Every finding on record at American Lutheran Home-Menomonie

Based on record review and interview, the facility did not notify the Ombudsman of a resident who was transferred from the facility to a hospital for 1 of 3 residents (R) (R1) reviewed. The facility policy, titled Notification of Changes, dated 03/32/2017, states, The facility will notify the proper parties when changes occur. Under Section 5(a)(1) states in part, The facility will send a copy of the notice to a representative of the office of the State Long-Term Care Ombudsman program when there is an appeal to the discharge decision. R1 was admitted to the facility on [DATE]. On 06/27/25, R1 had a change in condition and was transferred to the hospital. A Bedhold and Notice of Transfer form was provided to R1. On 08/26/2025 at 2:58 PM, Surveyor requested Ombudsman notification of hospital transfer with return anticipated. Social Services C stated a notice was not able to be located for the notification to the Ombudsman for R1's hospital transfer. On 08/27/2025 at 10:47 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who indicated there are different reports in the system involving transfers and discharges and believes the incorrect form that didn't include hospital transfers was sent to Ombudsman and are currently looking into issue at this time. Notice to the Ombudsman was not provided to the Surveyor.

Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition post procedure. This occurred for 1 of 4 residents (R15) reviewed for physician notification and consultation. R15 presented with new symptoms of lethargy and fever post ureteral stent placement. Staff did not immediately notify R15's provider of this occurrence resulting in actual harm when R15 was found unresponsive and admitted to the hospital 12/07/23 - 12/13/23, with a diagnosis of sepsis (a serious condition in which the body responds improperly to an infection) secondary to acute (sudden onset) pyelonephritis (a type of urinary tract infection where one or both kidneys become infected), acute hypoxic respiratory failure (happens when you don't have enough oxygen in your blood), and acute metabolic encephalopathy (caused by a chemical imbalance in the blood. The imbalance is caused by an illness or organs that are not working as well as they should). Findings include: The facility policy entitled, Change in a Resident's Condition or Status, dated 6/17/19, states: .Our facility shall promptly notify the resident, his or her attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition .The nurse will notify the resident's attending Physician or on-call Physician when there has been: .a significant change in the resident's physical/emotional/mental condition; instructions to notify the Physician of changes in the resident's condition .A significant change of condition is a decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than one area of the resident's health status; .ultimately is based on the judgment of the clinical staff and the guidelines outlined in the resident assessment instrument and 42 CFR 483.20(b)(ii) . Monitoring Protocol Post Procedure includes: After readmission to the facility postoperatively, the physician and staff will maintain appropriate communication with the referring surgeon to ensure that the resident receives adequate postoperative care and that the staff and attending physician receive relevant medical information . The staff and physician will monitor for and address postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal, urosepsis from indwelling catheters inserted in the hospital, delirium, depression, etcetera. R15 was admitted to the facility on [DATE], and had diagnoses that included in part, dementia, epilepsy, diabetes, urinary tract infection, and kidney stones. R15 had a ureteral stent placed on 12/05/23 as an outpatient procedure and returned to the facility the same day. On 12/07/23, R15 was sent from the facility to the hospital and admitted with diagnoses of sepsis secondary to left acute pyelonephritis, acute hypoxic respiratory failure, and acute metabolic encephalopathy. R15 returned to the facility on [DATE]. R15's care plan, dated 12/20/23, states: .The resident has a history of Urinary Tract Infection (UTI), sepsis due to pseudomonas bacteremia with left sided pyelonephritis, recurrent kidney stones, recurrent cystitis. Interventions include: The resident's urinary tract infection will resolve without complications by the review date. Encourage adequate fluid intake. Give antipyretics, analgesics, and antispasmodics as ordered/PRN (as needed). Monitor/document for side effects and effectiveness. Monitor/document/report to MD (Medical Doctor) PRN for signs or symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated . R15's care plan, dated 10/15/22, states: .The resident has chronic mixed bladder incontinence related to loss of peritoneal tone, use of antidepressant, antianxiety, and antipsychotic medications, diabetes, weakness, chronic dysuria, kidney stone lithotripsy, and JJ stent placement 12/5/23 urinary retention, UTI history. Interventions include: [R15] will often refuse to ambulate to bathroom but will inform staff of when her incontinence product needs to be changed. Clean peri-area with each incontinence episode. R15's orders: Nitrofurantoin Macrocrystal Oral Capsule 100 MG (Nitrofurantoin Macrocrystal) Give 100 mg by mouth two times a day for urinary tract infection for 7 Days. Start 11/30/2023. End 12/7/2023. This antibiotic was prescribed prior to R15's ureteral stent placement and continued through until the hospital admission on 12/07/23. R15's urine culture collected 11/28/23 indicated Escherichia Coli. R15's urine culture collected during the hospitalization on [DATE] indicated Pseudomonas Aeruginosa. Prior to stent placement: 11/22/2023 Resident had a preop visit today. Okay to proceed to surgery. Medically optimized. Procedure is 12/05/23. Prior to the procedure, R15 was clinically cleared to have the ureteral stents procedure completed. Prior to the ureteral stent procedure, R15 had no difficulty with lethargy, fevers, nausea/vomiting, hypoxia, or mentation. Post stent placement: R15's nursing note on 12/5/2023 at 12:43 PM: Resident returned from procedure for ureteral stent placement at 12:45 PM. R15's after visit summary for ureteral stent placement dated 12/05/23: .Seek emergency treatment if you experience: inability to urinate, chest pain, shortness of breath. Call your provider if you experience: Temperature greater than 100.4, pain not relieved by medication, wound swelling/bleeding/redness, foul smelling/pus-like drainage, persistent dizziness or light headedness, urine is ketchup colored or you have large clots, opening of the stitches or wound edges even after sutures have been removed, rash, calf pain redness or firmness in your leg, heavy bleeding, nausea/vomiting . R15's nursing note on 12/6/2023 at 11:01 AM (late entry): Resident very lethargic at 8:00 AM, needed assist with taking of medications, spoon fed and then handed glass of water x 2, this writer stayed in room while resident took medications, temperature at 9:15 AM 101.2 room heat on very warm in room and resident covered with numerous blankets, resident received scheduled APAP (Tylenol) at 8:30 AM, pulse 100, respiratory rate 16, oxygen sats 90% on room air non labored and regular breaths, blood pressure 137/68 skin warm, dry and flushed, rechecked temp at 9:40 AM 100.1, rechecked temp at 10:30 AM 100.9 rechecked temp at 11:00 AM 100.4 resident responding to name and making eye contact, encouraged to drink fluids, skin warm dry and pink. *Note: R15 was post ureteral stent placement on 12/5/23 and became very lethargic with a temperature of 101.2 despite Tylenol given 45 minutes earlier. Post procedure orders were to call the provider for a temperature greater than 100.4. The facility failed to call the provider to notify of these signs and symptoms. R15's nursing note on 12/6/2023 at 6:12 PM (late entry): At 3:30 PM, resident's temp was 98.0. She was shaking and stated she was having pain. PRN Tylenol was administered. At 4:00 PM, resident had emesis x 3 followed by dry heaving. Vitals at 4:00PM: Temp 98.0, BP 148/82, HR 121, RR 18, O2 92. Doctor on call was notified. Order a change to tramadol from 50mg Q4H to 25mg Q6H with same end date of 12/08. Also ordered Zofran 4mg ODT Q8H for nausea/vomiting. At 5:00 PM vitals were: Temp 97.7, BP 142/76, HR 122, RR 18, O2 92. Resident appearing more alert and shaking ceased. Drinking water but no hunger for food at this time. R15's vital signs on 12/06/23 at 8:10 PM: Oxygen saturation 94% room air, blood pressure 138/72, pulse 124 beats per minute / regular, respiratory rate 16 breaths/minute, temperature 98.1 degrees Fahrenheit. R15's nursing note on 12/6/2023 at 9:03 PM (late entry): At 8:30 PM VS (vital sign) stable, except HR (heart rate) was 124. Resident states she is feeling better and did take her HS (hour of sleep) meds. She is encouraged to drink fluids and notify staff if she is feeling nauseated or unwell. *Note: Pulse of 124 is abnormal. Normal range 60-100. The facility did not notify the provider that there was no improvement as the pulse was still elevated at 124 beats per minute four hours after notification was made to the provider at 4:00 PM earlier that day of elevated pulse and emesis. R15's nursing note on 12/7/2023 at 12:54 AM: Resident developed a temperature of 100.9. She is two days post ureteral stent placement. She has a change in cognition/mentation, unable to answer questions, unresponsive to stimulus. She can answer what her name is, but not where she is or anything else. VSS (vital signs stable) updated in PCC (point click care). POAHC (power of attorney health care) contacted and in agreement with sending to ER (emergency room ) for evaluation. On call provider contacted, he is in agreement with sending to ER. DON (director of nursing) notified of transfer. Forms completed. Call to ER for report on incoming transfer. R15's vital signs on 12/07/23 at 1:04 AM: Oxygen saturation 87% room air, blood pressure 148/88, pulse 128 beats per minute / regular, respiratory rate 18 breaths/minute, temperature 100.9 degrees Fahrenheit, repeat temperature at 1:05 AM 102.6 degrees Fahrenheit. R15's history and physical hospital note dated 12/07/23: She recently underwent ureteroscopy and JJ ureteral stent placement on 12/05/23. She was taken to the emergency department as she was noted to have altered mental status and had developed fever. She also had two episodes of vomiting. On presentation she was tachycardic with heart rate in the 110s and hypoxic with oxygen saturation 89 percent on room air, improved to 95% on 2 liters nasal cannula oxygen. Her labs were significant for Leukocytosis with WBC (white blood cell) 23.3 (neutrophilic predominance), elevated anion gap of 16, elevated lactate of 4.4. Urinalysis was positive for nitrates, leukocyte esterase, ketones, WBC greater than 100, RBC (red blood cell) greater than 100. Chest X-ray showed no acute findings and CT abdomen pelvis showed patch areas of decreased enhancement in the left kidney. Left double J nephroureteral stent in place with mild periureteral and perinephric fat stranding, suggestive of left pyelonephritis and left ureteritis; no urinary tract stones were seen. Lactate trended down to 3.6 with IV (intravenous) fluids. She received a three-liter bolus of normal saline, IV ceftriaxone 2grams, she was continued on maintenance IV normal saline at 100 milliliters an hour. Samples were collected for blood and urine cultures. She was discussed with Urology by the emergency department with recommendations for placement of a Foley catheter to expedite removal of infected urine. She was transferred to the hospital in Eau [NAME] as there were no inpatient beds available in Menomonie. R15's Discharge Summary Hospital Note dated 12/13/23: Principal diagnosis: 1) Sepsis secondary to left acute pyelonephritis and left ureteritis 2) Acute hypoxic respiratory failure 3) Acute metabolic encephalopathy R15 was discharged back to the facility on [DATE] with fever resolved and mental status returned to baseline. R15 was started on IV cefepime at the hospital and continued at the facility until 12/21/23. Interviews: On 06/20/24 at 9:50 AM, Surveyor asked Director of Nursing (DON) B what the expectation would be to notify the provider with the change in condition for R15. DON B stated the nurse should have notified the provider at that time of R15 being very lethargic and temperature of 101.2. Surveyor asked DON B for any provider notification documentation on R15 post ureteral stent placement until she was hospitalized . Surveyor asked DON B for the policy and procedure for provider notification. On 06/20/24 at 11:15 AM, Surveyor interviewed Registered Nurse (RN) E and RN F and asked what the expectation is for notification to the provider of a resident who came back from a ureteral stent procedure. Both RN E and F said if there were any abnormal things found during assessment of the resident, they would call the provider/send the resident out to the hospital/email/place on follow up board depending on how severe the findings were. Surveyor told RN E and F of R15's symptoms on 12/06/23 in the morning and asked what they would have done with this information. Both RN E and F said they would have called the provider and pushed to have the resident sent to the hospital and monitor resident closely due to being very lethargic with a temperature post procedure. On 06/20/24 at 12:35 PM, Surveyor interviewed RN G (the nurse for Medical Doctor (MD) H who placed the ureteral stents) about R15's ureteral stent placement if the facility had contacted the provider prior to R15 being hospitalized on [DATE]. RN G said there was no communication from the facility to MD H. Surveyor explained the signs and symptoms R15 was experiencing on 12/06/23: resident very lethargic at 8:00 AM, temperature at 9:15 AM 101.2 room heat on very warm in room and resident covered with numerous blankets, resident received scheduled APAP (Tylenol) at 8:30 AM, pulse 100, respiratory rate 16, oxygen sats 90% on room air non labored and regular breaths, blood pressure 137/68 skin warm, dry and flushed. Notified RN G of the rechecked temperatures. Surveyor asked RN G what the expectation is for the facility to do with this information post ureteral stent. RN G said the expectation was for the facility to call the provider once these symptoms occurred. On 06/20/24 at 1:00 PM, Surveyor asked DON B if they had found any provider notification of R15. DON B said no, they could not find any documentation. On 06/24/24 at 12:30 PM, Surveyor interviewed MD H and made aware of the facility's nurse's note on 12/06/23 that stated R15 was very lethargic at 8:00 AM, Tylenol given at 8:30 AM, and fever of 101.2 at 9:15 AM, post ureteral stent placement. Surveyor asked MD H what the expectation is for the facility to do with the information concerning R15's signs and symptoms post ureteral stent. MD H stated she would expect the facility to call her because of the temperature and lethargy, especially since R15 had received Tylenol. Surveyor asked MD H what she would have done if the facility had called her with this information. MD H said she would have sent R15 to the emergency department for further evaluation. Surveyor asked MD H if R15 was sent to the hospital upon first signs and symptoms on 12/06/23, would that have changed the hospital course. MD H said R15 was placed on Macrobid appropriately prior to the stent placement. Post stent placement urine culture at the hospital was a different strand needing a different type of antibiotic. MD H stated R15 would have likely still been hospitalized due to the infection, but if she was notified sooner of R15's symptoms and R15 sent to the hospital sooner, the severity of R15's signs and symptoms upon hospitalization could have been prevented. When R15 was hospitalized on [DATE] the symptoms of hypoxia and metabolic encephalopathy were present.

Based on interview and record review, the facility failed to ensure residents (R) receive treatment and care in accordance with professional standards of practice for residents experiencing changes in condition for 1 of 4 residents (R15) reviewed for changes in condition. The facility did not properly assess R15 post ureteral stent (a thin tube that's inserted into the ureter to treat or prevent blockages that prevent urine from flowing from the kidney to the bladder) placement. This is evidenced by: The facility policy, entitled Monitoring Protocol Post Procedure, states: After readmission to the facility postoperatively, . The staff and physician will monitor for and address postoperative risks and complications such as infection, deep vein thrombosis, cardiac arrhythmia, bleeding, failure of surgical wounds to heal, urosepsis from indwelling catheters inserted in the hospital, delirium, depression, etcetera. R15 was admitted to the facility on [DATE], and had diagnoses that included in part dementia, epilepsy, diabetes, urinary tract infection, and kidney stones. R15 had a ureteral stent placed on 12/05/23 as an outpatient procedure and returned to the facility the same day. On 12/07/23, R15 was sent from the facility to the hospital and admitted with diagnoses of sepsis secondary to left acute pyelonephritis, acute hypoxic respiratory failure, and acute metabolic encephalopathy. R15 returned to the facility on [DATE]. R15's care plan, dated 12/20/23, states: .The resident has a history of Urinary Tract Infection (UTI), sepsis due to pseudomonas bacteremia with left sided pyelonephritis, recurrent kidney stones, recurrent cystitis. Interventions include: The resident's urinary tract infection will resolve without complications by the review date. Encourage adequate fluid intake. Give antipyretics, analgesics, and antispasmodics as ordered/PRN (as needed). Monitor/document for side effects and effectiveness. Monitor/document/report to MD (Medical Doctor) PRN for signs or symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes. Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated . R15's care plan, dated 10/15/22, states: .The resident has chronic mixed bladder incontinence related to loss of peritoneal tone, use of antidepressant, antianxiety, and antipsychotic medications, diabetes, weakness, chronic dysuria, kidney stone lithotripsy, and JJ stent placement 12/5/23 urinary retention, UTI history. Interventions include: [R15] will often refuse to ambulate to bathroom but will inform staff of when her incontinence product needs to be changed. Clean peri-area with each incontinence episode. Post stent placement: R15's after visit summary for ureteral stent placement dated 12/05/23: .Seek emergency treatment if you experience: inability to urinate, chest pain, shortness of breath. Call your provider if you experience: Temperature greater than 100.4, pain not relieved by medication, wound swelling/bleeding/redness, foul smelling/pus-like drainage, persistent dizziness or light headedness, urine is ketchup colored or you have large clots, opening of the stitches or wound edges even after sutures have been removed, rash, calf pain redness or firmness in your leg, heavy bleeding, nausea/vomiting . R15's nursing note on 12/5/2023 at 12:43 PM: Resident returned from procedure for ureteral stent placement at 12:45 PM, instructions to call for medical treatment if 1. temp greater than 100.4 (38 degree Celsius), 2. pain not relieved by medication, 3. wound swelling/bleeding/redness 4. foul smelling /pus-like drainage 5. persistent dizziness or light-headedness 6. urine or ketchup colored, or you have large clots . No vital signs, no assessment noted for R15 upon return from ureteral stent procedure. Post procedure, vital signs and an assessment should have been completed by the nurse upon arrival back to the facility and each shift (AM / PM / NOC (night)). MAR (Medication Administration Record): R15 administered Acetaminophen (Tylenol) 650mg PRN on 12/6/2023 at 1:14 AM. Pain rate = 7. Follow up = effective. Unsure if this was given for pain or temperature, there was no nursing progress note or assessment of R15's condition. Tylenol can lower temperatures too. On 12/6/2023 at 4:46 AM (late entry): Resident had difficulty sleeping due to pain and discomfort. She was finally able to sleep around 2:00 AM and was sleeping at last rounds tonight. She did void x 1 overnight and was repositioned to help relieve pressure on her buttocks. No vital signs, no assessment noted for R15 post ureteral stent procedure. Post procedure, vital signs and an assessment should have been completed by the nurse each shift upon resident's return to the facility. R15's nursing note on 12/6/2023 at 11:01 AM (late entry): Resident very lethargic at 8:00 AM, needed assist with taking of medications, spoon fed and then handed glass of water x 2, this writer stayed in room while resident took medications, temperature at 9:15 AM 101.2 room heat on very warm in room and resident covered with numerous blankets, resident received scheduled APAP (Tylenol) at 8:30 AM, pulse 100, respiratory rate 16, oxygen sats 90% on room air non labored and regular breaths, blood pressure 137/68 skin warm, dry and flushed, rechecked temp at 9:40 AM 100.1, rechecked temp at 10:30 AM 100.9 rechecked temp at 11:00 AM 100.4 resident responding to name and making eye contact, encouraged to drink fluids, skin warm dry and pink. This is the first set of vital signs since readmission 12/5/24 at 12:43 p.m. MAR (Medication Administration Record): R15 administered Acetaminophen 650mg on 12/6/2023 at 12:00 PM. Pain rate = 4. Not sure if this was given for pain or temperature as there was no nursing note or assessment indicating reason for giving. R15's nursing note on 12/6/2023 at 12:51 PM (late entry): Rechecked temp at 11:00 AM 100.4, resident making eye contact and verbally interacting with writer, skin warm, dry and pink, resident watching T.V. in bed. resident's temp at 11:24 AM 97.8, resident fully awake and alert per baseline, skin warm dry and pink. resident hoyered out of bed into recliner chair, for lunch fed self without difficulty, consume greater than 75% of meal, carrying on conversation with this staff member, this writer encouraged resident to take fluids and explained to resident the importance of fluid intake related to recent procedure, resident took 12:00 PM meds after this writer handed resident pills in med cup. wash pills down with full glass water. A complete assessment is not done at 11:00 a.m., only the temperature is recorded. MAR (Medication Administration Record): R15 administered Acetaminophen 650mg PRN on 12/6/2023 at 3:30 PM. Pain rate = 4. Follow up = ineffective. Not sure if this was given for pain or temperature as there was no nursing note or assessment indicating reason for giving. Assessments of R15 were completed from 12/6/24 at 8:10 p.m. until resident sent out at 1:22 a.m, but no complete assessments per protocol prior to this. R15's nursing note on 12/7/2023 at 12:54 AM: Resident developed a temperature of 100.9. She is two days post ureteral stent placement. She has a change in cognition/mentation, unable to answer questions, unresponsive to stimulus. She can answer what her name is, but not where she is or anything else. VSS (vital signs stable) updated in PCC (point click care). POAHC (power of attorney health care) contacted and in agreement with sending to ER (emergency room ) for evaluation. On call provider contacted, he is in agreement with sending to ER. DON (director of nursing) notified of transfer. Forms completed. Call to ER for report on incoming transfer. R15's nursing note on 12/7/2023 at 1:22 AM: Resident was transported via non-emergency ambulance to ER for evaluation and treatment of elevated temperature and change in cognition. Resident had ureteral stent placement on 12/5/23. This afternoon she developed a change in cognition from AOx4 (alert and oriented) to AOx1. She had emesis this afternoon, and again after being positioned in the stretcher. POAHC, on call provider, DON were all notified of transfer. Interviews: On 06/20/24 at 9:50 AM, Surveyor interviewed Director of Nursing (DON) B and discussed concern of no assessments and vital signs for R15 post return from ureteral stent placement until the note on 12/6/23 at 11:01 AM. Surveyor asked DON B what the expectation or standard of practice was for vital signs and assessment post procedure. DON B said she would expect vital signs and assessment to be completed upon arrival to the facility. Surveyor asked how often these should have been completed. DON B said she would need to look at the policy and procedure as it would depend on the type of procedure. Surveyor asked DON B for any vital signs and assessment documentation on R15 post ureteral stent placement until she was hospitalized . Surveyor asked DON B for the policy on assessments post procedure. On 06/20/24 at 11:15 AM, Surveyor interviewed Registered Nurse (RN) E and RN F and asked what the expectation is for assessment and vital signs of a resident who came back from a ureteral stent procedure. Both RN E and F said once the resident came back from the procedure and then at least all three shifts post procedure they would do vital signs with temperature, monitor urine output, full assessment, look at the orders the provider gave and follow them too, if there were any abnormal things found they would call the provider/send the resident out to the hospital/email/place on follow up board depending on how severe the findings were. On 06/20/24 at 1:00 PM, Surveyor asked DON B if they had found assessments and vital signs for R15 post ureteral stent placement. DON B said no, they could not find any documentation.

Based on observation, interview and record review, the facility did not have a system in place to maintain the scale inhibitor for the Rational oven per manufacturer's guidelines. This has the potential to affect all 28 residents in the facility. The facility had no system to ensure changing of the scale inhibitor filter, causing malfunction of the Rational oven. [NAME] repairs, the facility did not implement a system to ensure routine maintenance was completed for the oven. This is evidenced by: On 05/17/23 at 10:40 AM, Surveyor asked the Culinary Supervisor (CS) F about the scale inhibitor filter for the Rational oven (kitchen equipment that cooks the food in varying ways such as steaming). Surveyor asked CS F when the scale inhibitor filter was last changed. CS F said he does not know when it was last changed. There is no sticker on the scale inhibitor filter to tell when it was last changed. CS F said maintenance might know. On 05/17/23 at 10:50 AM, Surveyor asked Maintenance Supervisor (MS) D who should be changing the scale inhibitor filter and the date last changed. MS D stated the maintenance department had never changed the inhibitor filter. MS D said this was just serviced last month by a contractor. MS D provided the invoice for the service completed that stated the following: Work requested due to rational oven sensors not working. Work performed: [DATE], went through the unit trying to determine why the unit was counting up in the clean cycle and determined that the quench solenoid was receiving signals but not feeding water. In the process of diagnosing, other scaled issues were found. Drilled out other orifices and removed scale throughout other areas. Also found the drain brushings leaking. Will need to order those along with the solenoid. Also, replacing the scale stick (a cartridge that has a unique composition to provide superior limescale prevention and corrosion control) that was empty. April 6, 2023, removed and replaced the quench solenoid and drain brushings. Installed a new scale stick. On 05/17/23 at 11:19 AM, CS F provided the manufacturer's guideline for the scale inhibitor filter that stated, .Inspect ScaleStick cartridges at least every 6 months. Replace the ScaleStick before the Hydroblend compound is completely dissolved. Pre-existing equipment scale may come loose and clog equipment. Remove any loose scale to assure satisfactory operation. Capacity: Approximately 6 months. Capacity will vary depending on the application and water usage . Surveyor asked CS F how long the facility has had the Rational oven and how often the scale inhibitor filter was changed. CS F stated the facility has had the equipment for years and the scale inhibitor filter for the Rational oven has not been changed that he was aware of. CS F stated the contractor who serviced the equipment last month only comes out as needed, and no service was provided on a routine basis to the Rational oven and scale inhibitor. Surveyor asked CS F about the role of the scale inhibitor. CS F stated the scale inhibitor prevents scale build up to the water to the Rational oven, which is used for steaming food and multiple other ways of cooking food. Surveyor asked CS F for the policy/procedure for the maintenance of the Rational oven and scale inhibitor. On 05/17/23 at 12:05 PM, CS F stated there was no policy/procedure for the maintenance of the Rational oven and scale inhibitor. CS F stated he will create a policy/procedure for this. Per the manufacturer's guideline, .Replacing your filtration cartridge will help you reduce sediment, rust, chlorine, bacteria and more just with the workings of the filter system. Moreover, it's going to work specifically with heated appliances in mind, holding back as much scaling as possible so that you'll be able to rely on the fact that the machines are going to keep running to the best of their ability .

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 28 residents in the building. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system. - Include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Maintain acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met. - Include a process to confirm the WMP is being implemented and is effective. - Document and communicate all the activities. No hand hygiene was offered to residents (R) prior to eating. This was observed for 14 of 28 residents (R8, R14, R20, R24, R13, R5, R3, R15, R2, R10, R27, R11, R26, and R21). This is evidenced by: On 05/17/23 at 9:45 AM, Surveyor reviewed the facility policy, entitled Water Management, dated 01/22/2020, which stated: . The facility will maintain the following documents: the CDC Legionella building worksheet, a flow diagram of water management measures updated as needed, an annual water pathogen risk assessment completed and updated as needed with major construction or equipment changes impacting the water service. The facility will complete the following maintenance of the water system: visual inspection of systems at least annually to ensure proper equipment function, repairs will be conducted following manufacturers recommendations, domestic hot water heaters maintain and store water at 140 degrees, the main hot water loop will be 140 degrees with delivering outlet water temperature set at 112 degrees using pre-set thermostatic mixing valves, outlet water temperatures are logged and checked on a regular basis. Included in the facility's Water Management Program (WMP) binder was the document entitled Legionella and Other Water Pathogens Monitoring. This document included the following information: Daily inspection and record temperature on hot water storage tanks, daily inspection of hot water recirculation pump, the ice machine will be cleaned and inspected semi-annually, water filters will be changed on an annual basis, condensate lines pans and pumps will be inspected annually, cooling tower tank will be inspected daily to ensure pumps are running, any service interruptions lines will be flushed. On 05/17/23 at 10:12 AM, Surveyor interviewed Maintenance Supervisor (MS) D concerning the facility's WMP. The WMP team included MS D, Maintenance Staff E, and Nursing Home Administrator (NHA) A. MS D stated there was no flow diagram of the building's water system. The facility did have a written description of the water system. Surveyor asked how the facility identified areas where Legionella could grow and spread. MS D stated they inspect the pumps on a yearly basis as well as glance at the pumps when they go past them. There was no documentation of this being done, nor the results of the inspection. Surveyor asked how the facility decided where control measures should be applied and how to monitor them. MS D stated the boiler log contained the documented temperatures. This was only done on the weekdays, not the weekends because maintenance was not in the building, unless needed. The only control measures completed are temperatures. They do not add chemicals to the water. A review of the facility's boiler log contained the following information: boiler 1 temp, boiler 2 temp, storage tank temp 1, storage tank temp 2, hot water circulating temp, hot water circulation pump (Y, N), air compressor pressure, supply loop temp, and cooling tower temp. The boiler log did not include what the temperature ranges should be and what to do if out of range. Surveyor asked how the facility established ways to intervene when control limits are not met. MS D stated valves are used to turn the water levels to the needed temperature. MS D stated they have never needed to adjust the water temperature. The boilers are set to 170 degrees. If the boiler's temperature goes out of range an alarm will go off. The alarm is only heard at the boiler. The facility has two water storage tanks with temperatures set at 150 degrees. Surveyor asked how the facility made sure the WMP was running as designed and was effective. MS D stated the facility had no cases of Legionella, he trusts the staff to do their job right, and the water temperatures were in normal ranges. The only documentation was the water temperatures. MS D stated there was no documentation of any assessments completed. Surveyor asked what the procedure was to change water filters. MS D stated water filters are changed quarterly. There is no written documentation of the filter being changed, only a reminder on the calendar to notify the need to be changed. Once the water filter is changed, a sticker is placed on the filter that states when it was last changed. MS D stated if there would be any abnormalities, they would clean with bleach if needed and would document what the abnormalities were and what was done to fix the problem. There were no specifics on how much bleach or how long they would need the bleach to be in contact with surfaces. On 05/17/23 at 10:40 AM, Surveyor observed the ice machine water filter located in the kitchen. There was no date listed on the filter. Surveyor spoke with Culinary Supervisor (CS) F to see where the date is on the water filter for the ice machine. CS F said he does not see any date on or near the water filter. On 05/17/23 at 10:50 AM, Surveyor spoke with MS D while in the kitchen to see where the date was located on the water filter for the ice machine. He said there should be a sticker with the date on it, but there was currently not one on the filter. There was no evidence provided the plan for water filter changes had been implemented. 40181 Facility infection prevention and control policy, section 11.3 Hand Hygiene by Residents, stated in part, Hand hygiene by residents is an important part of preventing transmission of potentially infectious organisms both to and from the resident .Hand hygiene can be performed by either washing hands with soap and water, using a waterless hand antiseptic, or cleansing wipes .Residents are encouraged to perform hand hygiene before and after meals . On 05/15/23 at 11:52 AM, Surveyor observed residents brought to the dining room for lunch. The residents were seated at tables and offered beverages and their meal order was taken. No hand hygiene was offered to residents. At 12:10 PM, Surveyor observed residents being served their lunch and began eating. No hand hygiene was offered to the residents prior to eating. On 05/16/23 from 8:10 AM to 8:30 AM, Surveyor observed the following residents brought to the dining room and served breakfast: R8, R14, R20, R24, R13, R5, R3, R15, R2, R10, R27, R11, R26. No hand hygiene was offered to the residents when they arrived in the dining room. All the residents observed fed themselves when served their breakfast. None of the residents were offered hand hygiene prior to eating. On 05/16/23 at 8:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C who stated did not offer or assist residents with hand hygiene prior to eating meals. On 05/16/23 at 9:02 AM, Surveyor interviewed R21 who ate breakfast in her room. R21 stated she always ate her meals in her room. R21 stated staff never offered hand washing or hand sanitizer before serving meals. On 05/16/23 at 2:54 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor explained observations of no hand hygiene offered to residents before meals. DON B stated staff should offer or assist residents with hand hygiene before meals.

Based on observation, interview and record review, the facility did not perform regular inspections of all bed frames, mattresses, and bed rails as a regular part of maintenance program to identify areas of possible entrapment for 5 of 5 residents (R) with bed rails. (R11, R18, R20, R5, and R22) Findings include: Example 1 R11 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes with peripheral [CONDITION(S)], and chronic pain. R11's Minimum Data Set (MDS) assessment identified R11 had a Brief Interview for Mental Status (BIMS) score of 15, indicating R11 was cognitively intact. R11's MDS assessment also identified R11 required extensive assistance for bed mobility and transfer. On 04/11/22 at 10:50 AM, Surveyor observed two padded half-rails on the upper half of R11's bed. Surveyor asked R11 about the rails, and R11 stated she used them to turn in bed. On 04/12/22 at 2:18 PM, Surveyor interviewed Maintenance Director (MD) G about routine maintenance of beds or bed rails. MD G stated he did not have any schedule for routine maintenance or assessment of the rails once they were installed. Surveyor asked if MD G did any measurements or assessments for safety or risk of entrapment when bed rails were installed. MD G stated he installed the rails when asked, but did not do any measurements or assessment for risk of entrapment. No documentation of routine bed rail maintenance or assessment for risk of entrapment was identified on R11's medical record. On 04/13/22 at 9:59 AM, Surveyor received a policy and procedure titled Bed Rails Policy & Procedure from NHA A. Surveyor reviewed the policy with NHA A, who pointed out the policy did address risk of entrapment and the 7 risk zones. Surveyor asked if NHA A had documentation that anyone in the facility did routine maintenance or an assessment for risk of entrapment. NHA A stated they did not have any documentation of routine maintenance or assessments being done for any residents with bed rails. Example 2 R18 was admitted to the facility on [DATE] with diagnoses including in part, acute [CONDITION(S)], chronic pulmonary [CONDITION(S)], visual hallucinations, and a history of falling. R18's MDS assessment dated [DATE] identified R18 had a BIMS score of 8 which indicated R18 was moderately cognitively impaired. The MDS assessment also identified R18 required extensive assistance with bed mobility, and was totally dependent for transfers. On 04/11/22 at 10:01 AM, Surveyor observed two half-bed rails on the upper half of R18's bed. R18 was unable to tell Surveyor if she used them. No documentation was found on R18's medical record showing routine maintenance or assessment for risk of entrapment with the rails. Example 3 R20 was admitted to the facility on [DATE] with diagnoses including in part, heart failure, chronic kidney disease, and [CONDITION(S)]. R20's MDS assessment dated [DATE] identified R20 had a BIMS score of 15, which indicated R20 was cognitively intact. The MDS assessment also identified R20 required extensive assistance for bed mobility, and was totally dependent for transfers. On 04/11/22 at 12:03 PM, Surveyor observed two half-rails on the upper half of R20's bed. R20 reported she used them to assist with turning from side to side while in bed. No documentation of routine maintenance of bed rails or assessment for risk of entrapment was found on R20's medical record. Example 4 On 04/11/22 at 10:51 a.m., Surveyor was interviewing R5 and observed R5 having bilateral grab bars on her bed. Surveyor asked R5 if the grab bars are used. R5 indicated when staff are assisting R5 will use the grab bars to hold onto. R5 indicated does not move around in bed much. Surveyor reviewed R5's medical record for bed-rail assessments. On 01/24/22, the bed-rail assessments for the bilateral grab bars documented R5 utilized the grab bars for bed mobility and was safe from entrapment and the consent was signed. Review of the chart did not document completed regular inspections of the bed frames, mattresses, and the installation of the bilateral grab bars to identify areas of possible entrapment. Example 5 On 04/11/22 at 9:04 a.m., Surveyor interviewed R22 asking if she uses the grab bars on the bed. R22 indicated she does use the grab bars. Surveyor reviewed R22's medical record for bed-rail assessments. On 03/14/22, the bed-rail assessments for the bilateral grab bars documented R22 utilized the grab bars for bed mobility and was safe from entrapment and the consent was signed. Review of the chart did not document completed regular inspections of the bed frames, mattresses, and the installation of the bilateral grab bars to identify areas of possible entrapment. Surveyor requested documentation of completed inspections for R5 and R22 and no information was provided.

Based on record review and interview, the facility did not conduct testing of facility staff in a manner that is consistent with current standards of practice for conducting COVID-19 tests. This had the potential to affect all 26 of 26 residents. Facility had one staff member partially vaccinated against COVID-19, who was not tested weekly while facility's Community Transmission level was Moderate. This is evidenced by: According to the Center for Medicare and Medicaid Services (CMS) memo, QSO-20-38-NH, revised 3/10/2022, To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary .Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community. Staff, who are up-to date, do not have to be routinely tested .Facilities should use their community transmission level as the trigger for staff testing frequency. Reports of COVID-19 level of community transmission are available on the CDC COVID-19 Integrated County View site: https://covid.cdc.gov/covid-data-tracker/#countyview. Please see the COVID-19 Testing section on the CMS COVID-19 Nursing Home Data webpage: https://data.cms.gov/covid-19/covid-19-nursing-home-data for information on how to obtain current and historic levels of community transmission on the CDC website. Table 2: Routine Testing Intervals by County COVID-19 Level of Community Transmission Level of COVID-19 Community Transmission .Minimum Testing Frequency of Staff who are not up-to-date+ Low (blue) .Not recommended Moderate (yellow) .Once a week* Substantial (orange) .Twice a week* High (red) .Twice a week* +Staff who are up-to-date do not need to be routinely tested . At the time of this annual recertification survey, the facility was using the CDC COVID-19 Integrated County View site to determine current community transmission levels. The site indicated between 3/28/2022 - 4/11/2022, [the facility's county] was yellow=moderate community transmission level. -2/26 residents were unvaccinated -87.7% of staff were vaccinated. Surveyor reviewed Facility's COVID-19 STAFF VACCINATION MATRIX, and identified facility had one newly hired staff member who was partially vaccinated. On 04/11/22 at 11:20 AM, Surveyor interviewed Administrative Assistant (AA) C. AA-C stated she had recently been hired. *Records listed AA-C's date of hire as 3/28/2022. AA-C stated she had been diagnosed with COVID-19 in December 2021, she had received her first dose of the COVID-19 vaccine 3/26/22 and was scheduled for the second of the two-dose series on 4/16/22. Surveyor asked how often she was tested . AA-C stated she had not been tested at all while employed at facility. AA-C's desk was located near front entrance. Surveyor asked if AA-C had any direct contact with residents. AA-C stated only when she delivered their mail. AA-C wore a surgical mask when delivering the mail and did not have any prolonged contact with residents. On 04/11/22 at 11:23 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked what additional protocols were required for AA-C since she was not yet fully vaccinated. DON-B stated since AA-C had received one dose and was not yet due for the second dose, she was considered up to date, and was therefore required to follow the same guidelines as all other up to date staff, which were: wearing source control mask, screening upon arrival to work and social distancing. Unvaccinated or not up to date staff must test weekly at this time. Surveyor asked if AA-C had been tested at all since her employment began on 3/28/2022. DON-B confirmed AA-C had not been tested at all. Surveyor asked for clarification as to where facility was getting its definition for up-to date. DON-B provided Surveyor with copy of Human Resources COVID-19 Vaccination policy dated 3/28/2022, which read, in part: NEW HIRES New staff who are non-vaccinated against COVID-19 and do not have an approved exemption will only be offered positions contingent on them being vaccinated for COVID-19. However, they must receive their first dose prior to working in the facility and must be scheduled for their 2nd dose if they received a multi-dose vaccine. The new hire will be allowed to work in the facility until they are eligible to receive the second dose of a multi-dose vaccine series. Once eligible to receive dose two in a two-dose series, the staff must be vaccinated to remain eligible to work in the facility. Surveyor discussed concern with misinterpretation of definition for up-to-date. According to CMS memo QSO 20-38-NH, revised 3/10/2022: DEFINITIONS . Up-to-Date means a person has received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. DON-B expressed understanding. At the time of the recertification survey, facility had not had any staff or residents with confirmed or suspected cases of COVID-19 in the past 4 weeks.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed Hoyer lift guidance to prevent accidents for 1 of 1 residents (R). (R20) Findings include: R20 was admitted to the facility on [DATE], with diagnoses including in part, heart failure, [CONDITION(S)], [CONDITION(S)], type 2 diabetes, major depressive disorder, and [CONDITION(S)]. R20's Minimum Data Set (MDS) assessment, dated 03/03/22, identified R20's Brief Interview for Mental Status (BIMS) score was 15. This indicated R20 was cognitively intact. The MDS assessment also identified R20 required extensive assistance for bed mobility and was totally dependent for transfers. On 04/11/22 at 12:03 PM, Surveyor interviewed R20, who stated she fell during a Hoyer lift transfer to the commode. R20 stated the lift tipped over during the transfer, and she fell to the floor. R20 stated she hit her head on the table by the window and hurt her tailbone. R20 stated she was sent to the hospital for x-rays after the fall, but nothing was broken. R20 thought it happened about 1 or 2 months ago. Surveyor identified the following nursing note on R20's electronic medical record: 1/15/22 9:53 AM: Nursing Note-Incident details: CNA [Certified Nursing Assistant] staff called writer to room due to fall while transferring using Hoyer lift. Resident was mid transfer from bed to commode when the Hoyer lift tipped. Legs to the Hoyer were open at the time though breaks were not locked. Staff was adjusting incontinent product to place her on the commode. Hoyer lift tipped towards the window and resident landed with back towards the window after bumping head on furniture placed in front of the window. The bar to the Hoyer lift struck resident's chest. Writer found resident sitting with back towards the window. She was alter [alert] and oriented with c/o [complaint of] pain in back and buttocks. She also has a superficial abrasion to center of her back approximately 10 cm [centimeters] in length. No active bleeding. She requested to be transported to ER [emergency room ] for further evaluation. On 04/12/22 at 7:28 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated they did not do a self-report to the state about this incident. NHA A stated they did a thorough investigation and determined they did not need to do a self-report as there was no abuse or neglect identified with the investigation. NHA A provided the investigation notes for Surveyor to review. Reviewed incident report and investigation. Immediate actions taken were R20 was sent to the ER for evaluation, the physician was notified, and the lift was pulled from use for examination to ensure it was working properly. All staff involved in the incident and R20 were interviewed. The Invacare lift was verified to have a 450-pound lift capacity, and R20's weight at the time of the incident was between 362 to 365 pounds. The CNAs involved in the incident had done this procedure with R20 many times in the past without incident. It was determined through interviews and recreation of the event that no variation in the procedure occurred during the incident. They verified the legs of the lift were completely in the open position. The determination from investigation was the fall may have been related to lowering of the incontinent brief while R20 was suspended in the lift. The plan put in place was to use the [NAME] lift for all residents greater than 350 pounds. Staff was educated to complete perineal care and remove incontinent brief while resident was in bed to prepare for the commode. The brief was not to be adjusted while resident was being transferred. Staff was to complete perineal care in the bed following transfer with the Hoyer lift. On 04/12/22 at 8:51 AM, Surveyor observed a Hoyer lift transfer of R20 from recliner to commode by CNA D and CNA E. Both used Alcohol Based Hand Rub (ABHR) as they entered the room and applied gloves. CNA D positioned the sling straps under R20's legs. The sling was already behind R20's back while she was seated in the recliner. CNA E opened legs of lift and positioned the lift in front of R20. Both CNAs attached the sling hooks to the lift and verified they were attached securely. CNA D asked R20 if she was ready. R20 stated yes and grabbed straps of sling in front. CNA D raised R20 off the seat of the recliner with the lift and pulled the lift away from recliner. CNA E placed the commode under R20. CNA E pulled R20's incontinent brief down to her legs while R20 was suspended over the commode. CNA D lowered R20 onto commode, while CNA E guided R20 to the seat of the commode with the sling. CNA E clipped the call light within reach of R20, instructed her to call when ready. Both CNAs removed their gloves, used ABHR, and left room, closing door. When R20's call light turned on, both CNA D and CNA E returned to the room. They both used ABHR and applied gloves. CNA D placed an incontinent pad on the bed. CNA E grabbed disposable wipes from the drawer and placed them on the bed beside the commode. CNA D asked R20 if she was ready and then lifted R20 from commode with the lift. CNA E used disposable wipes to perform perineal care on R20 while she was suspended in the lift over the commode. After the perineal care was completed, CNA D rolled the lift, with R20 suspended in the sling, over the bed. CNA D lowered the bed and assisted to guide R20 onto the bed. While in the bed, both CNAs assisted R20 to roll from side to side to reposition the incontinent brief and place a different sling under R20. CNA D rolled the lift with legs opened wide over the bed. Both CNA D and CNA E fastened the sling hooks to the lift, and verified they were attached securely. CNA D asked R20 if she was ready. R20 grabbed the straps of sling in front. CNA D raised R20 off the bed with the Hoyer lift and rolled it toward the wheelchair. CNA E guided the wheelchair under R20, and guided R20 into the chair as CNA D lowered R20 with the lift. CNA E placed a blanket over R20's lap and used ABHR. CNA D used ABHR, applied gloves, and wiped down the lift with sanitizer wipes at the doorway to R20's room. On 04/12/22 at 8:56 AM, Surveyor interviewed CNA D about the Hoyer lift incident in January. CNA D stated she was one of the aides doing the lift when it tipped. CNA D stated she had done that lift with R20 hundreds of times before incident, and nothing different was done when the lift tipped. CNA D stated the incident was investigated, and no errors were identified with their procedure. CNA D stated when we had R20 suspended in the lift over the commode and were pulling down the incontinent brief, the lift started to tip and there was nothing we could do to stop it. CNA D stated they ensured R20 was safe and got the nurse immediately. CNA D stated R20 was sent to ER for evaluation because she hit her head on the table by the window on the way down, and also complained of back and tailbone pain. CNA D did not think they found any serious injuries, but she had large bruises, and pain for a while. CNA D stated immediately we stopped using that lift. CNA D stated we use a different lift with R20 now, and they got a different sling as well. CNA D stated they all received re-training on Hoyer lift procedures after the incident. On 04/12/22 09:29 AM, Surveyor interviewed Registered Nurse (RN) F about R20's incident with the Hoyer tipping in January. RN F stated she was called to the room immediately to assess R20 for injury. RN F stated R20 had hit her head on the table on the way down, but did not lose consciousness. RN F found no visible injury to R20's head, but R20 did have an abrasion on her back. R20 was sent to the ER for evaluation but no fractures or injuries were found. The bruising and abrasion took a while to resolve but have completely healed now. RN F stated R20 complained of back and tailbone pain for a while but that has resolved as well. RN F stated they immediately pulled the lift out of use until it could be determined if it was defective. RN F stated they are now using a different lift for R20 and got different slings. RN F stated staff were re-educated on Hoyer lift procedures. On 04/12/22 at 10:50 AM, Surveyor interviewed CNA D again, and asked if any changes were made to the procedure or process for R20's Hoyer lift transfers after the incident. CNA D stated the only changes to the process was to lay R20 down in bed after the transfer to re-apply or adjust the incontinent brief, and to always use the [NAME] lift, and the new sling. On 04/12/22 at 11:02 AM, Surveyor interviewed Director of Nursing (DON) B about the incident investigation, possible cause of the incident, changes made to the process, and education provided to staff following the incident. DON B will provide documentation of education given to staff for Surveyor to review. DON B stated the changes to the lift procedure would not be noted on R20's care plan. The only change made on the care plan was to only use the [NAME] lift for transfers with R20. Surveyor reviewed the education provided to staff on 1/17/22 which stated in part, When assisting residents to the commode via Hoyer lift: It is the expectation you are laying resident in bed prior to the transfer to remove pad/lower pants and then assisting into the toileting sling. After using the commode, resident should be assisted back into the bed for peri care and pad change. Removing or lowering the pad is not to be done while resident is suspended in the lift. On 04/12/22 at 12:14 PM, Surveyor interviewed DON B about the education given to staff stating to place resident in bed to remove incontinent brief and pull down pants before transferring to commode, and to perform perineal care when R20 was lying in bed. Surveyor reviewed the observation of the transfer by CNA D and CNA E with DON B. Surveyor explained the CNAs did not lay R20 in the bed to pull down the incontinent brief. They pulled it down while R20 was suspended in the lift. Surveyor also reviewed the CNAs completed perineal care while R20 was suspended over the commode. They did not lay R20 in bed to complete perineal care. DON B stated they did audits of staff performing the transfer after training and did not observe any staff doing the incorrect procedure. DON B stated during the observation that morning, the CNAs did not follow the proper procedure for the transfer of R20 to the commode that was put in place for safety. Manufacturer's guidance for safety with [NAME] lift and the sling used for R20 were reviewed, and no safety information was provided related to this incident or the process described above. On 04/12/22 at 3:03 PM, Surveyor interviewed R20 and asked how the CNAs usually do the transfer to the commode with the Hoyer lift. Surveyor asked specifically if the aides pull the brief down while she was suspended above the commode like they did during the observation that morning. R20 stated they usually just pull the brief down when in the lift over the commode and clean me up when in the lift over the commode, before putting me back to bed.

Based on record review and interview, the facility did not provide written notice of bed hold policy for 6 of 6 residents (R) reviewed for transfer to the hospital. (R9, R18, R20, R22, R1, and R5) At the time of transfer to the hospital all 6 residents, or their representatives, did not receive written notice of bed hold policy. Findings include: Example 1: R9 was admitted to facility on 3/2/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set Assessment (MDS), dated [DATE], identified R9 had a Brief Interview for Mental Status (BIMS) score of 14. This indicated R9 was cognitively intact. On 04/11/22 at 1:25 PM, Surveyor interviewed R9, who said she was recently hospitalized with heart problems. R9 stated she thought someone asked her about a bed hold, but did not remember receiving anything in writing before being transferred to the hospital. Record review showed R9 was hospitalized from 01/29/22 to 02/2/22. No written bed hold policy was identified on R9's medical record for the time of the transfer to the hospital on 01/29/22. On 04/13/22 at 10:29 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated they did not have any documentation showing a written bed hold policy was given to R9 at the time of transfer to the hospital on 01/29/22. Example 2: R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's MDS assessment dated [DATE] identified R18 had a BIMS score of 8. This indicated R18 was moderately cognitively impaired. R18's sister was designated as the Power of Attorney for Health Care (POA-HC) for R18. Review of R18's medical record showed R18 was hospitalized from 02/02/22 to 02/15/22, and from 02/22/22 to 02/25/22. No written bed hold policy was identified on R18's medical record for the transfers to the hospital on 02/02/22 or 02/22/22. On 04/11/22 at 1:50 PM, Surveyor interviewed R18's POA-HC who stated R18 had two recent hospitalization s. The POA-HC stated someone from the facility updated her with a phone call and asked about a bed hold, but she did not receive anything in writing. On 04/13/22 at 10:29 AM, Surveyor interviewed NHA A who stated they did not have any documentation showing a written bed hold policy was given to R18's POA-HC at the time of transfer to the hospital on 02/02/22 or 02/22/22. Example 3: R20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's MDS assessment dated [DATE] identified R20's BIMS was 15, indicating R20 was cognitively intact. Record review identified R20 was hospitalized from 01/03/22 to 01/7/22. No written bed hold policy was identified on R20's medical record for the transfer to the hospital on 01/03/22. On 04/11/22 at 10:25 AM, Surveyor interviewed R20, who stated she had been in the hospital in the recent past. R20 did not know if anyone from the facility gave her or her husband a written bed hold policy when she went to the hospital. On 04/13/22 at 10:29 AM, Surveyor interviewed NHA A who stated they did not have any documentation showing a written bed hold policy was given to R20 or R20's husband at the time of transfer to the hospital on 01/03/22. Example 4 ~Review of R1's medical record documented a transfer to the hospital on 10/29/21 for a urinary tract infection and on 12/23/21 for [CONDITION(S)]. The medical record did not document a written notice of a bed hold was given to R1's representative upon the transfer to the hospital. Example 5 ~Review of R22's medical record documented a transfer to the hospital on 02/18/22 for signs of confusion and weakness to right side of body. The medical record did not document a written notice of a bed hold was given to R22 upon the transfer to the hospital. On 04/11/22 at 9:03 a.m., Surveyor interviewed R22 asking if a written notice of a bed hold upon transfer was given. R22 indicated went to the hospital for an infection in the bladder and came back to same room. Example 6 ~Review of R5's medical record documented transfers to the hospital on 12/22/21 for [CONDITION(S)], on 01/16/22 for [CONDITION(S)], on 01/18/22 for weakness, and on 02/01/22 for [CONDITION(S)]. The medical record did not document a written notice of a bed hold was given to R5 or R5's representative upon the transfers to the hospital. On 04/11/22 at 10:48 a.m., Surveyor interviewed R5 asking if a written notice of a bed hold upon transfer was given to R5 or their representative. R5 indicated not recalling getting a written notice to hold the bed. R5 indicated always came back to the same room. On 04/12/22 at 10:33 a.m., Surveyor interviewed Registered Nurse (RN) H about notice of transfer and bed hold. RN H indicated the notice of transfer is done verbally and documented and with a bed hold notice would ask the resident at the time of transfer or the POA if they wanted the bed to be held. If in an emergency this would be followed up by the social worker. RN H stated, To be honest, I have not filled out a bed hold notice in a long time.

Based on interviews and record review, the facility did not ensure 6 of 6 residents (R) reviewed for hospitalization were notified in writing of the reason for transfer from the facility, which included appeal rights, related contact information, and Ombudsman contact information. (R9, R18, R20, R1, R22, and R5) Findings include: Example 1: R9 was admitted to facility on 3/2/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set Assessment (MDS), dated [DATE], identified R9 had a Brief Interview for Mental Status (BIMS) score of 14. This indicated R9 was cognitively intact. R9 was her own decision-maker. On 04/11/22 at 1:25 PM, Surveyor interviewed R9, who said she was recently hospitalized with heart problems. R9 did not remember receiving anything in writing before being transferred to the hospital. Record review showed R9 was hospitalized from 01/29/22 to 02/2/22. No written notice of transfer was identified on R9's medical record. On 04/13/22 at 10:29 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who stated they did not have any documentation showing a written notice of discharge was given to R9 at the time of transfer to the hospital on 01/29/22. Example 2: R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's MDS assessment dated [DATE] identified R18 had a BIMS score of 8. This indicated R18 was moderately cognitively impaired. R18's sister was designated as the Power of Attorney for Health Care (POA-HC) for R18. Review of R18's medical record showed R18 was hospitalized from 02/02/22 to 02/15/22, and from 02/22/22 to 02/25/22. No written notice of transfer was identified on R18's medical record for the transfers to the hospital on 02/02/22 or 02/22/22. On 04/11/22 at 1:50 PM, Surveyor interviewed R18's POA-HC who stated R18 had two recent hospitalization s. The POA-HC stated both times someone from the facility updated her with a phone call, but she did not receive anything in writing. On 04/13/22 at 10:29 AM, Surveyor interviewed NHA A who stated they did not have any documentation showing a written notice of discharge was given to R18's POA-HC at the time of transfer to the hospital on 02/02/22 or 02/22/22. Example 3: R20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's MDS assessment dated [DATE], identified R20's BIMS score was 15, indicating R20 was cognitively intact. Record review identified R20 was hospitalized from 01/03/22 to 010/7/22. No written notice of transfer was identified on R20's medical record for the transfer to the hospital on 01/03/22. On 04/11/22 at 10:25 AM, Surveyor interviewed R20, who stated she had been in the hospital in the recent past. R20 did not know if anyone from the facility gave her or her husband a written notice of discharge/transfer when she went to the hospital. On 04/13/22 at 10:29 AM, Surveyor interviewed NHA A who stated they did not have any documentation showing a written notice of discharge was given to R20 or R20's husband at the time of transfer to the hospital on 01/03/22. Example 4 ~Review of R1's medical record documented a transfer to the hospital on 10/29/21 for a urinary tract infection and on 12/23/21 for [CONDITION(S)]. The medical record did not document a written notice of transfer was given to R1's representative with the written reason for the transfer to the hospital. Example 5 ~Review of R22's medical record documented a transfer to the hospital on 02/18/22 for signs of confusion and weakness to right side of body. The medical record did not document a written notice of transfer was given to R22 with the written reason for the transfer to the hospital. On 04/11/22 at 9:03 a.m., Surveyor interviewed R22 asking if a written notice of the reason for the transfer was given. R22 indicated went to the hospital for an infection in the bladder and came back to same room. Example 6 ~Review of R5's medical record documented transfers to the hospital on 12/22/21 for [CONDITION(S)], on 01/16/22 for [CONDITION(S)], on 01/18/22 for weakness, and on 02/01/22 for [CONDITION(S)]. The medical record did not document a written notice of transfer was given to R5 or R5's representative with the written reason for the transfers to the hospital. On 04/11/22 at 10:48 a.m., Surveyor interviewed R5 asking if a written notice of the reason for the transfer was given to R5 or their representative. R5 indicated not recalling getting a written notice. On 04/12/22 at 10:33 a.m., Surveyor interviewed Registered Nurse (RN) H about notice of transfer. RN H indicated the notice of transfer is done verbally and documented and with a bed hold notice would ask the resident at the time of transfer or the POA if they wanted the bed to be held. If in an emergency this would be followed up by the social worker. RN H stated, To be honest, I have not filled out a bed hold notice in a long time.

Based on observation, interview and record review, the facility did not provide routine maintenance of bed rails for 10 of 12 sampled residents with bed rails, plus 2 supplemental residents with bed rails (R17, R26, R28, R20, R23, R2, R183, R10, R184, R18, R22, R30). Routine maintenance to ensure proper working order was not provided for beds with bedrails for 12 residents within the facility. This is evidenced by: Facility Side Rails Policy states, in part: The facility will conduct regular bed inspections, utilizing an interdisciplinary, team-based approach (e.g. nursing and maintenance) to risk identification and prevention. The Director of Nursing and Maintenance Director (or qualified designees) cooperatively will be responsible or completion of bed inspections on a regular basis. On 03/06/19 at 7:04 AM, Surveyor interviewed Director of Nursing (DON), who stated the maintenance department installs the assist bars on residents' beds when requested by nursing staff. The maintenance department provides maintenance of bars if a problem is identified. DON was unsure if the maintenance department had a process for routine follow up inspection of installed rails. DON stated the maintenance supervisor could answer those questions. On 03/06/19 at 9:06 AM, Surveyor interviewed Environmental Services Director (ESD) B, who stated the facility did not perform any routine follow up or maintenance schedule once bed rails are installed on residents' beds. ESD B stated the maintenance personnel do repairs to bed rails on a case by case basis, if the nursing staff notice any problems, such as a loose bed rail. The nursing staff fills out a maintenance request for the bed rails when problems are noted. 1. Record review indicated R17 was readmitted to the facility on [DATE]. Minimum Data Set (MDS) assessment dated [DATE] indicated R17 required extensive assistance with bed mobility. On 03/04/19 at 10:27 AM, Surveyor observed bilateral grab bars on R17's bed. Record review of R17's medical record showed no maintenance record for bed rails. 2.Record review indicated R26 was admitted to the facility on [DATE]. MDS assessment dated [DATE] indicated R26 requires extensive assistance with bed mobility. On 03/05/19 at 9:55 AM, Surveyor observed bilateral grab bars on R26's bed. Surveyor interviewed R26, who stated she did have trouble getting used to the grab bars at first because they are a little bit loose or wobbly when she pulls on them. Record review did not identify any maintenance record for the bed rails on R26's bed. 3. Record review indicated R28 was admitted to the facility on [DATE]. MDS assessment dated [DATE] indicated R28 required extensive assistance with bed mobility. On 03/05/19 at 7:44 AM, Surveyor observed bilateral half bed rails on the upper half of R28's bed. Record review did not identify any maintenance record for the bed rails on R28's bed. 4. Surveyor reviewed a document for R20 entitled Care Card Report which is used by the Certified Nursing Assistants (CNAs) to direct cares. Under the heading of Safety the care card read 1/2 assist rails. There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 5. R23's [DIAGNOSES REDACTED]. R23's Brief Interview for Mental Status (BIMS), dated 09/17/18, was 15, indicating that R23 was cognitively intact. On 03/04/19 at 8:30 a.m., Surveyor interviewed R23. R23 was lying in his bed. One assist rail was present on each side of the bed. R23 told Surveyor that he is independent with all mobility, and uses a walker when up. There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 6. On 03/05/19 at 1:35 p.m., Surveyor observed R2. R2 was sleeping in bed. One assist rail was in place on each side of the bed. There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 7. On 03/04/19, Surveyor interviewed R183, in her room. R183 had a sling on her left shoulder, and was sitting in her recliner. One assist rail was present on each side of R183's bed. R183 stated that she requires assistance with all cares since her left arm is immobilized due to the fracture.There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 8. On 03/04/19 at 9:00 a.m., Surveyor interviewed R10. R10 was up in her wheelchair in her room. One assist rail was present on each side of the bed. R10 stated she is not able to walk, and relies on staff assistance for Activities of Daily Living (ADLs). There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 9. R184 was admitted to the facility on [DATE]. On 03/04/19 at 9:30 a.m., Surveyor interviewed R184. R184 was sitting up in his wheelchair, and was able to mobilize independently in the wheelchair in his room. R184 was alert and oriented. One assist rail was present on each side of the bed. There was no evidence in the clinical record that the facility regularly inspected the assist rails for correct fit and functionality. 10. On 03/05/19 at 7:38 AM, Surveyor observed bilateral grab bars (side rails) on R18's bed. The grab bar on the right side of the bed as resident the resident lay face up in the bed was observed to be padded. Review of R18's medical record on 03/04/19 - 03/06/19. No regular inspection of bed frames or bed rails or any routine maintainence maintainence records could be located. No information related to the compatibility of mattress, frames or bed rails was located. On 09/06/19 at 9:06 AM, an interview with ESD B revealed no routine inspection, or maintainence was being completed. 11. On 03/05/19 at 7:51 AM, Surveyor observed bilateral grab bars (side rails) on R22's bed. Review of R22's medical record on 03/04/19 - 03/06/19 indicated no regular inspection of bed frames or bed rails or any routine maintainence maintainence records could be located. No information related to the compatibility of mattress, frames or bed rails was located. On 09/06/19 at 9:06 AM, an interview with ESD B revealed no routine inspection, or maintainence was being completed 12. On 03/04/19 at 1:58 PM, Surveyor observed bilateral half rails on each side of R30's bed. Review of R30's medical record on 03/04/19 - 03/06/19. No regular inspection of bed frames or bed rails or any routine maintainence maintainence records could be located. No information related to the compatibility of mattress, frames or bed rails was located. On 09/06/19 at 9:06 AM, an interview with ESD B revealed no routine inspection, or maintainence was being completed.

Based on observation, record review and interview, the facility did not complete an entrapment risk assessment or obtain informed consent prior to implementation of assist bars/bed rails for 10 of 12 sampled residents, plus 2 supplemental residents (R20, R23, R2, R183, R10, R184, R17, R26, R28, R18, R22 and R30). The facility did not compete assessments or obtain consents for 12 residents who were observed to have bedrails attached to their beds. This is evidenced by: 1. On 03/05/19 at 9:53 a.m., Surveyor observed R20's room environment. The resident's bed showed one assist rail on each side of the bed. R20 was in the bed, sleeping. Surveyor reviewed R20's clinical record. The Minimum Data Set (MDS), dated [DATE], showed that R20's Brief Interview for Mental Status (BIMS) was 14, indicating that R20 was cognitively intact. R20 required extensive assistance with bed mobility. Resident is able to independently maneuver an electric scooter. On 02/19/19 at 9:00 p.m., R20 was attempting to reach her call light, which was on the bed. While attempting to reach the call light, R20's right foot was caught in the lowered assist bar. R20 sustained a small skin tear and a 3 cm (centimeter) x 2cm bruise to her right foot. Three steri strips were applied to a skin tear on the anterior portion of R20's right foot. R20's physician was notified, and ordered the facility to monitor the area. The facility interventions were to obtain an x-ray to rule out fracture, to monitor R20's wounds, and to treat for pain with ordered pain medication as needed. Local interventions included placing R20's call light at the end of the bed when R20 is in her wheelchair to ensure that R20 can easily reach the call light. The x-ray was completed on 02/20/19, and was negative for a fracture. Surveyor reviewed a document entitled Care Card Report which is used by the Certified Nursing Assistants (CNAs) to direct cares. Under the heading of Safety the care card read 1/2 assist rails. A consent to utilize the assist rails was not included in the clinical record. The record did not contain an assessment for safe use of the assist rails. On 03/06/19, Surveyor interviewed the Director of Nursing (DON). The DON stated that while R20 required the two assist rails for bed mobility, a consent for the assist bars and an assessment for entrapment safety should have been completed. 2. R23's BIMS, dated 09/17/18, was 15, indicating that R23 was cognitively intact. On 03/04/19 at 8:30 a.m., Surveyor interviewed R23. R23 was lying in his bed. One assist rail was present on each side of the bed. R23 told Surveyor that he is independent with all mobility, and uses a walker when up. Surveyor reviewed R23's clinical record. The care plan noted that R23 uses assist rails. The clinical record did not contain a signed consent form for the use of the assist rails, or an assessment indicating that R23 could safely use the assist rails. On 03/06/19 at 1:30 p.m., Surveyor interviewed the DON. The DON stated that a consent for the assist bars and an assessment for entrapment safety should have been completed for residents who use assist bars for bed mobility. 3. On 03/05/19 at 1:35 p.m., Surveyor observed R2. R2 was sleeping in bed. One assist rail was in place on each side of the bed. Surveyor reviewed R2's clinical record. The record did not include a consent for the use of the assist rails, or an assessment to ensure that R2 could use the assist rails safely. On 03/06/19 at 1:30 p.m., Surveyor interviewed the DON. The DON stated that a consent for the assist rails and an assessment for entrapment safety should have been completed for residents who use assist rails. 4. On 03/04/19, Surveyor interviewed R183, in her room. R183 had a sling on her left shoulder, and was sitting in her recliner. One assist rail was present on each side of R183's bed. R183 stated that she requires assistance with all cares since her left arm is immobilized due to the fracture. Surveyor reviewed R183's clinical record. The record did not include a consent for the use of the assist rails, or an assessment to ensure that R183 could use the assist rails safely. On 03/06/19 at 1:30 p.m., Surveyor interviewed the DON. The DON stated that a consent for the assist rails and an assessment for entrapment safety should have been completed for residents who use assist rails. 5. On 03/04/19 at 9:00 a.m., Surveyor interviewed R10. R10 was up in her wheelchair in her room. One assist rail was present on each side of the bed. R10 stated that she is not able to walk and relies on staff assistance for Activities of Daily Living (ADLs). Surveyor reviewed R10's MDS. The MDS indicated that R10's BIMS score was 12, indicating moderate cognitive impairment. The MDS showed that R10 required one person assistance with bed mobility. Surveyor reviewed R10's clinical record. The record did not include a consent for the use of the assist rails, or an assessment to ensure that R10 could use the assist rails safely. On 03/06/19 at 1:30 p.m., Surveyor interviewed the DON. The DON stated that a consent for the assist rails and an assessment for entrapment safety should have been completed for residents who use assist rails. 6. On 03/04/19 at 9:30 a.m., Surveyor interviewed R184. R184 was sitting up in his wheelchair, and was able to mobilize independently in the wheelchair in his room. R184 was alert and oriented. One assist rail was present on each side of the bed. Surveyor reviewed 184's clinical record. The record did not include a consent for the use of the assist rails, or an assessment to ensure that R184 could use the assist rails safely. On 03/06/19 at 1:30 p.m., Surveyor interviewed the DON. The DON stated that a consent for the assist rails and an assessment for entrapment safety should have been completed for residents who use assist rails. 7. On 03/04/19 at 10:27 AM, Surveyor observed bilateral grab bars on R17's bed. Surveyor interviewed R17, who indicated the grab bars assist her with turning and repositioning in bed. R17 did not recall receiving any education on risks of entrapment or injury with the use of bed rails, and did not recall signing an informed consent before the bed rails were placed on the bed. Record review of R17's chart identified a care plan problem which stated: Problem: I use assistive devices for increased comfort and mobility. Goal: To have no concerns related to the use of the assistive devices. Interventions: I have bilateral assist bars on my bed to help increase my bed mobility. Further record review identified no bed rail assessment for risk of entrapment or informed consent for bed rails on R17's chart. On 03/05/19 at 2:28 PM, Surveyor interviewed DON who stated R17 does not have side rails on her bed, they are assist bars, so a consent is not done and a bed rail safety assessment is not needed. The facility just care plans for the assist bars. Surveyor requested a copy of facility bed rail policy. Facility's Side Rails Policy states, in part: It is the policy of this facility to prevent entrapment and other safety hazards associated with bed rail use .DEFINITIONS: SIDE RAILS Bed rails (also referred to as side rails, bed side rails, and safety rails) are constructed of metal or rigid plastics, and are available in various sizes .PR[NAME]EDURE I. RESIDENT ASSESSMENT .D. Assess the resident for risk of entrapment from bed rails prior to installation .F. The facility will document ongoing need for the use of a bed rail G. Review the risk and benefits with resident and resident representative H. Obtain informed consent . On 03/06/19 at 7:04 AM, Surveyor interviewed DON, who stated the facility does not do safety risk assessments prior to implementing assist bars on residents' beds. The facility does not consider them bed rails, they are assist bars to assist the residents with positioning in bed. DON stated the facility care plans for the use of assist bars on residents' beds. DON also stated she does not obtain informed consent forms for assist bars before implementing them, or discuss the safety risks or risks of entrapment with the resident or their responsible party prior to implementing assist bars on resident's beds. 8. R26's care plan includes, in part: Problem effective 02/04/19: I use assistive devices for comfort, positioning and mobility. Goals: To have no complications related to my assistive devices. Interventions, in part: I have bilateral assist bars on my bed to aid in positioning and transfer assistance. Further record review identified no bed rail assessment for risk of entrapment or informed consent for bed rails on R26's chart. On 03/05/19 at 9:55 AM, Surveyor observed bilateral grab bars on R26's bed. Surveyor interviewed R26 about the grab bars on her bed. R26 stated she was not educated on the risks of entrapment or hazards prior to installation, they were just installed to help with turning in bed. R26 does not think she signed any consent form for the use of the rails. R26 stated she did have trouble getting used to the grab bars at first because they are a little bit loose or wobbly when she pulls on them. 9. On 03/05/19 at 7:44 AM, Surveyor observed bilateral half bed rails on the upper half of R28's bed. Surveyor interviewed R28, who stated the bed rails were helpful to pull himself up in the bed. R28 stated the bed rails are always in the up position and they do not get in the way of getting in and out of bed. Review of R28's record identified a care plan problem: Problem: I use assistive devices for positioning and comfort. Goals: To have no complications related to my assistive devices. Interventions: I have bilateral assist bars on my bed to help with transfer assistance and positioning. Further record review identified no bed rail assessment for risk of entrapment, and a blank Informed Consent for Physical Devices on R28's chart. 10. On 03/05/19 at 7:38 AM, Surveyor observed bilateral grab bars (side rails) on R18's bed. The grab bar on the right side of the bed as resident lay face up in the bed was observed to be padded. Review of R18's medical record on 03/04/19 - 03/06/19 revealed a care plan which states, problem, has impaired mobility due to compression fracture, intervention has half side rails to assist with bed mobility, and they do not restrict her mobility in bed. The medical record did not contain a bed rail assessment for entrapment, or an informed consent for bed rails or any lesser restrictive options tried first. On 03/06/19 at 10:30 AM, Surveyor requested further information related to R18's side rail usage from the DON. 11. On 03/05/19 at 7:51 AM, Surveyor observed bilateral grab bars (side rails) on R22's bed. Review of R22's medical record on 03/04/19 - 03/06/19 revealed a care plan which states problems, I use assistive devices for comfort and positioning, interventions include I have bilateral assist bars on my bed to aid in increased bed mobility. The medical record did not contain a bed rail assessment for entrapment, or an informed consent for bed rails or any lesser restrictive options tried first. On 03/06/19 at 10:30 AM, Surveyor requested further information related to R22's side rail usage from the DON. 12. On 03/04/19 at 1:58 PM, Surveyor observed bilateral half rails on each side of R30's bed. Review of R30's medical record on 03/04/19-03/06/19 revealed a care plan which states problems, I have assist devices to increase my mobility, interventions include I have bilateral assist bars on my bed to aid in bed mobility. The medical record did not contain a bed rail assessment for entrapment, or an informed consent for bed rails or any lesser restrictive options tried first. On 03/06/19 at 10:30 AM, Surveyor requested further information related to R30's side rail usage from the DON. On 03/06/19 at 1:30 PM, the DON stated they did not have any consents for the use of the bed rails, or assessments for entrapment for R18, R22, or R30.

Based on interview and record review, the facility did not ensure that residents with a limited range of motion receive appropriate treatment and services to increase range of motion, or to prevent further decrease in range of motion for 3 of 5 sampled residents (R20, R18, and R30). The facility did not provide restorative services for R20 as outlined in the care plan. R18 has a limited range of motion in her upper extremity. R18 has no range of motion program to maintain or prevent further decrease in range of motion. R30 has limited range of motion in both lower extremities. R30's range of motion program has not been completed consistently in order to maintain or prevent further decrease in range of motion. This is evidenced by: 1. R20's [DIAGNOSES REDACTED]. On 03/04/19 at 8:45 a.m., Surveyor interviewed R20. R20 stated she did not have an exercise program in place. Surveyor reviewed R20's clinical record. A document entitled Care Plan Report listed in part, Continue with and encourage participation in current nursing restorative program to maintain current level of function . However, the care plan does not list specific exercises to assist R20 to maintain or improve her range of motion. Surveyor reviewed R20's Minimum Data Set (MDS). The admission MDS, dated [DATE], listed functional limitations of both lower extremities. R20 requires two person assistance with all Activities of Daily Living (ADLs), except when up in her electric wheelchair, which R20 is able to maneuver independently. The clinical record did not contain evidence that a restorative program was in place to improve or maintain R20's current level of range of motion. The clinical record did not show periodic assessments of R20's range of motion abilities to determine an increase or decrease in R20's range of motion. Surveyor interviewed the Director of Nursing (DON). The DON acknowledged that R20 did not have specific range of motion exercises in place, or assessments related to R20's range of motion abilities. The DON stated there is not currently a restorative program in place in the facility. 2. On 03/04-06/19, Surveyor reviewed R18's medical record. The resident has [DIAGNOSES REDACTED]. R18's MDS on admission in 2014 and most current MDS, dated [DATE], indicate R18 has a functional limitation in range of motion impairment on one side of her upper extremities. R18's care plan makes no mention of a program to maintain or increase R18's range of motion. Interview with the DON on 03/06/19 at 10:30 AM, Surveyor requested information on R18's range of motion program. At 12:25 PM on 03/06/19, the DON responded that they don't have anything related to range of motion for R18. There are no assessments and there is no program in place for R18. 3. On 03/04-06/19, Surveyor reviewed R30's medical record. The resident has [DIAGNOSES REDACTED]. R30 was observed to utilize a wheelchair for mobility throughout survey. R30's most recent MDS dated [DATE] indicates R30 has a limited range of motion in both lower extremities. R30's care plan indicates R30 displays a need for a restorative nursing program related to weakness, [MEDICAL CONDITION], arthritis, and severe dementia. Goals include participating in a range of motion program. Interventions include assisted range of motion (AROM) program. During an interview with the DON on 03/06/19 at 10:30 AM, Surveyor requested details about the range of motion programs, and documentation about the program being completed. On 03/06/19 at 12:25 PM, the DON provided documentation related to R30's AROM program being completed for the past three months. The documentation states the AROM program was completed twice during the time period; once on 02/05/19 and on 02/23/19. No information was provided in relation to what the program entails. The DON added the CNAs implement the programs, but no formal plan in place for reviewing ROM data to see if adjustments to the programs need to be made. Interview with Certified Nursing Assistant (CNA) F on 03/06/19 at 11:13 AM revealed CNA F routinely works with R18 and R30. CNA F stated she is not aware of R18 or R30 having any range of motion programs. She works with them both often, but does not recall any exercises or anything. CNA F stated R30 has a hard time with her lower extremities and R18 has one arm which gives her trouble, and it's hard for her.

Based on observation, interview and record review, the facility did not ensure that a person centered care plan was in place to address specific resident needs for 3 of 12 sampled residents (R2, R10 and R12). The facility did not develop a care plan to include the need to monitor potential [MEDICAL CONDITION] for resident (R2) on diuretic for [MEDICAL CONDITION]. The facility did not develop a plan of care to address specific interventions for the treatment of [REDACTED]. The facility did not develop a care plan to address specific needs related to feeding assistance for R12 resulting in prolonged dependence on tube feedings. This is evidenced by: 1. R2's [DIAGNOSES REDACTED]. R2's Brief Interview for Mental Status (BIMS) was 6, indicating that R2 is cognitively impaired. On 03/04/19 at 9:39 a.m., Surveyor interviewed R2. When asked if resident was experiencing any swelling, R2 nodded and pointed to her feet. Surveyor reviewed R2's clinical record. The physician orders [REDACTED]. R2 also wears a leg brace on her right leg. Surveyor conducted a review of R2's recent recorded weights, which could indicate fluid retention. The record showed that R2's weight fluctuated. On 12/24/18, R2 weighed 234 pounds. On 12/31/18, R2 weighed 239.5 pounds, showing a 5.5 pound weight gain. The next recorded weight was recorded on 01/20/19, and was 234 pounds. Surveyor reviewed a document entitled Care Plan Report. The care plan did not include interventions for monitoring R2's [MEDICAL CONDITION] status. Surveyor interviewed the Director of Nursing (DON). The DON acknowledged that R2's care plan did not contain specific interventions for monitoring R2's [MEDICAL CONDITION] status. 2. R10's [DIAGNOSES REDACTED]. On 03/04/19 at 11:33 a.m., Surveyor interviewed R10. R10 stated, I have to ask for a sandwich and juice or my blood sugar drops and then they are waking me up at night to check my blood sugar and it is low and they are having to try to bring it up If I have a snack then I am fine but I don't always have a snack .I have to ask It is too long to go from 5:00 p.m. to 8:00 a.m. without anything .my blood sugar cannot take it. Surveyor reviewed R10's clinical record, including blood sugar logs for the last three months. The nurses notes showed on 02/01/19, at approximately 4:00 a.m., R10 called the staff due to symptoms of feeling shaky and sweaty. Blood sugar was 78. R10 received a snack and blood sugar returned to normal limits. Other blood sugar readings were within normal limits, and no other documentation of hypoglycemic episodes were recorded. R10 receives 40 units of [MEDICATION NAME] (a type of insulin) in the a.m. and 50 units at night. R10's blood sugar is checked twice a day, once at 7:30 a.m. and once at 8:00 p.m. Surveyor reviewed R10's plan of care. The plan of care did not address R10's [DIAGNOSES REDACTED]. Surveyor interviewed the DON. The DON agreed that R10's plan of care should have included specific interventions for the treatment of [REDACTED]. 3. R12 was admitted to facility on 11/04/16 with diagnoses, which included in part, [MEDICAL CONDITION], muscle weakness, unspecified lack of coordination, and cognitive communication deficit. The Minimum Data Set (MDS) assessment dated [DATE] showed R12 had a BIMS score of 2 out of possible 15 points. This indicates severe cognitive impairment. The MDS assessment also indicated R12 required extensive assistance with eating. On 03/04/19 at 12:16 PM, Surveyor observed a dining assistant place a small bowl containing potato salad, a plate with half of a hamburger and baked beans, and a small cup of ice cream on the table in front of R12. There was already a glass of water and a glass of milk on the table in front of R12. R12 was seated in a standard wheelchair, slightly away from the table and leaning over the right arm rest of the wheelchair. R12 reached up to the plate and dropped the top of the hamburger bun on the floor. Two Certified Nursing Assistants (CNAs) were assisting other residents at the same table. No assistance was offered to R12. At 12:20 PM, Surveyor observed R12 pick up the bowl containing potato salad and slowly bring it to his mouth, as if to drink from the bowl. R12 placed the bowl back on the table, raised his hand toward CNA C, who was feeding another resident at the same table, and mumbled unintelligible words. CNA C did not respond to R12 or offer assistance. R12 then pushed wheelchair slightly away from the table and closed his eyes. At 12:32 PM, Surveyor observed CNA C go to assist a resident at another table. R12 was still sitting slightly away from the table, leaning over the right arm rest of the wheelchair with eyes closed and had made no further attempt to feed himself. At 12:39 PM, another staff member entered the dining room, sat beside a resident on the right side of R12 and encouraged that resident to try to eat. No staff offered to assist R12 with eating or encouraged him to feed himself. At 12:48 PM, Surveyor observed CNA D approach R12, remove the clothing protector from R12 and said, I will help you back to your room. CNA D then pushed R12's wheelchair out of the dining room. CNA D did not ask R12 if he was done eating or if he needed assistance with eating. R12 did not eat or drink any of the food or liquids that were placed in front of him. On 03/05/19 at 8:36 AM, Surveyor observed R12 brought to the dining room in his wheel chair. CNA C asked R12 what he would like for breakfast and placed a glass with chocolate milk and a straw in front of R12. R12 began to slowly sip the milk and coughed frequently after each sip. CNA C placed a clothing protector on R12 and asked if he was okay when he was coughing. At 8:40 AM, a dining assistant placed a plate with one piece of toast in front of R12. R12 reached up to the table and took one bite of the toast, then continued to slowly sip his chocolate milk. At 8:47 AM, a dining assistant placed a plate with one fried egg on the table in front of R12. The dining assistant offered salt and pepper, but did not assist with cutting up the egg. R12 attempted to place his glass of chocolate milk on the table, and CNA C, who was feeding a resident on the left side of R12, said, You make me nervous. Don't spill your milk. CNA C then reached across the table and pulled R12's toast plate back to make room for the milk glass. R12 could no longer reach the toast. At 8:53 AM, R12 finished the milk and placed the glass on the table, but did not attempt to feed himself the egg. He could not reach the toast. CNA C poured R12 a glass of water, and placed a straw in it. At 8:58 AM, the straw fell out of R12's water glass as he was attempting to drink and he struggled to place it back in the glass. CNA C stated, Don't spill your water, but did not offer assistance. At 9:04 AM, R12 attempted to pick up the egg with his fingers, but was unsuccessful. At 9:08 AM, R12 pushed his wheelchair away from the table. He had consumed 8 ounces of milk, a few sips of water and one bite of toast with jelly. CNA C asked R12 if he was finished. R12 did not reply. CNA C removed the clothing protector and pushed his wheelchair into the hallway. On 03/05/19 at 9:20 AM, Surveyor interviewed CNA C. When asked if R12 ever receives any assistance with eating, or if there is a plan in place for assisting him with feeding, CNA C replied that R12 doesn't usually eat much for breakfast because his tube feeding runs all night and he is not hungry. CNA C stated R12 sometimes eats better for lunch, and if staff sees he is interested in eating, someone can sit beside him and assist. Record review showed R12 is receiving tube feedings every night through a gastrostomy (stomach) tube continuously from 6:00 PM through 6:00 AM. Weekly nursing summary dated 12/13/18 stated in part, He is able to take thin liquids but does require cuing and some physical assistance. Most of his nourishment is via tube feeding. Record review of R12's chart identified a care conference summary dated 1/10/19 Dietary: Current weight is 170. Down 4 # (pounds) from 12/9/18. Will reweigh and monitor. Intakes 3259 cc (cubic centimeters) average daily fluid intake, 54% of food, Mechanical soft diet. Care card for R12 identified: Diet: Mechanical soft diet. Fluid Amt (amount): Small spoons, Thin liquids, may use straw if he prefers; remind to take small sips. Eat: Limited Assist-guide (A1) ADL Notes: Mechanical soft diet. Small bites, alternate solids and fluids. slow pace. Thin liquids. No specific instructions on how to assist R12 with eating identified on care card. Care plan for R12 identified: Problem: At risk for choking and aspiration. Goals: (R12) will not exhibits (SIC) signs and symptoms of aspiration. Interventions: Cues for (R12) shall include, small bites, alternate solids and liquids, and to eat at a slow pace. Serve (R12) small portions. Encourage no talking while he has food in his mouth. (R12) will dine independently when able. (R12) will eat his meals in the main dining room, with supervision. DO NOT RUSH (R12) AT MEAL TIME. ALLOW HIM PLENTY OF TIME TO COMPLETE HIS MEALS. (MONTH) use regular silverware, encourage to take small bites/sips. Encourage to eat 100%. R12's care plan did not identify a problem related to R12's ability to physically feed himself or specific interventions for the staff on how to set up or assist R12 with eating. On 03/06/19 at 6:49 AM, Surveyor interviewed Registered Nurse (RN) E, who reported R12's tube feeding was originally continuous, but had been changed to overnight from 6:00 PM to 6:00 AM in an attempt to improve his oral intake. The hope was that R12 will begin to improve his oral intake so that the tube feedings can be decreased and eventually discontinued, but R12 has reached a plateau currently with his oral intake, so they have not been able to decrease the tube feedings. When asked about the plan for offering assistance to R12 with eating, as it appears that resident struggles with eating, RN E stated that R12 is resistant to help, so the staff has to try to maintain an appropriate approach and not appear to be hovering, or R12 becomes upset. On 03/06/19 at 7:04 AM, Surveyor interviewed DON about R12's oral intake and assistance from staff. DON reported the facility decreased the tube feedings in attempt to improve R12's oral intake so the tube feedings could eventually be discontinued but R12's weight dropped. When asked if the staff assists R12 with oral intake, DON stated R12 is very stubborn and wants to be independent. If staff appears to be hovering too much or helping too much, R12 will push away from the table and try to leave the dining room. On 03/06/19 at 8:59 AM, Surveyor conducted a phone interview with R12's daughter. R12's daughter stated she had expressed her concerns about R12 needing more assistance from the staff with eating in the past. R12's daughter requested the facility staff cut up the foods and set up the food so that it is easier for R12 to feed himself before it is brought to the table. R12's daughter stated he is proud and does not like to seem like a burden to others by asking for help. R12's [MEDICAL CONDITION] also makes it difficult for him to feed himself and to communicate his need for help. On 03/06/19, Surveyor received a copy of R12's comprehensive care plan from DON. DON acknowledged R12's care plan did not contain any problems or interventions related to R12's ability to feed himself or specific interventions about how to assist R12 with feeding.

Based on observation, interview and record review, 2 of 12 sampled residents' care plans were not revised to reflect the resident's current status. R14's care plan indicates the resident needs half assist rails on the bed for bed mobility. R14 does not have assist rails on the bed. R14's care plan has not been revised to reflect R14's current needs. R18's care plan indicates the resident has a roommate conflict. R18 does not have a roommate. R18's care plan has not been revised to reflect R18's current status. This is evidenced by: 1. On 03/04-06/19, Surveyor reviewed R14's medical record. The resident has [DIAGNOSES REDACTED]. Surveyor reviewed R14's Care Plan which indicates R14 has half assist rails on the bed to aid with bed mobility. This does not restrict his ability to get in/out of bed. Observations on 03/04-06/19 of R14's bedroom and bed revealed no assist rails were present on his bed. Interview with R14 on 03/05/19 at 8:30 AM revealed R14 does not use assist rails on his bed and he feels he doesn't need them. On 03/06/19 at 10:30 AM, Surveyor informed the Director of Nursing (DON) of the care plan identifying the resident as having assist rails on R14's bed, and the observation of none being there. The DON stated R14 doesn't need assist rails, and the care plan needs to be changed. 2. On 03/04-06/19, Surveyor reviewed R18's medical record. The resident has [DIAGNOSES REDACTED]. Surveyor reviewed R18's Care Plan which indicates R18 will continue to not have conflict with her current roommate and that she will voice frustrations and concerns over roommate in a private, confidential area. Observations of R18 on 03/04-06/18 reveal R18 resides in a private room and does not have a roommate. On 03/06/19 at 10:30 AM, Surveyor informed the Director of Nursing (DON) of the care plan identifying the resident as having a roommate conflict. The DON stated R18 has been in a private room since the DON came in November, so a roommate conflict would not apply to R18, and the care plan needs to be changed. Interview with Life Enrichment Supervisor (LES) A on 03/06/19 at 11:16 AM revealed R18's roommate conflict information no longer applies to R18 as she has a private room. LES A revealed R18 moved to the private room in (YEAR).

Based on interview and record review, the facility did not complete a smoking safety assessment for 1 of 2 residents reviewed for smoking (R20). This is evidenced by: R20's [DIAGNOSES REDACTED]. Surveyor reviewed R20's clinical record. The MDS (Minimum Data Set), dated 08/14/18, showed R20's Brief Interview for Mental Status (BIMS) was 14, indicating that R20 was cognitively intact. R20 requires extensive assistance with bed mobility. Resident is able to independently maneuver in an electric scooter. On 03/06/19 at 9:55 a.m., Surveyor attempted to interview R20. R20 was not available for interview at this time. Surveyor reviewed a document entitled Care Card Report. Under the heading ADL (Activities of Daily Living) Notes, a notation is listed stating (MONTH) go outside of building independently to smoke. Surveyor reviewed a document entitled Smoking Evaluation present in R20's clinical record. The clinical record did not not specify that R20 can safely independently smoke or if R20's smoking needs were discussed with the Interdisciplinary Team (IDT). The storage needs of R20's smoking materials were not listed. At 1:30 p.m., Surveyor interviewed the Director of Nursing (DON). The DON stated she was not aware that a smoking safety assessment was not complete, and that R20 should have a completed smoking safety assessment. At 2:52 PM Surveyor interviewed R20 who stated, No staff don't always come with me .only if there is fresh snow I keep my cigarettes and lighter in my fanny pack which I cannot reach, staff have to reach them for me .staff open the exit doors at the end of the hall and let me out to smoke.

Based on interview and record review, the facility did not provide a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status to the receiving facility when resident was discharged to an assisted living facility for 1 of 1 discharged residents reviewed (R34). Findings include: Closed record review identified that R34 was admitted to the facility on [DATE] following hospitalization for acute [MEDICAL CONDITION]. R34 had [DIAGNOSES REDACTED]. Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 points. According to the BIMS assessment, a score of 10 indicates a moderately impaired cognition. Social services notes dated 08/07/18 indicated that R34's daughter was appointed legal guardian over R34 due to incompetency, and R34 was protectively placed at the facility until a less restrictive placement at an assisted living facility could be arranged. Social services notes further indicated R34 was upset about this. On 09/25/18, a PHQ-9 assessment (assessment to detect possible mood disorder) was completed for R34, with a score of 12. According to the PHQ-9 severity score, a score of 12 indicates possible moderate depression. The PHQ-9 assessment was faxed to R34's physician resulting in an order to increase R34's [MEDICATION NAME] (antidepressant) dose from 25 milligrams (mg) once daily to 50 mg once daily. Nursing progress notes indicated R34 was discharged to an assisted living facility on 12/10/18. Record review identified no discharge summary on R34's chart with a summary of R34's depression and upset over legal guardianship and protective placement. On 03/06/19, Surveyor interviewed Life Enrichment Supervisor A, who stated she did not complete a discharge summary for R34 or provide a verbal discharge summary to receiving facility to ensure continuity of care for R34.

Based on observation, record review, and interview the facility did not ensure that 2 of 4 residents' (R2 and R1) assistive devices to prevent falls and injuries were in place and were in good repair. R2 is to have Dycem (a nonskid material) in her wheelchair and a reacher. Neither intervention were observed to be in place as outlined in her care plan. R1 has anti-roll back breaks installed on her wheelchair. The locks were in disrepair and may not have functioned properly. This is evidenced by: Example 1: Review of R2's current formal plan of care indicates that she will remove the dycem from her recliner herself and it is used to prevent her sliding out of her recliner. Review of the aide care card since at least 2/15/18 indicate staff are to use dycem in her wheelchair and in her recliner and since the day of survey, 7/25/18, to encourage her to use a reacher to pick up items from the floor in order to discourage her actually reaching for them. On 7/25/18 at 11:10 a.m., Surveyor observed CNA-A (Certified Nursing Assistant) assist R2 from the toilet to the wheelchair. There was a pink hand towel in the chair, but no Dycem. CNA-A did not put any Dycem in the wheelchair before assisting R2 to sit in the wheelchair. On 7/25/18 at 1:40 p.m. Surveyor observed CNA-A assist R2 to her recliner. There was no Dycem observed in the recliner and CNA-A did not place any Dycem in the recliner before assisting R2 to sit. CNA-A also did not offer R2 the reacher that was observed in the corner of the room. CNA-A was asked about the dycem and the reacher and CNA-A stated she had no idea about these items but would check. At 2:06 p.m. Surveyor asked CNA-A about R2's fall interventions and CNA-A stated she was still in the process of finding out. At 2:32 p.m. Surveyor asked CNA-A about the Dycem and the reacher in the presence of CNA-C. CNA-A stated she had found the reacher and had given it to R2 and also found the dycem and put it on R2's bedside table so her things wouldn't move around. CNA-A was asked where she would find specific information about a resident's devices and CNA-C answered for her and stated that they would check with the nurse and the care plan. Example 2: Review of R1's current formal plan of care and aide care card finds she has this device was added to her wheelchair since at least 3/5/18. Review of the POS [REDACTED]. The interdisciplinary team noted that after this fall . the anti-roll backs were tightened on the wheelchair after the fall as they were found to be loose and the wheelchair was across the room on it's back. No further intervention. On 7/25/18 at 1:10 p.m., Surveyor observed R1 in the beauty parlor in her wheelchair. R1's wheelchair has an add-on anti-roll back device that was in disrepair with one pressure arm rubbing constantly on one rear wheel and the other arm positioned away from the opposite rear wheel. This would negate the effectiveness of the safety device as this would cause one wheel to catch and the other wheel to move freely in a possible uncontrolled twist and turn should R1 forget to lock her wheelchair brakes. On 7/25/18 at 1:58 p.m., Surveyor observed CNA-A and CNA-C assist R1 to transfer from her wheelchair to the bed. The anti-roll back device continued to be in disrepair. On 7/25/18 at 3:20 p.m., Surveyor interviewed CNA-B about the fall intervention measures for R1. Surveyor alerted the CNA to R1's broken anti-roll back device. CNA-B stated it must have happened in the last 2 days as he had been off and it was not like that when he had last worked with R1. CNA-B stated he would get maintenance to fix it. On 7/26/18 at 12:03 p.m., Surveyor interviewed the POD (Plant Operations Director) as he was alerted to R1's broken device and repaired it late afternoon on 7/25/18. The POD stated that unfortunately there are no routine maintenance checks of the residents' assistive devices. The POD stated the maintenance staff rely on the staff on the floor to alert them to broken equipment. The POD stated there are two ways for staff to alert them to an issue; one being to fill out a formal work order request outside the office and the second being just slipping them a note with the information.

Based on observation, record review, policy review, and interviews the facility did not ensure a medication error rate of 5% or less. Surveyor observed 3 errors out of 35 medication opportunities which calculates to an error rate of 8.57%. R12 received 3 liquid medications via a feeding tube. The 3 medications were mixed together in a cocktail instead of given individually followed by a water flush. Medication cocktails are not recommended unless reviewed by the pharmacist for stability and comparability and ordered by the physician. There was no pharmacy review and no physician order for [REDACTED]. R22 received [MEDICATION NAME] eye drops and there was no pressure applied to the inner canthus of the eye (bridge of the nose) to prevent systemic absorption of the medication. [MEDICATION NAME] is an eye drop to treat [MEDICAL CONDITION]. When absorbed systemically, [MEDICATION NAME] can cause negative side effects including but not limited to reducing blood pressure R22 received an [MEDICATION NAME] coated aspirin and the physician ordered a chewable aspirin. The medication was given in the wrong form. This is evidenced by: Example 1: Surveyor reviewed the facility policy titled Enteral Tube Medication Administration. The policy instructed staff to dilute liquid medications, administer each medication separately, and flush with 5 mls (milliliters) of water after each medication. R12 was admitted on [DATE] due to [MEDICAL CONDITION] and dysphagia (difficulty swallowing.) Review of the physician orders signed on 12/06/17 noted R12 was to receive [MEDICATION NAME] 20 mgs (milligrams), Potassium chloride 20 mEq (milliequivalent), and Levetiracetam 100 mgs via the feeding tube. The physician orders did not include to give medications to be mixed and administered at the same time. Surveyor reviewed the pharmacy recommendations since the feeding tube was placed in June 2017 and found no pharmacy recommendations for these 3 medications to be mixed and given at the same time. On 01/10/18 beginning at 7:25 a.m., Surveyor observed RN (Registered Nurse)-A dispense [MEDICATION NAME] 20 mgs liquid, Potassium chloride 20 meq liquid, and Levetiracetam 100 mgs liquid and pour all 3 medications into a plastic cup. RN-A entered R12's room and proceeded to check the feeding tube for placement, flush the tube with water, administer these 3 medications into the feeding tube, and flush again with water. On 01/10/18 at 4:23 p.m., Surveyor interviewed RN-A regarding the above observation. RN-A stated she was aware of the practice to administer all feeding tube medications separately followed by a water flush between each medication. RN-A stated she had checked with pharmacy in the past and was given approval by pharmacy to administer all 3 medications together. Surveyor asked RN-A for documentation of that pharmacy recommendation and RN-A stated she was unable to provide any documentation. Surveyor asked for the physician order to administer medications in this manner and RN-A stated there was no physician order to do so. On 01/10/18 at 4:43 p.m., Surveyor interviewed the RPh (Registered Pharmacist) regarding R12's liquid medications. RPh stated he had not made any recommendations regarding R12's liquid medications. RPh reviewed his documentation and stated currently there were no pharmacy recommendations or notations to mix these 3 medications for R12. Surveyor interviewed the DON (Director of Nurses) regarding facility expectations of administering medications via a feeding tube. The DON stated all medications should be give separately followed by a water flush. Example #2 and #3: Surveyor reviewed the facility policy titled Eye Drop Administration. The policy did not instruct the facility staff to apply pressure on the inner canthus which is the current standard of practice and manufacturer recommendation of [MEDICATION NAME] eye drops. R22 was admitted to the facility on [DATE]. Review of the medical record noted R22 was diagnosed with [REDACTED]. Review of the physician orders signed on 01/08/18 noted R22 was to receive [MEDICATION NAME] 0.1% eye drops in both eyes twice daily. R22 was also to receive chewable Aspirin 81 mgs daily. On 01/10/18 beginning at 8:23 a.m., Surveyor observed RN-A dispense and administer an [MEDICATION NAME] coated Aspirin 81 mgs to R22. Surveyor also observed RN-A instill 1 drop of [MEDICATION NAME] 0.1% eye drops into R 22 eyes. RN-A did not instruct R22 to keep eyes closed for 1 minute and RN-A did not apply pressure to R22's inner canthus or instruct R22 to apply pressure to the inner canthus. On 01/10/18 at 4:28 p.m., Surveyor interviewed RN-A regarding eye drop administration. RN-A stated she had been educated to apply pressure to the inner canthus of the eye following eye drop administration but she stated she failed to do so when she administered eye drops for R22. On 01/10/18 at 4:47 p.m., Surveyor interviewed the DON regarding the facility expectation for eye drop administration. The DON stated she had been educated to apply pressure after eye drops however she was unsure if the facility policy instructed staff to apply pressure to the inner canthus to prevent systemic absorption.

Based on observation, interview and record review, the facility did not ensure that care and services were provided to attain or maintain the highest practicable physical, mental and psychosocial well-being for 3 of 10 sampled residents (Resident (R)7, R10, R1). This is evidenced by: The facility did not apply fundamental principles of care for persons with dementia, focusing on the needs of R7. The facility did not identify and treat the pain and anxiety manifested by R7 for bathing, and transfers. The pain assessments were not completed when R7 was transferring. Effective interventions were not implemented to address behavioral expressions of distress, anxiety, crying, and calling out that were observed and reported for R7. R10 did not receive effective pain management. R1 did not receive care and services to treat red, painful eyes, which were not mentioned on plan of care. Examples 1 and 2 are being cited at scope/severity of G. Example 3 is being cited at severity level 2 (potential for more than minimal harm). 1. R7's [DIAGNOSES REDACTED]. The Minimum Data Set, (MDS) with assessment reference date (ARD) of 12/21/16 documents R7's brief interview for mental status (BIMS) score was completed by the staff, showing R7 has severe cognitive impairment. The MDS indicates R7 needs extensive assist for transfers and personal hygiene. The CNA care plan in part: .A2 (assist 2) hoyer anxiety w/ transfers/rolling. Remind .to breathe and relax .provide 1:1 time if behaviors give stuffed animal to hold. Turn on polka Joe . The care plan, .has potential pain and knee contractures due to impaired mobility, history of fractures and [MEDICAL CONDITION], Goal: .pain will be managed, Interventions in part: .receives scheduled pain medication due to chronic pain and contractures .assess effectiveness of pain medication and notify healthcare provider if pain not well controlled . The care plan, .has a self care deficit- Extensive assistance require with bathing,, hygiene, dressing, grooming .Interventions in part: .has a history of anxiety with bathing at times, trial of [MEDICATION NAME] on bath days with no beneficial effects noted, bath in whirlpool tub weekly and prn .will at times get anxious with transfer. Speak to in a calming matter. Explain what you are doing. Physician orders [REDACTED].>[MEDICATION NAME] 0.5 mg tablet oral prn anxiety 3/16/16 [MEDICATION NAME] 50 mcg/hr [MEDICATION NAME] 72 hours, 09/15/16 The quarterly pain assessments completed 09/16/16 and 12/13/16 document no pain. Surveyor interviewed the Director of Nursing (DON) to ask if the assessments had been done while R7 was being transferred or repositioned. The DON stated the assessments were not done at that time, but when R7 was sitting still. The nurses' notes in part: 07/07/16 IDT (interdisciplinary team/ met with the resident's family .at times the resident will have anxiety with showering. Overall, no nursing concerns . 07/11/16 Behavior committee .Behavior has occurred 8 x this month .interventions include holding her stuffed animal which is sometimes effective, 1:1 time, [MEDICATION NAME] to calm nerves, (effective at times), turning on .Polka Joe .talking resident through what is being done .not always effective. Has scheduled [MEDICATION NAME] bid (twice a day) has prn med as well. Due to resident's advanced dementia interventions are not always effective will look at increasing [MEDICATION NAME] to see if this decreases anxiety .fax out to MD. 07/13/16 [MEDICATION NAME] given prior to am bath with effectiveness noted . 07/20/16 Behavioral tracking for s/s of anxiety: .the resident continues to consistently display behaviors of s/s of anxiety.resident has dx (diagnosis) of dementia which impedes interventions at times. Resident is reported to have increased anxiety with transfers and baths .The past interventions of offering a stuffed animal to hold during transfers was removed by behavioral committee . 08/10/16 Given prn [MEDICATION NAME] prior to bath it was effective. 09/14/16 Behavior committee .Interventions include 1:1, [MEDICATION NAME] to calm nerves .polka joe .talking resident through what is being done, not always effective. Has scheduled [MEDICATION NAME]. Due to resident's advanced dementia interventions are not always effective. Committee discussed anxiety may be r/t pain as resident has c/o back pain at times. Will update MD and request increase in [MEDICATION NAME] . 09/15/16 Returned fax from MD. Increased [MEDICATION NAME] to 50 mcg q (every) 72 hours . 10/10/16 Behavior committee .Interventions include 1:1, [MEDICATION NAME] to calm nerves .polka joe .talking resident through what is being done, not always effective. Has scheduled [MEDICATION NAME]. Due to resident's advanced dementia interventions are not always effective. [MEDICATION NAME] increased to see if s/s of anxiety is r/t pain. Continuing to monitor . 11/01/16 Behavioral tracking .Resident is reported to have increased anxiety with transfers and baths. Behavior committee to discuss updating interventions . 11/14/16 Behavior committee .Behavior has occurred 6 x thus far this month which is approx the same as last month Interventions include 1:1, [MEDICATION NAME] to calm nerves .polka joe .talking resident through what is being done, not always effective. Has scheduled [MEDICATION NAME]. Due to resident's advanced dementia interventions are not always effective. [MEDICATION NAME] increased to see if s/s of anxiety is r/t pain. Recent GDR of [MEDICATION NAME] showed little difference in residents anxiety. committee feels antianxiety medication is not effective for resident and feels the anxiety is r/t her dementia progression. Fax sent to have [MEDICATION NAME] d/c'd at this time . 11/16/16 Signed fax back from MD with orders to DC [MEDICATION NAME] ([MEDICATION NAME]) . 11/26/16 CNA reported finding resident sitting in her wheelchair with .right leg bent and foot on the seat. Resident was crying in discomfort. Staff reposition resident and brought .stuffed puppies .tearfulness resided and .has not had any more signs of discomfort. 12/03/16 Resident rarely c/o pain, staff have to anticipate needs. Wears [MEDICATION NAME] for contractures which is effective . 12/08/16 Behavioral tracking .the resident displayed more behaviors of s/s of anxiety in the month of October .Interventions include 1:1, [MEDICATION NAME] to calm nerves .polka joe .resident has dx of dementia which impedes interventions at times. Resident is reported to have increased anxiety with transfers and baths. Behavior committee to discuss updating interventions and changes that can be made to help decrease anxiety . 12/31/16 Resident does not complain of pain .has contractures. Has dementia so cannot often express self, staff anticipate needs/wants. Wears a [MEDICATION NAME]. Takes routine Tylenol and prn [MEDICATION NAME] for anxiety. (There is no order for routine Tylenol) 01/26/17 resident does not complain of pain .resident cannot express self d/t (due to) dementia, staff anticipate needs . 02/15/17 resident will be added to behavior committee for next month with monitoring in place .due to being on anxiety prn medications .03/02/17 Resident is unable to complain of pain d/t dementia. Indications would be agitation, restlessness or crying .has hip and leg contractures .wears a [MEDICATION NAME] that is effective . On 03/09/17 at 8:50 a.m., Surveyor observed CNA J and CNA K assist R7 into bed, using the hoyer lift. R7 was crying out, Stop, that hurts, stop. Surveyor could see tears streaming down R7's face. The CNAs stopped repositioning R7. Surveyor asked R7 if resident was hurting. R7 started speaking but unable to understand what was stated. The CNAs started to try to move R7 and R7 yelled out. Surveyor asked if staff had a lift sheet they could use. CNA K stated,Yes and went to get a lift sheet. The CNAs turned R7 onto side to inspect skin. R7 yelled out, ow! ow! CNA K explained that R7 calls out because of the pain in contracted legs. CNA K stated medicine does not really seem to help and R7's legs are very sensitive. CNA K also indicated R7 seems to be fearful of the hoyer lift, stating that when R7 sees the lift coming R7 starts to get anxious, yells out, and starts shaking. CNA J also stated transfers hurt R7, and staff try to be as careful as they can and reassure the resident. Surveyor asked if R7 gets pain medication prior to transfers. CNA K was not sure, but thought R7 was getting something for pain. At 9:20 a.m. Surveyor interviewed CNA L who is a bath aide. CNA L stated R7 usually gets a shower and is put in a reclining shower chair. CNA L stated R7 has high anxiety about the bath; R7 cries and calls out for dad and mom. CNA L stated staff give reassurance and tell R7 the bath is almost done. Surveyor asked if R7 is in pain during bathing. CNA L indicated it seemed R7 is more scared, and seems scared when resident sees the hoyer lift. Surveyor asked if R7 is given any medications before the shower. CNA L stated R7 does not get anything before shower; it had been tried in the past and did not work. At 9:25 a.m., Surveyor interviewed Director of Social Services (DSS) D to ask what interventions were in place for R7's anxiety with bathing. DSS D indicated he is aware R7 does not like bathing. Surveyor asked if R7 takes a shower or a whirlpool. DSS D did not know. DSS D was aware medication had been tried but did not work, and that it was an ongoing issue. Surveyor asked if fear was related to pain. DSS D stated he did not know. Surveyor asked when the last time the anxiety with transfers and bathing had been addressed for new interventions. DSS D thought it had been a few months ago. Surveyor asked if DSS D had spoken with the family member to find any triggering events related to the possible fear of bathing and transfers. DSS D stated he had not done so. At 9:30 a.m., Surveyor interviewed Med Tech (MT) G about R7's anxiety. MT G stated R7 becomes very anxious with bathing, but that she personally has not given R7 a bath. MT G stated she does not think R7 has taken anything before her bath. Surveyor asked if MT G has seen any signs of pain exhibited. MT G stated she thought it was mostly anxiety. Surveyor interviewed RN F about R7's anxiety. RN F stated R7's concerns are related to fear, If you roll (R7) or anything (R7) will holler due to thinking (R7) will fall. The hoyer makes (R7) feel like she is falling, more so than pain related. The shower is most likely the movement that is the issue. I did hear (R7) yell out yesterday, a CNA said, 'Oh it's (resident's name) bath day to day'. If you look back at October and November there will be better notes related to pain and behaviors. The previous Director of Nursing did a good job documenting. Surveyor asked if there were other ways to keep R7 clean rather than a shower or whirlpool if R7 has such distress. RN F agreed there were other options. Surveyor reviewed the bath documentation from 01/04/17 to present. R7 had a whirlpool or shower each week. The documentation does not address R7's response to the bath or interventions implemented. On 03/09/17 at 10:00 a.m. DSS D came to Surveyor with more information stating that after talking to CNA L he was told R7 is screaming out during all cares, not just bathing; It is transfers, toileting and bathing. CNA L reported to DSS D that she spoke with a family member and thought possibly R7 had something bad happen as a child and that is why R7 has a problem with cares. Surveyor asked when DSS D found out about this. DSS D replied, Just now. Surveyor asked when CNA L was told this. DSS D went back to CNA L and returned to say it was about one year ago. Surveyor asked if DSS D had done a thorough assessment of the triggering events of the behaviors recently. DSS D replied, No. At 11:00 a.m. Surveyor interviewed CNA K again to ask what behaviors R7 exhibits. CNA K replied that when R7 even sees the shower chair or the hoyer lift she starts getting upset and yells, No! No! No! Not that! CNA K went on to say that she sees fear in R7's face. Surveyor asked what R7 exhibits during transfers. CNA K stated that R7 says things like, It hurts! I see tears sometimes as R7 gets very upset and starts to shake. Surveyor asked if the showers are stopped when R7 is upset. CNA K stated that staff do not stop but go as fast as they can to get it over. CNA K stated staff feel bad for R7, but think the nurses have tried to do all they can with medicines and interventions. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The scheduled [MEDICATION NAME] was discontinued 11/16/16. The last increase in pain medication was 09/15/16. 2. R10's quarterly MDS with ARD of 11/15/16 indicates a BIMS score of 15, meaning R10 is alert and oriented and able to answer questions accurately. R10's mobility is coded as needing extensive assistance with transfers and bed mobility. The MDS documents R10 has scheduled and as needed pain medication for occasional pain that is mild in severity. The care plans in part: Potential for neediness related to excessive staff requests non health related manifested by frequency of call light usage. Goal: Will have decreased call light usage for non health related requests . .has trouble sleeping and is using hypnotics. A sleep wake cycle that is acceptable to .will be achieved by next review. Interventions in part: Provide environment conducive to sleep .sleep study and assessment prn to determine appropriateness of hypnotic .administer medications as ordered. .has pain r/t (related to) self reports of hip/back pain. No current dx of hip/back pain causes. Pain will be managed as evidenced by no decline in appetite, mobility status will not be negatively impacted, and there will be no decrease in socialization or activities. Interventions in part: Assess and document location , quality intensity and duration of pain, assess the effectiveness of pain medication and notify health care provider if pain not well controlled., assist .to reposition as needed for comfort, monitor factors affecting discomfort, .will report pain 10/10 with no outward s/s of pain .MD has been updated. Per MD utilize Aqua K pad at night for comfort to cold feet. Often refuses .often yells out without turning on her call light. Educated to utilize call light .foot cradle on bed to hold blankets off feet. Physician orders [REDACTED].>[MEDICATION NAME] 650 mg bid (twice a day) and every 4 hours prn, 09/19/16 [MEDICATION NAME] 5 mg po between 10 p.m. and 3 a.m., 10/13/16 [MEDICATION NAME] 5 mg po between 9 pm and 3 a.m., prn [MEDICAL CONDITION] .may repeat once. 10/24/16 [MEDICATION NAME] 650 mg tid (three times a day) 10/25/16 Bumetamide 0.5 mg every am 11/17/16 [MEDICATION NAME] 50 mg every HS, [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg prn 9 p.m. - 3am 12/09/16 [MEDICATION NAME] 10mg/5 ml oral solution 10 mg as needed every four hours 12/19/16 [MEDICATION NAME] 7.5 mg po every HS 01/06/17 Nurses notes in part: 10/25/16 Resident has c/o leg pain rating at 8/10. Reports .often has leg pain and has had for years. Currently has 650 mg APAP as scheduled BID and prn APAP and [MEDICATION NAME]. fax sent to MD requesting to increase APAP 650 mg to TID 10/29/16 .requested prn apap and [MEDICATION NAME] at 0018 for c/o RLE (right lower extremity) pain 10/10 .noted to be effective. 10/31/16 Resident very often asks for Tylenol and [MEDICATION NAME] for leg/back discomfort, and when given, shortly thereafter asks for it again, not remembering that .has just had them. Resident gets scheduled Tylenol 2 x per day .spends most of the day in bed needs encouragement to be up in w/c or in recliner chair . Fax to physician 10/31/16 Resident has continued c/o pain rating 10/10 in hips and leg utilizing prn apap and [MEDICATION NAME] frequently. Would you like to make any medication changes at this time? Schedule [MEDICATION NAME]? Doctor's follow up: pt needs to be seen by Doc if .having 10/10 pain. Nurses notes continue: 11/04/16 .requested PT eval for pain that resident has been reporting recently. Per PT screen: 'stated .had no pain in .hips or legs.' 11/06/16 Resident had c/o pain in legs rating 7/10 and requested prn APAP at 1830. Reported as effective .requested and given [MEDICATION NAME] 2100. At 2150 resident [MEDICATION NAME] . A pain assessment was completed 11/08/16 documents pain level 4-5 mild .vocalization and/or behavioral indicators: grunting. Behavioral indicators: decrease in activities, lying very still. Current pain medications: [REDACTED]. Nurses' notes continue: 11/09/16 Resident requested and given prn [MEDICATION NAME] with scheduled Apap at 1615 for c/o hip and leg pain rated 8/10 .at HS resident requested prn APAP and [MEDICATION NAME] for c/o pain, 'all over' rated 10/10. No non-verbal s/sx pain noted, Requested and given prn Ambien. 11/13/16 Prn APAP, [MEDICATION NAME] and given at HS, did not give numerical rating to pain, but displays s/s of restlessness. 11/14/16 Returned from appointment with signed script .Aqua pad place in foot of be prior to bed time to keep feet from getting painfully cold at night. [MEDICAL CONDITION] unspecified, leave it there during sleep, if pt's nocturnal crying out is due to painfully cold feet this will greatly help.Behavior committee: Behavior of excessive request has occurred 24 x thus fat this month .which was doubled from the previous month .behaviors greatly increasing despite interventions .no interventions appear to be effective for resident .Sign will be placed in residents room as new intervention to remind .to use .call light . 11/16/16 noted increased [MEDICAL CONDITION] of right foot and bilateral lower legs, [MEDICAL CONDITION] around bilateral hips and 3rd compartment spacing of right dorsal arm continues . 11/21/16 Receiving budesenide for lower extremity [MEDICAL CONDITION], is improving. 11/24/16 .continues to request prn [MEDICATION NAME] HS for pain rating at 8-10/10. Resident shows no outward s/s of pain .often refuses heating pad to feet stating it 'makes them hurt more', fax sent to MD for referral for pain clinic. 11/26/16 Resident has utilized call light approx every 30-45 minutes .c/o pain and requests for pain meds. Reminders .had pain meds. Resident then dozes back off soon after asking, then turns call light on again to ask for sleeping medication and pain medication. Reminders as to medications given only minimally effective .will update MD on refusals of aqua K pad . 11/27/16 Resident was approached by several staff members to go to activities and declined as resident lying in bed . 11/28/16 Fax returned from MD resident continues to c/o pain 8/10, refer to pain clinic? MD stated, 'no pain clinic referral would be appropriate'. Hospice referral would be o.k. 12/02/16 Resident reported pain 9/10 in back at 0510. Prn apap and [MEDICATION NAME] given at that time. No outward s/s of pain . 12/06/16 [MEDICATION NAME] given at HS .reported pain as 8/10 in legs. No outward s/s of pain. Upon follow up report pain is 'better' . 12/09/16 weekly skin assessment a 2.0 cm x 0.2 cm light blue located 4th digit at base of toe and top of left foot, located distal to 2nd digit of foot .resident denies anyone hurt .resident continues with 3-4 [MEDICAL CONDITION] from waist to top of feet and toes. 12/09/16 Fax was sent to MD re sleep, ineffectiveness [MEDICATION NAME].order for [MEDICATION NAME] 50 mg po every HS, [MEDICATION NAME] 0.25 mg po prn 9 pm -3am, for rescue from [MEDICAL CONDITION] .d/c Ambien. (trazadone is an antidepressant medication). 12/11/16 .res slept until 0400 when .awake calling out .was restless after retuning to bed. Res c/o was BLE pain. Given APAP and [MEDICATION NAME] po prn .effective. 12/12/16 .res awoke 0420 calling or for help .says .is cold but can't stand .heavy comforter on .feet/toes as they are sensitive and this causes pain at that time it was too soon per order parameters to have more APAP or [MEDICATION NAME] for pain. CNA suggests a foot cradle at foot of res bed for the blankets. At 0530 resident resting .resident was reviewed by hospice .resident reported .had no pain when asked by hospice and did not qualify for services most effective intervention is to assist resident to lay down .staff encourage .to come out of .room, but resident chooses to self isolate . 12/17/16 .started calling out at 0430 for 'help' .c/o BLE pain, given [MEDICATION NAME] po prn for pain mgemnt with effective results. 12/18/16 Res slept well this noc with use Trazadone until 0200. Started calling out for 'help' c/o BLE pain, given [MEDICATION NAME] po prn for pain management. with [MEDICATION NAME] 0.25 mg po prn to aid with sleep . 12/19/16 Resident had appt today .return with signed script for [MEDICATION NAME] 20mg/5ml 10 mg, po every 4 hours prn pain . physician progress notes [REDACTED].Nursing indicate .has had excessive requests for staff assistance it is unclear whether .is having pain. 12/20/16 .toileted at 0305 with moans/groans, anxiousness, calling out for 'help' and facial grimace, c/o BLE pain, given [MEDICATION NAME] oral solution .dose of 10 mg, po prn pain mgmt res able to return to sleep until waking at 0500 .asked if [MEDICATION NAME] was effective and res stated, 'a little'. 12/27/16 0215 requested [MEDICATION NAME] and apap for c/o bilateral LE pain rated 10/10 . A pain assessment is completed on 12/30/16, the first one since 11/08/16. The pain assessment documents pain hip/back and all over. Pain scale 4-5 mild .vocalization: grunting, Behavioral indicators: decrease in activities, lying very still, what quality of life areas are affected: functioning physical ability activity participation, mood/emotions. Current pain medications: [REDACTED]. Nurses' notes continue: 01/02/17 Res c/po BLE pain. Moaning, groaning, facial grimace, calling out 'help, my legs hurt' .given [MEDICATION NAME] 10 mg po .res cont'd to be awake restless, c/o BLE pain, calling out despite staff responding .At 0130 given [MEDICATION NAME] prn per order .along with PRN [MEDICATION NAME] and APAP with no effect noted. [MEDICATION NAME] 10 mg po prn given at 0348 .for BLE pain with effective results noted .sleep monitoring completed for December. Out of 31 days resident noted to be awake for 1-3 hours 4 days during the NOC (night) .nurses charting on sleep patterns shows more occurrences than charted by cna staff. Staff continues to look for ways to promote sleep for resident. MD aware of sleep issues . 1/06/17 Resident had prn pain meds previously in the evening. Effective until approx 0300, Resident woke .had c/o pain in legs. Stated .could not get comfortable. Offered and given prn [MEDICATION NAME] .resident woke again at 0500 stating .feet and legs and heels hurt .'so bad'. Rating pain 10/10 .explained to resident if her pain is 10/10 should be evaluated in the ER .resident shown the faces pain scale and again rated pain as 'the worst'. Declined to be evaluated in the ER .stated the [MEDICATION NAME] helped some .fax sent to MD with update on continued pain and [MEDICAL CONDITION], Received order from Dr. for [MEDICATION NAME] 7.5 mg po HS A pain assessment is completed on 01/06/17 documenting the pain scale is 10: the worst pain imaginable .pain relief description: minimal relief from pain on NOCS. Facial expressions: grimacing or distorted face, frowning/scowling, vocalization: grunting, Behavioral indicators: frequent position changes, [MEDICAL CONDITION]. What quality of life areas are affected: functioning physical ability, activity participation, mood/emotions. There are no other pain assessments completed for R10. 01/09/17 Resident requested pain medication and was given Tylenol and [MEDICATION NAME] for severe pain; in legs/feet at 0015 .resident rested in bed until 1000 am, very pale, dry warm skin .[MEDICAL CONDITION] continues around upper hip region .12:22 p.m. Resident appears to be having increased respiratory difficultly .'I don't feel well' .sent to urgent care 1235 p.m .Call from ER nurse stating that resident returning .family refused any procedures or follow up. They discussed hospice .has written orders for [MEDICATION NAME] and to continue same dose of [MEDICATION NAME] .[MEDICATION NAME] given at 1830 for reported pain rated a 10/10 .Woken up at HS and HS med given, no pain at that time.01/11/17 resident .moaning and making facial grimaces with repositioning. [MEDICATION NAME] give for discomfort with effective pain control . 01/12/17 c/o pain BLE, whining, restless, moans/groans, facial grimace post being repo .MS given prn at 0240 .able to rest until 0445 .per signed .fax .hospice, okay to D/C all non-comfort related meds . 01/15/17 3:09 a.m., Resident moaning and yelling 'help' at 0305 .reported 'all over' pain. Prn [MEDICATION NAME] given .resident yelling out at 0630 a.m. 'help me, help me' .resident 'I hurt', RN asked where and resident gave no indication. RN asked resident if .hurt all over and resident nodded .head yes, prn [MEDICATION NAME] given resident continued to yell out help, prn [MEDICATION NAME] given with effective pain and anxiety control .resident repositioned at 0742 felt warm temp assessed (100.4) .5 seconds apnea noted . 01/16/17 Resident has been restless most of PM shift into night shift. Prn [MEDICATION NAME] and [MEDICATION NAME] have been utilized as frequently as ordered. [MEDICATION NAME] ha been given as well . 01/17/17 Resident seen today on Dr .rounds .resident showing agitation at times, unknown if related to pain. MD signature obtained for POA activation. Pain meds reviewed. The physician progress notes [REDACTED].just a couple of days ago .had an acute change in condition .it was felt .had a neurological event and should be provided with comfort care .is agitated at times, impossible to know whether some of this is pain related .I told the staff that they should use the liquid [MEDICATION NAME] liberally . 01/18/17 0055 CNA entered res room and observe res on the floor .was unresponsive .Auscultated apical pulse for one minute and no heartbeat heard .spoke with coroner about res being found on floor with no s/sx life .coroner concludes that fall was not a contributing factor to the death . Review of the medication administration (MAR) records for November, December and January, document R10 was utilizing the prn [MEDICATION NAME] and the prn [MEDICATION NAME] three times a day. The pain levels are documented as 7-10. The [MEDICATION NAME] was ordered on [DATE] and used 10 times, from 12/20/16 to 12/30/16. It was ordered to be used as needed every four hours. The January MAR indicated [REDACTED]. R10 did not have an increase in scheduled pain medication since the [MEDICATION NAME] was scheduled three times a day on 10/25/16. On 03/09/17 at 10:55 a.m., Surveyor interviewed CNA I about R10. CNA I recalled that R10 called out a lot, and had frequent pain in legs that R10 stated was very bad. On 03/09/17 at 11:00 a.m., Surveyor interviewed CNA K about R10. CNA K recalled that R10 complained of pain and always asked for medications. CNA K stated that you would have to remind R10 had already had pain medicine because R10 would ask again. On 03/09/17 at 10:50 a.m., Surveyor interviewed Med Tech (MT) G. MT G recalled that R10 used a lot of pain medication, and yelled out in pain many times. MT G stated the pain meds worked for a little while. On 03/09/17 at 10:55 a.m, Surveyor interviewed Registered Nurse (RN) H. RN H stated R10 called out constantly, and always rated pain 10/10, so it was hard to tell how much pain R10 was having. Surveyor asked if R10 ever showed any grimacing or moaning. RN H stated R10 complained of all over pain and did grimace and moan, but once up and about seemed alright for awhile then would start hollering our again for medicine. On 03/09/17 at 12:50 p.m. Surveyor interviewed RN A. RN A recalled R10 complained of most pain at night when lying down. RN A stated staff tried many things, such as snacks, sleep aides, a foot cradle, and a referral to the pain clinic which the doctor refused. RN A stated R10 refused ER treatment. Surveyor knew ER refusal occurred on 01/06/17 and asked if that had happened any other times. RN A was not able to identify any other time R10 refused emergency treatment for [REDACTED]. 3. R1's medical record states resident is legally blind due to [MEDICATION NAME] degeneration and retinal hemorrhages. R1's lower eye lids protrude; eyes and lids are red. Surveyor interviewed R1 on 03/07/17 at 1:35 p.m. R1 stated that eyes aren't any good, are sore once in a while, and sometimes they just burn. R1 stated R1 could tell there is a television on the wall but could not see the picture on it. R1 stated, I can see movement, but I can't see what's moving. During the interview, R1's nose was dripping and eyes were very red; R1 was dabbing eyes with a handkerchief. Surveyor noted R1 has an as-needed order for artificial tears; R1 can have two drops up to three times per day. R1 stated once in a while the nurses will use the drops, but not every day. According to R1's prn orders, R1 could have had the eye drops administered 198 times between 01/01/17 and 03/07/17. On 03/08/17, Surveyor reviewed the last three months of R1's Medication Administration Record [REDACTED]. None of the other nurses have signed that they offered the artificial tears to R1. All of the times when drops were administered state drops were effective and/or that R1 had relief. R1 received these eye drops five times in January, 10 times in February, and three times in March 2017. All of these instances were administered by LPN N. R1 also has an order for [REDACTED]. Surveyor asked R1 about the ointment and R1 stated that eyesight was already poor, and when staff put ointment in eyes three times a day, R1 didn't like how it gooped up eyes. Surveyor asked if R1 would be willing to use the ointment just before he goes to sleep at night if it would help his eyes, and R1 said, I guess so. On 03/08/17 at 9:15 a.m., Surveyor discussed R1's eyes with Registered Nurse (RN) B. Surveyor asked about eye medications, and RN B stated R1 gets them as needed, and has the ability to ask for them. Surveyor asked RN B if the nurses actually offer the prn eye medications when R1's eyes look red. At 9:40, RN B stated she had offered the artificial tears to R1, who stated wanting them. RN B stated she was unable to find the [MEDICATION NAME] ointment, and that she called the pharmacy and it would be delivered that evening. RN B then administered the artificial tears in R1's eyes. Cross reference F 441. Surveyor reviewed R1's care plan which mentions R1's poor eyesight, but does not address eyes are red and sore, and that lower lids protrude. The above concerns were discussed during the daily meeting at 3:00 p.m. on 03/08/17, attended by the Nursing Home Administrator and department heads.

Based on observation, interview and record review, the facility did not provide necessary care and services in order to attain and/or maintain the highest practicable physical, mental and psychosocial well-being. This occurred for one of one residents (Resident #8) reviewed for diabetic foot care; two of ten residents (Residents #3 and 6) reviewed for pain; one of two males (Resident #6) reviewed for appropriate care and treatment; and one of six residents (Resident #2) reviewed for bowel function. 1. Resident #8 has [DIAGNOSES REDACTED]. Interventions were not put into place to protect his feet and his feet were not inspected daily. When the resident refused, there is no evidence the nurse was notified, no assessment of why he was refusing foot inspection or cares, no evidence of reapproaching or educating on the risk and benefits of daily foot care. This resulted in the resident foot identifed with advanced infection, resulting in further amputations and leading to a decline in function. The failure to promptly identify [MEDICAL CONDITION] with daily foot inspections, and implement interventions (for Resident #8) in order to prevent foot ulcers from quickly deteriorating created a finding of immediate jeopardy. The immediate jeopardy began on 02/05/16. The Nursing Home Administrator (NHA), Director of Nursing (DON) and the Corporate Registered Nurse (RN BB) were notified of the immediate jeopardy on 05/17/16 at 2:00 p.m. The immediate jeopardy was removed on 05/17/16. However, the deficient practice continues at a scope/severity of G (actual harm/isolated), as evidenced by the following. 2. Resident #3 developed an unstageable heel ulcer in the facility, that is now a stage III pressure ulcer. Resident #3 experienced severe pain with dressing changes. The facility did not assess the pain when pain medications were changed, or alter the pain management interventions when the pain continued for Resident #3. Observations of wound care identify the premedication for pain was not given in advance to allow time for the pain medication to be effective before the wound care was performed, resulting in severe pain for the resident. 3. Resident #6 had been resisting personal cares for pericare for an unknown length of time. On 03/28/16, Certified Nursing Assistants (CNAs) reported they were unable to move foreskin back. Resident #6 was sent to urgent care and diagnosed with [REDACTED]. Record review and observations indicate Resident #6 is experiencing significant penile pain. Resident #6 has pain in his joints. The facility did not do a pain assessment after the increase in pain medication. Resident #6 continued to have severe pain when observed during personal cares. 4. Resident #2 experienced a decline in bowel function. No assessment was completed with the decline and no interventions were put into place to improve or prevent further decline. This is evidenced by: On 05/17/16 at 7:51 a.m., Surveyor received and reviewed a facility policy entitled, Standard Protocol Diabetes Mellitus. The policy, dated July 2012, states the following in part: Approaches .Provide encouragement and education as needed regarding aspects of diabetic care such as .skin care, and reporting of abnormal signs/symptoms .CNA staff completes skin inspections (as resident permits) but encourage inspections to be daily during cares or at a minimum of weekly. If non adherent, contact a nurse and try to re-approach at a later time .Licensed nursing staff completes weekly diabetic foot assessments .Remind resident to inform nurse of any complaints of not feeling well . 1. On 05/12/16 at 3:40 p.m., Surveyor reviewed Resident #8's medical record. Resident #8 was admitted to the facility in April 2015. The resident has [DIAGNOSES REDACTED]. The resident receives [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Resident #8's Minimum Data Set (MDS), with an assessment reference date (ARD) of 12/30/15, identifies that Resident #8 requires extensive assistance with one staff member for dressing, bathing and toileting. The MDS identifies that Resident #8 has a surgical wound, but has no pressure ulcers or foot infections. The MDS indicates that Resident #8 is continent of bowel function. Resident #8's Brief Interview for Mental Status (BIMS) score, dated 12/30/15, is 14 out of 15 possible points, indicating the resident has intact cognitive functioning. Resident #8 previously had all five toes amputated on the left foot due to the resident's multiple co-morbidities. Surveyor reviewed Resident #8's nurses' notes from 07/06/15 to 07/17/15 and 09/01/15 to 01/09/16. The notes state the following, in part: -07/06/15: Weekly skin assessment completed. (1) Right great toe amputation site measures 0.4 x (by) 1.5 (no unit of measurement identified) superficial open area .(2) Right 2nd toe .no open area or redness noted .(3) Right 3rd toe continues to have intact dry scab like area measuring 1.0 x 0.8 (no unit of measurement identified) .(4) Right 4th toe has 1.5 x 1.3 (no unit of measurement identified) soft red area .Resident wears slipper on right foot, no area of rubbing or wear noted . -09/01/15: Resident #8's second toe on the right foot was amputated. Resident #8 required a wound vac (a pump which suctions fluids from wounds that are difficult to heal on their own) to be used every Monday, Wednesday, and Friday. Resident #8 was not able to bear weight on the right foot while the surgical wound was healing. -01/09/16: Resident #8 wears socks at all times to protect his feet. The American Diabetes Association (ADA), which is a current standard of practice for diabetic foot care, recommends people with diabetes should wear shoes and socks at all times. A person should never walk barefoot, but wear comfortable shoes that protect the feet from injury. Socks would not be an effective intervention to protect the resident's feet when bumped. The ADA and AMDA (American Medical Directors Association) recommend people with diabetes check their feet daily for red spots, discoloration, cuts, swelling and blisters. There is no evidence in Resident #8's medical record that Resident #8's feet/toes were inspected daily. Surveyor reviewed Resident #8's comprehensive care plan, dated 02/01/16. The care plan states the following, in part: Problems: (Resident #8's first name) has impaired skin integrity R/T (Related To) toe amputations. He has [MEDICAL CONDITION], is diabetic, is on [MEDICAL TREATMENT], afib ([MEDICAL CONDITION]), history of [MEDICAL CONDITION] with chronic ulcerations, has PAD (Peripheral Artery Disease, also known as [MEDICAL CONDITION]) . Goals: Current skin impairments will resolve with no evidence of further skin breakdown through next review. Will comply with nursing interventions . Interventions: Braden scale assessment performed quarterly and PRN (as needed) to address risk factors .Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown .Weekly skin assessment with bath/shower performed by nursing. Report areas of concern .RD (Registered Dietician) to assess quarterly and discuss with team as necessary at monthly Nutrition at Risk to adjust diet/supplements as indicated to reduce the risk of skin breakdown .Administer Neprocaps .and folic acid as ordered .Schedule appointments and report declines in wound to (MD X) . The comprehensive care plan does not direct staff to check Resident #8's skin and feet daily. The care plan does not address the type of footwear Resident #8 wears, or the interventions used to protect Resident #8's feet and toes. The care plan does not identify if Resident #8 refuses personal cares such as foot checks. Surveyor reviewed Resident #8's nurses' notes, from 02/01/16 to 05/14/16. The notes state the following, in part: -02/02/16: Resident is independent with transfers. Ambulates with assist of 1 staff, walker, and gait belt .Skin is intact. Independent with repositioning. Assist of 1 for all other ADL's (Activities of Daily Living) . Surveyor reviewed Resident #8's bath sheets. The medical record identifies that Resident #8 received a bath, on 02/04/16, by CNA AA. No skin issues were identified by CNA AA at this time. Nursing notes continue: -02/08/16, 4:03 p.m.: Call received from Mayo [MEDICAL TREATMENT] nurse .stated that residents pulse was ranging from the 100's to the 140's, continue to monitor and send to see MD if (resident) becomes symptomatic. DON updated. -9:27 p.m.: Resident's BP (Blood Pressure) this shift 118/66, pulse 139. Resident denies having any chest pain for SOB (Shortness of Breath), nurse talked to him about notifying staff immediately if he experiences any and he was in agreement with it. Will continue to monitor. -02/09/16, 11:52 a.m.: Staff report of concerns of potential odor noted with resident. Has history of toe amputations due to necrosis (the death of the skin tissue which occurs when there is not enough blood and oxygen supplied to the area of the skin). Resident states he bumped his toe recently and thinks his toe nail is falling off. Writer (Registered Nurse C) removed his sock and 3rd toe noted to have moist, dark necrosis, very swollen and top layer of skin peeling off on top, side and bottom of toe. End of toe dark in color. Hard area of possible bone identified but is also dark in color, end of toe very mushy and hard area of possible bone very movable at end of toe. Has dark pink coloration of entire foot to ankle area. Also noted to have [MEDICAL CONDITION] (swelling) of entire foot. Resident denies pain but states has been more tender .ankle are (sic) noted to have increase discomfort with palpation .4th toe also noted to have darker discoloration at nail area. Entire area covered with kerlix to protect and gripper sock on. Temp 97.2, BP 120/60 .HR (Heart Rate) 124 (has been [MEDICAL CONDITION] (heart rate/pulse above 100 beats per minute) as reported per [MEDICAL TREATMENT] yesterday also). Call placed to (MD X) .Received return call .from (MD X)-resident is to be sent to ER (emergency room ) .for evaluation . An infection is one possible cause of [MEDICAL CONDITION] The nurses' notes continue, in part: -02/09/16, 1:12 p.m.: Per review of shower book, resident had shower on Thursday 2/4 (2016) and had no skin concerns at that time. -02/11/16: IDT (Interdisciplinary Team) met on 2.9.16 to discuss resident's toe. CNA (Certified Nursing Assistant) approached this writer (DON) to report the (residents name) room smelled 'funny' like a wound .Resident reported .that he bumped his toe within the past couple of days. Resident had bath on 2.4.16 and at that time had no skin concerns related to foot/toe. Resident does have PAD and therefore has a hard time with feeling in his extremities. Has lost multiple other toes due to diabetes as well. Hx (History) of VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]) in wounds .Resident's wife reported he had bumped his foot and told her not to say anything to anyone regarding this. Resident's wife saw the toe and reported she told him 'you need to have a nurse or doctor look at that'. Resident refused and told her not to say anything. Resident's wife reported this to CNA staff after resident had left for the hospital .As of 2.11.16 resident is scheduled for surgery for [REDACTED]. Currently on abx (antibiotic medication) for this and [MEDICAL CONDITION] (a bacterial infection of the skin and surrounding tissue) . -02/18/16: Safety committee met on 2.17.16 to discuss resident necrotic toe located on his R (right) foot .Resident had refused to let staff remove socks from Thursday 2.4.16 to Tuesday 2.9.16 . There is no evidence in the medical record that Resident #8 refused to have staff remove the socks, or inspect the feet, from 02/05/16 to 02/08/16. There is no evidence the facility provided education, including risk factors when Resident #8 refused to remove his socks, and why the resident was refusing to remove the socks for staff (i.e. pain, etc.). Surveyor reviewed Resident #8's hospital History and Physical Assessment, dated 02/09/16. The assessment states the following, in part: .HISTORY OF PRESENT ILLNESS: (Resident #8) .who has a known history of [MEDICAL CONDITION] and prior toe amputations. Comes in with right 3rd toe hurting for the last 2 weeks or so. He says that he bumped his toe; he did not specify where he did, and it was painful and there was some bleeding too .He will be admitted to the hospital for further management of gangrenous toe with possible underlying osteo[DIAGNOSES REDACTED] (an infection of the bone and/or bone marrow) . PHYSICAL EXAMINATION .EXTREMITIES .On the right foot there is swelling and there is some redness and some warmth on the dorsum (top) of the foot. The 1st and 2nd toes are previously amputated and the 3rd toe is black and red and necrotic-appearing. He is tender over the foot in general and the pulses are not easily palpable either at the dorsalis pedis or at the posterior tibalis (inside of the foot) . IMPRESSION/REPORT/PLAN .He has surrounding [MEDICAL CONDITION] of the foot. Will start him on antibiotics .He will definitely need amputation but at what level is the question . A hospital consultation summary, dated 02/10/16 and written by MD X, states the following, in part: .EXTREMITIES: The patient has palpable femoral pulses bilaterally (on both sides). He has no palpable pulses in the left or right foot. He does have a positive Doppler signal in the let peroneal and posterior tibial distributions .The right lower extremity has 1+ [MEDICAL CONDITION]. It is warm. There is some [DIAGNOSES REDACTED] (redness) extending away from his right 3rd toe up to mid-foot and extending posteriorly (back side) .The 3rd toe shows dry gangrenous changes. There does appear to be a wound in between the 3rd and 4th toes that is somewhat sloughy. There is no odor . The hospital discharge summary, dated 02/18/16, states the following, in part: .DISCHARGE [DIAGNOSES REDACTED].bilateral lower extremity angiogram with stent placement in both proximal superficial femoral arteries .right foot transmetatarsal amputation (the 3rd, 4th and 5th toes of the right foot were amputated) . A dictated note by MD X, dated 03/17/16, states in part, .IMPRESSION/REPORT/PLAN .Previous osteo[DIAGNOSES REDACTED] of the right foot . Resident #8 was readmitted to the facility on [DATE]. Resident #8 requires the use of a hoyer (a full body sling) mechanical transfer with the assistance of two staff members, and uses a commode. Resident #8 is not able to bear weight on the right foot, and requires daily dressing changes to the surgical wound. Resident #8's MDS, with an ARD of 02/25/16, indicates the resident requires extensive assistance with two staff members for dressing, bathing and toileting. The MDS identifies the presence of a stage I pressure ulcer, a foot infection and surgical wound. Resident #8 is frequently incontinent of bowel function. The medical record identifies the pressure ulcer is located on Resident #8's buttocks. Resident #8's BIMS score, dated 02/25/16, is 15 out of 15 possible points. According to the BIMS assessment, a score of 15 indicates the resident has intact cognitive functioning. Surveyor reviewed an undated investigation regarding Resident #8's necrotic toe. Undated witness statements state the following, in part: -Licensed Practical Nurse (LPN) Y: Did you assist (Resident #8's first and last name) with cares on 2.4.16 to 2.9.16? Yes .Did (Resident #8's first name) have any c/o (complaints of) pain during this time? 2/7/16 he had c/o general discomfort (and) I gave him a PRN [MEDICATION NAME] (and) it was effective .If you did see his feet, did you notice any skin concerns? N/A (Not Applicable) . -CNA M: Did you assist (Resident #8's first and last name) with cares on 2.4.16 to 2.9.16? Yes-Sunday .Did (Resident #8's first name) have any c/o pain during this time? Wasn't (sic) standing well .If you did see his feet, did you notice any skin concerns? Bottom red/raw .reported to nurse Takes himself to bathroom .Didn't (sic) want to (change) socks or pants often . -CNA N: .Did you help with socks/shoes during this time? Yes 2/9 (2016) when getting him ready to go to hospital didn't do anything with his (right) foot. No shoes on (at) that time and declined to have his sock changed .Did you notice any odor? Yes-about 6:45 (am). talked to night CNA she thought it was from B.M (Bowel Movement) or redness on his bottom but was reported. I then told .(DON) I thought it smelled and not BM smell . -CNA Z, (which the facility dated 09/11/16): Did you assist (Resident #8's first and last name) with cares on 2.4.16 to 2.9.16? Yes .Did you help with socks/shoes during this time? Shoes yes, socks no. (Resident #8's) never lets me change his socks and honestly I thought the nurses were still doing dressing changes and looking at his toes every day so I wasn't too concerned when he said his socks were fine .Did (Resident #8's first name) have any c/o pain during this time? (Resident #8) never complained about his toe to me, but when I was helping (Resident #11, who is Resident #8's spouse) (with) cares on Wed. (Wednesday) She told me she was worried about (Resident #8) and he should have told us girls he was in a lot of pain. She told me (Resident #8) bumped his toe awhile ago but wasn't going to say anything since he had a doc (doctor) appt (appointment) anyways (sic) and he told (Resident #11) not to say anything either because it wasn't a big deal . -Registed Nurse (RN) H: Did you assist (Resident #8's first and last name) with cares on 2.4.16 to 2.9.16? delivered meds 2-4, 2-5, 2-8, 2-9 (2016) .Did (Resident #8's first name) have any c/o pain during this time? Tue. am (Tuesday a.m.) stated he did not sleep well, given prn [MEDICATION NAME] (an antianxiety medication) (with) AM meds .If you did see his feet, did you notice any skin concerns? Last time I looked just the tip of toe was black-which was his usual. If you noticed skin concerns, what did you do about it? Report it? (No) There is no evidence in Resident #8's medical record that the tips of any toes were black, prior to 02/09/16, or if this was normal. RN H did not identify which toe and the date in which she saw the black tip of the resident's toe. There was no witness statement from CNA AA, who gave Resident #8 a bath on 02/04/16. Surveyor reviewed Resident #8's current comprehensive care plan, provided by the facility on 05/11/16. The care plan problem, goal and interventions are the same as the care plan from 02/01/16. The only change to the skin integrity care plan was the addition of an air mattress to Resident #8's bed to help treat the pressure ulcer. Resident #8's comprehensive care plan does not currently identify Resident #8's refusals of removing socks and/or refusing foot inspections, as well as interventions and education when the resident refuses cares. The care plan does not identify the current standards of practice of having Resident #8's feet checked daily, as well as how the facility will protect the resident's feet from injury. Resident #8's current CNA care plan, provided by the facility on 05/11/16, states the following, in part: .diabetic .Skin: Toes amputated on R and L (left) foot. Cushion in recliner, ROHO (an air filled cushion) in wheelchair. Hx of VRE in bowel movements. Air mattress .Toilet/TIMES: Hoyer (lift). Mobility/Transfers: Hoyer. Behvrs (Behaviors) nurse (check) nails. ADL's: A1 (Assist of one staff member) Will at times decline help. Offer assistance as he will not ask .Other Pertinent Information: sleeps in recliner at times .[MEDICAL TREATMENT] .Offer assistance every HS (Hour of Sleep) with cares . The CNA care plan does not instruct the CNA staff to check Resident #8's feet daily or weekly, what kind of help the resident refuses, or if the resident's refusals should be reported to the nurse. On 05/16/16 at 9:57 a.m., Surveyor interviewed Resident #8. Resident #8 was wearing grippy socks. Resident #8 indicated he used to be able to use the bathroom a while ago, but now has to depend on staff assistance to use the commode. Resident #8 stated he used to bang his toe (did not indicate which one) on objects now and then and the toe would hurt when bumped. Surveyor asked if nursing staff check the resident's feet daily, to which Resident #8 replied his feet are not checked every day. When Surveyor asked if the resident has ever refused to remove his socks or refuse foot inspections, Resident #8 did not respond. At 1:46 p.m., Surveyor interviewed RN H, who generally works with Resident #8. RN H did not think Resident #8's feet were inspected daily by nursing staff. RN H stated she would check Resident #8's feet when any dressing changes were performed, but these inspections were not documented. At 1:28 p.m., Surveyor interviewed CNAs P and R. CNA R stated nursing staff assist Resident #8 with dressing everyday, and Resident #8 has been allowing staff to change the resident's socks each morning. CNA R indicated that Resident #8 likes to wear socks to bed at night. At 3:34 p.m., Surveyor interviewed the DON. RN BB, who is the corporate quality assurance consultant, was also present at this time. The DON indicated Resident #8's feet and skin are checked weekly on the resident's bath day, and the facility has no physician's orders to check Resident #8's feet daily. At this time, Surveyor asked which standard of practice for diabetic foot care is used by the facility. The DON and RN BB replied the facility uses its own policy for a standard of practice. At 4:14 p.m., Surveyor interviewed RN C, who is the unit manger. RN C referred to a wound certification manual, from the American Medical Director's Association (AMDA), indicating a comprehensive foot inspection for diabetic residents should be completed annually. RN C was not able to find the date the manual was published. Surveyor asked how often the facility should inspect the feet of a resident with [MEDICAL CONDITION], diabetes and previous toe amputations. RN C replied the facility would inspect the feet weekly during the resident's bath, and more often with cares by the CNAs. During the continued interview, Surveyor asked if the CNAs have been trained to inspect the feet of residents with diabetes and [MEDICAL CONDITION]. RN C replied CNAs look for any red or discolored areas on the skin, whether the resident is diabetic or not. RN C was unaware of the facility's standard of practice used for diabetic foot care. On 05/17/16 at 10:03 a.m., Surveyor interviewed the DON and RN C. RN C confirmed Resident #8's third, fourth and fifth toes were amputated, when Resident #8 was hospitalized in February 2016. Surveyor asked if Resident #8 wears appropriate footwear, in order to prevent toe and foot injuries. RN C stated that Resident #8 wears shoes when leaving the facility for appointments and [MEDICAL TREATMENT], but only wears socks in the facility. RN C did not know if Resident #8 was ever offered or educated on the importance of wearing appropriate footwear. During the continued interview, the DON and RN C indicated CNA staff check Resident #8's skin and feet during baths. The nurses will then assess the resident's skin if the CNAs report any concerns or skin issues. Surveyor discussed Resident #8's care plan does not identify the resident only wears socks, along with preventative interventions in order to protect the resident's feet from injury. The care plan does not identify that Resident #8 may refuse to change socks, or have foot inspections. RN C indicated she tries to have Resident #8's refusals documented on the care plan. Surveyor asked how the facility has been protecting Resident #8's feet from future injury. RN C stated the incision on Resident #8's right foot is wrapped with kerlix (gauze bandages), with daily dressing changes. During the continued interview, Surveyor referenced Resident #8's History and Physical assessment, indicating the resident had pain in the third toe for two weeks prior to 02/09/16. The DON stated she later asked Resident #8 about this pain, and Resident #8 replied the injury to the toe had just recently occurred. Surveyor referenced Resident #8 [MEDICAL CONDITION] episodes on 02/08/16, and asked if the high pulse rates were normal for the resident. The DON was unsure, and stated she would have to look into this matter. On 05/17/16 at 12:40 p.m., the DON and RN C informed Surveyor the odor, identified on 02/09/16, came from a dead mouse in Resident #8's room, and did not come from the necrotic toe. RN C reported Resident #8 has a history of not reporting things to staff and indicated the resident did not report having black, tarry stools prior to Resident #8's admission in April 2015. RN C indicated the information of Resident #8 not reporting issues is not identified on the care plan. The facility removed the immediate jeopardy on 05/17/16 when the facility began education to all staff regarding importance of daily foot observations. CNAs will now complete daily skin audit on the computer and nurses will chart on weekly skin assessements. The facility also implemented a procedure to follow in the event residents refuse skin observations or foot care. The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by: 2. On 05/11/16, Surveyor reviewed Resident #3's medical record and identifed the resident has [DIAGNOSES REDACTED]. The MDS, with ARD of 03/23/16, documents Resident #3 has moderate cognitive impairment and is not able to answer the interview questions. The functional area identifies Resident #3 is dependent on staff with the assist of one for mobility in bed and transfers. The pain interview identifies that pain limits Resident #3's activities and is described as moderate pain. There is one unstageable pressure ulcer identified, measuring 5 x 4.5 cm. A significant change in status MDS, with ARD of 04/20/16, identifies a brief interview for mental status score of 4, meaning Resident #3 has severe cognitive impairment. This MDS identifies Resident #3 needs extensive assist of two for bed mobility and transfers. The pain interview identifies frequent pain that affects sleep and limits Resident #3's activities. The unstageable ulcer is measured as 4.5 cm x 4.5 cm. The care plan, (Resident #3's name) has pain related to [MEDICAL CONDITION] of her legs, .and heel ulcer with osteo[DIAGNOSES REDACTED], interventions: assess effectiveness of pain medication and notify healthcare provider if pain not well controlled, assess and document location, quality, intensity, and duration of pain .notify hospice and MD if pain is not adequately controlled. Review of physician orders for pain medications: [REDACTED] 01/20/16: Fax to the physician, In regards to the wounds on her heels, may we get an order to d/c Teds .she has had increased pain, she currently has scheduled Tylenol 500 mg 4 x day and no prns, can she get something in addition? The doctor's order is: D/C Teds 01/25/16 - [MEDICATION NAME] 50 mg every 6 hours as needed. Nurses notes, Res (resident stated), is that Tylenol, that does not help, just shoot me, I would rather die than have this pain, just shoot me, give me a gun and I will do it. Resident was moaning and grimacing in pain lying in bed . 02/08/16 - We have a fax out to you requesting pain med increase as scheduled APAP (Tylenol) and [MEDICATION NAME] 50 mg every 6 hours po prn is not effective for her left heel wound pain. L heel is 100 % eschar. Resident cries in pain. The doctor order is: D/C [MEDICATION NAME]. Give [MEDICATION NAME] 5/325 every 6 hours . 02/16/16 [MEDICATION NAME] 12 mcg patch one every 72 hours is added. Nurses note: Resident seen by Dr .Resident does have a sore on her left heel .It is very painful and we did order her a [MEDICATION NAME] 12 mcg . 03/29/16 [MEDICATION NAME] increased to 25 mcg, one every 72 hours. 04/03/16 Fax to physician, She has been having an increase in pain due to left heel sore. Would you consider increasing current [MEDICATION NAME] order or adding prn doses? The doctor order is: Change [MEDICATION NAME] to 7.5/325 every 6 hours. 04/11/16 [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg/325 mg four times daily for pain. Nurses note: .resident has scheduled pain medication prior to treatment, continues to have pain with dressing change-will review pain management with MD . 04/12/16 MS liquid 5 mg 15 minutes prior to dressing change prn. 04/26/16 Upon return from the hospital, the [MEDICATION NAME] is increased by 12 mcg, adding to the [MEDICATION NAME] 25 mcg, for a total of 37.5 mcg one every 72 hours. Nurses note: .We could tell resident was in pain by her facial expression. When asked she stated, 'yes she was in pain', .increased her pain patch by adding 12 mcg to her 25 mcg or a total of 37.5 mcg . 05/10/16 The [MEDICATION NAME] is increased to 50 mcg every 72 hours physician progress notes [REDACTED].>04/26/16 .it is apparent she is in a fair amount of discomfort despite her 25 mcg [MEDICATION NAME]. We will increase that by adding a 12 mcg patch. We will initiate enrollment in hospice . The wound flow sheets in part; 02/22/16 DTI, unstageable, full thickness, 6 cm length X 5 cm width. 10% slough, 90 % eschar. Drainage moderate, serosanguineous, odor none. Pain associated with wound, Yes. [MEDICATION NAME] and [MEDICATION NAME]. The treatment is skin prep, bordered foam, and kerlix. Same information documented 02/26/16, and 03/07/16, except no drainage, 100 % eschar. The order was changed to Santyl and 4x4, on 02/25/16. 03/14/16 DTI, unstageable, full thickness, 5.5 cm x 4.5 cm, 10% slough 90% eschar, Drainage scant, serosanguineous, odor none. Pain associated with wound, yes. [MEDICATION NAME] and [MEDICATION NAME]. 03/21/16 Unstageable, 5 cm x 4 cm, 10% slough, 90% eschar, drainage scant serosanguineous, odor: Present. Pain is not answered. Santyl and gauze. 03/28/16 Unstageable, 5 cm x 4 cm, 10 % slough, 90 % eschar, Drainage: moderate, serosanguineous, Pain: yes. Treatment: Skin prep Duoderm, and kerlix. 04/04/16 Unstageable 5 cm x 4 cm, 100 % slough, dark eschar is now moist moveable slough. Drainage: moderate, serosanguineous, Odor is present. Pain: Yes, [MEDICATION NAME] and increased [MEDICATION NAME]. Treatment: skin prep Duoderm, kerlix. 04/11/16 Unstageable 5 cm x 4 cm, 100 % slough, Drainage: heavy, Odor is present. Wound edges: erythyma Pain: yes, [MEDICATION NAME] and [MEDICATION NAME]. Treatment: Duoderm and ace wraps. 04/18/16 Unstageable, 5.0 cm x 4.0 cm, 100 % slough, Drainage: heavy, tan. Odor is present. [DIAGNOSES REDACTED]. Pain: yes, [MEDICATION NAME]. Physician notified: Yes. Dr.--updated. appointment to be scheduled .Duoderm applied .change every 2 days. (The nurse's note documents the wound nurse spoke with the physician's nurse to arrange an appointment, the physician was not consulted for treatment). 04/26/16 Unstageable full thickness. 4.5 x 4.5 .drainage moderate, .Pain: Yes 05/02/16 Unstageable full thickness, 4.5 x 4.5 .Pain: Yes 05/09/16 Unstageable full thickness 4.5 x 4.5 . Pain: Yes The nurses' notes in part: 02/17/16 .c/o complain of leg/heel hurting this am. 02/18/16 .when asked about pain resident stated, 'this foot is okay pointing to right foot but this one (pointing to left one) is rotting.I will just have to suffer .heels floated off bed with pillow as resident refused to wear podus boots . 02/22/16 .Area painful, .feet elevated on pillows .but resident moved feet around freque

Based on interview, record review, and policy review, the facility did not consult a physician when a need to alter treatment should have been identified for 1 of 10 sampled residents (Resident #3). Resident #3 had developed an unstageable pressure ulcer in the facility that developed signs and symptoms of infection on 04/11/16 (increased pain, increased drainage, odorous drainage, and erythyma around the wound). A physician was consulted about the pain on 04/12/16, but there was no documentation of discussion regarding signs of infection. On 04/18/16, the facility spoke with the podiatrist's nurse and scheduled an appointment. The patient was assessed on 04/22/16 by the physician and hospitalized with osteo[DIAGNOSES REDACTED] in the heel ulcer. This is evidenced by: The facility policy, Change in condition, when to report to the MD .adapted by AMDA (American Medical Director's Association), includes in part: Immediate Notification: Any symptoms, sign or apparent discomfort that is: -acute or sudden onset, and: - a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Resident #3 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with assessment reference date (ARD) of 03/23/16, documents Resident #3 has moderate cognitive impairment, and is not able to answer the interview questions. There is one unstageable pressure ulcer identified, measuring 5 x 4.5 cm. The MDS for a significant change in status, with ARD of 04/26/16, identifies a brief interview for mental status score of 4, meaning Resident #3 has severe cognitive impairment. The unstageable ulcer is measured as 4.5 cm x 4.5 cm. Resident #3's most current POLST (plan of life sustaining treatment), dated and signed 04/11/16, identifies Resident #3 is do not resuscitate (DNR), but wants hospitalization and aggressive treatment with antibiotics. The deep tissue injury was first noted 12/22/15 as stage I pressure ulcers on both heels; weekly assessments were completed. Subsequently the right heel ulcer did heal. The wound flow sheets for the left heel, in part: 03/28/16 Unstageable, 5 cm x 4 cm, 10 % slough, 90 % eschar, Drainage: moderate, serosanguineous, Pain: yes. Treatment: Skin prep Duoderm, and kerlix. 04/04/16 Unstageable 5 cm x 4 cm, 100 % slough, dark eschar is now moist moveable slough. Drainage: moderate, serosanguineous, Odor is present. Pain: Yes, [MEDICATION NAME] and increased [MEDICATION NAME]. Treatment: skin prep Duoderm, kerlix. 04/11/16 Unstageable 5 cm x 4 cm, 100 % slough, Drainage: heavy, Odor is present. Wound edges: erythyma Pain: yes, [MEDICATION NAME] and [MEDICATION NAME]. Treatment: Duoderm and ace wraps. (This note documents increased drainage, odor, increased pain, and redness around the area, all signs of infection.) 04/18/16 Unstageable, 5.0 cm x 4.0 cm, 100 % slough, Drainage: heavy, tan. Odor is present. [DIAGNOSES REDACTED]. Pain: yes, [MEDICATION NAME]. Physician notified: Yes. (MD V) updated. appointment to be scheduled .Duoderm applied .change every 2 days. (The nurses' note documents the wound nurse spoke with the physician's nurse to arrange an appointment; the physician was not consulted for treatment). physician progress notes [REDACTED].>Podiatry note 02/25/16 .stable circumferential eschar s identified at the posterior aspect of the left heel .there is no purulence, malodor .Vascular: .audible doppler examination did reveal biphasic pulses in regard to the dorsalis pedis and perforating peroneal pulses of the foot and ankle. Monophasic sounding pulses were identified above the posterior tibial pulse on the medial ankle bilaterally .Diagnostics: There is no evidence of infection .Plan: .there is the risk of developing an osteo[DIAGNOSES REDACTED]. She will need to be watched closely, If there is any concerns for osteo[DIAGNOSES REDACTED] MRI exam could be an option . 03/24/16: .there are no active signs of infection .decubitus heel ulceration with stable eschar .the other concern would be that she develops an infection, such an infection could be limb threatening .If there is any change in appearance of the ulceration (resident name) will return to clinic to see me at that time . 04/22/16: .the nursing home has related there have been changes in the appearance of the ulceration and it has developed a rather foul odor .a severe malodor is appreciated from the wound .at this time treatment could include partial calcanectomy or even a possible [MEDICAL CONDITION] She may require longer term IV antibiotics .probably anticipate an infectious disease consultation for discussion of treatment based upon how aggressively family would wish to proceed with treatment .direct admit to hospital . Primary physician progress notes [REDACTED].>05/10/16 .(MD V) saw her for a 3rd time on April 22nd, now with worsening of the ulcer and X-ray showing evidence of bone erosion .he talked to her daughter, who said there would a family conference and that the family would be considering comfort measures .I do not feel that antibiotics at any point in the course of this heel ulcer would have made a difference. What she needed was to unload and take pressure off the area which she would not comply with . (This note written 18 days after the hospitalization ). Nurses' notes in part: 03/24/16 2:24 p.m. Received call from (MD V) . reviewed options of surgical debridement .recommend to encourage to wear boot to offload heel. Discussed eschar is stable and not infected .change to [MEDICATION NAME] dressing .only needs follow up appointment .if area becomes infected or family decides for more aggressive treatment. Resident had torn side of previous heel lift boot off, did allow heel float boot to be applied at this time . 03/28/16 .Resident noted to have increased pain with treatment today, states feels okay with heel protector . 03/29/16 Resident seen today by (MD V), .we talked about her sore heel .resident stated that something needed to be done .we did increase her pain patch . 04/03/16 .resident had a lot of facial grimacing and some moaning during the dressing change . 04/04/16 Received fax from (MD W) -- to increase [MEDICATION NAME] to 7.5/325 every 6 hours . 04/04/16 2:11 p.m. .Moderate serosanguineous drainage noted and odor noted from debridement with Duoderm .declines heel protectors . 04/05/16 Dressing changed to left heel, moderate amount of drainage to old Duoderm, odorous .continues to c/o discomfort with dressing change . 04/07/16 Dressing changed to left foot, continues with odor yellowish slough over dark eschar. Resident had some discomfort during procedure . 04/11/16 .heavy amount yellowish drainage noted and increased odor noted from debridement with duoderm .declines heel protectors to be put on. Resident had scheduled pain medication prior to treatment, continues to have pain with dressing change .will update .podiatry due to increase in odor and drainage . There is no documentation of an update to podiatry. (There is no documentation on the status of the pressure ulcer from 04/12 to 04/18/16.) 04/12/16 Resident was not seen today by (MD W), but we were asked to write an order for [REDACTED]. 04/18/16 Weekly skin assessment: .100% grayish dark moist moveable slough .heavy amount tan drainage noted and foul odor noted .resident had prn [MEDICATION NAME] for pain prior to treatment, continues to have some pain with dressing change but tolerated okay. Writer contacted (MD V's) office .reviewed with (MD V's) nurse, and resident is to have appointment scheduled . 04/19/16 .noted to have shadowing of drainage to kerlix. Resident was premedicated with [MEDICATION NAME] .resident tolerated treatment and responded that was not so bad. She has appointment scheduled with podiatrist for this week . 04/22/16 Resident left for podiatry appointment this am, .then was a direct admit to .hospital . Admission note in part: .she is demented and was present by herself during this visit. The following information was gathered from chart note and her nursing home.the patient was noncompliant and had difficulty leaving the boots in place. For the last 5 days or so, the nursing home has noticed increased foul smell from the ulceration. The odor was noted on 04/04/16 in wound nurse notes. Systems review Extremities: Left posterior heel has approximately 4.5 x 5.5 grade 3 decubitus ulceration with foul yellow purulent discharge .palpation around the heel causes extreme pain . Hospital discharge summary in part: admitted : 04/22/16 discharge date : 04/25/16 [DIAGNOSES REDACTED].>1. osteo[DIAGNOSES REDACTED] 2. [MEDICAL CONDITION] 3. Dementia Diagnostics 1. MRI of the left ankle review osteolytic erosive changes in the calcaneum worrisome for osteo[DIAGNOSES REDACTED]. 2. Ultrasound segmental pressures of the lower extremity revealed falsely elevated index due to calcified arteries. Hospital Course .transferred from home because of severe left heel pain. 1. Left foot osteo[DIAGNOSES REDACTED]. Patient has clinical and radiological evidence of left calcaneal osteo[DIAGNOSES REDACTED].the patient was having signs and symptoms of systemic symptoms .the patient was having severe pain .it was felt the patient will need a surgical intervention to treat the osteo[DIAGNOSES REDACTED]. The surgical intervention could be removal of the calcaneal or the amputation given her [MEDICAL CONDITION] .given her multiple comorbidities and ongoing infection causing severe pain, the daughter agreed to comfort care measures . Interviews On 05/12/16 at 12:30 p.m., Surveyor interviewed Registered Nurse (RN) C, who is the wound care nurse. Surveyor asked about the note on 04/11/16, that says they will contact podiatrist. There are no notes or faxes to indicate the physician was consulted. RN C indicated she can not find any documentation that she consulted him but would have medical records check. No additional evidence of a physician consult with the podiatrist was located for 04/11/16. On 05/12/16 at 2:50 p.m., Surveyor interviewed CMT L about the note for 04/12/16. CMT L indicated she did rounds with MD W and told him about the heel and MD W increased the pain medication. Surveyor asked if the MD was aware of signs of infection. CMT L indicated she thinks she told MD W about the odor, and the physician did not want to debride the wound, because he was afraid of how deep the area might be. On 05/12/16 at 3:15 p.m., Surveyor asked RN C, who documents the daily assessment of the wound. RN C stated, The nurses check it off on the medication adminstration record. Surveyor asked if they include any information on drainage, odor, or pain. RN C replied, No, I do a weekly assessment. Surveyor continued to ask RN C about the signs of infection and reporting to the MD. RN C stated, Duoderm can cause a foul odor, so I was not concerned. Surveyor reviewed the Duoderm insert that reads in part, Wounds .are often accompanied by a disageeable odor; however this is not necessarily indicative of infection. The odor should disappear when the wound is cleansed. Infection: If signs of a clinical infection should develop, such as uncharacteristic odor or change in the color of the exudate, fever or cellulitiis (tenderness and [DIAGNOSES REDACTED] in the area of the wound), a bacterial culture of the wound site should be taken. If clinical signs of infection are present, appropriate medical treatment should be initiated . Resident #3 had clinical signs of infection (increased pain, increased drainage, a change in the color of the drainage, erythyma around the ulcer, and an odor to the drainage) on 04/11/16.

Based on medical record reviews, policy review, observation and interview, the facility did not ensure that a resident who has had a history of [REDACTED].#3). Resident #3 developed an unstageable heel ulcer in the facility 12/22/15; the ulcer did not improve. Resident #3 experienced increased pain. The intervention of heel boots was not offered during survey. Changes in the support surface to provide better pressure redistribution were not implemented. Signs and symptoms of infection in the heel ulcer were observed; the physician was not consulted until ten days later. A physician did not assess the wound until 04/22/16, when Resident #3 was hospitalized and diagnosed with [REDACTED]. Staff did not use aseptic technique when providing wound care to Resident #3. This is evidenced by: The facility policy, Policy and Procedure for the Prevention and treatment of [REDACTED]. III. Resident Choice In order for a resident to exercise his or her right to appropriately make inform choices about care and treatment or to refuse treatment, the facility and the resident (or the resident's legal representative) will discuss the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment The facility will address the resident's concerns and offer relevant alternatives if the resident has refused treatments/interventions. This will be documented in the resident's medical record . The Minimum Data Set (MDS), with assessment reference date (ARD) of 03/23/16, documents Resident #3 has moderate cognitive impairment, and is not able to answer the interview questions. The functional area identifies Resident #3 requires the assistance of one staff for mobility in bed and transfers. The pain interview identifies that pain limits the resident's activities, and is described as moderate pain. The MDS identifies the presence of one unstageable pressure ulcer measuring 5 x 4.5 cm. A significant change in status MDS, with ARD of 04/26/16, identifies a brief interview for mental status score of 4 , meaning Resident #3 has severe cognitive impairment. This MDS identifies Resident #3 needs extensive assist of two for bed mobility and transfers. The pain interview identifies frequent pain, that affects sleep, and limits activities for Resident #3. The unstageable ulcer is measured as 4.5 cm x 4.5 cm at this time. Resident #3's most current POLST (plan of life sustaining treatment), dated and signed 04/11/16, identifies Resident #3 is DNR (do not resuscitate), but wants hospitalization and aggressive treatment with antibiotics. The care plan states the following in part, (Resident #3's name) is at risk for skin breakdown, has history of vascular ulcer on right inner ankle, has DTI (deep tissue injury)/vascular ulcer on heel with osteo[DIAGNOSES REDACTED] .on hospice, interventions in part: .declines to wear heel protector sleeves or prevalon boots. As of 12/2015 is in acceptance of wearing prevalon boots at times but frequently declines any type of heel protectors. Encourage use due to potential breakdown of heels .has an air mattress (12/24/15) .foot cradle to keep blankets off feet for comfort CNA care plan, undated, in part: Attempt heel protectors, often refuses. Air mattress, breakdown to left heel . The care plan, (Resident #3's name) has pain related to [MEDICAL CONDITION] of her legs, .and heel ulcer with osteo[DIAGNOSES REDACTED], interventions: assess effectiveness of pain medication and notify healthcare provider if pain not well controlled, assess and document location, quality, intensity, and duration of pain .notify hospice and MD if pain is not adequately controlled. The most recent Braden assessment, completed on 03/18/16, had a score of 19. This does not accurately reflect Resident #3's condition and mobility status, documented on the 04/26/16 MDS. The wound flow sheets in part: The pressure ulcer was first identified as a purple discoloration on 12/22/15. The first measurement on 12/28/15 is 2.3 x 2.8 cm, no open area and no pain, weekly measurements continue, the ulcer increases in size, and Resident #3 experiences increased pain. 02/15/16 DTI 6 cm x 5.0 cm, 100% eschar, moist and peeling edges, .dressing changed to polymem.02/22/16 DTI, unstageable, full thickness, 6 cm X 5 cm. 10% slough, 90 % eschar. Dark black eschar with moist edges and eschar, loose at edges. Drainage moderate, serosanguineous, odor none. Pain associated with wound, Yes. [MEDICATION NAME] and [MEDICATION NAME]. The treatment is skin prep, bordered foam, and kerlix. 02/26/16, DTI, 6 cm x 5 cm, 100 % eschar, no drainage. 03/07/16, DTI 6 cm x 5 cm, 100 % eschar, no drainage. The physician's orders [REDACTED]. (Santyl is a [MEDICATION NAME] agent that will remove the eschar). The national pressure ulcer advisory panel (NPUAP) 2014 quick reference guide includes in part: Unstageabe/unclassified full thickness skin or tissue loss- depth unknown .until enough slough and/or eschar are removed to expose the base of the wound, the true depth can not be determined, but it will be either a Category/stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural biological cover, and should not be removed. The facility follows the NPUAP as their current standard of practice for pressure ulcers. The wound flow sheets continue in part; 03/14/16 DTI, unstageable, full thickness, 5.5 cm x 4.5 cm, 10% slough 90% eschar, Drainage scant, serosanguineous, odor none. Pain associated with wound, yes. [MEDICATION NAME] and [MEDICATION NAME]. 03/21/16 Unstageable, 5 cm x 4 cm, 10% slough, 90% eschar, drainage scant serosanguineous, odor: Present. Pain is not answered. Saintly and gauze. 03/28/16 Unstageable, 5 cm x 4 cm, 10 % slough, 90 % eschar, Drainage: moderate, serosanguineous, Pain: yes. Treatment: Skin prep Duoderm, and kerlix. 04/04/16 Unstageable 5 cm x 4 cm, 100 % slough, dark eschar is now moist moveable slough. Drainage: moderate, serosanguineous, Odor is present. Pain: Yes, [MEDICATION NAME] and increased [MEDICATION NAME]. Treatment: skin prep Duoderm, kerlix. 04/11/16 Unstageable 5 cm x 4 cm, 100 % slough, Drainage: heavy, Odor is present. Wound edges: erythyma Pain: yes, [MEDICATION NAME] and [MEDICATION NAME]. Treatment: Duoderm and ace wraps. 04/18/16 Unstageable, 5.0 cm x 4.0 cm, 100 % slough, Drainage: heavy, tan. Odor is present. [DIAGNOSES REDACTED]. Pain: yes, [MEDICATION NAME]. Physician notified: Yes. Dr.--updated. appointment to be scheduled .Duoderm applied .change every 2 days. (The nurse's note documents the wound nurse spoke with the physician's nurse to arrange an appointment; the physician was not consulted for treatment.) 04/26/16 Unstageable full thickness. 4.5 x 4.5 .drainage moderate, .Pain: Yes 05/02/16 Unstageable full thickness, 4.5 x 4.5 .Pain: Yes 05/09/16 Unstageable full thickness 4.5 x 4.5 . Pain: Yes The nurses' notes in part: 02/17/16 .c/o complain of leg /heel hurting this am. 02/18/16 .when asked about pain resident stated, 'this foot is okay pointing to right foot but this one (pointing to left one) is rotting.I will just have to suffer .heels floated off bed with pillow as resident refused to wear podus boots . 02/22/16 .Area painful, .feet elevated on pillows .but resident moved feet around frequently . 02/25/16 Resident returned from appt with (MD V) .with the following orders: 1. off loading heel boot to left foot whenever sitting or laying down 2. daily dressing change with Santyl ointment . 02/29/16 .resident refuses off loading boot or prevalon boots .heel painful to touch. 03/02/16 .heels are floating on pillows in bed . 03/24/16 Resident left to facility to appt with (MD V). We are to still continue the use of the heel boot at all time to the left foot. Continue Santyl ointment .(MD V) stated that there is no infection in the sore. 03/24/16 2:24 p.m. Received call from (MD V) reviewed options of surgical debridement .recommend to encourage to wear boot to offload heel. Discussed eschar is stable and not infected .change to [MEDICATION NAME] dressing .only needs follow up appointment .if area becomes infected or family decides for more aggressive treatment. Resident had torn side of previous heel lift boot off, did allow heel float boot to be applied at this time . 03/28/16 .Resident noted to have increased pain with treatment today, states feels okay with heel protector . 03/29/16 Resident seen today by (MD W), .we talked about her sore heel .resident stated that something needed to be done .we did increase her pain patch . 04/03/16 .resident had a lot of facial grimacing and some moaning during the dressing change . 04/04/16 Received fax from (MD W) to increase [MEDICATION NAME] to 7.5/325 every 6 hours . 04/04/16 2:11 p.m. .Moderate serosanguineous drainage noted and odor noted from debridement with Duoderm .declines heel protectors . 04/05/16 Dressing changed to left heel, moderate amount of drainage to old Duoderm, odorous .continues to c/o discomfort with dressing change . 04/07/16 Dressing changed to left foot, continues with odor yellowish slough over dark eschar. Resident had some discomfort during procedure . 04/11/16 .heavy amount yellowish drainage noted and increased odor noted from debridement with Duoderm .declines heel protectors to be put on. Resident had scheduled pain medication prior to treatment, continues to have pain with dressing change .will update .podiatry due to increase in odor and drainage . There is no documentation of an update to podiatry. 04/12/16 Resident was not seen today by (MD W) but we were asked to write an order for [REDACTED]. 04/18/16 Weekly skin assessment: .100% grayish dark moist moveable slough .heavy amount tan drainage noted and foul odor noted .resident had prn [MEDICATION NAME] for pain prior to treatment, continues to have some pain with dressing change but tolerated okay. Writer contacted (MD V's) office .reviewed with (MD V's) nurse, and resident is to have appointment scheduled . 04/19/16 .noted to have shadowing of drainage to kerlix. Resident was premedicated with [MEDICATION NAME] .resident tolerated treatment and responded that was not so bad. She has appointment scheduled with podiatrist for this week . 04/22/16 Resident left for podiatry appointment this am, .then was a direct admit to .hospital . 04/25/16 Resident arrived to facility at 1550 (3:50 p.m.), She is on hospice care along with comfot cares. She returned with [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. Podiatry note 02/25/16 .stable circumferential eschar is identified at the posterior aspect of the left heel .there is no purulence, malodor .Vascular: .audible doppler examination did reveal biphasic pulses in regard to the dorsalis pedis and perforating peroneal pulses of the foot and ankle. Monophasic sounding pulses were identified above the posterior tibial pulse on the medial ankle bilaterally .Diagnostics: There is no evidence of infection .Plan: .there is the risk of developing an osteo[DIAGNOSES REDACTED]. She will need to be watched closely, If there is any concerns for osteo[DIAGNOSES REDACTED] MRI exam could be an option . 03/24/16: .there are no active signs of infection .decubitus heel ulceration with stable eschar .the other concern would be that she develops an infection, such an infection could be limb threatening .If there is any change in appearance of the ulceration (resident name) will return to clinic to see me at that time . 04/22/16: .the nursing home has related there have been changes in the appearance of the ulceration and it has developed a rather foul odor .Dermatological: .The prior noted eschar is partially self avulsed. There is a copious amount of drainage .with debridement of the residual eschar .it does appear that the posterior portion of the calcaneous is exposed and easily palpable. There is marginal [DIAGNOSES REDACTED] around the ulcerative site .a severe malodor is appreciated from the wound .Radiographs: Two views of the heel with comparison made to prior views performed there is focal radiolucency along the lateral margin of the posterior calcaneous suggesting erosion with suspicion of infection and osteo[DIAGNOSES REDACTED]. Plan: .at this time treatment could include partial calcanectomy or even a possible [MEDICAL CONDITION] She may require longer term IV antibiotics .probably anticipate an infectious disease consultation for discussion of treatment based upon how aggressively family would wish to proceed with treatment .direct admit to hospital . Hospital Admission notes state in part: .she is demented and was present by herself during this visit. The following information was gathered from chart note and her nursing home.the patient was noncompliant and had difficulty leaving the boots in place. For the last 5 days or so, the nursing home has noticed increased foul smell from the ulceration (The odor was noted 04/04/16 in wound nurse notes.) Systems review Extremities: Left posterior heel has approximately 4.5 x 5.5 grade 3 decubitus ulceration with foul yellow purulent discharge .palpation around the heel causes extreme pain . The hospital discharge summary states in part: admitted : 04/22/16 discharge date : 04/25/16 [DIAGNOSES REDACTED].>1. osteo[DIAGNOSES REDACTED] 2. [MEDICAL CONDITION] 3. Dementia Diagnostics 1. MRI of the left ankle review osteolytic erosive changes in the calcaneum worrisome for osteo[DIAGNOSES REDACTED]. 2. Ultrasound segmental pressures of the lower extremity revealed falsely elevated index due to calcified arteries. Hospital Course .transferred from home because of severe left heel pain. 1. Left foot osteo[DIAGNOSES REDACTED]. Patient has clinical and radiological evidence of left calcaneal osteo[DIAGNOSES REDACTED].the patient was having signs and symptoms of systemic symptoms .the patient was having severe pain .it was felt the patient will need a surgical intervention to treat the osteo[DIAGNOSES REDACTED]. The surgical intervention could be removal of the calcaneal or the amputation given her [MEDICAL CONDITION] .given her multiple comorbidities and ongoing infection causing severe pain, the daughter agreed to comfort care measures . A hospital note, dated 04/23/16, states in part: .Plan: .we will attempt to continue the offloading prevalon boot. However, if she continues to remove the boot, the other option would be placement in a postoperative shoe .Segmental pressures performed yesterday noted that the exam was severely limited due to noncompressibility of the vessels .further vascular work up would be indicated prior to determining effective level of amputation. Primary physician progress notes [REDACTED].>12/22/15 .She is eating and drinking very poorly now and the family would like to institute comfort measures . (This was not implemented until after Resident #3's return from the hospital.) 01/20/16 .her only complaint is that the heel of her left foot hurts. She has a bruise there that is probably a pressure sore from being in bed. She refused to wear podus boots so it may be a little difficult to get this healed up . 02/16/16 .Her primary problem now is she has a quite severe pressure ulcer involving her left foot. She refused to wear a Podus boot or leave it on. They have a minimal pressure mattress on her bed but the wound care nurse reports that this continues to look worse. It is extremely painful, especially with dressing changes. We will try a 12 mcg [MEDICATION NAME] .might actually need to cast this in order to take pressure off this area since she won't leave a podus boot on. 03/29/16 .has ongoing pressure ulcer of left foot .(MDV) has seen this and feels like it is really to far advance to do much with it .wondered about putting a cast on it. (MD V) did not want to do that however for good reasons . 04/26/16 .she was hospitalized recently because of much worsening of her heel ulcer .I was hoping family might allow an amputation simply for palliative reasons but she came back for comfort cares and will be enrolled in hospice . 05/10/16 .(MD V) saw her for a 3rd time on April 22nd, now with worsening of the ulcer and X-ray showing evidence of bone erosion .he talked to her daughter, who said there would a family conference and that the family would be considering comfort measures .I do not feel that antibiotics at any point in the course of this heel ulcer would have made a difference. What she needed was to unload and take pressure off the area which she would no comply with . (This note is made 18 days after the hospitalization for the infection.) Observations On 05/11/16 at 12:02 p.m., Surveyor observed Resident #3 up in her wheelchair for lunch. Resident #3 had no offloading boots on and was wearing only gripper socks. The left foot was directly on the left wheelchair foot rest and the right foot directly on the floor. Surveyor continued to observe Resident #3 wheel herself around the facility after lunch until approximately 1:35 p.m. At 2:05 p.m., a visitor came and took Resident #3 to her room. Surveyor asked if she was family. The visitor stated, No, just a real good friend. I visit her at least two times a week. The friend indicated she hoped the pain was getting better. Surveyor asked what she meant. The friend stated, That heel has been bothering her so; she's cried quite a few times when I have been here. At 3:10 p.m., Surveyor observed personal cares for Resident #3. When Certified Nursing Assistant (CNA) M touched the lower leg to raise it or reposition, Resident #3 cried out in pain and moaned. Surveyor asked if this happened very often. CNA M said, Every time you touch her left foot. I help with wound care and it always hurts. After personal cares were completed, the heel boots were not offered to the resident, nor was the wedge cushion used. The wedge cushion was located on the recliner in the resident's room. On 05/12/16 at approximately 6:45 a.m., Surveyor walked down the hall and could hear moaning. The nurses' med cart was in front of Resident #3's room. Surveyor knocked to come in. Registered Nurse (RN) H was just finishing the wound care, and the kerlix was being fastened. Resident #3 was moaning and groaning, and crying out with whimpering expressions; her face was grimacing. RN H stated, Oh this was terrible. I just feel so bad for her. RN H had tears in her eyes. RN H went on to say, I just hate that I have to do that to her. Surveyor asked for more information. RN H said, It just hurts her so bad the minute you touch her foot. Surveyor asked if it hurt the entire time of the dressing change. RN H replied, Yes, the minute we start. Once we touch her foot she cries out. I premedicated her with the MS, but it did not help. She is on hospice. I will contact them today. The Director of Nursing (DON) came down the hall. At this time, RN H told the DON, The pain is just horrible. The heel boots were not offered to the resident during this observation, nor was the wedge cushion used. On 05/12/16 at 10:35 a.m., Surveyor interviewed CNA R, asking about the heel boots. CNA R replied, I have worked here only a few months, all I know is that she kicks them off. On 05/16/16 at 8:30 a.m., RN C, who is the Unit Manger, told Surveyor that the facility was pre-medicating Resident #3 prior to the dressing change, and RN C would inform the surveyor when she would be performing the dressing change. Per the Medication Administration Record [REDACTED] On 05/16/16 at 9:30 a.m., Surveyor observed RN C perform a dressing change on Resident #3. RN C told Surveyor that Resident #3 had osteo[DIAGNOSES REDACTED] in the ulcer on the left heel. RN C used hand sanitizer and donned a disposable gown. RN C gloved and carried dressing supplies from a treatment cart into the resident's room. RN C laid a clean barrier on the bedside table and then laid the dressing supplies on top of the clean barrier. Resident #3 was lying in bed on her back with blue boots on both feet. Resident #3 was lying on an air mattress set at a level 6. RN C raised the entire bed up and then degloved and used hand sanitizer. RN C laid a chux pad under the resident's left foot. Hospice RN I knocked on Resident #3's door and entered the room. RN I asked if she could see the ulcer. RN C removed Resident #3's boot off the left foot. During the removal of the boot, Resident #3 said, Ow, Ow. RN C told RN I that Resident #3 had been pre-medicated at 9:00 a.m. At 9:39 a.m., RN I stated she thought Resident #3 needed more [MEDICATION NAME] and asked RN H to get another dose of [MEDICATION NAME]. RN C continued the dressing change. While RN C used a bandage scissors to cut the resident's soiled dressing, Resident #3 said, Stop it. Stop it. RN C asked the resident if she had pain. Resident #3 did not answer. At 9:41 a.m., RN H entered the room and administered the second dose of [MEDICATION NAME] 10 mg sublingually. RN I stated that Resident #3 can have [MEDICATION NAME] 10 mg every half hour. RN C continued the dressing change without waiting for the [MEDICATION NAME] to take affect. RN C continued to cut the soiled dressing cutting through layers of roller gauze and 4 x 4 gauze. RN C then removed the cut soiled dressings. The soiled [MEDICATION NAME] Extra Ag dressing was stuck to the ulcer. RN C used a clean Qtip to remove the [MEDICATION NAME] Extra Ag dressing from the ulcer while Resident #3 stated, Ow, ow. When RN C placed Resident #3's left heel to float on a blue boot, Resident #3 stated, Ow, ow. The soiled dressing was bloody. RN C removed her gloves and used hand sanitizer. RN C regloved and continued the dressing change. RN C sprayed Resident #3's left heel ulcer with wound cleanser and wiped the edges of the ulcer with sterile 4 x 4 gauze. While RN C cleansed the ulcer, Resident #3 said, Stop it. Stop it. Ow. Ow. RN I held Resident #3's hand during the rest of the dressing change. RN C continued the dressing change. RN C degloved and used hand sanitizer. When RN C raised Resident #3's left foot and placed a mirror underneath to see the ulcer on the heel, Resident #3 stated, Stop it. Stop it. The time was 9:56 a.m. RN I told RN H to give Resident #3 [MEDICATION NAME]. RN H left the room to obtain the [MEDICATION NAME]. RN C measured the ulcer and described the left heel ulcer as a stage III ulcer measuring 3.3 centimeters (cm) by 4.0 cm by no depth. RN C stated there was no tunneling, no odor, no slough and no bone exposed. RN C stated there was a darker color around the wound edges from 12 o'clock to 5 o'clock and healthy tissue except white strands. RN C then degloved, used hand sanitizer and regloved. At 9:59 a.m., RN I returned to the room and administered [MEDICATION NAME] 1 mg sublingually to Resident #3. RN C continued the dressing change and applied skin prep to the outer edges of the ulcer. With the same gloved hands, RN C then opened the sterile package of [MEDICATION NAME] Extra Ag and applied the dressing to the ulcer with her gloved hands. RN C then, without changing her gloves, opened a sterile package of 4 x 4 gauze and applied the gauze to the ulcer. RN C, without changing her gloves, opened a package of sterile roller gauze and applied the roller gauze over the 4 x 4 gauze on the ulcer and wrapped the roller gauze around Resident #3's foot and heel. RN C then placed tape on the dressing, degloved and used hand sanitizer. During the application of clean dressings, Resident #3 moaned. RN C then placed a blue boot on Resident #3's left foot. When the boot was applied to Resident #3's left foot, Resident #3 stated, Ow. Ow. My toe, I never knew that and moaned. RN I told Surveyor that she had assessed Resident #3's pain on 05/12/16 and had increased Resident #3's [MEDICATION NAME] from 5 to 10 mg every 30 minutes, discussing the need to give a bolus of [MEDICATION NAME] prior to dressing changes. RN I stated she was going to increase the [MEDICATION NAME]. The hospice nurse's note written by RN I on 05/16/16, stated, Routine hospice visit. Hospice dx. [MEDICAL CONDITION]. A. Pt lying in bed during visit. Wound care was observed with (RN C's name) at facility prior to assessment visit. Wound measurements obtained and wound bed observed. Wound care was painful; 10 mg [MEDICATION NAME] was given 30-45 minutes prior to dressing change and repeated at during dressing change along with [MEDICATION NAME]. State surveyor present during dressing change. Pain Ad 0/10 at rest, 1/10 awake and 8/10 with dressing change .(RN H's name) reports pt appears comfortable at rest but has increased pain with dressing changes and sometimes with movement. On 05/16/16 at 10:20 a.m., Surveyor discussed with RN C the breaks in aseptic technique during the dressing change. On 05/16/16 at 11:00 a.m., Surveyor discussed the observation of the dressing change with the DON. Surveyor informed the DON of the breaks in aseptic technique of opening packages of dressing supplies, applying the dressings without changing gloves beforehand. On 05/16/16 at 11:05 a.m., Surveyor interviewed RN J, Infectious Disease Nurse Consultant. RN J stated she performs audits of wound care performed by nurses and had performed an audit on RN C in April. RN J stated if she identifies any concerns she addresses it right away with staff. On 05/12/16 at 9:00 a.m., Surveyor interviewed the wound care nurse, RN C, to ask for dates on the interventions; the care plan given was undated. RN C indicated heel boot started in 09/29/15, and the air mattress on 12/24/15. Surveyor asked what standard of practice the facility uses for pressure ulcers. RN C reviewed her policy book, and replied, National Pressure Ulcer Advisory Panel. Surveyor asked for clarification between podus boot and prevalon boot. The terms are both used in the medical record. RN C replied, It is the prevalon boot. We call it a podus boot. Surveyor asked what alternate interventions were tried when the boots were refused. RN C stated, I added foot cradle, and sent her to podiatry (Resident #3 had two visits prior to the day she was hospitalized by the podiatrist). She did not like the boot from podiatry (ordered 02/25/16). We tried pillows but that did not work, because she has restless legs and kicks them out. Surveyor asked if the facility determined why Resident #3 did not like the boots. Surveyor noted a wedge cushion in the room during cares yesterday that was not used, and asked how it is to be used. RN C indicated, I think we started that this week. As of Monday it was pillows, even though she kicks those out. The care plan and nurses' notes were reviewed; the wedge cushion was not documented anywhere. The prevalon boots initiated September 2015 are the same boots that are observed in the room, on the floor in a corner beside the dresser. Review of the medical record 02/10/16 to present, did not document risk/benefits or education with the POAHC about the consequences of not wearing the heel boots. On 05/12/16 at 10:30 a.m., Surveyor had RN H go to Resident #3's room and check her heels. Surveyor asked what the intervention is. RN H said, Heel boots, but she refuses. Surveyor indicated no one had offered them. RN H put on the prevalon boots, that were beside the dresser on the floor. Resident #3 did not refuse the boots. Surveyor asked about the wedge cushion in the recliner. RN H was not sure when that was to be used. Surveyor checked in on Resident #3 a few times for the next few hours; the heel boots were in place at 12:06 p.m. Surveyor checked on the heel boots again at 1:50 p.m., with CNA P; the heel boots were still in place. On 05/12/16 at 3:15 p.m., Surveyor interviewed RN C about the signs of infection and reporting to the MD. RN C stated, Duoderm can cause a foul odor, so I was not concerned. Surveyor reviewed the Duoderm insert that reads in part, Wounds .are often accompanied by a disageeable odor; however this is not necessarily indicative of infection. The odor should disappear when the wound is cleansed. Infection: If signs of a clinical infection should develop, such as uncharacteristic odor or change in the color of the exudate, fever or cellulitiis (tenderness and [DIAGNOSES REDACTED] in the area of the wound), a bacterial culture of the wound site should be taken. If clinical signs of infection are present, appropriate medical treatment should be initiated . Resident #3 had increased pain, increased drainage, a change in the color of the drainage, erythyma around the ulcer, and an odor to the drainage. On 05/17/16 at 8:50 a.m. Surveyor interviewed the DON about the above concerns of the ulcer becoming infected and increased pain. The DON looked in the computer and verified the above dates for interventions. The DON shared that the boot ordered by the podiatrist was ripped apart by Resident #3 around 03/24/16. Surveyor asked what other interventions were implemented after that date. No other interventions were identified. Surveyor reviewed the most recent Braden assessment. The DON stated additional assessments should have been completed with the changes Resident #3 experienced. Surveyor asked for the air mattress specifications. On 05/17/16 at approximately 12:30 p.m., RN C provided the mattress information. The air mattress is a Matrix ALAL and is a group 2 support surface. This is indicated for patients who are at high risk and up to stage 2 - 4. The product information states in part: The mattress acts like a group 3 when used with the gel insert technology (matrix solace). Group 2: .is covered if the patient has a stage II pressure sore located on the trunk or pelvis, and has sores which have worsened or remained the same over the past month. Group 3- A group 3 support support surface is covered if the patient has a stage III or stage IV pressure ulcer, is bedridden or chair bound .at least one month of conservative treatment has been administered including the use of a group 2 support surface .group 3 systems , known as air-fluidized beds . The NPUAP 2014 quick reference guide in part: Support surfaces; 2. Replace the existing mattress with a support surface that provides better pressure redistribution, shear reduction, and microclimate control for the individual if she or he: cannot be repositioned off the ulcer .fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care. 3. If pressure ulcers are not healing: 3.2 Intensify prevention strategies as indicated. 3.3 Consider changing the support surface . On 05/17/16 at 12:50 p.m., Surveyor asked RN C if Resident #3's mattress had been changed since it was started on 12/24/15. RN C indicated it had not been changed. A different mattress was not implemented for Resident #3. On 05/18/16 at 1:35 p.m., Surveyor interviewed Custom Medical Solutions Representative (CMSR) CC. CMSR CC informed Surveyor that the solace gel [MEDICATION NAME] would be effective for Resident #3. Surveyor stated that was not the mattress observed, but the packet of information given to the surveyor was about the Matrix Solace, with a gel [MEDICATION NAME]. CMSR CC stated she would call and verify the mattress type. CMSR CC called back and informed Surveyor that Resident #3 does not have the Matrix Solace with gel [MEDICATION NAME], rather the air alternating mattress and that Resident #3 would be eligible for the gel mattress.

Based on observations, interviews, record reviews, and a review of the facility's infection control program, the facility did not establish an infection control program under which it investigated, controlled, and prevented infections in the facility; and did not maintain records of incidents and corrective actions related to infections. Appropriate infection control procedures were not followed during 1 dressing change (resident #4). The facility did not implement their infection prevention and control program and did not: Assure that the individual responsible for infection prevention and control received adequate training to implement the program. Follow their policies and procedures, according to current standards of practice, for identification of specific micro-organisms which may be present in residents who show symptoms of a communicable illness, including monitoring of staff who may have shown symptoms. Specifically, signs and symptoms of Influenza A. Follow their policies and current standards of practice to implement their established procedure of tracking and trending all residents or staff with signs/symptoms of Influenza A. Follow their policies and current standards of practice to immediately implement appropriate precautions and isolation measures when multiple residents displayed signs and symptoms of possible Influenza A. Educate staff appropriately, according to current standards of practice, regarding transmission Influenza A either before, during or after an outbreak. Provide adequate, ongoing and competent surveillance when the Infection Control Preventionist is not available. These failures had the potential to affect all residents in the facility. The facility's failure to immediately implement appropriate procedures to limit the transmission of disease, which can be particularly serious for individuals with compromised conditions or multiple co-morbidities, created a situation of Immediate Jeopardy which began on 12/27/12, when residents presented with a commonality of signs/symptoms of ARI(Acute Respiratory Illness). The facility did not suspect and take appropriate action related to the outbreak until 01/08/13, and then did not consistently continue to implement appropriate procedures to limit the transmission of disease. The facility was notified of the finding of Immediate Jeopardy on 08/12/13. The facility removed the immediate jeopardy by the conclusion of the survey on 08/12/13. The deficiency continues at a scope/severity of "F" potential for harm that is not immediate jeopardy/widespread) as the facility did not correct the problem to include all necessary policies and procedures reviewed and/or revised, that all staff were educated on infection control related to transmission of communicable illnesses (Influenza A), that all staff were educated on an infection control program that identifies, investigates, controls and prevents the transmission of infections in the facility, with appropriate isolation precautions applied to all residents according to current standards of practice, and with a record of infectious incidents and corrective actions related to potential transmission of Influenza A, after proper identification. Additionally, it was noted during survey that Resident #4 received wound care on an arterial ulcer by a nurse who did not follow aseptic technique. This is evidenced by the following: On 08/08/13, Surveyor reviewed the facility's tracking/trending of infectious disease. Data reviewed included the 2012-2013 Influenza season. The surveillance data showed that Residents #14, #17, #18 and #19 experienced cough and fever symptoms on 12/27/12-01/03/13. No isolation measures were implemented during this time period for these residents nor were cultures obtained to rule out Influenza A/B. This created circumstances through which the infection could spread. On 01/03/13, Resident #3 experienced tachycardia, cough and fever. No isolation measures were implemented during this time period for this resident, nor was the resident cultured for Influenza A/B. On 01/04/13, Resident #2 experienced malaise, cough and fever. Resident #20 also experienced cough and fever. No isolation measures were implemented during this time period for these residents nor were cultures obtained to rule out Influenza A/B. On 01/05/13, Resident #21 experienced fever and cough. No isolation measures were implemented during this time period for this resident nor were cultures obtained to rule out possible Influenza A/B. On 01/06/13, Resident # 24 experienced fever and cough. No isolation measures were implemented during this time period for this resident nor were cultures obtained to rule out possible Influenza A/B. On 01/07/13, Residents #22, #23 and #25 experienced fever and cough. It was not until 01/08/13 (12 days after the outbreak had occurred) that the facility identified a possible outbreak. Two residents were identified as testing positive for Influenza A. Resident #2 and Resident #7. Resident #7 is not identified as having possible influenza symptoms until 01/08/13, when she experienced cough, malaise and fever. However, Resident #2's identified symptoms began on 01/04/13 and the origin of these symptoms (Influenza A) was not identified until 01/08/13, placing other residents at risk for transmission. Interventions by the DON, who functions as the facility ' s Infection Control Preventionist were as follows, beginning on 01/08/13: 01/08/13: "All Department Supervisors notified per email, residents in isolation, visitor notices on doors." 01/09/13: "Attempted to contact Dr. (Doctor) N. unavailable today. NP (Nurse Practioner) updated and will be contacting Dr. BB. 01/09/13 at 10 a.m.: Contacted Dunn County Health Department, updated RN (Registered Nurse) CC. 01/09/13: Listened to WI Division of Public Health Influenza Outbreak Webcast. 01/09/13 at 4 p.m.:" Received phone message from RN CC, Dunn County Public Health-instructed with 3 or more with illness onset recommend [MEDICATION NAME] treatment for [REDACTED]. Also email contact." 01/10/13: "Dr. N updated per phone-order for [MEDICATION NAME] 75 mg (milligrams) orally, daily for 10 days (unspecified who this order is for). Staff should see their medical provider if symptoms for treatment order (sic)." Surveyor reviewed the facility ' s [MEDICATION NAME] administration records, as outlined in the facility surveillance notes and confirmed in the Nurses Notes. Two residents, Resident #2 and Resident #7, began prophalactic [MEDICATION NAME] on 01/08/13, the other residents in the facility received [MEDICATION NAME] on 01/10/13. On 08/12/13, at 10:20 a.m., Surveyor interviewed the DON. The DON stated that she did not obtain Influenza cultures for Residents #14, #17, #18 and #19 on 12/27/12. She stated "It did not occur to me to obtain Influenza swabs on 12/27/13. I believe I was out of the building at that time. I don't know who was covering. The Residents identified had chronic COPD (Chronic Obstructive Pulmonary Disorder), so maybe that's why they weren't tested ." The DON told Surveyor that either the NHA or RN I provides overview while she is on vacation, but could not produce evidence that RN I or the NHA were closely monitoring the facility for possible infectious disease outbreaks during her absence. Asked what measures were put into place after the identification of the outbreak, the DON stated that the residents on the West Wing were confined to their rooms per policy, although this was unclear. The surveillance data did not list the specific room numbers of the residents, only the wings were identified. The data showed that the outbreak was not confined only to the West Wing. Two Residents (Resident #2 and Resident #17) were housed on the East Wing. No evidence of isolation measures were provided by the facility to Surveyor regarding the East Wing of the facility. The DON stated that she initiated droplet precautions in addition to standard precautions which are practiced continuously. The facility ' s droplet precautions are identified as: A mask is to be worn when working within 3 feet of the resident. Have the resident wear a mask if coming out of the room. Beds must be at least 3 feet apart. Door can be left open. The CDC (Centers for Disease Control) recommends that facilities initiate contact precautions if the origin of the micro-organism is unknown, or until it is identified. The facility did not initiate contact precautions prior to the identification of the infectious micro-organism. The DON told Surveyor that housekeeping measures were performed according the the facility ' s policy. The policy states that environmental staff should wear glove and gown (sic) while cleaning and handling potentially contaminated articles. All bedding needs to be removed and washed. Bed and furniture need to be removed and washed. Vacuum all cloth fabric articles/objects. The DON told Surveyor that consistent staff were assigned to the West Wing to prevent the spread of infection. However, review of staffing patterns showed that the night shift staffed with only 2 CNAs (Certified Nursing Assistant) and one nurse. The facility did not identify if staffing patterns varied during the night shift at the time of the outbreak. On 08/08/13, Surveyor interviewed RN(Registered Nurse) I, who was functioning as the DON since the DON was on vacation until 08/12/13. RN I told Surveyor that she did not know how to interpret the surveillance data and that the DON was responsible for the collection and analization of the data as well as all aspects of infection control. She stated that she "just knew how to run it off of the computer." She did not know how to collect or put the data in chronological order for interpretation. Surveyor interviewed the NHA. The NHA told Surveyor that he "does not manage infection control or outbreaks. I do not know what standards of practice we (the facility) use. The DON handles all of that." Surveyor asked the DON to provide evidence of staff training regarding infection control and possible infectious disease outbreak. The DON stated that the facility provides the staff with annual infection control training, but that "the training does not include Influenza A outbreak management, I know that." Surveyor asked to review evidence of staff training. The DON stated she would provide this information to Surveyor . The DON provided Surveyor with a memo entitled "Isolation Updates" posted on 01/11/13 (3 days after the outbreak was identified, and 10 days after the initial report of symptoms). The memo stated, in part, that ....."West Aids will remain on West unit.....Droplet isolation (sic) has to continue for 7 days from the onset of symptoms or until fever free for 24 hours after all fevers resolved.........." No other staff training regarding infection control was provided. There was a temporary change to the breakfast service, which included residents who were isolated on the west wing. This memo was dated 01/11/13 (3 days after the outbreak was identified and 10 days after the report of initial symptoms) which included housekeeping and laundry staff to serve the residents in the dining room, assuring that the residents who were isolated to the West Wing timely service. The DON also provided the staff with a copy of the facility ' s Infection Control Policy which entitled "Upper Respiratory Management Outbreak." The DON did not conduct formal staff education related to the Influenza A outbreak. The DON stated that she provided these memos during shift changes and posted copies of them in the copy room and nurses station. No other evidence of staff teaching regarding infectious disease prior to or following the outbreak was provided to Surveyor . The NHA told Surveyor that the facility did not provide additional training to the DON regarding functioning as an Infection Control Preventionist. The facility ' s Infection Control policy states, in part, that "............The facility employs qualified and trained infection control staff to direct and perform the infection control functions.....the ICP (Infection Control Preventionist) will participate in ongoing education.....the ICP should have a background and training appropriative for carrying out these (sic) responsibilities. This includes a background in infectious diseases, microbiology, geriatrics and educational methods. Management, communicaitons and teaching skills are also necessary. The ICMP has the authority to institute infection control measures (Isolation or special precautions, visitor restrictions, outbreak control measures)....... The ICP establishes and enforces the policies and procedures to reflect current regulatory requirements and best practice guidelines." Surveyor asked the DON, the NHA and RN I for data collected by the facility for staff surveillance during the outbreak period. The facility did not provide a staff line list. However, 99% of staff agreed to and received influenza vaccinations. Most of the staff were vaccinated 9/28/12 to 10/30/12. 10 staff members received the vaccination 01/08/13 to 01/30/13. Surveyor reviewed resident vaccination statuses. 35 of 41 residents received the influenza vaccine. 3 residents were vaccinated prior to admission. On 08/12/13, Surveyor interviewed Dr. N, who functions as the facility ' s Medical Director. Dr. N stated that he remembers the facility reporting an Influenza outbreak a while ago, and that he was sure everyone was immunized (residents/staff). Dr. N stated her would expect to be notified if 2-3 residents or staff displayed symptoms of cough or fever. Dr. N stated he could not recall discussing infection control during meetings with the staff. The facility ' s policy states, in part, that ".......outbreak measures to prevent transmission........will be implemented in coordination with the Medical Director........." According to the facility ' s policy, entitled "Infection Control Program," the facility should "...........assess clinical features of illness for consistency with influenza A, i.e., abrupt onset of headache, fever, malaise, Malaga and respiratory symptoms. 3 or more cases of clinically significantly, facility acquired infections caused by the same organism occurring in the same general area within a period of 7 days OR (sig) Twice the normal number of these infections per month observed for a period of 3 consecutive months OR the identification of a single unusual or highly contagious infections (e.g., influenza, [DIAGNOSES REDACTED], E. Coli, Salmonella). The ICP (Infection Control Preventionist), or designee, will conduct the outbreak investigation and has the authority to implement outbreak measures to control possible transmission. These measures will be implemented in coordination with the Medical Director, Administration and medical staff as well as state and local health agencies. In the absence of the ICP, the DON will conduct the investigation. Control measures may include simple resident isolation or unit isolation or quantitative measures for the entire facility. An interdisciplinary evaluation of the outbreak will be completed and recommendations or preventative measures will be presented at the quarterly Quality Assurance Committee meeting.............Outbreaks can cause significant morbidity and in some cases mortality, making expedient identification and prevention strategies a primary goal." The Division of Public Health has noted that "Facilities should immediately institute aggressive infection control measures anytime an outbreak is suspected " and that " When appropriate prevention and control measures are not implemented immediately, outbreaks can continue for weeks causing many illnesses, some hospitalization s and the occasional death from dehydration and other complications of vomiting and diarrhea. " The failure to ensure that qualified staff was on duty to analyze infection control data, the failure to immediately identify that a possible outbreak had occurred beginning 12/27/12 and the failure to immediately implement measures to prevent the spread of infection created a finding of immediate jeopardy. The facility removed the jeopardy on 8/12/13 when it ? implemented appropriate interventions which included daily surveillance of signs and symptoms of potentially infectious organisms. The IJ was removed on The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread. Other deficient practices related to infection control include the following: Resident #4's medical record states that he has [DIAGNOSES REDACTED]. Resident #4 has an arterial ulcer on his inner left ankle, and chronic edema in his left foot. He also has a supra-pubic catheter (inserted into his lower abdomen) for urinary output. Surveyor observed Registered Nurse (RN) G, who was orienting RN H, perform wound care for Resident #4 on 08/07/13 beginning at 7:30 a.m. RN G washed her hands and donned gloves, and placed a paper towel barrier on his tray table and put a container of wound cleanser on the barrier. She opened a garbage bag and placed it on the foot of the bed. RN G then opened a dresser and closet door, looking for a blue chux pad. She lifted Resident #4's left foot and placed the chux under the foot. RN G then removed her gloves, but did not wash or sanitize her hands. RN H donned gloves and held Resident #4's left foot while RN H removed the dressing from his arterial ulcer on the inner ankle. RN G picked up the container of wound cleanser, removed the cover, and sprayed the ulcer, and dabbed it with a gauze 4-by-4. RN G removed her gloves, placed them and the other garbage in the plastic bag, tied the garbage shut and washed her hands. Resident #4 then went for his weekly shower. At 8:32 a.m., after Resident #4's shower, Surveyor observed RN G and RN H finish the wound care on Resident #4's arterial ulcer while he was seated on the bathing chair. An open binder was on a soiled linen hamper, and on that binder was an ace wrap which was retrieved from Resident #4's room by Certified Nursing Assistant (CNA) P, and a sock. RN G washed her hands and placed a disposable blue chux under Resident #4's foot. RN G placed all of the dressing supplies on the chux on the floor. Both nurses then knelt directly on the floor. RN G opened packages of gauze 4-by-4s, sanitized a scissor with alcohol, and placed it on the chux pad on the floor. She picked up the container of wound cleanser and sprayed the ulcer, and dabbed it with gauze 4-by-4s several times. RN G then removed her gloves, but did not wash or sanitize her hands before she attempted to don clean gloves. She then asked CNA P to get another size of gloves, which she did. RN G then donned the gloves and opened a no-stick barrier product and swabbed it on the skin around the ulcer. RN G then opened a package of [MEDICATION NAME] AG and picked up the scissor and cut a small piece of it and placed the scissor back on the chux on the floor. She tucked it into the wound with her gloved finger. RN G applied a boarder dressing to the ulcer, then reached into her pocket, took out a pen, removed her right glove, dated and initialed the dressing with the pen, removed her left glove, and placed the pen back in her pocket. RN G then wrapped Resident #4's foot and lower leg with the ace wrap. RN G picked up the scissor and put it on the open binder on the soiled linen hamper, and gathered all the garbage, wrapped it in the chux pad, and threw it away. She handed the sock to RN H to put on Resident #4's left foot, and washed her hands for the first time since beginning the wound care.

Based on interview, policy review and record review, the facility did not ensure the policy and procedures which prohibit mistreatment, abuse and neglect of residents were developed and implemented. The facility did not ensure all allegations involving mistreatment and abuse of Resident #4 and #8 were reported immediately to the administrator of the facility so steps could be taken to prevent further potential abuse while an investigation was in progress. This had the potential to affect all 41 residents. The failure to have a system in place in which allegations were immediately reported and acted upon to prevent further abuse from occurring created an Immediate Jeopardy situation. The Immediate Jeopardy began on or about 05/01/13. The facility was notified of the Immediate Jeopardy on 08/07/13. The facility removed the Immediate Jeopardy on 08/07/13 when they began to retrain staff on abuse reporting requirements prior to working their next shift. The deficient practice continues at a scope/severity level of F (potential for harm/widespread) because not all staff have been retrained regarding abuse prevention, reporting, and the protection of residents and as evidenced by the following: Resident #8 sustained a laceration on her forehead which required sutures. The Administrator was not immediately notified of the incident, the staff person was not removed from patient care or sent home, the investigation did not begin until the day following the incident, statements/interviews contained conflicting information and no further interviews were completed, the facility did not complete a through investigation, the incident was not self reported by the facility as the Administrator did not feel it was necessary. No re-education of all staff was completed after Resident #12 was left on a bed pan for an extended period of time. The facility policy did not include required information regarding the Elder Abuse Act. This is evidenced by: The facility's abuse prevention policy, most recently revised on 06/10/10, states, in part, "Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals." "Quality Assurance rounds, based on resident rights, will be conducted monthly by the Director of Social Services (in his/her absence, to the designated social worker.) Other Quality Assurance rounds will be conducted by Administration covering various items, including resident rights." Prevention: American Lutheran Homes will prevent abuse, neglect and misappropriation of resident's property by having the following in place: -Will provide residents, families, and staff information on how and to whom they may report concerns, incidents and grievances without fear of reprisal; and provide feedback regarding the concerns that have been expressed. -Will identify, correct, and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. -This includes an analysis of: ... --The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs; --The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents ' needs; and --The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. Abuse is any one of the following acts commited by any person in contact with the resident: 5. A course of conduct or repeated acts by a caregiver which serve no legitimate purpose and which, when done with intent to harass, intimidate, humiliate, threaten or frighten a client, causes or could reasonably expected to cause the client to be harassed, intimidated, humiliated, threatened, or frightened. Investigation Procedure: 1. In the event in which any of the above is suspected or identified, staff will immediately stop the situation from continuing (if relevant), will ensure that the resident is protected from further incidents of misconduct or injury and report the incident to the first available facility supervisor, who will then evaluate the resident to verify that the resident not in immediate danger and/or contact LPN/RN on the resident's living unit to evaluate the resident. 2. The immediate facility supervisor will contact his/her Department Director, Facility Administrator, and refer to the specific procedure for the reported incident. If the incident is considered an alleged Resident Rights violation, the investigation begins immediately... 3. The alleged abuser(s) will write and sign a statement of involvement on the American Lutheran Homes Resident Concern/Complaint Report Form...or other facility designated investigative form and then immediately leave the American Lutheran Homes campus for the duration of the investigation to ensure resident safety by preventing possible subsequent incidents while the investigation is completed. All allegations are treated as potential misconduct until the investigation is complete. 5. ...If the alleged incident occurs when there is not a facility supervisor or Social Worker immediately available, the interviews will be conducted by LPN/RN starting with the American Lutheran Homes Grievance/Complaint Form. Each staff interviewed will be asked to complete and sign a written statement of knowledge regarding the incident on the American Lutheran Homes Resident Concerns/Complaint Report Form...or other facility designated investigative form and submit to the Interviewee. 7. It is the Department Director or designee's responsibility to notify the following individuals of the alleged resident rights violation: -Facility Administrator -Director of Nursing -Executive Director of Housing and Administration (Human Resources) (whenever any employee is identified as alleged to have violated a resident's rights) -Director of Social Services (in absence, the designated social worker) -Facility Medical Director 8. The Facility Administrator, Director of Social Services, or Director of Nursing must immediately report all incidents of alleged mistreatment, abuse and neglect of residents, misappropriation of resident property and injuries of unknown source if the allegation meets the federal definitions of misconduct as listed above to the DQA (Department of Quality Assurance) via the online reporting system...which is required to meet the requirements in Federal regulation 42 CRF 483.13(c)(2)...Failure to provide the information to DQA within 24 hours of discovering an incident may result in a citation under federal or state codes. 9. An interdisciplinary staffing will be held to discuss the alleged incident. This will occur immediately on the first (1) working day following the alleged incident, or the date the facility became aware of the incident. 10. The Social Services Department and/or facility supervisory staff are responsible to interview all parties with knowledge of the alleged incident including: -Resident(s) -Staff of all relevant shifts and/or departments -Responsible Party -Other persons of knowledge as necessary Each person interviewed will be asked to complete and sign a written statement... 12. Within four (4) working days, all other investigative reports are to be submitted to the Director of Social Services...and an interdisciplinary staffing will be held to discuss the alleged incident with guidance of the State and Federal misconduct definitions to determine if an alleged incident constitutes a resident rights violation. 13. Director of Social Services...will document all actions taken and other corroborating or disproving evidence in a final summary reported on the Misconduct Incident Report form, F- ...and will assume the responsibility for submitting a copy of the Misconduct Incident Report and all other relevant investigative reports within five (5) working days of the incident... Cross reference F 223 and F 225. The facility's abuse prevention policy was not followed for Resident #4 as follows. -Multiple staff were aware of CNA B's mistreatment of [REDACTED]. This resulted in continuing the abuse over a course of several months, and escalated over 2 - 3 weeks. CNA-F told Surveyor on 8/07/13 at 4:15 p.m. that Resident #4 is "a lot happier now that she's not here anymore ...she's been disrespectful for months and it was worse the last few weeks. Not so bad when I first started here last May." CNA J told surveyor on 8/07/13 at 4:55 p.m. that "this started occurring about 6 months ago ..." CNA O stated to surveyor on 8/07/13 at 4:45 p.m., when asked if she had reported this to the nurses, that "It was talked about in report. They all knew..." -Facility administration did not identify the abuse through the Quality Assurance process. -CNA B was not escorted from the campus, leaving residents unprotected. She was allowed to continue to provide cares to vulnerable residents until the end of her shift on 06/04/13. RN D stated on 6/04/13 between 3:00 and 4:00 p.m., "I am the Manager at night, but if I send someone home then that just leaves 2 of us to care for the all residents. We all work together at night, and I didn't know I could send her home." -The facility did not conduct an immediate investigation. The first report (an e-mail from RN D to the Director of Nurses sometime in the beginning of May 2013 was not investigated) and the final incident on 06/04/13 was not investigated until 06/05/13. When interviewed on 8/07/13 at 4:25 a.m., RN D stated that no one had questioned her regarding the first e-mail she had sent to the DON approximately a month before 6/04/13 and that no one called her on 6/04/13 after her second e-mail. -The facility did not conduct a thorough investigation. The facility did not interview all pertinent staff who had information about the mistreatment. Social Worker A stated on 8/07/13 at 7:45 a.m. stated that she interviewed CNA C, that she did not interview any p.m. staff or any other night staff who worked with CNA B, and that she was not sure if she had interviewed RN D. Residents were questioned during the investigation, but the questions were not specific regarding the night shift, or regarding CNA B's behavior. -The facility's Medical Director was not immediately informed of the mistreatment. -The facility chose to not self-report the abuse as required to the Office of Caregiver Quality. The NHA stated on 8/06/13 at 3:35 p.m. that he ultimately made the decision not to self-report because his association had informed facilities that 80% of all self-reports result in citations and because OCQ (the Office of Caregiver Quality) does not always choose to investigate. -The facility did not immediately re-train all staff regarding resident protection, abuse prevention, burnout, reporting, and following the abuse prevention policy. The facility's failure to implement its abuse prevention policy and procedures resulted in Resident #4 being always angry with her (CNA B) because she was "mean and rough." Resident #4 stated that he dreaded the nights when she would be working. (Interview by Surveyor with Resident #4 on 8/06/13 at 5:05 p.m.). The immediate jeopardy at F226 was removed on 08/07/13 by which time the facility had developed a plan to retrain all staff on abuse reporting procedures prior to working their next shift. The deficient practice continues at a scope/severity of F (potential for harm that is not immediate jeopardy/widespread) because the facility has yet to fully implement its corrective action plan. 2. Resident #8 has [DIAGNOSES REDACTED]. Resident #8's initial MDS (Minimum Data Set) dated 08/08/12 and quarterly MDS dated [DATE] identified Resident #8 required extensive assistance of 2 persons with transfers and repositioning in bed. She required total assistance with locomotion to move about on and off the unit. Resident exhibited no behaviors and had long/short term memory problems. Resident #8's medical record identified she used a Broda chair. On 08/08/13 Surveyor noted a physician order [REDACTED].#8's medical record. The medical record also contained a FAX dated 04/13/13 to Resident #8's physician. The FAX stated, "10:45 Resident was being repositioned in chair and hit her head on the railing in the west hallway. 7 cm by 3 cm, 1/2 -1 cm deep laceration in forehead. Sent to ER (emergency room ) via non ER transport for stitches." On 08/07/13 the Administrator provided Surveyor with incident report and investigation as requested by Surveyor . The NHA stated the incident report and investigation, provided to Surveyor , contained all the information related to the investigation. The Incident Report identified the date/time of the incident as 04/21/13 at 10:20 a.m. The location of the injury was identified as the right forehead. The type of injury was identified as a laceration that was 7 cm x (by) 3 cm x 1/2 -1 cm. The description of exactly what happened was, "CNA (Certified Nursing Assistant) was attempting to reposition the resident as she was leaning to the right in her chair. Resident hit her head on the edge of the railing in the hallway - needs stitches. Sent to ER via non emergency transport per POA (Power of Attorney). Why/How did this occur was identified as "Unknown origin." The Incident Report contained a statement, "If unknown origin ask resident if they were treated roughly/inappropriately. No entry was made. The statement following stated, "If yes notify administer immediately for further information. The Incident Report identified the physician was notified by FAX. No time or date was identified as to when the MD was notified. The Incident Witness Form identified CNA W as the person reporting the incident on 04/21/13 at 10:30 a.m. and she was the only person involved. There was no one else with specific knowledge/witness of the incident. The description in order of how the incident took place was, "I (CNA's W name) was pushing (Resident #8's first name) w/c (wheelchair) and stopped in front of (Resident #1's first name) rm (room) to grab the "hoar" lift, (Resident #8's first name) was flopping around in her chair and she flopped her head forward hard enough and it hit the railing, her head started bleeding. The specific location the incident occurred was stated, "room [ROOM NUMBER] in front of her Rm (room.) her door was shut I (CNA W's first name) was grabbing the lift by her rm. Why did this occur? "See above. " Effect of incident on resident/Resident's response: "She was OK. She was bleeding she went to the ER got stitches. 5 stitches Family was called they talked with me when they came to ALH (American Lutheran Home). They said they were OK accidents happen. " CNA W signed and dated the form on 04/21/13. The Clinical Notes dated 04/21/13 at 10:48 a.m. stated, "Resident was being repositioned in her chair as she was leaning to the right in the hallway. CNA reported that resident hit her head on the railing in the hallway, now has a 7cm x 3cm 1/2 to 1 inch deep area in the right side of her forehead. pressure applied and resident transferred to bed via hoyer lift. POA notified and resident sent to ER via non emergency transport for stitches, vitals stable. MD faxed and DON notified. Will contact POA when resident returns." Upon readmission to the facility the Provider Notes stated: Brief Summary "hit head during transfer; patient non-verbal; history obtained in EMS. " New Clinical Impressions: "[MEDICAL CONDITION] 3 cm. " New orders: "5 simple sutures placed; no bleeding. " Prognosis/Follow-up: "double or triple antibiotic ointment 2 x/day suture removal 5-7 days." Review of statements obtained from nursing staff on duty on 04/21/13 at the time of the incident identified: CNAs NN and LL were together in another resident's room providing care when they heard the walkie talkie message for a nurse to go to Resident #8's room, per CNA NN's written statement on a sheet of paper dated 04/23/13. CNA NN's questionnaire statement obtained by telephone, 04/23/13 at 1:28 p.m., identified, "went down to see if they needed help. CNA W said she hit her head on her way out of the room. When CNA NN went down the hall, Resident #8 was facing the room in her w/c (wheelchair). CNA LL did not provide a written or verbal statement. CNA KK's handwritten statements dated 04/22/13 identified she was in a room with the door closed providing care to a resident. CNA KK heard a page for the nurse to come to room [ROOM NUMBER]. The written statement on 04/23/13 identified she was getting another resident up at the time. The signature and the handwriting on the written statement do not match. CNA OO's questionnaire statement dated 04/23/13 at 1:29 p.m. identified she was on the east wing (opposite wing from where Resident #8 resided). CNA OO stated she did not know what had happened, but she had been told Resident #8 "leaned." An undated handwritten statement by CNA OO identified she had been coming back from break and saw CNA W holding something on Resident #8's head saying that the resident had been sitting by the railing and hit her head on it. CNA W walked down to get a nurse. RN (Registered Nurse) Q's typed statement dated 04/23/13 identified she arrived for work on 04/21/13 at 2:15 p.m. and after report CNA W had come to the nurse's station to ask for an incident report sheet to fill out. CNA W stated the incident report was for Resident #8 and she had to fill it out before she left for the day. CNA W informed RN Q that Resident #8 had bumped her head on the railing in the hallway and cut her forehead open. CNA W expressed several times how bad she felt that this incident occurred. LPN (Licensed Practical Nurse) PP's undated questionnaire identified she "stayed w/ (with) resident until the EMT was painful - applied pressure." Her theory as to what may have caused this injury was, "was pushing out of room & Bumped coming out of room. Denied when asked." LPN PP documented, "Soft foam on ends of railings. Don't reposition in Hallway next to railing", for the question asking if she noticed and safety issues that needed to be fixed to prevent this from happening again. RN MM's undated questionnaire stated, "CNA W clld (called) on walkie -stated resident was bleeding. applied pressure immed. (immediately). CNA W stated resident was leaning to Right & she was trying to reposition her & Resident hit her head on the railing." RN MM's statement included, "Why reposition in Hall? How close to wall? CNA W couldn't answer." RN JJ in an undated typed statement wrote, "Regarding Resident #8's head injury. In the nurses notes it is stating that she was being repositioned when it occurred. LPN R stated some of her CNA's were asking about this and how it happened because they were hearing a different story. I heard it as well, but they are saying that CNA W was pushing her in her wheelchair and ran into the wall and she hit her head. I am not sure if this is just a rumor or not, it very well could be. I was just letting you know." The information in the investigation packet contained 3 hand written notes: ~04/22/13 at 1:13 p.m. a phone interview with RN MM was conducted. The written note does not identify who wrote the note or made the telephone call. The note identified RN MM had been working at the nurses station and she was paged. Resident #8 was leaning to the right side - more upright (not leaning back). There were no witnesses. CNA W had said she had repositioned Resident #8 since she was leaning more to the right. When asked if she had any observations of Resident #8 flopping RN MM said Resident #8 did lean to the right and rocks a bit. RN MM said the laceration was 1 inch deep. When asked if hitting the railing could cause a 1 inch deep laceration RN MM said, "Not in her opinion. " When asked where there was blood located RN MM said it was on the floor. She did not see any blood on the wall/handrail/door jamb. ~04/23/13, no time identified) an interview with CNA W was conducted. The written note does not identify who wrote the note or made the telephone call. The note identified CNA W had brought Resident #8 out of the TV lounge and to her room. The room door was shut and Resident #5 was "flopped to the side. " CNA W stated she had left Resident #5 and went a coupled of doors down to get the Hoyer lift. CNA W said Resident #8 was a "flopper. " CNA W stated when she came back Resident #5 was bleeding and was still leaning over. CNA W said she believed Resident #8 hit her head on the corner of the railing. CNA W described flopping as leaning and a rocking motion and chews on her clothing. CNA W stated Resident #8 was already leaning to her side at the room door. CNA W stated she made a walkie request for somebody to come outside Room (#) ASAP (as soon as possible). RN MM came then LPN PP arrived. The last sentence stated, "No witnesses; no other res (residents) in Hallway. " ~On 04/23/13 at 4:05 p.m. a handwritten interview with CNA W was documented. The Administrator's, Social Worker A's and RN I's first names are written on top of the page. The handwritten entry was: "-TV lounge: -to room, door shut-CNA KK with resident (only identified by a first name); -left her next to railing & she was leaning to the right; -went to grab the Hoyer - couple doors down in hall; -saw blood when she came back - assuming hit head on rail didn't actually witness it; -then got on walkie - someone to rm (room #) ASAP; -RN MM and LPN PP's first name (RN's); - CNA KK's first name peeked out head - but couldn't leave a resident's first name only; - CNA NN came down; -CNA OO came down: - no other residents in hall; - no staff in hall; and had her next to side rail & she flopped & hit head on the corner of the railing." The facility discharged CNA W on 04/24/13. The explanation of current problem, including specific dates and examples stated, "Incident of 4/13/2013 where a totally dependent was injured while in CNA W's first name direct care. Following corrective action earlier this year for a separate incident resulting in Res (resident) injury, Termination for failure to ensure safety of a resident is necessary." The information provided to Surveyor did not include a summary of the investigation, did not contain additional interviews when conflicting statements were received, did not contain information if CNA W was sent home on 04/21/13, suspended pending the outcome of the investigation or if CNA W was allowed to continue to work during the time the investigation was being conducted. On 08/08/13 at 8:45 a.m. Surveyor interviewed CNAs (Certified Nursing Assistants) P and X who stated Resident #8 had used a Broda chair for a long time. They had never seen her thrust or throw her body while in the Broda chair. CNAs P and X stated she always transfers with assistance of 2 and a Hoyer lift. On 08/08/13 at 11:15 a.m. Surveyor interviewed RN (Registered Nurse) I and requested to any additional information related to the investigation. RN I stated the Administrator completed the investigation. RN I stated she had not seen or heard staff talk about Resident #8 flopping or thrusting her body around. RN I stated Resident #8 had used a Broda chair for a long time and did not know why some witness statements would say she was in a wheelchair. On 08/08/13 at 1:55 p.m. Surveyor interviewed the Administrator who stated he had not self-reported the incident (to the Office of Caregiver Quality) as he did not feel it was necessary. The NHA stated CNA W had been terminated. Surveyor requested to review any additional information he had related to the investigation. The Administrator stated he believed he had provided all the information he had to Surveyor already. The Administrator stated if he found any additional information he would provide it to Surveyor . On 08/12/13 at 10:50 a.m. Surveyor interviewed the DON (Director of Nurses) who stated CNA W had been terminated. All the different stories including CNA W's did not match up. The DON stated she has not seen Resident #8 thrust forward or flop in her Broda chair. The DON stated no staff have ever reported this to her. The DON stated Resident #8 sometimes kind of wiggles and will then lean to the side in her Broda chair. The DON stated Resident #8 should not have been positioned close enough to the hand rails in the hallway or repositioned in the hallway. The DON stated Resident #8 requires the use of a Hoyer lift with 2 staff for all transfers/repositioning. The DON stated the Administrator would have all the information related to the investigation. On 08/12/13 at the time of the final exit the facility had not provided any additional information to the survey team. On 08/15/13 at 10:06 a.m. Surveyor spoke with the DON who provided additional information. The DON stated the Administrator said he did not have any additional information related to the investigation other than what provided. He did not have any other statements to clarify the conflicting statements. The DON stated the Administrator was the lead investigator. The DON stated she became involved on 04/24/13 when CNA W was terminated. The DON stated she had received a voice message from RN MM. The message left was that Resident #8 had been taken to the hospital and was either returning or had returned to the facility. The DON stated she had called RN MM back at the end of the shift. The DON stated she did not know if the Administrator or Social Worker A had been contacted at the time of the incident. The DON stated staff are all aware that they are to contact her first and if she is not available they are to immediately contact the Administrator and SW. The DON stated RN MM had not documented that she had called the Administrator or SW A. The DON stated that she had been out of the building on 04/22 - 04/23/13. The DON stated the investigation did not start until 04/22/13. The DON stated CNA W had been allowed to finish out her shift on 04/21/13 and had not been removed from patient care. The DON stated CNA W had not worked from 04/21/13 until CNA W's termination on 04/24/13. The DON stated no self report had been filed as the Administrator had stated it was not necessary. The DON stated the facility self reported the incident yesterday (08/14/13.) The DON stated she felt the incident should have been reported based on the findings during the investigation and resulting termination. The DON stated she did not know of any inservices/training that had been done by the Administrator or SW A following the incident. The DON stated if the Administrator scheduled any training she would have heard about it, and a posting (letter or memo) with the time, date and information would have been posted. The DON stated she had reviewed the education file and did not find any training following the incident on 04/21/13. 3. On 08/08/13 Surveyor reviewed a document titled Problem/Complaint Form and accompanying investigation for Resident #12. It states that on 06/18/13 at 4:30 a.m., Resident #12 was placed on a bedpan and was not removed until 6:00 a.m. The investigation shows the staff involved were disciplined and re-educated on bedpan timeliness. On 08/12/13 at 12:47 p.m., Surveyor interviewed the Director of Nursing (DON) regarding re-education for all staff regarding bedpan timeliness. DON stated there was shift-to-shift education. Surveyor asked if there was any documentation regarding this. DON stated she would check. On 08/12/13 at 1:50 p.m., Surveyor requested a copy of the Problem/Complaint Form and accompanying investigation regarding this incident. Surveyor asked if this was everything there was. DON stated it was. Surveyor informed DON if additional information was found that it should be faxed. On 08/12/13 at 1:55 p.m., Nursing Home Administrator (NHA) asked Surveyor if she had received all information requested. Surveyor explained there was no documentation showing re-education of all staff regarding bedpan use, and that the DON was informed to fax any additional information if found. NHA then provided Surveyor with a document that read in part: "The following staff has been educated on bed pan use." It contained three signatures all dated 08/09/13 and a nurse signature date of 08/09/13. 4. Surveyor reviewed the facility's abuse prevention policy, on 08/06/13 at 01:00 p.m. The facility's abuse prevention policy, most recently revised on 06/10/10, states, in part, "Investigation Procedure: 6. If the allegation involves a potential criminal offense and/or the resident and/or responsible party so chooses, Law Enforcement and/or other requested required community involvement agency (ie Adult Protective Services) is to be notified immediately following the initial alleged incident interview(s) of resident(s), family member(s), and staff." The facility abuse prevention policy does not refer to the S & C Elder Abuse Act, regarding reporting reasonable suspicion of a crime in a Long-Term Care Facility. The facility did not post the information regarding reporting of a crime as required. During an interview with Social Worker (SW) A on 08/07/13, Surveyor asked SW A how the facility ensures staff is aware of the Elder Abuse Act. SW A replied, "We are working on posting that in the breakroom. (Director of Business Operations E) is working that into our new abuse policy." Surveyor interviewed Licensed Practical Nurse (LPN) R on 08/06/13 regarding Abuse Prohibition. When Surveyor asked LPN R about the Elder Abuse Act and where this information was posted in the facility, LPN R responded, "I'm not sure." Surveyor interviewed Scheduling Coordinator S on 08/07/13 regarding Abuse Prohibition. When Surveyor asked Scheduling Coordinator S about the Elder Abuse Act and where this information is located in the facility, Scheduling Coordinator S replied, "I don't know. I'm not sure of its location." Surveyor received the facility's New Employee Orientation and Quarterly Mandatory Staff Training handouts on 08/12/13 at 07:30 a.m. from SW A. SW A is responsible for educating new and current employees regarding resident rights, as well as abuse and neglect. Surveyor reviewed the training handouts, which is given to all staff during new employee orientation as well as quarterly staff training. The material provided did not include any information or reference regarding the Elder Abuse Act.

Based on interview and record review, the facility did not ensure all allegations involving mistreatment of [REDACTED]. Resident #4 reported to the facility staff, and staff witnessed, that Certified Nursing Assistant (CNA) B was mean to him and handled him roughly. Although CNAs reported this concern to their nurses, and although a night nurse e mailed the Director of Nursing (DON) about this concern, an immediate and thorough investigation was not conducted, Resident #4, as well as other vulnerable residents, were not protected. Resident #4 asked the p.m. shift each evening who was working the night shift, and stated that he hoped that CNA B was not working. CNA B verbally abused Resident #4 on multiple occasions. This abuse continued, and increased in frequency and intensity, until the night nurse sent a second e mail to the DON, approximately one month later. The investigation did not begin until the following day. The investigation was not thorough, (not all staff who would have knowledge about the abuse were interviewed) and the facility did not self-report the allegation of abuse as required to the Office of Caregiver Quality. The failure to have a system in place in which allegations were immediately reported and acted upon to prevent further abuse from occurring created an Immediate Jeopardy situation. The Immediate Jeopardy began on or about [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility identified retraining on abuse reporting to all staff prior to working their next shift. The deficient practice continues at a scope/severity level of E (potential for harm/pattern) because not all staff have been retrained regarding abuse prevention, reporting, and the protection of residents. This is evidenced by: Resident #4's medical record states that he has [DIAGNOSES REDACTED]. Physician's notes dictated on [DATE] and [DATE] describe him as a "very pleasant" male resident. His BIMS score is 13 out of 15, indicating mild dementia. Resident #4's care plan states that he "sometimes makes inappropriate sexual comments to female staff. He has also attempted to grab female staff inappropriately." Approaches for this concern include: -Change topic of conversation. Talk about past events. -Re approach. Use different caregiver as needed. -Allow time to calm down, reapproach him. -Maintain safe body stance/distance. -Remind of appropriate interactions with staff members. The facility is staffed with 1 nurse and 2 CNAs on the night shift. The CNAs have the potential to have contact with all 41 residents who live there. On or about [DATE], RN D sent an e-mail to the Director of Nurses informing her of a concern of possible abuse reported by CNA C. CNA C had observed CNA B putting on Resident #4's shirt and putting it on awkward. Resident #4 had asked, 'Why are you doing it like that?' CNA B responded to Resident #4 by saying, 'If you are going to act like a baby, I am going to treat you like a baby.' RN D stated in interview on [DATE] at 6:25 a.m. that no one questioned her after this first e mail, which she sent to the DON approximately a month before [DATE]. Surveyors and interviewed the NHA on [DATE] at 9:40 a.m. Since RN D had stated that she had previously e mailed the DON about the concerns between CNA B and Resident #4, Surveyor asked if there is any way that this e mail could be retrieved. The NHA stated that he would have his IT person try to retrieve it. He stated that it might be difficult, because the facility is using a new computer system. He stated that the DON (who is on vacation) does not remember receiving the first e mail. The facility did not initiate an investigation to this first e-mail in [DATE] and did not take steps to prevent further possible abuse. As evidenced in the interviews below, CNA B's abusive behaviors escalated over the next several weeks. On [DATE], Surveyor requested to review the facility's complaint file. Social Worker (SW) A provided an investigation regarding Resident #4's complaint of how CNA B treats him. The investigation contained an e mail to the Director of Nursing (DON) written by Registered Nurse (RN) D and dated [DATE], which states, "On NOC (night) shift I am continuing to experience problems with (CNA B's name) and (Resident #4's name). (Resident #4) does not like her because she is rude and inappropriate to him. She doesn't like him because he requests to 'send in someone else' ...when she comes in to help him because she is rude and inappropriate to him. When he requests other help, she gets more upset. At times, I or another CNA will be in his room and she will enter, when no help is requested, and make comments to taunt him, like she only entered to start some trouble. I have had numerous talks with her about this. I have apologized to him on behalf of her, etc ...asked her to make a truce with him, etc. She became very upset on NOC shift last night when I took the resident's side of the issue. I could explain better in person. And am running out of room to type ...I can't see past this line and it doesn't scroll down. So let me know if you have any more questions. Thanks You. (RN D's name) (Sorry for any typos. I can't see!)" Cross reference F 223 for more information regarding the abuse of Resident #4. RN D stated on [DATE] at 6:25 a.m. that no one questioned her about the details she wrote in her statement. Even though the Director of Nurses was aware of RN-D's email on [DATE], the facility did not begin investigating until [DATE]. RN D stated that she was asked to write her statement on [DATE] because she had discussed the situation with another nurse who probably mentioned it to the DON. Surveyor interviewed CNA C on [DATE] at 6:32 a.m., who stated that Resident #4 often asked p.m. staff if CNA B was working that night, and that he would get anxious if they told him that she would be working. CNA C stated that CNA B "has lost her [MEDICATION NAME]. When he made that comment about (Resident #16) - (that she wished he had a stroke and it would kill him), she said that right after she knew that my grandpa just died of a stroke. Pretty heartless...she was permanently burned out - she complained about everything." CNA C stated to Surveyor and Surveyor at 6:50 a.m. that Resident #4 does sometimes say inappropriate things to the young CNAs, and that Social Worker A has given the CNAs a list of appropriate things to say to Resident #4 when he acts inappropriately. Surveyor asked CNA C if CNA B was ever sent home when she mistreated Resident #4, and CNA C stated, "I never knew that they should - I would be the only one left on the floor then." Surveyor asked RN D in an interview on [DATE] at 6:25 a.m. if she ever considered sending CNA C home when she was acting out, and RN D stated, "I was in a bind, having less staff (one nurse and 2 aides for 40 - 50 residents) - it put me in a sore spot - I am the Manager at night, but if I send someone home then that just leaves 2 of us to care for all the residents. We all work together at night, and I didn't know I could send her home." Surveyor asked why she sent an e mail to the DON vs calling her and the Nursing Home Administrator (NHA). RN D stated that she had read something that was in her mail box, and knows now that she should have called. She stated that no one ever interviewed her about the details of the incidents; she was just asked to write a statement, which was dated [DATE]. Surveyor asked RN D if she had abuse prevention training when she was hired, and RN D stated that she could not remember. Surveyor asked RN D if she perhaps signed a form stating that she would not abuse residents and report abuse immediately, and RN D stated that she did not remember signing anything like that. Surveyor reviewed RN D's personnel file on [DATE], which contains a page entitled, "UNDERSTANDING OF RESIDENT/CLIENT RIGHTS" and is dated on RN D's date of hire, [DATE]. It was also signed by an instructor. This statement has all boxes checked by RN D which state the following: -I will not abuse any resident/client either emotionally, mentally or physically. -I will not make use of unusual force in restraining or controlling any resident/client. -I will report immediately, to my Supervisor, any mistreatment of [REDACTED]. -I will promptly report any accidents and/or incidents to residents/clients, visitors or myself, regardless of how minor. The above statement was also signed by CNA C in her personnel file, dated [DATE]. No instructor signed CNA C's form. There was no similar form found in CNA B's personnel file. Surveyor asked RN D in the above interview if CNA B was alone with residents after the above incident (on [DATE]), and RN D stated yes; that CNA B was getting her list of residents up for the day before going home. She worked the rest of her shift before going home. The DON was on vacation during the first week of the survey. The facility did not self-report the above concerns to the Office of Caregiver Quality (OCQ) as required. Surveyors and Surveyor interviewed the NHA on [DATE] at 3:35 p.m. and questioned why. The NHA stated that he was not really involved in the investigation, that he had the DON and SW A take care of it. He stated that ultimately he made the decision to not self-report, because his association has informed facilities that 80% of all self-reports result in citations. He also stated that in the past, the OCQ does not always choose to investigate the CNAs named in the self-reports. Surveyor stated that the OCQ makes those decisions, but that the facility is still responsible for following regulations regarding preventing and reporting allegations of abuse and protecting residents. Surveyor and Surveyor interviewed Social Worker (SW) A on [DATE] at 7:45 a.m. SW A stated that she was unaware of any concerns about Resident #4 and CNA B until the DON informed her, after the e mail was sent by RN D. SW A stated that she interviewed CNA C as part of the investigation. She stated she was not sure if she had interviewed RN D, perhaps the DON had called her and asked her to write a statement, and that perhaps she (SW A) was present during that call, but that she could not say for sure. SW A stated that she had just started at the beginning of April, and that at her previous job she was not the Director of Social Services, and had never done an investigation like this before. She stated that she did not interview any p.m. staff, or any other night staff who worked with CNA B. She stated that the NHA told her yesterday that the facility should have self-reported the incident. She stated, "I'm still learning about what needs to be self-reported." Surveyors and interviewed the NHA on [DATE] at 9:40 a.m. The NHA looked at a copy of the investigation and stated, "This is gut-wrenching, nobody should have to go through this. Was this truly reported before. I feel we took appropriate action on [DATE]. They get training at least 2 times a year, it's frustrating - they're told to report, and they don't report like they should." Surveyor asked why the facility did not self-report this investigation. The NHA stated that there is a risk when you self-report, and that data says that you are likely to get a cite from self-reporting. "But we will re-evaluate our reporting right away." Surveyor mentioned the need for protecting residents. The NHA stated he is worried that when one CNA leaves on the night shift, that only leaves one nurse and a CNA to care for the residents. Surveyor stated that this is why it is important to call the NHA and DON (vs. email), so that the DON can come to the facility to help, or call someone else in to help care for the residents. Surveyor encouraged the NHA to provide any other information pertaining to this investigation. The NHA stated to Surveyor at 11:30 a.m. on [DATE] that he would now complete a self-report to the Office of Caregiver Quality. SW A and Director of Business Management E were also present. Surveyor noted that the investigation's first page states that the NHA, DON and SW A were notified of the allegations on [DATE] at 8:00 a.m. According to the dates on the investigation, interviews did not take place until [DATE]. SW A could not recall why the investigation did not take place immediately. Surveyor interviewed several p.m. staff on [DATE], as follows: CNA F, 4:15 p.m. - CNA F stated to Surveyor that she is a more quiet person, and CNA B is loud, and "seemed rushed." Surveyor asked if Resident #4 asked CNA F if CNA B would be working the next shift. CNA F stated, "Oh yes - he did not like her at all - she's [MEDICATION NAME] and to the point with him. He sometimes likes to touch staff, and she'd tell him that's not going to happen, but was rude about it. He would ask me if the b-word was working tonight. If she was, well, he didn't like it. He'd say, 'I'm not going to get any help tonight.' I'd assure him that yes, she will help you. He was sarcastic, but he's a lot happier now that she's not here anymore...she's been disrespectful for months and it was worse the last few weeks. Not so bad when I first started here last May." Surveyor asked CNA F what she would do if another CNA looks like she's having a bad day, and how she would intervene before they snapped and did or said something unkind. CNA F stated, "I would tell them you need to talk to someone." Surveyor asked CNA F if she would report this, and CNA F said, "I'm not sure I'd tell someone unless I think they'll hurt someone." Surveyor asked CNA F if she has seen burnout at the facility, and she stated, "Oh I've seen a lot of that - I wonder, 'Why did you pick up 10 days in a row? ...so others get crabby if they work too much. One resident likes to tell dirty jokes, and they'll say, 'Really! That's disgusting! Don't say that!' to the resident. I have reported things (to the nurses) before but nothing ever gets done. Maybe a resident is irritable and they'll brush it off and say oh that's just their behavior and they don't go and check on them. Two months ago we were working short and a lot of people were quitting, and we were mandated to work." Surveyor asked if the facility has CNA meetings where these things can be discussed, and she said, "Yes but I have only gone to 2 of them, because they just turn into a [***] fest; everyone gripes about each other; the pm shift complains about the day shift, and the day shift is mad at nights, and the night shift hates the pm shift. And nothing changes." Surveyor interviewed CNA L on [DATE] at 4:40 p.m. CNA L said she did not witness any altercations between Resident #4 and CNA B. She said she had just heard rumors/murmurs, and does not like to repeat gossip. Surveyor interviewed CNA O on [DATE] at 4:45 p.m., who stated that when CNA O would answer Resident #4's call light, "there was bitterness, so I'd take over and she'd leave the room. When (CNA B) would walk into (Resident #4)'s room, he'd say, "Oh, it's you." CNA O stated that CNA B "didn't have a chance (to mistreat Resident #4) with me because I'd sense the tension and tell her to leave and I'd take over his care." Surveyor asked if she had reported this to the nurses, and CNA O stated, "It was talked about in report. They all knew. I kept an eye on it, and did my part, that was that and I'd go about my business, and take care of the rest." CNA O also said, "If I heard her (CNA B) muttering, I didn't pay any attention. But I could see it with (Resident #4). He's fairly with it, and would joke with us. His whole face would change if she'd walk in. He's say, 'Oh it's you' so I'd ask her to leave to make it easier for him. I would let the nurse know, and they'd say, 'Yes I know and blah blah blah.' I figured it was their job to let social services know, and it's not my place to follow up. They didn't tell us to not let her take care of him. It was sad to see how his face changed when she'd walk in." Surveyor interviewed CNA J on [DATE] at 4:55 p.m. He verified that Resident #4 once asked him, "Is that old hag working tonight?" He talked about not liking the CNA on the night shift with the gray hair. He stated that this started occurring about 6 months ago, but he didn't think anything of it because everyone picks their favorites. Surveyor interviewed CNA K on [DATE] at 5:00 p.m. CNA K stated that she never saw CNA B work with Resident #4, and never worked a shift with CNA B, but that she did hear Resident #4 ask about that old lady on the night shift; he would say he didn't like her, and he made it very clear that he did not want her in his room. (This was not identified on his care plan.) "We told him that the rest of us would care for him." Surveyor asked CNA K if she reported this concern to the nurses, and CNA K stated, "The nurses all knew about it." CNA K stated, "Someone told me she was mean to him, really rude to him. They explained it to me when we left his room. It was kind of a big thing. Everyone knew about it - they all knew. I didn't know if she was told to not go into his room." CNA K stated that she had only worked at the facility for 3 months, and did not see CNA B very much. She stated, "I'd come in to do a second half of a shift when she was leaving. Other aides would tell her that they will take care of him." Surveyor asked CNA K if anyone told the Director of Nursing (DON). CNA K stated she did not know. CNA K then stated, "We're always told to report, report, report. I had an issue a day or so ago when a resident had a rash, and we've reported it but it was getting worse. My partner (CNA L) went to tell the nurse (LPN Q) and the nurse gave her the worst attitude - she said something (angrily) like, 'Do you want me to pass my meds, or fax this to the doctor, or give this lady her [MEDICATION NAME], or come and look at her bottom?' My partner was stunned; she told her well, she's on the toilet now, so maybe you could come now. CNA K stated that usually when we tell the nurses someone has a sore or red bottom, they say, 'Yeah, I'll look at it' and they don't. In [AGE] years of working as a CNA I've never seen it this bad. We CNAs work with the residents way more, and when we report behaviors they say, "He's that way all the time." And I think, "No he isn't; this is different." "You just get that attitude. You want to just stay away from LPN Q - it's that bad. If she's working one hall I hope I'm on the other. She makes you feel like you're this big (indicating about a half an inch with her thumb and forefinger); like you're nothing; you're just a CNA. People are afraid to open their mouths here, because they'll lose friends, and because of how they'll treat you afterward. We need an inservice for the nurses - on how to treat co-workers. My biggest peeve at this job is we're made to feel dumb for reporting, and balled out if we don't report." Surveyor re-interviewed CNA L on [DATE] at 5:30 p.m. regarding LPN Q. CNA L stated, "I think she was just busy, and I tried not to make a big deal about it. It's just her personality. She's just a [MEDICATION NAME] person." Surveyor asked CNA L if LPN Q has acted like that around residents, and CNA L stated, "I don't remember." Surveyor asked if she reported RN Q's demeanor to another nurse, and CNA L stated, "I don't think so." Surveyor asked if anyone had interviewed her about the concerns between CNA B and Resident #4, and CNA L stated, "No; no one has." Surveyor interviewed CNA M on [DATE] at 5:20 p.m. CNA M stated that she did not know CNA B very well, and didn't work with her because CNA M works in rehab and is done by 9:00 p.m., and CNA B mostly worked night shift, which starts later. Surveyor asked CNA M if she knew of any concerns between CNA B and Resident #4. CNA B said, "Yes, when I worked the floor he'd ask if (CNA B) was working, and he said that he didn't want her in his room. He didn't like her because she was mean to him. He especially started mentioning it about a month before she left. He told me to not let her in here if she would answer his light. I did tell the nurses; it didn't sit right. Everyone knew that the 2 of them clashed." Surveyor asked if someone had told the DON about the concern, and CNA M stated, "I don't know if anything was done, and I don't know if she knew...This is the residents' home and they needed to be treated with respect. He didn't want her in his room...(CNA B) was a big personality...Everyone was aware that the two of them didn't get along - but the supervisors might not have known." The facility's failure to promptly report allegations of abuse to the administrator, to promptly and thoroughly investigate allegations of abuse, to prevent further possible abuse while an investigation was in progress, and to immediately report allegations of abuse to the Office of Caregiver Quality allowed abuse against Resident #4 to continue and to escalate, creating a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] by which time the facility had began retraining all staff on abuse reporting. All staff were to be retrained prior to working there next shift.

Based on review of facility investigation, interview, policy review and medical record review, the facility did not prevent abuse from occurring for 1 of 11 sampled residents. Resident #4 was handled roughly and verbally abused on several occasions, over several months, by a Certified Nursing Assistant. This caused Resident #4 to dread the nights that this CNA was working. The facility: -Did not prevent the abuse -Did not take steps to prevent further potential abuse when the abuse was first reported (which enabled the behaviors to escalate) -Did not immediately protect residents when the CNA spoke derogatorily about residents and had a history of [REDACTED]. -Did not initiate deliberate observations of the CNA's treatment of [REDACTED]. -Did not interview all staff who worked with the CNA -Did not retrain all staff after the abuse was discovered -Did not immediately notify the Nursing Home Administrator (NHA) of the abuse -Did not self-report the abuse to the Office of Caregiver Quality These deficient practices resulted in an Immediate Jeopardy. The Immediate Jeopardy began on or about [DATE] when the night nurse sent an e mail to the Director of Nursing (DON) notifying her of her concerns with CNA B. No investigation was initiated at that time. This CNA was allowed to continue to work, and incidents escalated in frequency and intensity. On [DATE], the night nurse sent another e mail to the DON, but an investigation did not begin until [DATE], and the Immediate Jeopardy was removed on that date, when CNA B was removed from employment. The deficient practice continues at a scope/severity level of E (potential for harm/pattern) because not all staff have been adequately re-trained in abuse prevention and reporting and protection of residents. This is evidenced by: Resident #4's medical record states that he has [DIAGNOSES REDACTED]. Physician's notes dictated on [DATE] and [DATE] describe him as a "very pleasant" male resident. His BIMS score is 13 out of 15, indicating very mild dementia. Resident #4's care plan states that he "sometimes makes inappropriate sexual comments to female staff. He has also attempted to grab female staff inappropriately." Approaches for this concern include: -Change topic of conversation. Talk about past events. -Re approach. Use different caregiver as needed. -Allow time to calm down, reapproach him. -Maintain safe body stance/distance. -Remind of appropriate interactions with staff members. The facility is staffed with 1 nurse and 2 CNAs on the night shift. The CNAs have the potential to have contact with all 41 residents who live there. On [DATE], Surveyor requested to review the facility's complaint file. Social Worker (SW) A provided an investigation regarding Resident #4's complaint of how CNA B treats him. The investigation contained an e mail to the Director of Nursing (DON) written by Registered Nurse (RN) D, which states, "On NOC (night) shift I am continuing to experience problems with (CNA B's name) and (Resident #4's name). (Resident #4) does not like her because she is rude and inappropriate to him. She doesn't like him because he requests to 'send in someone else' ...when she comes in to help him because she is rude and inappropriate to him. When he requests other help, she gets more upset. At times, I or another CNA will be in his room and she will enter, when no help is requested, and make comments to taunt him, like she only entered to start some trouble. I have had numerous talks with her about this. I have apologized to him on behalf of her, etc ...asked her to make a truce with him, etc. She became very upset on NOC shift last night when I took the resident's side of the issue. I could explain better in person. And am running out of room to type ...I can't see past this line and it doesn't scroll down. So let me know if you have any more questions. Thanks You. (RN D's name) (SOrry for any typos. I can't see!)" There is no documentation that shows that this e mail was responded to on [DATE]; however, the front page of the investigation indicates that the NHA, DON, and the SW were aware of the e mail on [DATE] at 8:00 a.m. An investigation was not begun until [DATE], when a nurse, in whom RN D confided about the details of the following events, mentioned it to a manager (unknown) on the day shift. Cross reference F 225 L. CNA C, who has worked the night shift with CNA B and RN D, wrote the following statement dated [DATE]. "The first time I reported to nurse (RN D) that (CNA B) was making inappropriate comments to (Resident #4), (CNA B) was putting (Resident #4's) shirt on and she was putting in (it) on awkward and (Resident #4) asked, 'Why are you doing it like that?' (CNA B)'s response to (Resident #4), 'If you are going to act like a baby, I am going to treat you like a baby.' "I have also witnessed (CNA B) making comments about (Resident #4) that are negative. She is short with him when speaking and rough with cares. Outside of (Resident #4)'s room, she often makes comments about him like he is an[***] , or a pervert." "(CNA B) has told me that he reminds her of her ex-husband." "(CNA B) has told me she comes in the room with me to protect me from him even though I don't ask her to or feel like I need protection from (Resident #4). I feel like she is doing it to find a reason to taunt him. Even if he puts his hand on my knee, she yells at him, and he isn't being inappropriate in any way." "(CNA B) came in the room the other night ([DATE], 3 - 4 a.m.) while (Resident #4's) penis was exposed and said, 'cover that up, no one wants to see that shriveled up old thing, makes me puke.' (Followed by making gagging noises)." A hand-written note then states, "-at 5 am, (Resident #4) told (CNA C) that he's glad (CNA B) didn't come back in." (Note, that CNA B did come into his room after being told to stay out.) "(CNA B) refuses to help put (Resident #4) on the toilet at night because according to her he only farts and we don't have time for that." "When (Resident #4) needs help sitting up, she will say, 'if you can't sit up by yourself I'm not going to help you. I'm not breaking my back for you.'" "Every night I work, (Resident #4) says, 'Who are you working with, I hope not that old [***] .' 'She is mean to me.' One night he asked me if (the NHA's name) was here and said, 'you know why.' (referring to CNA B) I asked (Resident #4) if he had said anything to (the NHA) about it and he said, 'I would need someone to push me down there.'" "The other night ([DATE], 11 p.m. - 12), (Resident #16) in room [ROOM NUMBER] had a numb arm and (CNA B) told me, 'good, maybe he is having another stroke and I hope this one kills him.'" "Numerous times that (CNA B) has said inappropriate things to various residents that have made me uncomfortable." A hand-written note at the bottom of this statement signed by SW A states, "addition from verbal interview [DATE] at 7 AM (CNA B)'s behaviors have really gotten bad last 2 - 3 weeks, but it seems there's always been some concerns & problems. Says (CNA B) can be short with all residents, but never heard her say things in front of other residents. Says things about other staff/that are inappropriate while in the halls, etc." Surveyor interviewed CNA C on [DATE] at 6:32 a.m., who confirmed the contents of the above statement. She stated that her first concern regarding CNA B putting on Resident #4's shirt, and saying, "If you're going to act like a baby I'm going to treat you like a baby" was said because Resident #4 prefered to put his shirts on one arm at a time. CNA B always put both arms in together, then pulled shirts over residents' heads. Survyeor asked CNA C how CNA B said the above statement, whether it was in a joking manner, etc. CNA C stated that no, it was said with an "overpowering attitude." After CNA C reported this concern to RN D, RN D sent an e mail to the Director of Nursing (DON). RN D stated in an interview which started at 6:25 a.m. on [DATE], and continued when CNA C entered the room, that she expected to hear back from the DON who would ask for more information, but the DON never contacted her, and no management staff came in on the night shift to watch CNA C's care of residents. Surveyor questioned CNA C about the time that Resident #4 mentioned to her that he might talk to the NHA about his concerns. Surveyor asked CNA C if she assisted to take Resident #4 to talk to the NHA, and CNA C stated, "No, because he (the NHA) doesn't get here before I leave in the morning." Surveyor asked CNA C if she told anyone on the day shift that Resident #4 wanted to talk to the NHA, and she said, "No." RN D also typed a statement dated [DATE], which states the following: "CNA (B) asked nurse into room (#) to assess a possible leaking catheter. Nurse entered room and began to assess catheter patency and function. During assessment (CNA B) entered room. Upon (CNA B) entering room, resident's genitalia was exposed d/t (due to) catheter inspection. (CNA B) stated words to the effect of, 'cover up that shriveled up old thing, nobody wants to see that wrinkly old thing, makes me want to puke.' - referring to resident's genitals." "Nurse spoke with (CNA B) re: (regarding) inappropriate/verbal abuse. (This is not the first time nurse has addressed this issue with this CNA.) Nurse has asked CNA not to enter resident room for cares if there is someone else available to meet his needs d/t the resident and CNA having verbal disagreements in past and during NOC shifts; stating that someone else will provide his cares if possible to decrease tention (sic - spelling incorrect) and incidents. CNA has continued to answer resident call light without alerting nurse or other CNA staff to help or at least to accompany her in room. CNA is noted to enter room when resident cares are being provided by one or more staff members, upon entering room, many times (CNA B) has been noted to speak down to patient or make demeaning comments. (CNA B) has stated that she feels the need to be in the room to protect young female staff from resident because (CNA B) per her verbal statements, believes resident is an 'Old pervert'. (CNA B) has been noted to demand resident keep his 'filthy hands' to himself; when resident is not acting inappropriately physically or verbally. (CNA B) has been noted to refer to resident as an 'Asshole' on various occasions outside of resident's room." "Nurse again on [DATE] discussed with (CNA B) the inappropriateness of her verbalizations to resident. CNA was asked again to not enter room of this resident because her actions/words are unacceptable. Nurse asked CNA to either not interact with patient or to apologize for her actions/words to the resident and call a 'truce' in order to have a healthy working relationship with this resident. (CNA B) responed (sic), 'What I should do is punch him in the face.'" "Approx (approximately) 30 minutes later, (CNA B) was noted to enter room when nurse and CNA (C) were providing cares. (CNA B) began verbally demanding resident to lean forward so she could fix his shirt in the back, (which nurse was doing when (CNA B) entered, and (CNA B) intervened and simply began to 'help'. Resident stated after several demands to sit forward, 'What do you want me to do put my chin to my knees?' (CNA B) stated, 'You couldn't get your chin to your knees if you tried.' Nurse stated to (CNA B) that her actions/words were inappropriate, (CNA B) stated, 'I'm done.' And left the room. (CNA B) began 'banging' things around in the hallway (expressing discontent). (CNA C) later told nurse that (CNA B) stated to (CNA C), 'I am not going to let her belittle me in front of him. Fine I won't go in there anymore and I will let him stick his fingers up her crotch and say he is going to kiss her all over her body.'" "Note, resident refers to (CNA C) as 'the old [***] ', not to her face but to other staff members when speaking of her. Many staff members will/could be witness to resident asking on PM shift who is working tonight because he does not look forward to nights when (CNA B) is working d/t verbal abuse and negative interactions." "Nurse has emailed DON in the past alerting that inappropriate comments were being made, reported by (CNA C) to nurse and witnessed by nurse. This is the second report made to DON, after various attempts to resolve the situation with (CNA B)." "In addition, CNA (C) brought to nurse's attention that on ,[DATE] - [DATE] NOC, resident in room (Resident # 16) was experiencing right arm numbness. (CNA B) verbalized to (CNA C), 'Good, I hope he has another stroke and it kills him." In the above interview with RN D, she stated to Surveyor that whenever she would pull into the facility parking lot and see CNA C's truck, she would get sick to her stomach. She stated, "If her name was Nancy, I'd call her Negative Nancy" because she was always negative about everything. Surveyor asked RN D and CNA C if there were any other examples of how Resident #4 was treated by CNA B. They confirmed that once, (they could not remember exactly when), RN D told CNA B that Resident #4 would be receiving a rectal suppository that morning, and CNA B stated, in front of a new CNA in training, "You should let me give it to him; I'll stick it in a gun and shoot it up his ass." This statement was not in the above investigation, and the NHA was not aware of it until Surveyor informed him of it on [DATE]. RN D and CNA C told Surveyor the following additional concerns: -It was kind of an ongoing thing where CNA B would make comments about Resident #4 when she left his room, and RN D would always try to redirect her/remind her about respecting residents, but she continued. -CNA B was told on many occasions that she should stay out of Resident #4's room by RN D, but CNA B did not listen, and still pushed her way into his room and there was a tension between her and Resident #4, described as a "very heated relationship." She would walk into his room, and Resident #4 would say, "Oh there's that [***] again" and she would say rude things back to him, and have an attitude. -When Resident #4 would activate his call light when he needed the bedpan, CNA C would answer it, and then CNA B would come storming in and take over, even though he had said on many occasions that he did not want her in his room. RN D stated that she had told CNA C that she had "intimidating behaviors which are not acceptable." -CNA B had worked at the facility since [DATE], (according to her personnel file.) CNA C has worked at the facility for approximately 2 years. CNA B was "OK" to work with at first but for the last few months she was getting more and more difficult to work with. She could be very nice to some of the residents. Surveyor asked if CNA B was ever alone with residents who could not speak up and report mistreatment, and RN D and CNA C stated that it was unavoidable, since there is only 3 caregivers on the night shift. They stated that a while back, CNA B was "burned out from working here" and went to work at the other nursing home in town, staying on in a casual position. However she could not get enough hours, so she returned to the facility, and worked part time on the night shift, and sometimes picked up extra shifts on the p.m. shift. CNA C stated that little things would set CNA B off, such as too many blankets on a resident's bed. -CNA C stated that CNA B felt she needed to protect the young CNAs from Resident #4, as he had behaviors of sometimes touching them inappropriately. CNA C stated that she is an adult and can take care of herself, and most of the time Resident #4 doesn't mean anything when he pats her upper back, but if CNA C saw that, she'd yell, "Keep your filthy hands to yourself!" -RN D and CNA C stated that on [DATE] between 3:00 and 4:00 a.m., Resident #4 stated that he thought his supra-pubic catheter was leaking, and the two of them were in his room while RN D was assessing his catheter. The covers were pulled back, and CNA B entered the room and said the above statement about Resident #4's penis and made gagging sounds. RN B told CNA B to leave the room, and later told her to not return to his room if she could not apologize to him and call a truce. CNA B stated, "What I should do is punch him in the face." RN D stated that approximately 30 minutes later, when she and CNA C were getting Resident #4 dressed for the day and tucking in his shirt, CNA B then barged into the room, "hip-checked me" by using her hip to push RN D out of the way, and started to forcefully push his shirt into the back of his pants with her hands. She stated, as written above, "Resident stated after several demands (from CNA B) to sit forward, 'What do you want me to do put my chin to my knees?' (CNA B) stated, 'You couldn't get your chin to your knees if you tried.' Nurse stated to (CNA B) that her actions/words were inappropriate, (CNA B) stated, 'I'm done.' And left the room. (CNA B) began 'banging' things around in the hallway (expressing discontent). (CNA C) later told nurse that (CNA B) stated to (CNA C), 'I am not going to let her belittle me in front of him. Fine I won't go in there anymore and I will let him stick his fingers up her crotch and say he is going to kiss her all over her body.' RN D stated to Surveyor that she told CNA B, "Leave the room. Now" and CNA B left the room and was banging water pitchers that were on the cart in the hall. Surveyor asked RN D if she ever considered sending CNA C home when she was acting out, and RN D stated, "I was in a bind, having less staff (one nurse and 2 aides for 40 - 50 residents) - it put me in a sore spot - I am the Manager at night, but if I send someone home then that just leaves 2 of us to care for all the residents. We all work together at night, and I didn't know I could send her home." Surveyor asked why she sent an e mail to the DON vs calling her and the Nursing Home Administrator (NHA). RN D stated that she had read something that was in her mail box, and knows now that she should have called. She stated that no one ever interviewed her about the details of the incidents; she was just asked to write a statement, which was dated [DATE]. Surveyor asked RN D if CNA B was alone with residents on the morning of [DATE] after the above incident, and RN D stated yes, she was getting her list of residents up for the day before going home. As stated in the above statements, Resident #4 would ask on the p.m. shift if CNA B was working, referring to her as "that old [***] ". Several CNAs were interviewed on the p.m. shift by Surveyor , who confirmed this. Cross reference F 225. There are no other interviews with p.m. shift caregivers or other staff documented in the facility's investigation. SW A interviewed Resident #4 on [DATE], and wrote the following statement: "(Resident #4) states that 2 nights ago, there was a female staff, wearing glasses, that is always 'mouthy' and 'smart' with him. 2 nights ago was the last time she worked. He doesn't recall specifics, but states that she is always mouthy to him, even if other staff are present. He states that she doesn't call him names, but is inappropriate with her tone and comments. He cannot recall specific comments. He states that there is only verbal, not physical. He states that it has gotten worse lately. He states that he has requested a couple times that this aide not work with him, but she always does anyway. He states that he has talked to another resident (Resident #16) (male) about his concerns, and that (Resident #16) also the concerns with this staff. (Resident #4) again was asked if he can recall any details of the negative interactions, and he said that he cannot remember details, just that she is mouthy and smart with him." Documentation reviewed indicated that SW A interviewed Resident #16 on [DATE] at 10 am. "(Resident #16) states that he has no issues with any staff here that he wants to share with us. He says that the night staff are good. He states that he has never witnessed inappropriate behaviors or overheard inappropriate comments from a staff, but that (Resident #4) has complained about a staff member before, but he doesn't remember which staff member or details." Surveyor interviewed Resident #4 on [DATE] at 5:05 p.m. Resident #4 was pleasant and alert. Resident #4 stated that he was a little sad today because one of his sons died . Surveyor asked if he remembered anything about a CNA who did not treat him well. He said, "Yes, but they got rid of her." He asked if CNA B was working somewhere else, doing the same thing there. He stated that he knows the NHA "very well" and that he stopped in one day, but that he has never talked to him about his concerns with CNA B. Resident #4 could not remember details of what CNA B said and did, but he remembered that he was always angry with her, and that she was "mean and rough". He stated that he dreaded the nights when she would be working. Other CNAs confirmed Resident #4's reaction to hearing that CNA B was working. Surveyor asked CNA F on [DATE] at 4:15 p.m. if Resident #4 ever asked CNA F if CNA B would be working the next shift. CNA F stated, "Oh yes - he did not like her at all - she's [MEDICATION NAME] and to the point with him. He sometimes likes to touch staff, and she'd tell him that's not going to happen, but was rude about it. He would ask me if the b-word was working tonight. If she was, well, he didn't like it. He'd say, 'I'm not going to get any help tonight.' I'd assure him that yes, she will help you. He was sarcastic, but he's a lot happier now that she's not here anymore...she's been disrespectful for months and it was worse the last few weeks. Not so bad when I first started here last May." Surveyor interviewed CNA J on [DATE] at 4:55 p.m. He verified that Resident #4 once asked him, "Is that old hag working tonight?" He talked about not liking the CNA on the night shift with the gray hair. He stated that this started occurring about 6 months ago..." Surveyor interviewed CNA M on [DATE] at 5:20 p.m. Surveyor asked CNA M if she knew of any concerns between CNA B and Resident #4. CNA B said, "Yes, when I worked the floor he'd ask if (CNA B) was working, and he said that he didn't want her in his room. He didn't like her because she was mean to him. He especially started mentioning it about a month before she left. He told me to not let her in here if she would answer his light. I did tell the nurses; it didn't sit right. Everyone knew that the 2 of them clashed." CNA M also stated, "This is the residents' home and they needed to be treated with respect. He didn't want her in his room...(CNA B) was a big personality...Everyone was aware that the two of them didn't get along..." In addition to causing Resident #4 to dread the nights when CNA B would be working, the failure to prevent abuse created the potential for other effects. According to a 2011 doctoral dissertation, Not Just a Playground Issue: Bullying Among Older Adults and the Effects on Their Physical Health, "Current victimization was also associated with current psychological problems in senior adults. In particular, being bullied was associated with being anxious/depressed, worrying more frequently, and being more irritable/disorganized." <http://dspace.uta.edu/bitstream/handle/,[DATE]/REXLEAR_uta_2502D_ .pdf?sequence=1> The findings in this dissertation are consistent with Maslow's hierarchy of needs, where safety/security are in the second lowest level of needs: If a person does not feel safe, growth becomes a secondary factor as safety needs dominate and residents are unable to attain/maintain their highest practicable level of well-being. Abused individuals can see the world as an unstable, frightening and dangerous place, which can undermine their sense of self-worth and their ability to cope with and adapt to their environment. This is particularly true when the resident - as in this case - cannot stop the abuse and sees that others will not intervene or even assist him in filing a complaint with the administrator. Abuse by staff is particularly egregious because residents can view staff as power figures since they are dependent on them for meeting their basic needs. "The role difference between expert and client ... results in vulnerability on the part of the client." The subsequent effect that the misuse of this power can have on those being cared for is consistent with the bullet for severity level 4 in the psychosocial guidelines of "Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation." The facility removed the immediate jeopardy on [DATE] when the administrator removed CNA-B from employment and eventually fired her.

Based on medical record reviews, policy review, observation, and interview, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers, and a resident who has had a history of [REDACTED].#2, #10, #9, #7). Resident #2 has resided in the facility since 2010. Resident #2 developed a pressure ulcer in the facility on the right ischial tuberosity on 05/03/13. The ulcer progressed to a stage III pressure ulcer. The care plan did not include updated interventions for repositioning until 08/09/13. The Braden skin assessments were not completed since 04/11/13. Daily inspection of skin by licensed nursing staff was not completed. Resident #2 developed an infection in the ischeal ulcer. The care plan was not followed when observation by surveyor. Wound care observations for Resident #2 showed poor infection control measures during the dressing change. Resident #10 resided in the facility less than 2 weeks when skin breakdown was observed on his sacral area. The ulcer progressed to a stage III ulcer, and became black with eschar requiring debridement on 08/07/13, resulting in the ulcer being unstageable on this date. The care plan was not updated with any new interventions to prevent pressure on Resident #10's buttocks while sitting in a rental electric wheelchair until 07/31/13 , nor was the repositioning schedule changed once the ulcer developed until 08/09/13. Resident #7 has recurrent pressure ulcers on her left ankle. Once skin problems developed, the facility did not revise the care plan, did not implement new measures to prevent the pressure ulcer from worsening. The facility did not identify types of interventions used when Resident #7 refuses to wear protective boots in bed or the type of mattress Resident #7 had on her bed. Resident #7 has recurrent infections in the wound the most recent on 07/22/13. A dressing change was not performed using aseptic technique. Resident #9 developed a pressure ulcer. The facility did not identify or implement interventions. This is evidenced by: The facility policy and procedure for the prevention and treatment of [REDACTED]. Procedure: I. Prevention of pressure ulcers A. Braden scale and Comprehensive Risk Data Collection form (which includes a skin audit) will be done: -Upon admission -Weekly, the first 4 weeks post admission -quarterly, and -With a change in status (i.e. pressure ulcer development...) A. Turning and Repositioning Observation (tissue tolerance) Pressure is the primary cause of pressure ulcers. An effective turning and repositioning schedule can help reduce the risk of developing a pressure ulcer. Everyone's tissue tolerance (the ability of the skin and its supporting structures to endure the effects of pressure without breakdown) is different. Therefore it is important to individualize each resident's turning and repositioning schedule. For those residents that are immobile, or need assistance with mobility, complete a turning and repositioning (tissue tolerance) Observation form ... -upon admission -Re-admission -With a change of condition (including the development of a pressure ulcer or change in mobility status) -Annually -In both the lying and sitting position B. Monitoring of Skin Integrity -skin will be observed daily by the nursing assistant. -weekly skin audits on the bath/shower day will be performed by the Licensed Nurse -The care plan for skin integrity is to be evaluated and revised based on response, outcomes, and needs of the resident. II. treatment of [REDACTED]. If a resident is admitted with or there is a New development of a pressure ulcer...the following procedure is to be implemented: 6. Reevaluate turning and repositioning intervals; initiate a new turning and repositioning observation form. 7. Initiate Braden Scale and Comprehensive risk data collection form. 8. Reevaluate interventions per risk factors identified. 9. Update the Care plan for skin integrity and nursing assistant cards with skin concern, appropriate risk factors, turning intervals and interventions appropriate. 10. Initiate Weekly Wound Documentation Progress Sheet... 11. When a pressure ulcer is present, daily wound monitoring should include: -an evaluation of the ulcer -an evaluation of the status of the dressing -The status of the area surrounding the ulcer -The presence of possible complications -whether pain is present III. Resident Choice ...The facility will address the resident's concerns and offer relevant alternatives if the resident as refused treatments/interventions. This will be documented in the resident's medical record or_______(fill in location). Available in the forms section is a Refusal of skin care Interventions Risk and Benefit Policy and Procedure and a Refusal of Skin Care Interventions Risk and Benefit form that can be utilized for refusal of care. Example 1 Resident #2's annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/26/12 identifies that Resident #2 is at risk for pressure ulcers, and has a pressure reducing device for chair and bed, and a turning and repositioning program in place. There are no open areas identified on this MDS. The quarterly MDS with ARD of 06/26/13 identifies 1 stage III pressure ulcer. The Brief Interview for Mental Status (BIMS) reveals that Resident #2 has a score of 10, meaning there is moderate cognitive impairment. The MDS documents that Resident #2 needs extensive assist with transfers and personal hygiene needs. Resident #2 uses a hoyer lift for transfers and sits in a wheelchair when out of bed. The Care Area assessment dated [DATE] for pressure ulcers includes in part: [MEDICATION NAME] risk factors: altered mental status, incontinence frequently, extensive assistance for bed mobility, recent decline in activities of daily living, and functional limitation in range of motion. Analysis of findings: resident is at risk for skin breakdown and staff monitors her skin closely. Barrier cream is used as needed and repositioning approx every 2 hours. Will proceed to care plan. The care plan in place on 05/03/13 had a problem titled: At risk of pressure ulcer. Goal: Will remain free of skin breakdown over the next 90 days. Interventions: Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Perform nutritional screening...Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition. (No frequency for a repositioning schedule is identified.) Do not massage skin over pressure areas. Problem: Resident is at nutritional risk for wounds. Goals: Will receive adequate nutrition to aid in wound healing. Interventions: Perform national screening...Will receive [MEDICATION NAME] to promote wound healing according to dietician recommendations. The CNA care plan instructs under skin: Knee splint?, air mattress, Roho. A repositioning schedule or identification of the existing ulcer is not included. The care plan in place on 08/06/13 has the problem titled: Has pressure ulcer. (The location of the pressure ulcer is not identified.) Goal: Current pressure ulcer will resolve. Interventions: The only added intervention on 07/09/13 (2 months after the pressure ulcer developed) is: Check feet and legs for redness, skin tears, swelling...frequency 1 time daily starting 07/09/13. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no information on positioning for the rest of the day. The most recent Braden Assessment was completed on 04/11/13 with a score of 16, meaning Resident #2 is at risk for developing a pressure ulcer. Further Braden Assessments were not completed as indicated per the facility policy. The physician faxes include in part: 05/03/13- Open area to right buttock noted. 1 cm x 1.5 cm open area with yellow moist center, surrounded by pink tissue with superficial abrasion 0.2 x 0.3 cm. cleansed with NSS and [MEDICATION NAME] applied. Will change every 3 days... 05/20/13- PT eval and treat for wound, OK as above. Please check with nursing staff re: regarding referral to wound care at RCMC (Red Cedar Medical Clinic). 06/02/13 - May we perform debridement on wound? per Carol NP agreed to PT performing. 06/04/13- could we please have a recommendation and order for [MEDICATION NAME] gel to debride wound? doctors order: as above, [MEDICATION NAME] gel prn to debride wound. Wound consult notes: 05/21/13- reason for visit: debridement of wound findings: selective debridement of 75% slough, [MEDICATION NAME] ribbon packed into dressing (z strips) Allevyn gentle border applied over that. Diagnosis: [REDACTED]. 05/24/13- reason for visit: follow up wound debridement. Orders: change dressings Sunday unless saturated before then. Pack with [MEDICATION NAME] if available. 05/29/13- reason for visit: debridement Findings: 60 % granulation, 40 % slough, increased pain in surrounding tissue Temp- 100 degrees F. Diagnosis: [REDACTED]. Physician telephone order: 05/29/13- Bactrim DS 1 tablet every 12 hours po for 10 days skin infection. Wound Consult notes continue: 06/10/13- Findings: 1.4 cm. length x 1.3 cm width x 2.5 cm depth 50 % granulation 50% slough. Diagnosis: [REDACTED]. trauma reduction principles of decreased pressure and shear. Alternating pressure mattress would be helpful if available... Observation revealed that Resident #2 did have an alternating pressure mattress in place that was rated effective up to a stage 4 pressure ulcer. The non- pressure ulcer skin conditions form was competed weekly 05/03,05/10, 05/17, 05/20, and 05/31/13. The documentation each week identifies slough in the wound bed, but does not indicate the location of the wound. The weekly wound documentation progress sheet that identifies the wound as a pressure ulcer was started on 06/07/13. Stage III, 1.8 cm length x 1.6 cm width x 2.4 cm depth. Weekly measurements are completed on the progress sheet, documenting decrease in size through 07/05/13 1.1 cm in length, 1. cm width, x 1.2 cm depth, no undermining or tunneling is noted on 07/05/13. On 07/15/13 the wound is larger at 1.4 cm in length x 1 cm width with 1.7 cm of tunneling. The weekly measurements continue showing a decrease in size on 08/02/13 with 1.1 cm length x 1.0 cm width 1.2 cm depth with tunneling of 1.7 cm. The latest measurement on 08/09/13 is 0.9 cm length x 1.0 cm width x 1.2 cm depth with tunneling of 1.3 cm. The physical therapy notes include in weekly documentation starting on 05/22/13 with the initial evaluation including in part: Justification for skilled services: Pressure ulcer with need for modalities to increase circulation and positioning to prevent additional breakdown. 05/28/13-"...Patient states it is less tender but has increased pain when in chair for prolonged periods...patient and staff education on pressure relief...NAs (nursing assistants) are beginning to get resident in bed..." The weekly physical therapy notes continue through 08/02/13 with the same measurements as the wound progress sheets above. On 08/07/13 at 10:18 a.m. Surveyor observed Resident #2 lying in bed on her left side with her heels directly on the mattress. On 08/07/13 at 12:55 p.m. Surveyor observed Resident #2 sitting in her wheelchair with no foot pedal on the right side, wearing gripper socks only. The left heel was resting directly on the wheelchair pedal, and the right heel was resting directly on the floor. On 08/07/13 at 2:45 p.m. Surveyor observed Resident #2 in bed on her left side, with her heels directly on the mattress. On 08/07/13 at 4:00 p.m. Surveyor interviewed Certified Nursing Assistant (CNA) F and O regarding cares and repositioning for Resident #2. CNA F stated, "We have to keep her on her sides because of the pressure ulcer, so we try to reposition her every 2 hours." Surveyor asked if every 2 hour positioning is used for all residents. The CNAs indicated that this is their practice. On 08/08/13 at 8:00 a.m. Surveyor interviewed Registered Nurse (RN) I. RN I indicated that Resident #2 had intact skin and this area opened up really fast and deteriorated. Surveyor asked if the care plan instructs how often to reposition the resident. RN I stated, "No, it does not." Surveyor asked how often Resident #2 is repositioned when up in her chair. RN I stated, "every 2 hours." Surveyor asked if Resident #2's heels are at risk for breakdown. RN I stated, "Yes." Surveyor asked what standard of practice they use to treat pressure ulcers. RN I indicated she was not sure of the standard of practice. Surveyor asked if every 2 hour repositioning was being done, if anyone had assessed to see if Resident #2 had the tissue perfusion form filled out to determine if every two hours was enough. RN I stated, "No." Surveyor asked if there is documentation stating that this pressure ulcer was unavoidable. RN I stated, "No". On 08/08/13 at 2:40 p.m. Surveyor interviewed wound care certified RN G. RN G indicated she does all of the wound assessments and documentation for Resident #2. Surveyor asked what the policy is for doing Braden skin assessments, RN G was not sure. Surveyor asked what standard of practice they follow for pressure ulcers. RN G is not aware of the standard of practice. Surveyor asked how often Resident #2's skin was being inspected. RN G said the CNAs do a daily skin check with cares. There would be nothing else documented for skin assessments prior to the weekly skin assessments started on 05/03/13. Surveyor asked how they determine the repositioning needs of residents. RN G stated they reposition every 2 hours. Surveyor asked RN G if she was familiar with the facility policy to do a tissue tolerance observation for residents at risk for pressure ulcers. RN G said she has never heard of it or even seen such a form. On 08/12/13 at 6:40 a.m. Surveyor interviewed CNA AA, he indicated that a new positioning schedule had been started on 08/09/13 for Resident # 2. CNA AA said they reposition her every 1 hour and sign off on the form on the back of the door. Surveyor asked CNA AA what the schedule had been before. CNA AA stated it was every 2 hour repositioning. Surveyor had CNA AA pull back the covers to visualize the feet of Resident #2. Resident #2's left heel was directly on the mattress. Surveyor asked if Resident #2's heels were floated off the mattress. CNA AA stated, "No." Wound Care Observation On 08/07/13 at 10:18 a.m. Surveyor observed wound care for Resident #2, performed by RN G. RN G put a barrier down and took the wound care supplies from a wash basin and put them on it. RN G then pulled down Resident #2's pants and incontinent pad, and pushed it down under Resident #2. RN G then took off her gloves and put on new gloves, without washing or sanitizing her hands. RN G next took off the old dressing and discarded it, she remover her gloves and put new gloves on, without washing or sanitizing her hands. RN G reached into the supply bag with the contaminated gloved hands to get dressing supplies. Next RN G irrigated the wound with normal saline, dried the inside of the wound, and the peri wound. RN G again took her gloves off, did not wash or sanitize her hands and put new gloves on. RN G then soaked a 2 x 2 piece of collagen with normal saline, layed this piece in her gloved hand, and then packed it into the wound using a q tip. RN G then took her gloves off, put on new gloves without washing or sanitizing her hands, opened the gauze dressing and applied it over the wound. RN G took her gloves off, put on new gloves, applied lotion to Resident #2's buttocks, reapplied the incontinent pad, removed the chux under Resident #2, and then pulled up Resident #2's pants. RN G then took her gloves off, did not wash her hands, put the normal saline and the wound wash back in the basin that contained wound care supplies, and put on new gloves. On 08/08/13 at 10:00 a.m.Surveyor interviewed RN I, who was the person in charge of infection control in the absence of the Director of Nursing. RN I stated that hands are to be washed or sanitized any time gloves are removed. Surveyor did a telephone interview with the Director of Nusing on 08/15/13 to clarify the date Resident #2 had the air mattress started. The DON stated that the only thing she can be certain of is the date of 05/17/13, after the area opened up. Example 2 Resident #10 is a paraplegic of his lower extremities, he had a shoulder repair surgery in June, affecting his ability to use his left arm with a non weight bearing restriction for his left arm. Resident #10 is in the facility to rehabilitate post surgery. The admission MDS with ARD of 06/28/13 documents Resident #10 is alert and oriented and able to answer questions appropriately. He needs extensive assist with transfers and all activities of daily living. The documentation for skin reveals Resident #10 is at high risk for pressure ulcers, has no open skin, and has a pressure reducing device in bed and chair. There is no check in front of the turning/repositioning program. The Braden Assessment was completed one time on 06/22/13 with a score of 15, meaning that Resident #10 has a mild risk for pressure ulcers. Resident #10 uses a hoyer lift for transfers, and uses an electric wheelchair for mobility. The CAA area for pressure ulcer dated 07/03/13 contains in part: [MEDICATION NAME] factors- poor nutrition, pain, recent decline in activities of daily living, functional limitation of range of motion, requires staff assist to move sufficiently to relieve pressure over any one site. confined to bed or chair most of the time, needs special mattress or seat cushion to reduce or relieve pressure, requires regular schedule of turning. Analysis of findings: Resident is dependent on staff for all skin care. Staff encourage him to reposition often and provide good pericare bid and prn. Will proceed to care plan to promote healthy skin and prevent the likelihood of skin breakdown. The initial care plan, undated, contains in part: At risk of pressure ulcer. Goal: Will remain free of skin breakdown over the next 90 days. Interventions: Check skin for redness, skin tears, swelling, or pressure areas. Report any signs of skin breakdown. Perform nutritional screening...Use pillows, pads, or wedges to reduce pressure on heels and pressure points. Turn/reposition. (The current pressure ulcer or frequency for a repositioning schedule is not identified.) The CNA care plan instructs under skin: position off buttocks as much as possible. (Specific schedule for repositioning or identification of the ulcer is not present) There are no updates to the pressure ulcer care plan since this. The admission skin assessment dated [DATE] identifies 1.4 cm x 2 cm bruise on left armpit. 2. Incision site. Left shoulder. Scattered purple/yellow bruising. Monitor daily, chart weekly until healed. Physician orders [REDACTED]. 07/03/13- cleanse wounds (to buttocks) with NSS (normal saline solution), pat dry, apply skin barrier prep and bordered edge [MEDICATION NAME] to be changed every three days and prn. 07/10/13 - Ok for PT diathermy to open are on buttocks, (3 areas) [MEDICATION NAME] drink to promote healing. Physician fax sheets: 07/10/13- MVI- multivitamin for wound healing, PT evaluate and treat for wound. Doctor order- OK 07/17/13- Could we have an order for [REDACTED]. Doctors order- OK Use zinc oxide bid (twice a day) prn areas of skin breakdown. 07/31/13- PT POC (plan of care) to include selective debridement of wounds as needed. Doctor order- order as above. 08/01/13- Residents wound on ischial area is being debrided by PT, area with increased drainage and dark necrotic tissue- Recommendation per PT and wound care nurse- change to [MEDICATION NAME] extra AG and cover with thin [MEDICATION NAME]. Change every day and prn. FYI- Resident does not want urgent care visit...Doctor order- OK... The nurses notes include in part: 07/03/13 "5 x 4 reddened area with 3 small excoriated areas noted to be on the upper right sacrum 0.6 x 0.5 excoriated area noted above the coccyx. Two [MEDICATION NAME] applied. MD notified." 07/04/13 "Resident left facility at 1530 via his electric wheelchair ..." 07/04/13 "Resident returned to the facility at 2325." 07/06/13 "[MEDICATION NAME] to buttocks changed areas macerated and slough removed with dressing removal...Roho cushion reinflated..." 07/09/13 "resident has denuded areas on coccyx area and right upper mid buttocks area...resident states he has had skin breakdown in the past, could not recall what treatment was done at that time...resident educated on effects of shearing and encourage positioning off buttocks." 07/10/13 "...orders for diathermy to open areas on buttocks (3 areas)..." 07/11/13 "Resident left facility via electric wheelchair at 1615. ..." 07/11/13 "Resident returned to facility via his electric wheelchair at 2100 ..." 07/15/13 "...Resident on alternating air mattress [MEDICATION NAME] for wound healing, uses hoyer lift for transfers, and electric wheelchair for mobility..." 07/17/13 "...area measures 8 cm x 2.7 cm red with small areas of white intact tissue near 12 O'clock location, coccyx area measures 13 cm x 14 cm with dark blue black area with white intact tissue on right side of anus, ...resident encouraged to be up in wheelchair for 2 hours at most then lay down..." 07/20/13 "...compliant with laying down after being up in wheelchair for 2 hours, compliant with left arm in sling..." 07/24/13 "Patient verbalized to nurse that he thinks the reason he is having skin issues with his buttocks is due to his rental power wheelchair. Patient states that the chair reclines more than he likes and causes him to be putting more pressure onto buttocks vs when he uses his own manual wheelchair that the back is at more of 90 degree angle. He cannot use manual wheelchair due to left shoulder repair and healing plan. PT eval filled out to have chair inspected and modified to relieve pressure from pt buttocks, in turn hoping to improve skin condition..." 07/25/13 6:56 a.m. "Patient declined to be repositioned in bed, ...states that he will ask for help with repositioning onto left side. Education provided and patient verbalized understanding of skin integrity issues that could arise. Chooses independence and comfort over risks..." 07/25/13 11:31 a.m. "...coccyx area including anus and left buttocks measures 10 cm x 1.3 cm width at widest part. U shape yellow/black slough on left inner buttock and yellow intact slough around anus..." 07/27/13 "...Patient encouraged to remain off of coccyx as much as possible. Patient needs assist of two staff and hoyer lift for transfers..." 07/30/13 "...moderate amount of exudate from lower wound...wound had black eschar and yellow exudate...arranging to have therapy evaluate for the need of debridement..." 08/01/13 "...Residents wound on ischial area appears deeper, increased drainage and continues with dark tissue in wound bed. Call placed to Doctor...Resident does have appointment at wound clinic next week." 08/02/13 "Change dressing to [MEDICATION NAME] Extra Ag and cover with [MEDICATION NAME]" 08/05/13 "...Dressing changed on bottom and appt confirmed at wound clinic Wed 08/07/13 at 1:30. Ionizer and room freshener placed in room to help control odor from wound..." 08/07/13..."Eschar area measures 11.2 cm x 8.1 cm with a depth of 2 cm between 6-7 O'clock, no eschar area measure 111 cm x 4 cmw ..small proximal area just above coccyx measures 6 cml x 1.6 cmw...resident noted to have increased temp at 0915 a.m. 100.9 APAP given at 0930 for increased in temp..." 08/07/13 6:58 p.m."Resident returned at 1835 from urgent care/consult at RCMC ...Patient needs to have consult ASAP. findings: large necrosis wound covered with [MEDICATION NAME] for now...summary of findings: left buttocks decubitus ulcer, approx 12 x 12 cm, with necrotic tissue throughout...3. Frequent(hourly) position changes to avoid prolonged pressure on buttocks area..." Non pressure ulcer skin conditions form includes in part: A. coccyx B. Upper med buttocks toward sacrum 07/03/13- A. 0.5 cm x 0.5 cm area with maceration B. 5 cm x 4 cm Reddened area, with 3 small excoriated areas. 07/9/13- A. 5.0 x 4.0 area with white slough 90%...B. 6.0 x 3.2 denuded area with 10.0 x 8.0 red periwound...At 1100 has darker purple area.. 07/17/13- A.- 13 cm x 14 cm denuded areas with dark blue black area with white near right side of anus...B. 8 cm x 2.7 cm excoriated with denuded area serous drainage with small cream intact tissue at 12 O'clock. 07/25/13 A. 10 cm l x 1.3 w with u shape yellow/black slough .. B. 0.8 cm x 0.9 cm beefy red granulation with defined edges 07/30/13 A. ...yellow/black slough wound base..(no measurement on this date) 08/07/13 A weekly wound documentation progress sheet is completed calling the area a pressure area. -11.2 cm length x 12.1 cm width x 2 cm depth - unstageable 75% eschar, gray black. Odor- present Wound progress- declined, increase in eschar. Wound Consult Notes 08/07/13 - Left buttock decubitus ulcer, approx 12 x 12 cm, with necrotic tissue throughout, additionally has superficial skin breakdown circumferentially for additional 1- 5 cm, including circumference of anus. - necrotic ulcer sharply debrided today. New orders: twice daily moist dry packing saline gauze to open wound. routine skin care to anal area, frequent (hourly) position changes to avoid prolonged pressure on buttock area...twice weekly physical therapy ...2-3 x per week bath/shower to assist with wounds cleansing. The physical therapy notes include in part: Physical therapy initial evaluation completed 07/12/13: reason for referral: Pressure ulcer noted at buttocks with patient decreased ability to do pressure relief. Functional outcome scores: Bed mobility prior 7 (complete independence) Eval 1.7 (Near total dependence) Wheelchair management prior level 7.0 ( near total dependence) Eval 1.7 (near total dependence). Summary statement: Patient is unable to participate effectively in transfers, pressure relief due to upper extremities restrictions post op... A rehab/nursing care plan communication form was completed on 07/12/13: Please provide pressure relief for patient when he is up in chair. He should be repositioned at least every 30 minutes. (There was no evidence by record review or interview that this was put in place.) 07/18/13- Patient wound has increased in length but has decreased in width, redness has increased in overall size... 07/25/13- wounds appear to be increasing at anal region with eschar, increased drainage. Pressure relief cont to be addressed... A Rehab addendum note dated 07/31/13 states: ...Patient feels he is tipped posteriorly in power wheelchair and putting additional pressure on buttocks. He has requested a wedge or other modification to try to change his positron. PT went to add wedge to power w/c...Patent appears comfortable in wheelchair...recommendation to nursing to have patient seen by wound clinic due to difficulty with maintaining position, for selective debridement and extensive area that needs [MEDICATION NAME]. Order request for wound care clinic... 08/01/13- PT provided wound debridement to necrotic tissue as patient could tolerate. Patients wound size did go up in L & W (length and width) due to removal of tissue. 08/08/13- Patient was seen at urgent care regarding wound. Patients has a large amount of eschar debrided with another follow up required... Patient on pressure relief. Outcome: patient has improved. Skilled PT to decrease wound size and for pressure relief. Occupational Therapy Notes: 07/31/13- patient has been in bed to relieve pain off of rear and secondary wound that PT is addressing... 08/01/13- ...Patient is restricted to bed often secondary to buttocks wound. Will start out patient wound clinic starting next week... Observations- Resident #10 is alert and oriented and declined to have the surveyor speak with him or do any observations of his cares. Surveyor interviewed the wound care nurse RN G on 08/08/13 at 2:40 p.m. Surveyor asked what stage the pressure ulcer was. RN G stated there was slough apparent on the wound about 2 weeks ago. Surveyor asked what stage that is, RN G stated "Stage III, but now it is unstageable because of the recent debridement." Surveyor asked if Resident #10 refuses to be repositioned. RN G stated, "I have stressed the importance of repositioning every few hours when he is up in his chair." Surveyor asked what the standard of practice is for repositioning in the chair when the resident has an open area. RN G said, "Every two hours." Surveyor stated that if it is not effective then it needs to be more frequent.. Surveyor asked if any tissue tolerance observations were completed for Resident #10. RN G said, "No, I have never seen them." Surveyor asked about the frequency of Braden assessments. RN G was not sure. Surveyor asked if Resident #10 has any feeling in his lower extremities. RN G said, "No, he can not feel anything." Surveyor pointed out that the only Braden completed on 06/22/13 states he has under Sensory Perception- Ability to respond to pressure-related discomfort scored at 4, meaning he has no sensory deficit which would limit ability to feel or voice pain or discomfort. RN G stated, "That is inaccurate." Surveyor asked if the Braden score would predict pressure score risk accurately for Resident #10. RN G said, "No." On 08/12/13 at 06:40 a.m. Surveyor interviewed CNA AA about the repositioning schedule for Resident #10. CNA AA stated, "We just started one hour repositioning, I think on Friday." Surveyor asked what the schedule was prior to this. CNA AA stated,"We repositioned every 2 hours." On 08/12/13 at 8:10 a.m. Surveyor interviewed RN I to ask if there was any documentation to show this pressure ulcer was not avoidable. RN I said, "Probably not." Surveyor asked if Resident #10 was at high risk for developing a pressure ulcer with no ability to use his left arm, and being confined to a wheelchair. RN I stated, "Yes." RN I went on to say that Resident #10 had to use a rental electric wheelchair in the facility due to the non weight bearing use of his left arm after left shoulder repair. RN I said, "For some reason the electric chair tilted him back, putting too much pressure on his bottom, therapy evaluated and wedges were added to the chair the end of July. RN I also indicated that Resident #10 would go on outings for several hours in this electric wheelchair. Surveyor asked if any changes for positioning in the chair have occurred since then. RN I said, "I do not recall any." Surveyor asked what kind of positioning schedule Resident #10 was on, RN I stated, "It was every 2 hours in bed and chair until 08/07/13 when the physician ordered hourly repositioning. RN I went on to say now there is a flow sheet in the resident's room to be signed by the CNAs for hourly repositioning. Surveyor asked if Resident #10 is refusing to be repositioned. RN I indicated at times he can be hesitant. Surveyor asked if it is care planned or if refusal of care forms per the facility policy was utilized. RN I indicated she was not familiar with that. Surveyor asked when daily skin inspection by licensed staff started. RN I stated that the MAR i