Every finding on record at Alden Estates of Evanston

Based on observation, interview, and record review the facility failed to provide privacy during blood glucose monitoring and insulin injections. This deficiency affects one (R60) of two residents in the sample of 16 reviewed for privacy during Medication Administration.Findings include: On 12/16/25 at 11:05AM, Observed V7 LPN (Licensed Practical Nurse) performed peripheral blood glucose/sugar monitoring to R60 in the hallway by the nursing station where visible to other residents and staff members. Then V7 prepared Humalog lispro 5 units and administered to R60's abdominal area subcutaneously. V7 said that R60 prefers to monitor his blood sugar and receive his insulin in the hallway without privacy.On 12/16/25 at 11:10AM, Reviewed R60's comprehensive care plan with V8 Charge Nurse. No care plan addressing R60's preference of monitoring his blood glucose/sugar and receiving insulin in the hallway without privacy. V8 said that R60's preference of having no privacy during monitoring of blood sugar and administration of insulin without privacy should be addressed in care plan.On 12/16/25 at 11:17AM, Informed V9 Resident Coordinator of above observations and concerns. V9 said that she is not aware that R60 prefers to monitor his blood sugar and receives insulin injection in the hallway without privacy. V9 said that his preference should be reflected in his comprehensive care plan.R60 is admitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, Type 2 Diabetes Mellitus, Chronic Kidney disease. Active physician order sheet indicated: Blood glucose monitoring AC and HS call physician for results less than 70 or greater than 300 before meals and at bedtime. Humalog Kwik pen subcutaneous (SC) solution pen injector 100 unit/ml (Insulin Lispro) inject 5 units SC with meals. Lantus solo star subcutaneous solution pen injector 100 unit /ml (Insulin Glargine) inject 8 unit subcutaneous in the morning. Comprehensive care plan revised by V9 resident coordinator after surveyor discussed concern with her dated 12/16/25 indicated: R60 prefers his blood check and insulin shot if applicable to be done in the hallway or dining area.Facility's policy on Medication Pass Guidelines 04/19 indicated: 6. Privacy*While privacy is always a priority, it is required for the following procedures: -Injections-Blood glucose monitoring.Facility's policy on Comprehensive Care plan 11/2027 indicated:An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs is developed and implemented to each resident. Procedure: 1. In coordination with the resident and resident representative, as applicable, the interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of focus statements, goals, and interventions. 8. Assessment of the resident is ongoing and care plans are revised based on the resident condition, preferences, treatments, and goal change.

Based on observation, interview, and record review the facility failed to ensure ongoing assessment to revise and updated the resident individualized care plan according to the resident's condition and treatments. This deficiency affects one (R2) of three residents in the sample of 16 reviewed for Care plan revision.Findings include: On 12/16/25 at 10:49AM, Observed R2 lying in bed. He is dependent with ADLs and transfers. He is incontinent of bowel and bladder. He is awake and responsive with but confused. On 12/17/25 at 10:17AM, Observed R2 lying in bed with V7 LPN ( Licensed practical Nurse). V7 said that R9 has indwelling catheter when he was admitted but it was discontinued couple months ago. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Cerebral atherosclerosis, Chronic Kidney Disease Stage 4, Type 2 Diabetes Mellitus, Hemiplegia, and hemiparesis following cerebral infarction. Active physician order sheet indicated no order of indwelling urinary catheter, but comprehensive care plan indicated that he requires the use of indwelling catheter with target goal dated 2/11/26. MDS significant change assessment dated [DATE] indicated no usage of indwelling urinary catheter, he is incontinent of bladder. On 12/17/25 at 10:28AM, V9 Resident Coordinator said she updates the resident's care plan for any changes in their condition and plan of care. Reviewed R2's medical records with V9. Informed V9 that R2's indwelling catheter was discontinued on 10/24/25 but it was not updated in R2's comprehensive care plan. V9 said that she updates the care plan if the nurse informed him of the changes. V9 said that she is not aware, and she did not update R9's care plan for discontinued catheter. V9 said that she completed the MDS/Resident significant change assessment for R2 on 11/11/25. V9 said that R2's care plan should be updated of discontinued indwelling urinary catheter. Facility's policy on Comprehensive Care plan 11/2027 indicated:An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs is developed and implemented to each resident. Procedure: 1. In coordination with the resident and resident representative, as applicable, the interdisciplinary team will develop and implement a person centered, comprehensive plan of care. Care plans are comprised of focus statements, goals, and interventions. 8. Assessment of the resident is ongoing and care plans are revised based on the resident condition, preferences, treatments, and goal change.

Based on observation, interview, and record review the facility failed to ensure resident medications were appropriately stored. This deficiency affected one resident (R79) reviewed for medication storage in a sample of 16. Findings include:On 12/16/25 at 11:10am, observed R79 with medication at bedside table, Ipratropium Bromide nasal spray, said she uses it for allergies. On 12/16/25 at 11:10am, V16 (R79 daughter) said that she is unaware of who brought the medication, said they must have been in her belongings from another place.On 12/16/25 at 11:15am, surveyor made V15 (Licensed Practical Nurse) aware of above findings and said that medications are not to be stored at bedside unless they have a physician order. V15 said that medications should have a physician's order to be administered. On 12/16/25 at 1:20pm, V2 (Director of Nursing) made aware that R79 had medications stored at bedside and made nurse aware of above findings. V2 said that medication should not be at bedside unless there is an order, all medications should have a physician order to be administered by the nurse. V2 was made aware that there was no order for, Ipratropium Bromide nasal spray, in the physician orders for R79, V2 said she was unaware. On 12/18/2025 at 12:15pm, V2 said there is no policy available for medication storage. R79's admission date 12/12/25 with diagnosis in part but not limited to primary osteoarthritis, right wrist, encounter for surgical aftercare following surgery on the genitourinary system, muscle weakness, need for assistance with personal care. Insomnia, and essential hypertension. Physician orders dated 12/15/2025 indicates no order for Ipratropium Bromide nasal spray. Facility Policy for Bedside Medications revision date 03/21Prerequisites:1. Physician order2. Medication Administration Record (MAR) or Electronic Medication Record (Emar)Policy:Bedside storage of medication may be allowed for sublingual, inhalation, eye drops, or select topical forms of drugs and then only upon specific order of the physician.

Based on observation, interview, and record review the facility failed to use appropriate infection control practices during medication administration. This deficiency affects two (R59 and R81) of 14 residents in the sample of 16 reviewed for Infection Control during Medication Administration. Findings include: On 12/16/25 at 9:48AM, Observed V7 LPN (Licensed Practical Nurse) administered medication to R59. V12 did not perform hand hygiene after medication administration. He answered call light of R83. He attended to R83's needs, turned off the call light. He took the food plate cover and cloth table napkin left on R83's tray table. He then walked toward the nursing station and handed the food plate cover and table napkin to one of the staff members. He then continued to with medication administration without hand hygiene. He prepared medications for R81 then he used hand sanitizer. Informed V7 of above observation. He said that he should performed hand hygiene after administration of medication to R59 and before preparing medications for R81. On 12/16/25 at 11:36AM, Informed V3 ADON (Assistant Director of Nursing) of above observation. V3 said that V7 LPN should performed hand hygiene before and after medication administrations. Facility's policy on Medication Pass Guidelines 04/19 indicated: 1. Hand hygieneHand wash with soap and water or a commercially prepared alcohol gel. When using alcohol gel, use friction for approximately 15 seconds. Allow gel to air dry on hands- do not dry with a paper towel, tissue, wipe etc. Do not use any product containing lanolin as it may weaken the barrier that gloves provide, risking exposure. When hand washing with soap and water, use friction for approximately 20 seconds. Practice hand hygiene under the following circumstances: *Before staring med pass.

Based on observation, interview and record review, the facility failed to maintain resident safety during a transfer utilizing the mechanical lift by failing to have two staff present during a transfer and failed to ensure the correct size mechanical lift sling is used during transfers as recommended by the manufacturer. This affected two of two residents (R2-R3) reviewed for safety and the mechanical lift. Findings Include: 1.) R2 alert and oriented with a BIMS score of 14 (Cognition Intact), Weigh 141.0 lbs. on 5/1/24. On 6/8/24 at 2PM, Mechanical lift transfer with 2 staff assistance was observed. V4 and V13 (CNAs) placed the Mechanical lift sling in bed behind R2. Mechanical lift sling is big in size and light bluish in color. V4 and V13 folded the bottom end to fit R2's body then hooked up and transferred R2 in wheelchair. V4 operated the machine and V14 assisted in guiding R2 in her wheelchair. R2 stated I have never seen a sling so big. Interviewed R2 and R2 stated that the sling they used today is bigger than R2 was used to. R2 then reported that sometimes they transfer me with the machine with only one staff present. V4 still in the room and confirmed that the sling that was used is big for R2. V4 stated that staff cannot find her small Mechanical lift sling pad. V4 also stated they probably washed it in the laundry, and we cannot find it. V4 stated that they usually used a small Mechanical lift sling pad for R2, which is blue in color. On 6/8/24 at 2:21PM, V13 (CNA) We cannot find Mechanical lift sling. Usually, we use the small one and this sling was big for her. V13 stated that today they don't have the right size for R2. Mechanical lift has to be 2 person assist, or more than two. But not less than 2. Our sling pad comes in blue or gray color. I think the one that we used for R2 was from the hospital. Too big for the patient. Maybe the one use for weights, maybe. We folded the bottom end of the sling pad because R2 needs to have her legs hanging. Usually, we don't have to fold it if the Mechanical lift sling is the right size for the resident. 2.) On 6/8/24 at 1:55PM, R3 is up in the wheelchair in her room, playing cards. Alert and oriented. When asked how many staff in assistance with Mechanical lift transfer, R3 stated at times one or two staff assistance. Today there was only one that transfer me using the machine. R3 has a BIMs score of 13 (cognition intact). Facility Mechanical lift transfer list provided by the facility. R2 and R3 are listed as transferring x 2 assist via Mechanical lift. Confirmed under task tab in residents' medical record and both shows that R2 and R3 are transferring via mechanical lift x 2 assistance. R2 and R3 also have a care plan for requires the use of a mechanical lift for transfers. On 6/9/24 at 10:45AM V16 (Minimum Data Set Coordinator/Covering Restorative Nurse) stated that Mechanical lift task is a two-person transfer assist. For the mechanical lift sling appropriate sizing the facility follows the manufacturer recommendation. If an inappropriate sizing was used to a resident, it may compromise the resident safety. Mechanical lift user manual provided by the facility, reads in part: Mechanical lift is a fully electric mobile lift, with ability to raise and lower the lift arm and the width adjustment of the base. The list is intended to give caregivers the ability to lift a patient safely and take them to pre-determined destination. The lift is designed to be used in conjunction with the Mechanical lift Company's brand accessories and slings. Sling sizing: small 34-68kg, 75 to 150 lbs. Large 55-90kg, 120-200 lbs. Before every lifting situation, always make sure the following: Correct selection of sling (type, size, material) and accessories safely meet the patients' needs. Total Mechanical Lift policy dated 1/14/21, reads in part: 2 care givers are required to operate the mechanical lift.

Based on observation, interview and record review the facility failed to label and date food placed in one of three resident unit refrigerator. This deficiency has the potential to affect 25 residents receiving a general diet. Findings include: On 1/17/24 at 1:31PM, Checked refrigerator in the 3rd floor dining room pantry with V8 (Dietary Aide/DA). Observed sliced turkey pale and dry, placed in small plate not completely covered, not labeled, and not dated; three (3) small plates of fruits not labeled and not dated. V8 said that all food inside the refrigerator should be covered, labeled, and dated. On 1/17/24 at 2:00PM, Informed V4 (Dietary manager) of the above observation. V4 said that food inside the refrigerator should be covered, labeled, and dated. Facility's policy on Labeling and dating indicates: Purpose: To reduce the risk of food borne illness. Procedure: 1. Ready to eat time/temperature for safety (TCS) food that is held for less than 24 hours may be labeled with the common name, date, and time it is placed in the refrigerator.

Based on observation, interview and record review the facility failed to place call light within resident reach. This deficiency affects one (R158) of three residents in the sample of 17 reviewed for accommodation of needs. Findings include: On 1/17/24 at 12:44PM, Observed R158 sitting in the wheelchair in her room on the left side of the bed closer to the door. She appears pale and weak. She said that she does not feel well, she feels dizzy. She said that she has been waiting for the CNA (Certified Nurse Assistant) to transfer her back to bed. Observed call light away from her and out of her reach. Call light is located on the right side of the bed. Surveyor went to the nursing station and asked for R158's CNA. They said that the assigned CNA went down for lunch break. V10 (Unit Manager /CNA) offered assistance to the surveyor. Both went to R158's room. Surveyor showed the observation of R158's call light not within reach. V10 said that call light should be always within resident's reach. On 1/17/24 at 12:59PM, Informed V2 (Director of Nursing) of the above observation. V2 said that call light should be within resident reach. Facility's policy on use of call light 9/20 indicates: Purpose: To respond promptly to resident's call or assistance. Procedure: 7. Be sure call lights are placed within resident reach at all times.

Based on observation, interview and record review the facility failed to ensure that a resident receives the necessary amount of assistant during a meal. This deficiency affects one (R26) of three residents in the sample of 17 reviewed for Providing Resident's meal. Findings include: On 1/17/24 at 12:47PM, Observed V11 (Activity Aide) went inside the R26's room knocking and placed the lunch tray on the bedside tray table on the right side of the bed and left. R26 is lying in bed. Before V11 left the room, surveyor informed him of observation made. V11 said that he left the lunch tray on the bedside table because R26 is sleeping, and he did not want to wake her up. R26 heard the conversation and said, I'm not sleeping, I'm just lying in bed. V10 (Unit Manager) came and was informed of the observation made. V10 explained to surveyor that when staff provide a lunch tray to the resident, staff should provide assistance as needed and set up the lunch tray for the resident. V10 asked R26 if she needs assistance in her lunch tray. R26 said Yes, that would be great, instead of just leaving the tray. On 1/17/24 at 12:57PM, Informed V2 (Director of Nursing) of the above observation. V2 said staff should inform the resident when the meal tray is brought to their room and ask if they need assistance. R26 was admitted on [DATE] with diagnosis listed in part but not limited to muscle weakness, need for assistance with personal care, morbid obesity. Care plan indicates she has ADL (Activity of daily Living) functional performance deficit related to weakness, deconditioned due to recent hospitalization . Intervention: Assist with ADL task. Provide needed level of assistance and support to complete ADL. Admission MDS (Minimum Date Set) assessment dated [DATE] indicated Section GG 130 Self Care -5 Set up or clean up assistance. Facility's policy on Meal service indicates: Purpose: 4. To assure that each resident receives the amount of assistance necessary. Procedure: 1. Assist resident to comfortable position. Note: To encourage social interaction and mobility, all residents should be encouraged to eat meals in the dining room per facility policy. 2. Ensure accuracy of diet served to each resident. 3. Served tray to resident with food covered, remove cover(s) from food 4. Identify resident to ensure correct diet is being served. 5. Place all utensils and food containers within easy reach of resident, assist as necessary. 6. Cover or assist resident to cover clothing with napkin, or clothing protector as desired. 7. Allow the resident to enjoy his/her meal after you are sure you have provided adequate assistance

Based on observation, interview and record review the facility failed to follow manufacturer recommendation in using a low air loss mattress to resident with multiple pressure ulcers and arterial wound. This deficiency affects one (R42) of three residents in the sample of 17 reviewed for Pressure ulcer prevention and treatment management. Findings include: On 1/18/24 at 11:09AM, Observed V10 (Unit Manager/Certified Nursing Assistant) and V13 (Wound Care Nurse) preparing R42 for wound care. R42 is on LAL (low air loss mattress) with a thick towel and flat sheet underneath him. R42 wears disposable brief. Informed observation to both V10 and V13. Both said that a resident on LAL mattress should only have flat sheet over it. There should be no multiple layers of linen over the mattress. On 1/18/24 at 1:30PM, Informed V2 (Director of Nursing/DON) of the above observation. V2 said that a resident on LAL mattress should only have a flat sheet over the mattress. No multiple layers of linen as the manufacturer's recommendation. On 1/18/24 at 2:00PM, V2 (DON) and V16 (Nurse Consultant) said that they don't have policy for using LAL mattress. R42 was initially admitted on [DATE] with diagnosis listed in part but not limited to Stage 3 Pressure ulcer of left heel, Peripheral vascular disease. Active physician orders indicate: Evidenced based practice for chronic wound. Cleanse right heel with normal saline, apply Betadine solution 10% topically every Monday, Wednesday and Friday and as needed for arterial non pressure ulcer. Cleanse left heel with 1/2 strength (name brand) solution, apply Silvadene, Calcium Alginate and cover with foam dressing to left heel every day shift and as needed. Cleanse with solution, pat dry, apply (name brand ointment) and hydrocolloid dressing to sacral to perineum every Monday, Wednesday, Friday and as needed. Apply (name brand cream) as needed for contamination. Care plan indicates: Actual alteration in skin integrity related to Left heel pressure ulcer, sacral pressure ulcer, Perineum MASD (Moisture Associated Skin Disorder), right heel arterial non pressure ulcer. Is high risk for alteration in skin integrity related to limited mobility, use of anti-coagulants, incontinence. Intervention: Pressure reduction foam mattress or pressure redistribution support (low air or alteration air) in bed. R42's wound report dated 1/12/24 indicated 1. Left heel- Stage 3 pressure ulcer. Date reported 12/29/23. Measurement-3x3.5x01cm. 30% granulation, 50% necrotic/eschar, 20% slough. Moderate serosanguineous. Subcutaneous tissue exposed. Treatment: Cleanse with 1/2 (name brand solution), apply Silvadene, calcium alginate and cover with foam dressing. 2. Perineum- Diaper dermatitis MASD, Superficial mycosis. Dare reported 12/29/23. 100% less erythema and scales. Undefined margins. Denuded peri wound. Treatment: Cleanse with normal saline twice a day and as needed. Apply Mycolog II. 3. Sacral extends to perineum- Stage 3 pressure ulcer. Date reported 12/29/23. Measurement- 8x7x0.1cm. 40% patchy granulation, 30% necrotic/eschar, 10% slough, 20% epithelization. Undefined margins. Denuded peri wound. Light serosanguineous exudate. Treatment: Cleanse with (solution). Apply (name brand ointment) cover with hydrocolloid dressing. (name brand cream) 0.75% as needed for contamination. 4. Right heel - non pressure arterial. Date reported 12/29/23. Measurement-3x6x0cm. 100% maroon. Dry peri wound. Treatment: Cleanse with normal saline. Apply betadine paint and cover with foam dressing. Facility unable to provide policy in using Low air loss mattress.

Based on observation, interview and record review the facility failed to ensure a resident received the correct oxygen flow as ordered for 1 of 2 residents (R14) reviewed for respiratory care in a sample of 17. Findings include: On 1/17/2024 at 12:05 PM R14 was observed in bed with oxygen via nasal canula set at 5 liters. On 1/17/2024 at 12:07 PM V12 (Registered Nurse) observed with surveyor R14's oxygen infusing at 5 liters. V12 said oxygen should on 2-3 liters. On 1/28/2024 at 11:20 AM V2 (Director of Nursing) said that if resident is using oxygen, it should be in place all the time if continuous and nurse to follow physician's order as far as oxygen setting. A Transfer and Discharge Report indicated R14 has a diagnosis of Dependence on Supplemental Oxygen and Acute Respiratory Failure with Hypoxia. An Order Summary Report indicates R14 has a Physician order dated 11/10/2023 for Respiratory: Oxygen per nasal cannula at 2 liters per minute continuous every shift. A Care Plan dated 11/10/2023 with an intervention of Administer oxygen per Medical Doctor -MD orders. Facility Policy: Oxygen Therapy Devices - Nasal Cannula 09/2020 Policy: Oxygen delivered per nasal cannula, will be used to prevent or reverse hypoxia and improve tissue oxygenation. Procedure: 1.Verify physician's order.

Based on observation, interview, and record the facility staff failed to wear the required PPE (Personal Protective Equipment) and failed to clean the PPE for 2 residents (R26 and R45) of 5 residents reviewed for transmission-based precautions in a sample of 17 residents. Findings include: On 1/17/24 at 12:38 PM V11 (Activity Aide) exited the room of R45. V11 removed the reusable face shield and placed it on the PPE (Personal Protective Equipment) cart. V11 did not clean the reusable face shield. R45 has a positive Covid 19 test result. There are postings indicating contact and droplet precautions for R45. On 1/17/24 at 1:00 PM V2 (Director of Nursing) said that staff are to clean the reusable face shields with the surface wipes after each use before returning them to the cart. On 1/17/24 at 1:10 PM V19 (Maintenance) entered the room of R45 wearing a facemask. V19 was not wearing an N95 mask, face shield, gown, or gloves. V19 said I'm just going to check the ceiling and went into the resident's bathroom. There were signs on R45's door indicating contact and droplet precautions with illustrations of PPE required to enter the room. On 1/19/24 at 10:00 AM V2 (Director of Nursing) said any staff that enter a room with contact and droplet and precautions ordered should wear mask, eye protection, gown, and gloves when entering the room. If the resident is positive for Covid 19 an N95 mask is required. The Order Report Summary for R45 indicates resident in single room isolation for active infection or suspected infection with symptoms, receiving all care within room. Policy: Infection Prevention and Control Manual Transmission-Based Precautions Revised 12/14/2023 Contact Precautions Procedure: 2. All individuals entering the resident's room must use PPE appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens. Do not wear the same gown and gloves for more than one person. 39781 On 1/17/24 at 12:47PM, Observed V11 (Activity Aide) went inside the R26's room which is contact isolation without donning gloves to serve lunch tray. V11 is wearing surgical mask and gown. Informed V11 of observation made that he did not put gloves when entering contact isolation room. V11 said that he there is no gloves available. V10 (Unit Manager) came and was informed of the above observation made. V10 said that V11 does not need to wear gloves because he will only bring the lunch tray and will not provide direct care. Showed to both V10 and V11 the signage posted at the door entrance indicating of contact isolation requiring hand hygiene, donning mask, gloves, and gown prior entering the room. On 1/17/24 at 12:57PM, Informed V2 (Director of Nursing/Infection Control Coordinator) of the above observation. V2 said that mask, gown, and gloves should be donned prior to entering the contact isolation room. R26 is admitted on [DATE] with diagnosis listed in part but not limited to MRSA (Methicillin- Resistant Staphylococcus Aureus) of the wound. Active physician order indicates: Contact isolation precaution due to MRSA of the wound. Care plan indicates: She is on antibiotic therapy with isolation contact precaution due to MRSA of the wound. Intervention: Monitor isolation set up and replenish supplies as needed. Facility's policy on Infection Prevention and Control Manual Transmission-Based Precautions indicates: Contact Precautions policy: The purpose of contact precaution is to prevent transmission of infections that are by direct (e.g., person to person) or indirect contact with the resident or environment. Procedures: 2. All individuals entering the resident's room must use PPE (Personal Protective Equipment) appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens. Facility's contact precaution sign adopted from CDC (Centers for Disease Control and Prevention indicates: Contact precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: * Put on gloves before room entry. Discard gloves before room exit. *Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. *Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.

Based on observation, interview and record review, the facility failed to post, in a form and manner accessible and understandable to residents, resident representatives including a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups including [NAME] Consent Decree program initiatives. This failure has the potential to affect all 60 residents currently residing in the facility. Findings include: On 11/3/23 at 9:45 AM, V1 (Administrator) informed surveyor of the current facility census which totaled 60 residents. On 11/3/23 at 10:30 AM, Z1 (Program Director for [NAME] Consent Decree Transition Program) stated, I have tried multiple times to call, email, and fax both the Administrator (V1) and Social Service Director (V6) at the facility and in every instance I would get a voicemail and/or I would leave a message directly with the receptionist and would never get a call back from either the administrator or social service director. I tried on June 6th, 7th, 9th, 27th; July 7th; August 3, and 20th. On 10/20 after my visit to the facility I finally obtained the information that we required. Having to wait almost 4 months is unacceptable. The last time, I had to pay the facility a visit and when I was there, both the administrator and social worker were not available to meet with me. I was informed that both were in meetings, and so I left the information that I needed and that is why I reached out to your department to get the facility to send this information once and for all. Observations conducted on 11/3/23 showed no [NAME] Decree information that was posted in any common areas where residents could view information. On 11/3/23 at 12:30 PM, V1 (Administrator) stated that V6 (Social Service Director) no longer was employed with the facility and that V6's last day was in the last week of October and a new social service director was expected to start on Monday 11/6/23. Asked if he received any calls, emails, or faxes from the program director for the [NAME] Program. V1 stated, Yes I did all the way back in June. Asked if waiting close to 4 months to follow through with the request for information was too long. V1 indicated that he did but did not intend to take the amount of time that it should have taken. On 11/3/23 at 12:40 PM, surveyor and V1 (Administrator) walked on the first-floor common area near the elevators where various framed resident information could be viewed. Surveyor asked if there is any posting he can see, or a resident could see pertaining to [NAME] Consent decree. V1 stated, No I do not have any posted [NAME] Decree anywhere here, but I will check and see where I can obtain that. V1 returned several minutes later and showed surveyor a small placard with small writing showing the [NAME] Decree in the front lobby for visitors to see when signing in. Surveyor asked if residents came to the front lobby where the receptionist sat. V1 stated, Mostly visitors and when we have tours but not the residents themselves. I will go ahead and post this information in the other areas now, so it is visible to residents. V1 showed surveyor records of an email dated 9/18/23 from the Program Director of the [NAME] Transition Program requesting for information. Another record provided to surveyor showed the facility sent a fax to said director on 10/19/23.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care and assistance with repositioning for a resident assessed to need staff assistance. This failure applied to one (R311) of four residents reviewed in a sample of 28 reviewed for pressure ulcers. This failure resulted in R311 developing an unstageable sacral pressure ulcer. Findings include: R311 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS (Minimum Data Set) dated 4/22/2022 documents that R311 has a BIMS (Brief Interview of Mental Status) score of 15, indicating a high level of cognitive functioning. R311 requires extensive assistance from two persons physical assist in bed mobility. V10's (Registered Nurse) initial assessment note dated 4/15/2022 indicated that R311 presented with blanchable redness in the sacral area upon admission. V2's (Registered Nurse, Director of Nursing) progress notes dated 4/22/2022 indicated that R311 had superficial sacral deep tissue injury with purple discoloration, measuring 3 cm (centimeters) x 5.5 cm. Unable to find any documentation that wound care nurse practitioner or medical doctor were informed about the deep tissue injury. A week later, V9's (Wound Nurse Practitioner) note dated 4/29/2022 reads, Unstageable pressure sore to the sacrum, measuring 3.8 cm x 6 cm x 0.3cm with 30% slough with defined margins. Re-positioning in the bed and with chair as needed, or per protocol, if patient cannot do it. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/2/2022 at 12:02 PM, R311 was observed in her room, sitting in the wheelchair. R311 is on a low air loss mattress, set up to an alternating mode, and sequential compression device, noted at the foot of the bed. Turn clock schedule seen on the wall above R311's bed. R311 was asked regarding pressure ulcer in the sacral area. R311 stated, This is the third time at this facility and my stay is way worse than the two previous stays. I developed multiple wounds this time. Staff lets me sit in the dirty brief for hours. I know they are shorthanded, but it should be prioritized who needs help first. I had a bowel movement, the day before yesterday and it took them almost two hours to change me. Also, nobody turns me when I'm in the bed, so I try to turn myself. On 5/3/2022 at 9.56 AM surveyor observed wound dressing change on R311. V7 (Licensed Practical Nurse/LPN) described the wound as circle shaped skin opening, was not sure about the size or condition of the wound. V7 checked wound care order and proceeded to perform dressing change. V7 cleaned sacral wound with normal saline, put on Santyl ointment, covered it with oil emulsion dressing and put on a foam dressing as ordered. V7 was interviewed regarding R311's sacral ulcer if it was present during admission. V7 replied, There was nothing, R311 didn't have any wounds at that time. Surveyor asked about repositioning routine, V7 stated, R311 gets her wound dressing changed in the morning, next she is placed via mechanical lift in the wheelchair which has a foam pillow, and then she goes to the physical therapy. Once she's back, she eats her lunch and stays in the wheelchair for the rest of my shift (morning shift, 7AM-3PM). On 5/3/2022 at 10:33 AM, V8 (Certified Nurse Assistant/CNA) was asked how often R311 is repositioned V8 stated, She (R311) is repositioned every two hours unless she is in the wheelchair. She gets repositioned only in the bed. She (R311) is alert and oriented, so she can tell us when she wants to be put back into bed. She uses cushion pillow when she is in the wheelchair, she didn't like the waffle pillow. Surveyor asked if R311 can reposition by herself while in the bed, V8 stated, No, she cannot do it by herself. Surveyor asked how staff keeps track of R311's repositioning, she (V8) stated, CNAs don't chart, we just tell nurses when we reposition residents. On 5/3/2022 at 10:39 AM, surveyor asked V7 (LPN) how staff tracks residents' repositioning times, V7 stated, There is no tracking system for repositioning in the electronic medical record system, we use turn clocks that are placed in residents' rooms. On 5/3/2022 at 11:45 AM, V3 (Nurse Consultant) stated that there is no repositioning policy available in the facility. On 5/3/2022 at 12:25PM R311 was sitting in wheelchair eating lunch. Continuous observations of R311 were made from 12:25PM to 2:35PM and was not observed to be repositioning or receive any incontinence care during this time. On 5/4/2022 at 11:09 AM, V2 (Director of Nursing) was interviewed regarding R311's pressure ulcer. V2 stated, The wound presented as blanchable redness on the sacrum upon admission. I assessed it again on 4/22/22 and it was a Deep Tissue Injury at that time, so I notified V9 (Wound Nurse Practitioner) to further assess it. He gave me orders over the phone and came to assess it on 4/29/22. R311 never complained about any skin issues. On 5/4/2022 at 1:56 PM, V9 (Wound Nurse Practitioner) was interviewed regarding R311 and pressure ulcer. V9 stated, I recommended foam dressing before I saw her for the first time on 4/29/22. I received a text message from the nurse before 4/29/22, don't remember the exact day they texted me. V9 was asked why would R311's wound deteriorates. V9 stated, Turning and repositioning would make a big difference, the wound can deteriorate over night without proper turning and repositioning. Residents should be repositioned whether they are in bed or in wheelchair. Residents should not be in the wheelchair for no more than two hours, my expectation of the staff would be to reposition her (R311) every two hours. Incontinence care is very important as well, stool and urine are really acidic, and it worsens the condition of the wound, it macerates the skin. On 5/4/2022 at 3:20 PM, V2 was again interviewed regarding factors that could worsen a wound. V2 stated, There are multiple factors that play role in wound deterioration, some of them are co-morbidities or limited mobility. Incontinence care is also very important, lack of incontinence care can have a negative outcome pertaining to wounds. Skin exposed to urine and bowel movement deteriorates because of the acidity. Repositioning is very important too. If a resident stays in the same position, they can develop wounds. Repositioning should occur every two hours or as needed, whether a resident is in the bed or in the wheelchair. Surveyor asked about R311 repositioning and incontinence needs, V2 stated, R311 should be repositioned and get checked for incontinence every two hours and changed as needed. Facility's policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . At least daily, staff should remain alert for potential changes in the skin condition during resident care. Skin integrity care plan dated 4/22/2022 reads in part, R311 has actual alteration in skin integrity due to surgical wound on right thigh, DTI (deep tissue injury) on the sacral region. Interventions include but are not limited to teach resident to shift weight in the wheelchair; turn and reposition every two hours and as needed.

Based on interview and record review, the facility failed to provide adequate supervision to prevent a resident from falling during toileting. This failure affects one (R264) out of 4 total residents (R58, R53, R41) who were reviewed for falls in the facility and led to R264 requiring immediate hospitalization with an admitting diagnosis of lumbar fracture. Findings include: R264 was admitted to the facility 1/11/2020 with diagnoses that included cervical fracture, lack of coordination, difficulty walking and generalized muscle weakness. At the time of Admission, R264 had a BIMS of 15 assessed 1/15/22 indicating a high level of cognitive functioning. R264 was admitted to the facility after a fall incident, in which she sustained a cervical spine fracture. According to a Minimum Data Set assessment dated [DATE], R264 used a walker requiring one-person physical assistance for locomotion and required supervision and one-person physical assistance for toileting. On 2/3/2020, R264 fell in the bathroom unattended and was sent to a local hospital shortly after due to complaints of back pain. R264 was admitted that day with a primary diagnosis of lumbar vertebral fracture. 5/4/22 3:27 PM V2 (Director of Nursing) said, most falls can be prevented by educating and asking the resident to call for assistance if they are alert and are able to make their needs known. Everyone is at risk of falls. On admission when the resident is assessed for fall risk, we utilize the assessment guide as a means to monitor for falls. For a patient who has had a history of falls prior to admission and based on their co-morbidities it could contribute to a resident being a high fall risk. If the patients are alert and oriented and want to be provided with privacy, we have to provide it upon request when toileting. If the patient tells us they will call us when they are ready, once we hear the bathroom light, we will check on the patient. On 5/4/22 at 11:47AM V6 (Licensed Practical Nurse) said, residents who use any type of ambulatory (walking) device is considered a high fall risk. We are trained not to leave resident's alone unattended in the bathroom as a safety precaution because they can fall or injure themselves. For residents that are able to toilet, we try to round on them hourly to assist to the toilet if needed. Some things that can contribute to falling is a previous history of falling, their cognitive status and medications. Some medications such as narcotic pain meds can alter their thinking and balance. On 5/5/22 at 10:45AM, V11 (Medical Director) said, if anyone is utilizing a walker, they would be at a higher risk of falling. I would not expect for a resident who is using a walker to be left unsupervised while using the bathroom because they would have a higher risk of falling. Lumbar fractures are significantly painful. Depending on the resident and other factors it could potentially be categorized as a serious injury. Facility fall incident report dated: 2/3/2020 at 3:15AM, reads: R264 was found in the bedroom bathroom sitting on the floor. In the report, it indicated that R264 ambulated to the bathroom using a walker without assistance. Nursing Progress note dated 2/3/2020 read: Patient noted to be using the bathroom at 3:12AM without calling for assistance. Writer encouraged patient to call for assistance when done. At 3:15AM, writer heard a noise in the patient's room from the nursing station. Writer responded immediately and entered the bathroom, noted patient on the floor sitting down. R264 Physician Order Sheet dated: January 2020. Resident had orders for narcotic pain medication [MEDICATION(S)]-acetaminophen 10-325mg 1 tablet every 6 hours as needed for pain dated 1/13/2020. R264 also had an order for hypnotic medication [MEDICATION(S)] 2.5 mg as needed every night for [CONDITION(S)] dated 1/30/20. Review of Medication Administration Record dated 02/03/20 notes that R264 was given a dose of [MEDICATION(S)]-acetaminophen 10-325mg at 3:09PM prior to when the fall incident occurred. R264's care plan dated 1/11/20 reads: R264 had limited functional transfer skills with transferring to the toilet indicating that she was not at the highest level of independence for toileting. R264 also care plans for impaired ambulatory skills and limited transfer skills with interventions that include lower leg strengthening. Care plan initiated 1/11/20 stated that R264 was high risk for falls with goal to be free from injury from falls. Facility fall management program updated 08/20 states in part, the facility is committed to minimizing resident falls and /or injury so as to maximize each resident's physical, mental and psychosocial wellbeing.It is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Management of falls policy updated 8/20 states in part; Risk factors may include but are not limited to the following: Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's, gait/transfer/balance issues, behaviors, and/or cognitive status.

Based on observation, interview, and record review, the facility failed to ensure that a resident is monitored, and incontinence care is provided every two hours for one (R311) of one resident in the sample of 28 reviewed for incontinence care. Findings include: R311 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per MDS (Minimum Data Set) dated 4/22/2022 under Section H, reads in part: R311 is always incontinent of urine and bowel. On 5/02/2022 at 12:02 PM, R311 was observed in room, sitting in the wheelchair at the side of her bed. R311 was asked regarding changing. R311 said, This is a third time at this facility and my stay is way worse than the two previous stays. I developed multiple wounds this time around. Staff lets me sit in the dirty brief for hours. I know they are shorthanded, but it should be prioritized who needs help first. I had a bowel movement, the day before yesterday and it took them almost two hours to change me. V10 (Registered Nurse) initial assessment note dated 4/15/2022 indicated that R311 presented with blanchable redness in the sacral area upon admission. V2 (Registered Nurse, Director of Nursing) progress notes dated 4/22/2022 indicated that R311 had superficial sacral deep tissue injury with purple discoloration, measuring 3 cm (centimeters) x 5.5 cm. No documentation observed that the Nurse Practitioner or Medical provider were notified of the deep tissue injury. A week later, V9 (Wound Nurse Practitioner) note dated 4/29/2022 reads, Unstageable pressure sore to the sacrum, measuring 3.8 cm x 6 cm x 0.3cm with 30% slough with defined margins. Bladder Incontinence care plan dated 4/22/2022 reads in part, R311 experiences bladder incontinence related to Overreactive Bladder. Interventions include but are not limited to change clothing PRN and after incontinence episodes; check resident for incontinence; provide incontinence care after each episode of incontinence; wash, rinse, and dry perineum with incontinence care. On 5/3/2022 at 9:56 AM, incontinence care was observed on R311 by V8 (Certified Nurse Assistant/CNA). The brief was heavily soaked with urine during incontinence care. R311 groins observed to be grossly red and irritated. On 5/4/2022 at 10:16 AM, R311 was asked on when her incontinence brief was changed. R311 said, They changed me earlier this morning and placed me in the wheelchair. They usually change me in the morning and in the evening before I go to bed, and then not again until next morning. I get changed twice a day. I don't get checked in between. I also get changed when I have a bowel movement, that would be additionally to the morning and evening diaper change. On 5/4/2022 at 10:38 AM, the surveyor inquired about R311's incontinence care. V8 (Certified Nurse Assistant) said, I checked R311 every two hours, but she is alert and calls us to get changed even if less than two hours. She was last changed around 7:00 AM today. I also checked her when she was getting dressed, after she finished breakfast. Continuous observation made on 5/3/2022 from 12:25 PM to 2:35 PM indicated that no staff monitored R311 for incontinence care. On 5/4/2022 at 1:56 PM, V9 (Wound Care Nurse Practitioner) was interviewed regarding R311 and pressure ulcer. V9 said, I recommended foam dressing before I saw the patient for the first time on 4/29/22. I received a text message from the nurse before 4/29/22, don't remember the exact day they texted me. V9 was asked why R311's wound deteriorates. V9 said, She (R311) has overactive bladder. Incontinence care is very important, stool and urine are really acidic, and it worsens the condition of the wound, it macerates the skin. On 5/4/2022 at 3:20 PM, the surveyor asked V2 (Director of Nursing) about factors that could worsen a wound. V2 state there are multiple factors that play role in wound deterioration, some of them are co-morbidities or limited mobility. Incontinence care is also very important, lack of incontinence care can have a negative outcome pertaining to wounds. Skin exposed to urine and bowel movement deteriorates because of the acidity. R311 should be repositioned and get checked for incontinence every two hours and changed as needed. On 5/5/2022 at 9:50 AM, V1 (Administrator) was asked to present a facility's incontinence policy. V1 indicated that there is no incontinence care policy available in the facility.

Based on observation, interview and record review, the facility failed to identify rooms that would be utilized specifically for Covid positive residents, failed to ensure that housekeeping personnel prevented cross contamination between Covid/non Covid residents and failed to ensure that housekeeping staff utilized disinfecting agents per manufacturer specifications which affected three residents (R2, R4, R5) and has the potential to affect all 31 residents in the facility. Findings include: On 11/16/20, V1 (Administrator) indicated that the facility had 31 residents. V1 and V2 (DON-Director of Nursing) indicated that the facility currently had eight residents that were positive for Covid and four residents that were on quarantine for 14 days as they were readmissions from the hospital with possible exposure to Covid. V2 stated that 11 of the 12 residents were located on the 3rd floor which is the isolation floor. R3, R4, R6, R7, R8, R9, R10 and R11 were all identified as Covid positive residents that reside on the 3rd floor. During the tour of the 3rd floor, there was no designated area for the Covid positive residents. R3, R4, R6, R7, R8, R9, R10 and R11's rooms were interspersed with rooms of quarantined residents that had no symptoms and rooms of residents that were recovered/waiting to be transferred to the 2nd floor. There were signs on the doors indicating Contact/Droplet precautions but there was no delineation of which residents were Covid positive. R4 was identified by the facility as Covid positive. On 11/16/20 at 11:55am, V5 (Housekeeper) entered R4's room wearing a gown, gloves, mask and face shield. At 12:00pm, V5 opened the door, exited passed the threshold of the door and came into contact with the housekeeping cart to retrieve items while wearing the same gloves. It was noted that V5 sprayed the door knobs and light switch with a disinfectant spray and wiped immediately. V5 placed mop on cart without disinfecting the handle. V5 brought the vacuum out of R4's room, unplugged the cord, dragged the cord across the floor and wrapped the cord around the vacuum. V5 did not disinfect the cord. V5 also came into contact with a secured compartment on cart, using the same gloved hands to lock and unlock the compartment. At 12:14pm, V5 entered R2's room after donning personal protective equipment (PPE). R2 was identified by V6 (RN-Registered Nurse) as quarantined without symptoms because R2 was readmitted from a hospital on [DATE]. At 12:18pm, this surveyor knocked on R2's door and observed V5 in R2's bathroom with a gown and gloves on but with her face shield and mask off talking on her personal phone. V5 continued to clean R2's room with the same PPE on. V5 removed garbage from the bathroom/room and came into contact with her cart to dispose of the garbage using the same gloves. V5 used the same gloves to access the secured compartment with keys that she retrieved from her pocket. V5 removed two bottles of disinfectant spray. V5 sprayed the bathroom surfaces and wiped them immediately. V5 cleaned the toilet and handled the disinfectant bottles with the same gloves. At 12:20pm, V5 came into contact with the cart again while using the same gloves. V5 removed a garbage liner and placed it inside the bathroom garbage can. V5 came in contact with the cart again to get a clean cloth to wipe down the dressers. V5 sprayed all the high touch surfaces in the room and wiped them down immediately after spraying. There was no contact time as per manufacturer specifications. At 12:27pm, V5 came into contact with R2's overbed table and touched R2's personal items with the same gloves that she used to wash the bathroom. At 12:30pm, V5 came back out to cart using the same gloves to retrieve mop, mopped quickly and placed the mop on the cart. V5 removed the mop head but did not sanitize the mop handle. At 12:32pm, V5 handled the vacuum and used the same gloves to handle it. After vacuuming, V5 unplugged the vacuum and dragged the cord along the floor. V5 wrapped the cord around the vacuum and placed it in the hallway without disinfecting it. At 12:38pm, V5 went directly to R5's room who staff identified as Covid negative. V5 spent 12 minutes in room using all the same products/cleaning items that were used in the isolation rooms. On 11/16/20 at 12:50pm, V5 stated, I go to any floor. It depends where I'm needed. I use (name retracted) disinfectant spray for the bathrooms. This is only used in the bathroom to clean the sink, and the handrails and the faucet. Yes, it's one minute contact time. I guess it's supposed to be on there for one minute before I wipe. (A disinfectant spray) is used for door knobs, handles, light switches, remotes, dressers, controls on bed, overbed tables. This is also supposed to be on there for one minute before I wipe. I don't have a pattern of whose room I clean first. I start and I just go down the line. No pattern for Covid rooms and Non Covid rooms. V5 further stated, I use same gloves from beginning to end because I'm just cleaning. On 11/16/20 at 3:49pm, V7 (Building Manager) indicated that the disinfectant spray for the bathrooms requires a contact time of two minutes. V7 stated, They are to spray the items with the disinfectant, wait two minutes and then wipe down the residue. If wipe down before two minutes, then they're not sanitizing area correctly or killing the bacteria effectively. V7 indicated that the disinfectant spray used for high touch areas has the same contact time of two minutes otherwise the bacteria will still be on that surface if the housekeepers don't wait the required time. V7 indicated that all isolation rooms should be done in a block. V7 stated, So all Covid rooms (cleaned) together to ensure that you have enough supplies and disinfect the cart then do the non isolation rooms. Need to prioritize, to not infect other residents. The facility submitted a document titled, Approved Disinfectants Available with Covid19 Kill Claims, that listed the two disinfectant sprays that the facility utilized, which documents: Cleaner LD: COVID Kill time - 10 minutes. Cleaner O: COVID Kill time - 5 minutes. On 11/16/20 at 4:30pm, V1 (Administrator) stated, There is no policy on how to clean isolation rooms. It's just best practice to clean all the isolation rooms first and then the non isolation rooms to prevent cross contamination. The plan is to start off day and clean non Covid rooms and then end the shift cleaning the quarantine rooms and then the Covid rooms. This will ensure that we are preventing cross contamination between infected rooms and non infected rooms. Initially, we didn't zone our Covid and non Covid residents because corporate didn't think we needed to and did not tell us to. But I think it's something that we will look into moving forward to try to prevent cross contamination. On 11/16/20 at 4:35pm, V1 confirmed that R3, R4, R6, R7, R8, R9, R10 and R11 tested positive for Covid while in the facility. V1 stated that of the eight residents that tested positive, none of them left the building or the premises in the 14 days leading up to their positive test result for Covid. On 11/16/20 at 2:23pm, V2 (DON-Director of Nursing) stated, Yes, all eight residents that were Covid positive when you entered the building on 11/16/20 contracted Covid here in the facility. None of those residents left the premises prior to contracting [MEDICAL CONDITION] here. V2 further stated, We started doing zoning. One wing will be Covid dedicated, 2nd wing will be for the quarantine residents and 3rd wing will be recovery. Corporate discussed zoning with us but did not say it was a requirement. We also inserviced the housekeeping staff on cleaning Non Covid rooms first then the quarantined rooms and then the Covid + rooms. A facility policy revised 5/8/2020 and titled, COVID-19 CONTROL MEASURES (ENVIRONMENTAL SERVICES) documents: GUIDANCE: The facility is committed to reducing the spread and transmission of COVID-19 and will continue to follow all guidance and recommendations from the CDC (Centers for Disease Control), state and local health departments. ENVIRONMENTAL SERVICES: 2. Educate and observe practice on appropriate disinfection (clean to dirty, appropriate dwell time, when to switch cloths and wipes, etc.). 3. Ensure cleaning and disinfection policies and procedures are being followed consistently and correctly.

Based on interview, and record review, the facility failed to obtain an order for [REDACTED]. Findings include: 1/23/2020 10:00 AM V6 (Social Services Director) said, when a resident signs a POLST (Practitioner Order for Life Sustaining Treatment, the nurse is notified to get an order re: resuscitation status. The code status is updated in the computer in the care pro file next to the picture. The POLST is signed by the doctor or the NP (Nurse Practitioner) and uploaded into miscellaneous file. (R45) signed a POLST and chose DNR (Do Not Resuscitate). She shouldn't have an order for [REDACTED]. 1/23/2020 10:10 AM V7 (Registered Nurse) said, if a resident arrests we check the computer or the front of the chart for the code status. For (R45) the order and the care plan profile say resuscitate. I would also check the front of the chart. 1/23/2020 10:15 AM V8 (Licensed Practical Nurse) said, I put the orders in when (R45) came back from the hospital. The hospital order read Advance Directives, is patient DNR: No. So I made her a full code. 1/23/2020 11:00 AM V2 (Director of Nursing) said, I know there was a problem with (R45) when she came back from the hospital. We have corrected it. I don't know what (R45) told them at the hospital when they asked about advance directive. She may have told them that she didn't have an advance directive. When she came back to the facility the nurse copied the orders that she was on at the hospital. She was listed as no advance directive, full code. The physician order [REDACTED]. The POLST form signed by R45, dated 10/23/19, reads Do Not Attempt Resuscitation/DNR. A policy titled Advance Directive/Life Sustaining Treatment reads 4. If a decision has been made, the Social Service Director/designee will document the decisions on the Advance Directives Assessment in the Electronic Medical Record (EMR). Additionally, any documentation received from the resident/resident representative will be documented and scanned into the EMR, and copies will be filed in the clinical record.

Based on observation, interview, and record review, the facility failed to follow the nutrition plan of care, which resulted in significant unplanned weight loss for two residents (R16 and R17) reviewed for nutrition and weight loss. R16 was admitted to the facility 12/06/19. R16's current nutrition care plan documents (R16) requires a mechanically altered diet secondary to chewing and swallowing problem. Interventions include feed slowly and give resident time to chew and swallow, monitor for signs and symptoms of aspiration or choking, provide tray set and and assist as needed for meals. 01/21/20 at 12:30 PM V10 (Certified Nursing Assistant - CNA) began feeding R16 while standing up and not directly communicating with R16. Observed R16 coughing and gagging frequently during her meal. 01/21/20 from 12:46 PM - 1:04PM V10 (Certified Nursing Assistant - CNA) left R16 to eat her meal without assistance. R16 only ate 15-20% of her lunch; at 1:00PM, when her tray was taken, (R16) asked for something sweet and was given a pudding to eat without assistance. 01/22/20 at 12:15 PM V11 (Certified Nursing Assistant - CNA) stated, R16 has to be watched carefully during meals because if you leave her with her tray she will not touch her food. V11 stated that R16 has to be fed very slowly because she has episodes of coughing and choking while eating. Observed R16 coughing frequently during her meal. 01/23/20 at 10:18 AM V4 (Speech Therapist) stated R16 needs set up and needs to be repositioned before and during her meals. V4 stated that R16 has had past dysphagia (difficulty swallowing) and currently has oral dysphagia. R16's weight records document R16's weight at 113lbs 12/13/19 and 105lbs 1/03/20 totaling a -7.09% weight loss in 3 weeks. R16's comprehensive nutritional assessment documents R16 is on a mechanical soft diet, needs meal assistance including tray set up and independent to total dependence and is needs to be fed. R16's admissions MDS (Minimum Data Set) dated 12/13/19 documents limited one person physical assist. The facility's feeding a resident policy documents: tell the resident that you are going to be seated during the feeding, staff to position a chair where it will be convenient for both them and the resident season the resident's food according to his or her likes and in accordance with the resident's diet encourage resident to participate in feeding encourage the resident to eat all his or her meal encourage and engage in resident centered conversation. R17 was admitted to the facility on [DATE] R17's dietary/nutrition care plan documents R17 requires nutritional support related to a mechanically altered diet, and poor to moderate intake of meals. Interventions include: assist with meals as needed,obtain food preferences and update at least annually, seat patient upright during meals, set up resident's tray and provide assist or cueing for meals as needed. 01/21/20 at 01:04 PM R17 ate a few bites of orange cream frozen supplement, half her mechanical soft meat, and a few bites of pureed vegetables. R17 did not eat any mashed potatoes. There was no staff present while R17 ate her meal. 01/22/20 at 11:41 AM V5 R17's family member stated that when she comes in in the morning she see's R17 eating by herself and she doesn't eat the food. V5 stated R17 won't get well if she's not going to eat. V5 stated that R17 doesn't like the facilities food and doesn't eat it. Observed R17 eating cultural food brought in from V5 and did not touch the food provided by the facility. 01/23/20 at 09:56 AM V3 (Dietician) stated that R17's family primarily brings her food and that the approved menu does not have a puree recipe available to prepare the puree according to R17s cultural preferences. V3 stated that R17s family brings her meals she prefers and they have been instructed to encourage R17 to eat. V3 stated that R17 does need assistance with eating and encouragement. V3 stated that it is possible to locate a puree recipe that meets her cultural preferences and the approved menu requirements on a case by case basis but this has not been done for R17 at this time. 01/23/20 at 10:11 AM V4 (Speech Therapist) stated that R17 has a history of esophogeal dysphagia and has had her esophagous stretched to allow more food to pass but it the results of the procedure are temporary. V4 stated that R17 had a video swallow about 4 weeks ago and went to the gastrointestinal physician on (MONTH) 13th. V4 stated that R17's reflux medication was increased to twice a day. V4 stated that due to her condition she is at risk for coughing and choking if consuming foods that are not pureed. V4 stated R17 only needs set up and can eat by herself safely with puree and thin liquids. R17s weight summary notes document R17's weight at 119.2 pounds 12/09/19 and 108.6lbs on 1/09/20 totaling an -8.89% body weight loss in 30 days. R17's weight change progress note dated 1/1/2020 documents R17 has a -9.56% weight loss in 1 month, fluctuating oral intake of meals. R17s comprehensive nutritional assessment dated [DATE] documents R17 has poor intake of meals, is on a pureed diet and has swallowing difficulty, needs meal assistance including feeding assistance and total dependence-extensive assist.

Based on observation, interview, and record review, the facility failed to ensure the use of gloves while feeding ready to eat food for one (R352) of 17 residents reviewed for dining. Findings include: 01/21/20 at 01:15 PM V9 (Certified Nursing Assistant) used her bare hand to pick up grilled cheese sandwich and feed it to R352. 01/21/20 at 1:40 PM V9 said, I washed my hands first. I always wash my hands and then feed the patients. 01/23/20 at 1:40 PM V2 (Director of Nursing) said, the CNA should perform hand hygiene and be sitting down. They should not use bare hands on finger food. A policy titled Disposable Gloves (undated) reads: Disposable gloves will be used when manual contact with ready-to-eat is unavoidable.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures to ensure the proper dishwasher sanitation temperatures and chemical concentrations in their 3-compartment sinks to prevent the spread of food-borne illnesses. These failures have the potential to affect 60 residents receiving oral diets in the facility. Findings include: CMS Form 672-- Resident Census and Condition of Residents dated 11/20/17 shows 61 residents. Of the 61 residents, 60 were receiving oral diets from the kitchen per E3 (Director of Nursing). On 11/20/17 at 9:45 AM during the initial kitchen tour, E10 (Dietary aide) was asked how he tested the sanitization efficacy of the dishmachine. E10 pointed to the temperature gauges on the dishmachine and stated, I write down the temp and put them in the log. Asked what else he did, E10 stated, Oh and we use test strips too. Asked when he used test strips for the dishwasher, E10 stated, I did it last week. Asked where the log was to show the dishwasher was tested using the test strips, E10 stated, We don't keep them, do you want me to test it now? E10 conducted the test using the test strip and ran the dishwasher through the entire wash and rinse cycle. E10 showed the surveyor of the test using the test strip. E10 was asked about the results of the strip and stated, The strip should turn black. Asked what color the strip turned, E10 said, It's gray sir. It should turn black. E10 conducted the test again using a fresh test strip, placed it on plate and onto a rack and ran the dishmachine through the entire wash and rinse cycle. E10 again was asked to read the results of the test. E10 showed the strip to the surveyor and stated, It's still gray sir. Asked what he'd do next, E10 stated, I don't know. The surveyor asked E10 to inform E11 (Dietary Manager) who remained in the dietary office while surveyor was in the kitchen. E10 was then asked about the three compartment sink where pots and pans and other utensils were observed drying on a shelf, E10 stated, There's chemicals I put in the sink. Asked how he tested the three compartment sink for sanitizing efficacy, E10 showed surveyor a test strip which he dipped into the sanitizing sink and showed the surveyor the strip. E10 stated, It turned green for 300 PPM (quaternary ammonium), it should turn brown for 200 PPM but 300 PPM is better. Asked what results he is looking for, E10 stated, I was told it should turn brown to be 200 PPM but it's green for 300 PPM. On 11/21/17 at 3:20 PM, E1 (Administrator), E2 (Assistant Administrator) were informed of the dietary concerns and asked to provide the sanitation logs for the dishwasher and three compartment sink. Sanitizing logs titled Dish machine ppm Log dated September 2017, October 2017, and November 2017 all show for breakfast, lunch and dinner, the 3 compartment sinks log read 200 ppm recorded when tested for the 3 month period. Asked about the 3 compartment sink logs reading 200 ppm for 3 consecutive months for every shift, E1(administrator) stated, Yes, I noticed that and found it odd it was 200 ppm each time. Facility policy and procedure titled Operation of the Three Compartment Sink dated 2/2011, states, Policy: The dietary staff will correctly operate the three compartment sink. Procedure: 1. Clean sinks before use. 2. Set-up the 3-compartment sink in the following manner: a. Fill the wash tank with warm water and detergent. b. Fill the rinse tank with warm water. c. Fill sanitizing tank with warm water and sanitizer; chlorine at 50 ppm, iodine at 12.5 ppm or quaternary ammonium at 200 ppm. 3. Depending on the sanitizing agent used- test with the appropriate test strip. Dip the test strip into the sanitizing solution for a minimum of 10 seconds. Compare the color of the strip with the recommended ppm. If the solution is too weak add more sanitizer. if the solution is too concentrated dilute by adding water. Retest sanitizing solution regularly. Facility policy and procedures titled Operation of the Dishmachine does not directly address the use of test strips to determine sanitizing efficacy. Asked about this policy, E1(administrator) stated, They're supposed to be using the test strips.

Based on observation, interview, and record review, the facility failed to use a mechanical lift with 2 staff assistance during transfers for 1 resident ( R2 ) out of 3 residents reviewed for falls in the sample of 10. This failure resulted in a laceration to R2's left lower leg which resulted to ER visit and suturing. Findings include : R2 was admitted to the facility with [DIAGNOSES REDACTED]. R2's Minimum data Set ( MDS ) dated 9/12/12 and 12/13/12 indicated that R2 needs extensive assistance of 2 or more staff during transfers. These 2 MDS's also showed that R2 is non- ambulatory. R2's 12/13/12 care plan also indicated that R2 requires use of mechanical lift for transfers with 2 staff assistance. On 2/15/13 at 11:15 AM, E6 ( certified nurse assistant / CNA ) said that on 2/14/13, he was assigned to R2. E6 said that he knew that R2 needed a mechanical lift with 2 staff assistance, but was in a hurry to get R2 up in his wheelchair. E6 said that he did not call for any staff to help him, and manually lifted R2 from bed to wheelchair by himself. E6 added that afterwards, when he was about to wash R2's face, he saw that he sustained a laceration on his left lower leg. E6 said that when he looked at the sharp metal part of the wheelchair where the left leg rest is normally attached, E6 noted some blood in there. E6 said that R2's left lower laceration must have came from that sharp metal part of his wheelchair during transfer. On 2/15/13 at 9:16 AM, E7 ( CNA ) also said that a mechanical lift with 2 - 3 staff is always used to transfer R2. E7 explained that one person operates the lift, one holds and guides R2's back area, and if R2's legs are stiff, another staff is needed to hold R2's legs to avoid accidental hitting of the lift bar. E7 said he never heard of R2 being transferred without a lift and with only one person assist. E7 further added that the staff gets inservice about mechanical transfers using 2 staff online and at the facility, the latest one being a month ago. Facility's Hydraulic Lift Policy indicated that during mechanical transfer, staff should be on each side of the lift. On 2/15/13 at 8:45 AM, E2 ( Director of Nursing ) confirmed that mechanical transfers always involve 2 staff members. E2 also said that R2 needed a mechanical transfer because R2 is non - ambulatory. On 2/14/13 at 1:50 PM, R2 was observed in the wheelchair after ER visit with a dressing on his left lower leg. When the dressing was removed by Z1 (facility consultant), the laceration was noted with sutures and is sideways from the anterior left lower leg just below the left knee, extending towards the back of the calf of the left leg. R2's nurses note on 2/14/13 at 9:23 PM, indicated that R2's left lower leg laceration was measured at 11 x 0.1 x 0.1 cm.

Based on observations, record reviews and interviews the facility failed to provide medical care to rule out gangrene for 1 of 4 residents (R10)and failed to have dietary interventions for 2 of 4 residents (R3 and R10) reviewed for pressure in a sample size of 14. There are 6 residents identified by the facility as having pressure sores. R3's and R10's pressure sores worsened in condition and characteristic. Findings Include: 1. R10 was observed on 1-20-12 at approximately 10:30am sitting in his wheelchair. R10 told facility staff that he will not allow surveyor to see pressure sore sites because it hurts and the doctor will be in shortly. Clinical record review shows R10 is a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to weekly skin assessments dated 12-16-11, R10 acquired a Stage II pressure ulcer on his right heel measuring 1cm (centimeter) x 1cm x 0.1cm. The wound was assess with 90% granulation and 10% [MEDICATION NAME] cells. Weekly skin assessment dated [DATE] notes an increase in size to 2.1cm x 3-2cm x 0.1cm with 30% slough and 60% granulation. The weekly notes dated 1-6-12 notes an unstagable wound measuring 3cm x 4cm x 0.1cm Weekly skin notes dated 1-13-12 notes further increase in size of 4.2cm x 4.0cm x .1cm. Physician orders [REDACTED]. Z2 (Wound Nurse, Nurse Practitioner) on 1-19-12 at 1:45PM explain that the reason for the order for R10 to see a Vascular Surgeon is because the wound was not healing and getting worse. Z2 went on to say that the characteristics of R10 wound was black with gray around the edges which could be a sign of gangrene. Z2 stated that further assessments are needed to get a definitive [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Z3 ( Attending Physician) explained on 1-19-12 at 2:30PM that the reason R10 was sent out to the emergency room was to see a group of physician to determine a [DIAGNOSES REDACTED]." E10 ( Staff Nurse) stated on 1-19-12 that she was waiting for the family first before making the appointment for R10 to see the Vascular Surgeon, so the order was not carried out. E2 ( Director of Nursing) reviewed the clinical records and found no consultation records from the emergency room and then assisted E10 with making the appointment for R10 to see the Vascular Surgeon. Review of R10's dietary's records dated 12-16-12 does not mention R10's pressure sore. E5 ( Registered Dietician) on 1-19-12 at 2:00PM in the conference room, explain that the policy at the facility is to only see the patients monthly with pressure sores and it was followed. E5 had no comments regarding a policy for dietary responsibility if there is a change in condition related to pressure sores or the development of pressure sores. Review of the facility's pressure ulcers policy notes the following: "Residents with pressure ulcers should be monitored monthly until all areas of skin have healed." 2. During observations on 1-18-12 at 2:00PM with E10 (Staff nurse), R3 is alert and oriented and able to follow directions. Direct observations of R3's sacral pressure sores shows a small wound with drainage. Admission records states R3 is [AGE] year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of R3's weekly skin records shows the following: on 12-17-11 the size of the sacral pressure sores was 0.9cm (centimeter) x 0.9cm x 0.1cm with exudates. Weekly skin notes dated 12-23-11 notes an increase in size and depth to 1.0cm x 0.9cm x 0.2cm and 100% slough. On 1-6-12 a surgical debridement was done to enhance healing. Review of the Physician order [REDACTED]. Z2 stated on 1-19-12 at 1:45PM that she ordered the nutritional supplements because R3 required additional help for healing and nutritionally her [MEDICATION NAME] level (protein level) is low at a 3.4. Z2 stated that for wound healing she prefers protein level to be 3.5. E5 (Registered Dietitian) stated on 1-19-12 at 2:30PM that she follows the protocol of the facility which is monthly assessment for residents with pressure sores. E5 went on to say that since R3's wound had gotten worse "I should have caught it but the protocol is monthly assessment." E5 had no comments as to failure to address the deteriorating wound status at dietary assessment done on 1-4-12. E5 did nothing until after new recommendations were made by Z2 on 1-15-12.