank 11/24/16, Out with family. The next note dated 11/29/16 read: Out of facility. There was no evidence the facility attempted to provide restorative services when R3 returned from any of the outings during the month. There were no additional notes for the month. The notes identified that R3 had received the restorative services one time for the month of November. 6. R13's [DIAGNOSES REDACTED]. On 01/11/16 at 9:05 a.m., Surveyor interviewed R13. R13 stated he only receives the services occasionally. R13 stated, Oh they come in and move my leg sometimes, but I would not say often. When asked if he receives the services three times a week, R13 stated, No. Surveyor reviewed R13's CAAs. The CAA stated R13 requires restorative services to maintain functional status and prevent decline. Surveyor reviewed R13's care plan. The care plan stated R13 should receive passive and active range of motion services three times a week to lower extremities. Surveyor reviewed a document entitled Nursing Rehab: Maintenance: Active ROM (Range of motion) bilateral lower extremities. The documents outlined the minutes and dates when R13 received restorative services. The restorative services received were as followed: October 2016: 10/03/16: 10 minutes 10/05/16: 0 minutes 10/10/16: 0 minutes 10/12/16: 0 minutes 10/14/16: 7 minutes 10/21/16: 10 minutes 10/31/16: 15 minutes The document indicated R13 received restorative services four times for the month of October 2016. November 2016: 11/02/16: 0 minutes 11/09/16: 0 minutes. 11/14/16: 10 minutes 11/16/16: 10 minutes 11/18/16: 0 minutes 11/21/16: 0 minutes 11/28/16: 10 minutes 11/30/16: 10 minutes The document indicated R13 received restorative services four times for the month of November 2016. December 2016: 12/2/16: Resident refused. 12/5/16: 7 12/7/16: 0 12/9/16: 0 12/12/16: 10 12/14/16: Not applicable. 12/19/16: Not available. 12/21/16: 15 12/26/16: Not applicable. 12/28/16: 0 The document indicated R13 received restorative services three times for the month of December 2016. Surveyor interviewed RN C, who is responsible for the facility's restorative program. Surveyor asked RN C to explain the facility's system for performing and documenting the residents' progress and/or needed changes in the restorative program, and what the facility's system was for ensuring that the programs were followed. RN C stated the CNAs are supposed to perform the restorative exercises. RNC stated, I do review them during care conferences. RN C was asked if restorative summaries were performed for the residents receiving restorative therapy to ensure that the restorative goals are being met, the progress of the resident and any changes in the residents' ability to perform the exercises. RN C stated, I haven't been doing restorative summaries, no.

Based on observation, medical record review and interview, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 of 9 residents (R5) observed. R5's care plan states he is to be checked and changed every two hours. R5 was observed not to be checked and changed for approximately 3 1/2 hours. This is evidenced by: R5's medical record states that he has had [MEDICAL CONDITION]([MEDICAL CONDITION] - stroke) which has left his left side paralyzed. R5 is dependent on staff for his personal care needs and is incontinent of bladder and bowel. R5's care plan instructs staff to check and change him, and wash, rinse and dry his perineum if incontinent every two hours. On 01/10/17 at approximately 6:36 a.m., Surveyor told the Nursing Home Administrator (NHA) that the surveyor would need to watch R5's personal cares. At 6:40 a.m., the NHA told Surveyor that R5 was already up in his chair. Surveyor then observed R5 in his wheelchair in his room, and he came out to the dining area for breakfast shortly after 8:00 a.m. R5 returned to his room after breakfast. At 10:00 a.m. on 01/10/17, Surveyor observed R5 in his wheelchair, where he had been observed to be sitting since breakfast. Surveyor spoke with Registered Nurse (RN) A, and asked when cares would be provided for R5. RN A stated, Whenever he calls, usually after lunch. Certified Nursing Assistant (CNA) B then verified that R5 was the first one up this morning and CNA B stated she was planning on caring for R5 around noon. Surveyor verified R5 had not been checked or changed since before breakfast, around 6:30 a.m. CNA B stated perhaps she could check him now. CNA B went into R5's room and asked, Do you want to lay down for a little bit? and R5 nodded yes. R5 was then transferred from his wheelchair to his bed, using the overhead Hoyer lift, by CNA B and RN A, who then provided cares for R5. R5 had been incontinent of both bladder and bowel. R5's scrotum was red, and he had several wrinkles on his buttocks from sitting. The above concern was discussed with the Assistant Director of Nursing on 01/10/17 at 10:30 a.m. and the Interim Director of Nursing on 01/10/17 at 10:45 a.m.

Based on medical record review, resident and staff interview, and observation, the facility did not ensure that care and services were provided to attain the highest practicable well-being for 2 of 15 residents (R11 and R4) reviewed for pain control. R11 complained of right heel pain since 10/16/16. The facility did not document a thorough assessment of the heel, did not mention the heel pain on the care plan and did not put new interventions into place to reduce pressure on the heel. R4 was exhibiting increased aggressive behaviors at the same time he was experiencing mouth pain. R4 did not have a comprehensive pain assessment to determine if pain was the cause of the behaviors. This is evidenced by: 1. R11's medical record states that he has [DIAGNOSES REDACTED]. R11's nurses' notes document that he was given [MEDICATION NAME] for pain in his right heel on the following dates and times. 10/16/16 at 7:11 a.m. 11/14/16 at 6:51 a.m. 11/27/16 at 3:49 a.m. 12/02/16 at 4:10 a.m. 12/04/16 at 4:46 a.m. 12/11/16 at 4:18 a.m. 12/31/16 at 6:51 a.m. 01/03/17 at 2:36 a.m. A pain assessment performed on 12/05/17 does not mention the pain in R11's heel, despite his recent complaints of heel pain on 12/02 and 12/04/16. None of the nurses' notes state that R11's physician has been informed of his heel pain. On 11/07/17 at 10:39 p.m., R11's nurse's note states that he received 1000 mg by mouth every 6 hours as needed for pain or fever but did not indicate where the pain was on his body. This also occurred on the following dates and times: 11/10/16 at 11:04 p.m. 11/21/16 at 9:41 p.m. 12/06/16 at 7:45 a.m. 12/11/16 at 9:20 a.m. 12/16/16 at 3:59 a.m. 12/17/16 at 1:36 a.m. R11's nurses' notes also state he receives as-needed [MEDICATION NAME] for general aches, shoulder pain, back pain, and head aches. On 11/27/16, a nurse's note states, Member c/o (complained of) pain to right foot heel and requested APAP ([MEDICATION NAME]). After more than an hour the APAP was ineffective. Writer convinced member to elevate foot off the bed. Member was sleeping within a half hour. Surveyor reviewed R11's care plan and noted that his care plan did not mention R11's right heel pain, and the intervention of elevating his foot was not mentioned. There is no documentation in R11's medical record since 10/16/16 which describes what R11's heel looks like. Weekly skin checks provided to Surveyor do not mention R11's heel. Except for descriptions of other open areas such as scratches, etc., the skin checks state that R11's skin is intact. Surveyor discussed the pain in R11's heel with the Interim Director of Nursing (IDON) and the Assistant Director of Nursing (ADON), Registered Nurse (RN) D, on 01/11/17 at 9:30 a.m. At 2:05 p.m., the IDON told Surveyor the Certified Nursing Assistants (CNAs) are to report to the nurse any concerns residents have, and R11 meets with RN A on a weekly basis and has not mentioned the pain in his heel to her. Surveyor interviewed R11 on 01/11/17 at 10:50 a.m. R11 stated his heel hurts on occasion. R11 stated he is awakened by the heel pain a couple times a week, usually between 3:00 and 4:00 a.m. R11 stated Tylenol is usually effective, and he is then rolled over and can go back to sleep. R11 stated he was concerned about his heel, and hopes that his physician will look at it sometime. R11 had a vinyl-covered wedge and a knee bolster on his bed. Surveyor asked R11 if he wears a boot on his heel at night. R11 stated he did not, that no one had offered him a boot, and despite the devices on his bed, he still has heel pain. R11's most recent Minimum Data Set (MDS), dated [DATE], states that he needs the extensive assist of one caregiver for bed mobility. Surveyor discussed R11's heel with RN C on 01/11/17 at 1:40 p.m. RN C is the facility's MDS nurse, and Infection Preventionist. RN C stated that he was not aware R11 has had heel pain. RN C and Surveyor went to R11's room, and RN C assessed R11's right foot and questioned him about his pain. R11 indicated the pain is at the bottom of the right foot near the heel, and it wakes him up between 3:00 and 4:00 a.m. RN C asked, Is it when you have to go to the bathroom? and R11 stated, No. There were no open areas on R11's heel. 2. R4 has [DIAGNOSES REDACTED]. The quarterly MDS with Assessment Reference Date (ARD) of 10/18/16 documents R4 is unable to complete the interview for his mental status. The staff answers indicate the resident is severely impaired cognitively. The MDS documents R4 is not experiencing any pain. The care plan, Potential for pain r/t history of chronic pain and [MEDICAL CONDITION] .will not have interruption in normal activities due to pain through the review date. If having low back pain offer warm towel to area. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible .Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Offer pain medication before restorative activities. The nurses' notes in part: 12/05/16 Member was sitting in front of another member door, CNA attempted to move member. Member backed himself up to the wall and would not move did strike out at nurse and member did make contact with nurses arm . 12/12/16 .member reviewed for period 11/13/16 - 12/10/16 for behaviors. Exhibited physical aggression 2 x, inappropriately grabbing staff 1 x. Interventions included offering snacks, bathroom, pain assessment, and bringing him to a quiet space There was no comprehensive pain assessment located for this time period. 12/12/16 Member has been in a pleasant mood, up and smiling/laughing with staff . 12/20/16 .awake since 2200 (10:00 p.m.), .has been verbally and physically aggressive towards staff with re-directions. Member hit and kicked writer with attempts to re-direct .member also would wheel self by the other 2 members that were awake and would run his wheelchair into them and shake his fist at them also. 12/21/16 This afternoon member was noted to become agitated. Member unable to explain why .noted to become agitated with other members and start swinging/hitting at them .offered snack. watched 1:1 with staff. Member refused supper. 12/22/16 At 1700 (5:00 p.m.), member wheeled up to a table put arms up as if he was going to hit another member .he wheeled his w/c backwards into the staff and tried to hit CNA .appeared to be calm suddenly wheeled backwards into her pinning her between his w/c and her med cart and rocking back into her over and over .member appeared flushed in the face .call placed to MD, EMS called, T- 101.2, taken in for evaluation. 12/23/16 00:30 (12:30 a.m.), .member returned to the facility . There are no new orders documented. 12/23/16 3:41 a.m., Member became agitated and aggressive .trying to hit, kick, and head-butt family members .member was given a [MEDICATION NAME] .after eating the ice cream member laid back down and has fallen asleep. 12/23/16 10:13 a.m., Fax to MD, To inform you an increase in concerning behaviors .staff has expressed concerns regarding their own safety and other member's safety. Do you have any new recommendations or orders? 12/23/16 23:18 (11:18 p.m.), .refused supper .became disruptive and aggressive when members began returning to their rooms .stuck his feet out as if to trip the ambulating member .offered food, snacks, toileting, television and soft music playing . A pain assessment was not completed. [MEDICATION NAME] was given at 0005 (12:05 a.m.) on 12/23/16 and was effective. 12/25/16 13:22 (1:22 a.m.), member awake entire shift . 12/25/16 At 15:30 (3:30 p.m.), .member hitting staff and refusing help . 12/25/16 23:04 (11:04 p.m.), member continued to seem agitated rest of shift .attempting to kick members/staff .offered toilet, .snack offered. Member had no complaints of pain or discomfort. A comprehensive pain assessment for the cognitively impaired was not completed .12/26/16 Received fax order from Dr .[MEDICATION NAME] 0.25 mg bid daily for dementia with aggressive behavior . 12/26/16 22:54 (11:54 p.m.), .member refused dose of Risperadone 3 different nurses tried 12/27/16 Member allowed staff to remove his dentures and member keeps pointing to mouth and says it hurts. Writer looked in members mouth with a flashlight and was unable to see any sore spots. 12/27/16 20:55 member became .agitated when staff member attempted to move him .refused any supper. 12/28/16 Fax out to MD .we recently received order for [MEDICATION NAME] 10%. This medication is not covered by insurance. We do have house stock supply for [MEDICATION NAME] 20% oral gel. R4 received the medication for mouth pain 12/28/16 at 1900 (7:00 p.m.). 12/29/16 2:03 a.m., Member .agitated and aggressive, prn med for increased irritation was attempted but member refused to take it, different staff tried to have member take it but was unsuccessful with all attempts . A pain assessment was not completed, the [MEDICATION NAME] oral gel was not given 12/29-12/31/16. 12/29/16 12:32 p.m., member did not indicate to nurse that he was having pain to his mouth. A pain assessment for the cognitively impaired was not completed to assess for R4's pain. 12/30/16 Member has been using prn [MEDICATION NAME] more often. With his dementia the recent increase of behaviors could be due to pain. We currently have [MEDICATION NAME] 50 mg every 4 hours prn. Do you wish to schedule this medications? 01/03/16 5:47 a.m., Member has been awake for most of the night . 01/03/16 Received fax back from Dr .to schedule [MEDICATION NAME] every 4 hours for pain when member is awake . The nurses' notes document no behaviors since the scheduled [MEDICATION NAME] was started on 01/03/17. A pain assessment has not been completed to determine the effectiveness of the pain medication since the scheduled [MEDICATION NAME] was initiated on 01/03/17. On 01/11/17 at 9:00 a.m., Surveyor interviewed RN H about the behaviors and indications of pain R4 was experiencing. RN H acknowledged a comprehensive pain assessment had not been completed since 10/15/16. RN H stated R4 was having problems with his dentures not fitting well, which may have been causing the pain. On 01/11/17 at 2:00 p.m., Surveyor interviewed Director of Social Services (DSS) G about dementia care and ruling out pain prior to starting an antipsychotic medication. DSS G stated that she had noted his behaviors improved with the use of the [MEDICATION NAME] and had contacted nursing to schedule a pain medication. DSS G acknowledges the pain should have been assessed and ruled out prior to starting the antipsychotic. DSS G stated that R4 has had no behaviors recently and is back to the way he used to be.

Based upon record review and interview, the facility was not respectful of Resident (R)4's right to to make choices about aspects of his or her life in the facility that are significant to the resident in regards to food choices. R4's care plan restricts the choice to eat dessert at meals and to receive sweet prizes at bingo or get bags of candy at the bingo store. This is evidenced by: R4 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/18/16 documents R4 is unable to complete the interview for his mental status. The staff answers indicate R4 is severely impaired cognitively. The care plan .has potential nutritional problem r/t (related to) dementia .weight fluctuations, varied appetite . approaches in part: No dessert unless he is eating 50% of his meals - per wife's request and MD order (12/26/16) The care plan .needs assistance with structuring his day and 1:1 visits r/t dementia . approaches in part: No candy, sweet prizes from Bingo, bags of candy from the Bingo Store or other treats offered to member, per wife request and MD order (12/26/16). Surveyor reviewed the medical record and noted R4's blood sugars are checked weekly and have been 118 to 130 for the past three months, which are normal for R4's age. R4 is not on any medications for his diabetes. The nurses' notes were reviewed and document R4 was having increased aggressive behaviors towards staff and other members that included hitting staff, taking his wheelchair and pinning staff against walls, and chasing after other members. The facility implemented several non-pharmacological interventions that were not effective. On 12/28/16, the MD ordered an antipsychotic ([MEDICATION NAME]) 0.25 mg twice a day. On 01/11/17 at 1:40 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) E about R4's food preferences for desserts or sweet foods. CNA E replied that R4 loves his desserts. Surveyor asked how CNA E can tell this when R4 is non-verbal much of the time. CNA E stated that before the desserts were limited R4 would always eat his dessert first, and reach for it if it was not offered. CNA E then talked about R4 having candy in his room previously from the bingo store. CNA E stated that R4 could open the candy himself and would come out of his room with the candy with a smile on his face. CNA E said she is concerned that now that he cannot have dessert he may not eat well because that was the one thing he would eat. On 01/11/17 at 1:45 p.m., Surveyor interviewed CNA F about R4's food preferences. CNA F replied that R4 loves sweets. Surveyor asked how CNA F knows that. CNA F replied that if the dessert is served R4 keeps reaching for the dessert, but he can not have it unless he eats 50% of his food. CNA F stated she knows R4 has always enjoyed his candy and desserts, and would choose to eat them first. On 01/11/17 at 2:00 p.m., Surveyor interviewed Director of Social Services (DSS) G about the restrictions in food choices for R4. DSS G stated that R4's Health Care Power of Attorney (HCPOA) believes the sugar causes behaviors. The HCPOA would not agree to the use of the antipsychotic medication unless the facility agreed to the diet restrictions. Surveyor asked if there has been any concern with R4's blood sugars. DSS G replied there was not, nor was there a medical reason for limiting his sweets. Surveyor stated a reasonable person who has demonstrated enjoying desserts and candy would have a preference to have them. The HCPOA must consider the resident's wishes and preferences in making decisions. If the resident can understand the situation and express a preference, the resident's wishes are to be respected.

Based on interview and record review, 7 of 15 residents whose medication regimen was reviewed were not free from medications used without adequate monitoring. 1. Resident #1 receives [MEDICATION NAME], an antidepressant medication, since 02/18/13. The facility did not document signs and symptoms that Resident #1 exhibits related to depression. Resident #1 takes [MEDICATION NAME] nightly for [MEDICAL CONDITION]. The facility did not complete sleep assessments or monitor for effectiveness of the medication. 2. Resident #13 receives [MEDICATION NAME] (an antidepressant), [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an antidepressant) all for depression. The facility did not provide documentation for the rationale of duplicative therapy. The facility did not review on a regular basis the effectiveness of the medications or rationale for no changes. 3. Resident #3 receives [MEDICATION NAME] three times a day, and [MEDICATION NAME] two times a day for anxiety. The facility did not identify and document signs and symptoms that Resident #3 exhibits related to anxiety. 4. Resident #9 receives [MEDICATION NAME] as needed (PRN) for anxiety. The facility does not document which behaviors Resident #9 exhibits related to anxiety. The facility does not document any non-pharmacological interventions that are used to reduce anxiety prior to giving the medication or their effectiveness. The facility also did not reduce this medication as their protocol indicates. 5. Resident #11 has been on Tylenol PM since 05/27/15. There is very limited documentation related to tracking/monitoring Resident #11's sleep patterns. A gradual dose reduction (GDR) has not been attempted and there is no documentation why a GDR attempt is clinically contraindicated. 6. Resident #2 receives [MEDICATION NAME], an antidepressant medication. There is limited documentation regarding evidence of adequate monitoring of behaviors related to Resident #2's use of the [MEDICATION NAME]. 7. Resident #15 received Ambien, a hypnotic medication, beginning with the physician order [REDACTED]. The facility staff did not identify non-pharmacological interventions used to promote sleep prior to administering the Ambien. This is evidenced by The facility's Nursing Home Administrator (NHA) provided the facility's guidelines for the use of [MEDICAL CONDITION] Medication on 02/23/16 at 11:07 a.m. The guidelines state in part: .Sedative/ hypnotics will be reviewed quarterly for gradual dose reduction. GDR must be attempted quarterly unless clinically contraindicated.Orders for PRN [MEDICAL CONDITION] medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances.Will monitor for the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present). 1.) Resident #1's medical record was reviewed by Surveyor on 02/17-02/23/16. Resident #1 has [DIAGNOSES REDACTED]. Resident #1 takes [MEDICATION NAME] 125 mg for depression each day and [MEDICATION NAME] 25 mg for [MEDICAL CONDITION] each day. Review of Resident #1's care plan states, in part, that Resident #1 has a [DIAGNOSES REDACTED].administer antidepressants as ordered. Monitor for effectiveness and for potential adverse reactions .provide a quiet calm environment for sleep, encourage interventions to assist with falling asleep; such as relaxation, deep breathing, etc. The care plan does not indicate what signs or symptoms Resident #1 might display to indicate depression. Review of the progress notes does not reveal any documented signs and symptoms of depression or what Resident #1 says or does to indicate his depression. Review of Certified Nursing Assistant (CNA) charting from 11/16/15 to 02/17/16 reveals no behaviors occurred. Review of interdisciplinary team progress notes, dated 01/21/16, reveals the team met on 01/20/16 and reviewed the period of 10/11/15 -01/09/16. It states in part that Resident #1 has had no behavioral or mood issues, same as previous .list interventions or measures tried or put into place to alleviate behavior: NA Review of nursing progress notes from 11/17/15 through 02/17/16 does not reveal any monitoring of sleep or information related to the use or effectiveness of non-pharmacological interventions, used to promote sleep. No sleep assessements were completed. No evidence was provided by the facility to show that Resident #1's [MEDICATION NAME] was reviewed quarterly for a gradual dose reduction as the facility's guidelines indicate. 2.) Resident #13's medical record was reviewed by Surveyor on 02/22-02/23/16. Resident #13 has [DIAGNOSES REDACTED]. Resident #13's physician orders [REDACTED]. Review of Resident #13's care plan states in part .under interventions to monitor, document, and report to nurse/MD (doctor) s/sx (signs and symptoms) of depression including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, negative statements, repetitive anxious or health - related complaints .avoid seating resident next to females .assist resident to develop more appropriate methods of interacting with staff, and when conflict arises, remove resident to a calm safe environment and allow to vent/share feelings. Review of progress notes from 11/17/15 through 02/22/16 does not document any depressive symptoms. Resident #13's Minimum Data Sets (MDS's) from throughout the last year include: 02/01/15 (admission) - depression score of 0 and no indicators of symptoms 07/15/15 (quarterly) - depression score of 3, only indicator is tired/loss of energy 10/13/15 (quarterly) - depression score of 2, indicator trouble concentrating 01/06/16 (quarterly) - depression score of 0, with no indicators of symptoms A score of 0 indicates no depression and a score of 1-4 indicates minimal depression. Resident #13's medical record does not include documentation of a pharmacy review or physician's note addressing the duplicative therapy or the rationale for continued use of all three medications. 3.) Resident #3's medical record was reviewed by Surveyor on 02/17-02/23/16. Resident #3 has [DIAGNOSES REDACTED]. Resident #3 receives [MEDICATION NAME] 15 mg three times daily and [MEDICATION NAME] .5 mg two times each day for anxiety. Review of Resident #3's medical record does not indicate the signs and symptoms of anxiety. The medical record does not indicate which behaviors Resident #3 may exhibit which would indicate he is having anxiety. Review of a behavior note, dated 11/24/15, states that the interdisciplinary team met on 11/19/15 and reviewed the period of 08/09/15 through 11/07/15. It reports that Resident #3 had one documented episode of abusive language, one episode of rejection of care and one episode of sexually inappropriateness. The team recommended no gradual dose reductions at this time and to continue to review quarterly. There is no physician's note indicating the rationale for continued use and for no dose reduction. This note does not address anxiety, or the two medications being used to treat it for Resident #3. Review of CNA charting for behaviors from 11/16/15 to 02/17/16 reveal only one incident of sexually inappropriate behaviors. No behaviors of anxiety were documented. 4.) Resident #9's medical record was reviewed by Surveyor on 02/17-02/23/16. Resident #9 has [DIAGNOSES REDACTED]. Resident #9 takes [MEDICATION NAME] .25 mg every six hours as needed for anxiety. Review of Resident #9's interdisciplinary team note, dated 11/20/15, which states in part that the resident has no behavioral or mood issues for the review period of 08/09/15-11/07/15. It states the resident is on [MEDICATION NAME] for anxiety, and they are not recommending a gradual dose reduction as he's doing well and tends to worry and not sleep at night. List interventions or measures tried or put into place to alleviate behavior: NA (not applicable). Review of CNA behavioral data reveals that from 11/16/15 to 02/17/16 no behaviors were observed. Review of Resident #9's Medication Administration Record [REDACTED]. The medical record does not document non-pharmacological interventions that are used to help Resident #9 reduce his anxiety prior to giving the PRN antianxiety medication or their effectiveness. The facility did not provide evidence that a gradual dose reduction was attempted quarterly or that it was clinically contraindicated, and a time limited period was utilized as the guidelines indicate. During an interview with the NHA at 11:07 a.m. on 02/23/16, the NHA indicated the Guidelines for [MEDICAL CONDITION] Medication usage is what the facility follows related to [MEDICAL CONDITION] medication usage. 5.) Resident #11 Beginning on 02/22/16, Surveyor reviewed Resident #11's medical record and identified Resident #11 has [DIAGNOSES REDACTED]. Resident #11's physician orders [REDACTED]. Resident #11 has taken the Tylenol PM since 05/2015. This medication is considered a hypnotic. Surveyor requested sleep assessments and documentation of sleep monitoring/tracking related to the effectiveness of the Tylenol PM. Surveyor was provided with a sleep assessment for Resident #11, dated 11/14/15. This assessment identified Resident #11 has pain at times that affects his sleep. The sleep tracking form completed for the nights of 11/14/15, 11/15/15 and 11/16/15 identified: Resident #11 slept from 10:00 p.m. to 5:00 a.m. on the night of 11/14/15. Resident #11 slept from 10:00 p.m. to 8:00 a.m. on the night of 11/15/15. On the night of 11/16/15, Resident #11 was asleep at 10:00 p.m., awake at 11:00 p.m. to use the bathroom, sleeping from 12:00 a.m. to 3:00 a.m., was up in his chair from 4:00 a.m. to 6:00 a.m. and sleeping at 7:00 a.m. and 8:00 a.m. Resident #11's sleep assessment, dated 02/03/16, also identified Resident #11 has pain at times that affects his sleep. The sleep tracking form completed for the nights of 02/03/16, 02/04/16 and 02/05/16 identified: Resident #11 was asleep from 10:00 p.m. until 4:00 a.m., and again from 5:00 a.m. until 8:00 a.m. on the night of 02/03/16. Resident #11 slept from 10:00 p.m. until 5:00 a.m. on the night of 02/04/16 and 02/05/16. Surveyor reviewed Resident #11's last three months of behavior tracking and identified sleep is not part of the tracking. Resident #11's sleep was tracked during the times identified above. Surveyor read the 12/15/15, Behavior note for Resident #11. This note read in part: Current review date is 9/6-12/5 (2015). It did not include information regarding Resident #11's sleep patterns or the use of the Tylenol PM for [MEDICAL CONDITION]. Nurses' notes, dated 11/11/15 and 01/18/16, read in part: Sleep: Member sleeps well at night . Resident #11's care plan identifies he has an alterations in sleep r/t (related to) [MEDICAL CONDITION]. Surveyor reviewed a fax sent to Resident #11's physician. This read in part: Discussed member's pain/sleep for annual review and member c/o (complained of) having sharp/achey (sic) pain in his feet/heels at night and makes it difficult to sleep. Member is rating is (sic) usually 6/10. Will encourage warm towels and massage but do you have any other recommendations for member? The physician wrote Tylenol PM q (every) HS (hour of sleep) and dated the form 05/27/15. On 02/22/16 at 3:16 p.m., the Director of Nursing (DON) told Surveyor that Resident #11 receives the Tylenol PM for pain not for [MEDICAL CONDITION] and has used it a long time for pain at bedtime because he was having trouble sleeping. Surveyor brought to the attention of the DON, the physician order [REDACTED]. Surveyor questioned why Resident #11 is not on something routinely for pain if it is pain that is causing him not to sleep. Surveyor requested and reviewed pharmacy consultant recommendations for Resident #11 and identified there was no recommendation made for a GDR attempt for Resident #11's Tylenol PM. No physician documentation was provided that addressed the continued use of the Tylenol PM and/or why a GDR attempt would be clinically contraindicated. 6.) Resident #2 On 02/17/16, Surveyor began review of Resident #2's medical record and noted Resident #2 receives [MEDICATION NAME] 50 mg daily for the [DIAGNOSES REDACTED]. Record review identified Resident #2 has been on the [MEDICATION NAME] 50 mg daily since at least 07/16/15. Review of Resident #2's CNA Kardex and Resident #2 care plan showed staff are to: Monitor/document/report to Nurse/MD (medical doctor) s/sx (signs and symptoms) of depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness. Surveyor requested the behavior monitoring done for Resident #2 related to the use of the [MEDICATION NAME]. Surveyor was provided with a one page summary for behavior tracking for 11/16/15 to 02/17/16. This document does not identify what specific behaviors are being monitored for Resident #2 in relation to his depression. The behavior tracking sheets list the same behaviors for all residents who have behaviors; 0-Frequent crying, 2-Repeats Movement, 3-Yelling/Screaming, 4-Kicking, 5-Pinching/Scratching/Spitting, 6-Biting, 7-Wandering, 8-Abusive Language, 9-Threatening Behavior, 10-Sexually Inappropriate, 11-Rejection of Care, 12-None of the above observed, 13-Pushing and 14-Grabbing. The behavior tracking sheet for those approximate three months contained the information of 12-None of the above observed 100% of the time for Resident #2. This tracking does not include all of the signs and symptoms of depression that staff are to monitor Resident #2 for as identified on Resident #2' care plan. Resident #2's mood assessment, an indicator for depression, was not completed on Resident #2's most recently completed Minimum Data Set (MDS) assessment of 01/12/16. Surveyor read the following behavior notes documented for Resident #2: 10/29/15-Behavioral IDT (interdisciplinary team) met on 10/28/15 to review member. Dates reviewed were as follows; 07/05/15 through 10/10/15. Member exhibited no behaviors which shows no change from previous review period. There were also no mood concerns. 01/22/16-Behavioral IDT met on 01/20/16 to review member. Current dates reviewed are 10/11/15-01/09/16. Member exhibited no behaviors in current review period. No significant change from previous review period, no mood concerns. Will review next quarter. The review for Resident #2 was conducted on 01/20/16, but staff had not identified Resident #2's mood assessment was not completed on Resident #2's 01/12/16 MDS. Surveyor also noted Resident #2 was in the hospital from 01/03/16 to 01/10/16, so it unclear how it was determined Resident #2 had no mood concerns for the time frame of 01/03/16-01/09/16. 7.) Resident #15 During review of Resident #15's medical record beginning on 02/22/16, Surveyor identified Resident #15 was admitted on [DATE] with an order for [REDACTED].#15's MAR for 11/2015, Surveyor identified Resident #15 received [MEDICATION NAME] a scheduled basis every night from 11/01/15-11/16/15. Resident #15 was hospitalized [DATE]. Resident #5 returned to the facility and on 11/21/15, [MEDICATION NAME] re-ordered for 5 mg every 24 hours as needed (prn) for [MEDICAL CONDITION]. Resident #15 received the [MEDICATION NAME] 11/28/15, 11/30/15, 12/05/15 at 12:15 a.m., on 12/05/15 at 11:21 p.m., and 12/18/15 at 1:00 a.m. (Resident #15 was hospitalized much of 12/2015). Resident #15's 01/2016 MAR indicated [REDACTED]. Surveyor cross referenced nursing progress notes for the above dates for Resident #15 and did not find documentation of non-pharmacological measures taken to promote sleep prior to giving the Ambien. On 02/23/16, Surveyor reviewed the Sleep Assessment for Resident #15, dated 11/21/15. This assessment identified Resident #15's bedtime is between 9-11:00 p.m., awake time varies, usually after three hours of sleep, Resident #15 naps, dozes off frequently in the morning and afternoon and it takes Resident #15 a few minutes to fall asleep. This assessment included sleep tracking for the nights of 11/21/15, 11/22/15 and 11/23/15. The 11/21/15 and 11/22/15 sleep tracking showed Resident #15 was asleep from 11:00 p.m. to 1:00 a.m. and again from 3:00 a.m. to 5:00 a.m. The 11/23/15 sleep tracking showed Resident #15 was asleep from 10:00 p.m. to 1:00 a.m., at 3:00 a.m., awake at 2:00 a.m. and 4:00 a.m. and sleeping at 5:00 a.m. and 6:00 a.m. Resident #15 had not received [MEDICATION NAME] the nights of 11/21/15-11/23/15 according to Resident #15's MAR. A sleep assessment completed for Resident #15 on 12/14/15, identified Resident #15's bedtime is from 11:00 p.m. to midnight and his awake time as 3:00 a.m. Resident #15 naps occasionally in the morning and no afternoon naps. This assessment identified it takes Resident #15 awhile to fall asleep. Sleep tracking was completed for Resident #15 on the night of 12/14/15, 12/15/15 and 12/16/15. On 12/14/15, the form showed Resident #15 was awake from 8:00 p.m. until 1:00 a.m., sleeping at 2:00 and 3:00 a.m., awake at 4:00 a.m. and sleeping at 5:00 a.m. and 6:00 a.m. On 12/15/16, Resident #15 was asleep 8:00 p.m. to 10:00 p.m., awake at 11:00 p.m., sleeping at midnight and awake from 1:00 a.m. through 5:00 a.m. The night of 12/16/15 the sleep tracking form for Resident #15 showed Resident #15 was awake from 10:00 p.m. through 6:00 a.m. From review of Resident #15's MAR, Resident #15 had not taken [MEDICATION NAME] nights of 12/14/15, 12/15/15 or 12/16/15. A nursing progress note related to Resident #15's sleep was done on 12/18/15 at 1:00 a.m. that read sunable (sic) to sleep. Resident #15 was given [MEDICATION NAME] that time. There was no identification of non-pharmacological measures tried. At 2:26 a.m. on 12/18/15, a note read: Has been quiet for almost hour. At 3:47 a.m. a nursing progress note read: Sleep tracking: member does not sleep at night, usually awake more than 80% of time. A 12/27/15, 5:33 a.m. nurses' note read in part: Awake at beginning of shift until early morning . Did settle about 3 am and wanted to sleep in recliner . Resident #15 had not received [MEDICATION NAME] night. A behavior note for Resident #15, dated 01/21/16, read in part: Behavioral IDT met on 01/20/2016 to review member for period of 10/11/15-01/09/2016 . Member is currently in hospital and team will review next month to discuss appropriateness of his [MEDICATION NAME] sleep. During review of Resident #15's medical record, Surveyor noted the care plan provided to Surveyor for Resident #15 did not identify [MEDICAL CONDITION] as a problem for Resident #15, nor contain non-pharmacological approaches to promote sleep prior to using the Ambien.