Every finding on record at American Lutheran Home-Mondovi

Based on observation, interview, and record review, the facility did not utilize enhanced barrier precautions (EBP) for 1 of 2 sampled residents (R9). R9 had a Jackson Pratt (JP) drain placed prior to his admission to the facility on [DATE]. The facility did not implement EBP to reduce the transmission of infections.Findings include: Facility policy titled, Enhanced Barrier Precautions, dated 03/12/26 reads in part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: g. device care or use (central line, urinary catheter, feeding tube tracheostomy/ventilator, etc.). 2. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. On 05/06/26 at 9:00 AM, Surveyor reviewed R9's medical record. R9 admitted to the facility on [DATE] after hospitalization for acute cholecystitis (inflammation of the gall bladder) and placement of a JP drain to his abdomen. R9 was not a surgical candidate due to his diagnosis of heart failure. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 05/05/26 revealed R9 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. On 05/06/26 at 10:03 AM, Surveyor reviewed the facility's resident matrix and noted R9 was identified for placement of EBP. Surveyor observed R9 did not have EBP signage on his door or personal protective equipment (PPE) placed at point of care. On 05/06/26 at 10:09 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C after Surveyor observed CNA C exit R9's room. CNA C stated R9 was not on any precautions. CNA C reported R9 has a drain with a bag but was unable to tell Surveyor the reason for this. CNA C stated Surveyor should speak with the nurse. On 05/06/26 at 10:28 AM, Surveyor observed staff place a contact precaution sign on R9's door and PPE outside of his room. On 05/06/26 at 10:45 AM, Surveyor asked CNA C if R9 was placed on contact precautions. CNA C stated she placed the sign the nurse gave her. Surveyor asked Registered Nurse (RN) D what type of precautions R9 was on. RN D stated she thought it was contact precautions, but she would call someone to verify. After RN D made a phone call, RN D stated R9 should be on EBP due to his JP drain. Surveyor asked RN D if R9 had been placed on any precautions since his admission, and RN D stated he had not. On 05/06/26 at 11:04 AM, Surveyor interviewed R9. R9 stated he had not been placed on any type of precautions since his admission, and staff had not been wearing PPE during high contact cares. On 05/07/26 at 7:36 AM, Surveyor interviewed Director of Nursing (DON) B. DON B also acts as the facility's infection preventionist. DON B stated the facility is very good about placing residents on EBP for wounds and indwelling devices. DON B reported the facility does not admit many residents with JP drains, and R9's EBP got overlooked. DON B stated R9 should have been placed on EBP upon admission. DON B acknowledged the facility's deficient practice and reported she started immediate staff re-education on EBP.

Based on record review and interview, the facility did not ensure PRN (as needed) orders for psychotropic drugs are limited to 14 days or have a physician's rationale to extend the medication for an indicated duration for 1 of 4 residents (R) reviewed (R8). R8's PRN Lorazepam (antianxiety medication) does not have a physician's rationale to extend the use of this medication past 14 days with an indicated duration to then evaluate the appropriateness of the medication. This is evidenced by: The facility's policy Psychotropic Medication Policy and Procedure with review date of 11/20/19 read in part, 6. Orders for PRN psychotropic medications will be time limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days. The provider must document their rationale in the resident's medical record and indicate the duration for the PRN order . R8 was admitted to the facility on [DATE]. R8's current diagnoses included in part, absence epileptic syndrome, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease, chronic pain syndrome, and vascular dementia. R8 was admitted to hospice on 02/12/25. Review of R8's medication orders on 02/12/25 documented Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) *Controlled Drug* Give 0.25 ml by mouth every 1 hours as needed for agitation. The order does not have an end date. Review of the Medication Administration Record (MAR) documented R8 received the PRN Lorazepam on 02/27/25 and 02/28/25. On 02/19/25, a pharmacist note to attending physician/prescriber documented in part, PRN Psychotropic Documentation Assessment Form. Please be sure the following two criteria are met to fulfill the CMS requirements for PRN use beyond 14 days. Orders may be extended beyond 14 days only if prescriber: 1. Documents clinical rationale for the extension and AND 2. Provides a specific duration of use. The physician marked the box, Continue above PRN psychotropic order. Rationale for PRN use beyond 14 day: Hospice/Palliative. The section Duration for order thru (month/day/year) is not filled out with a date. The physician signed the form with no date and the facility staff marked the form as noted and faxed on 02/26/25. On 03/12/25 at 2:28 PM, Surveyor interviewed Director of Nursing (DON) B about the PRN Lorazepam not having an end date. DON indicated there was note in the computer from the MD about the use for end of life and for seizure activity. Surveyor explained the scheduled Lorazepam order is indicated for use for seizure and the PRN Lorazepam is ordered for agitation with no end dated. The PRN medication use needs to be evaluated again after 14 days for adequate indication for use and to have longer than 14 days it would need an end date to be evaluated again by the physician. DON B indicated she understands and will see if there is more information on the rationale for no end date and understands the need for an end date for the PRN use of Lorazepam. No further information was given to Surveyor for an end date of use of the PRN Lorazepam.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for each resident (R) to meet medical, nursing, and psychosocial needs identified for 2 of 12 sampled residents (R3 and R9). R3 did not have a depression care plan developed when R3 was prescribed an antidepressant medication for depressive disorder. R9 did not have a risk of bleeding care plan developed when R9 was prescribed an anticoagulant medication. This is evidenced by: R3 was admitted on [DATE] with diagnoses of polymyalgia, weakness, major depressive disorder, cerebral infarction, and mood affective disorder. Review of the Minimum Data Set (MDS) dated [DATE], a 5 day admission assessment documented R3's brief interview of mental status (BIMS) score of 1, meaning minimal depression severity. Review of R3's medication orders documented on 5/14/24, Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 3 tablet by mouth one time a day related to major depressive disorder, recurrent, moderate. Note, this order was carried forward from R3's previous admission and continues to be a current order. On 03/10/25 at 11:30 AM, Surveyor observed R3 in her room sitting in the recliner and Surveyor heard R3 making crying sounds. Surveyor observed Director of Nursing (DON) B enter R3's room to deliver medications. Surveyor interviewed DON B about R3 crying. DON B indicated R3's brother, who was her caretaker, had passed away and that is why R3 is here. R3's insurance wants R3 to discharge to an assisted living in a couple of weeks. R3 is not happy about the move and likes all the staff here. On 03/10/25 at 12:00 PM, staff entered R3's room to ask R3 if she wanted lunch. R3 received lunch in her room and did not eat at that time. Surveyor reviewed R3's care plans after above observations and did not locate a plan of care for depression with non-pharmacological interventions. Example 2 R9 was admitted to the facility on [DATE] and current diagnoses include in part, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, congestive heart failure, paroxysmal atrial fibrillation, presence of cardiac pacemaker, abnormal coagulation profile, neurocognitive disorder with Lewy bodies, and dementia. Review of R9's medication orders documented on 07/10/24 Apixaban Oral Tablet 2.5 MG (Apixaban) Give 2.5 mg by mouth two times a day related to paroxysmal atrial fibrillation. Note, Apixaban is an anticoagulant medication used to treat and prevent blood clots and to prevent stroke. Apixaban can increase the risk of bleeding which may be serious. Review of R9's care plans and medication administration record did not document a plan of care for risk of bleeding related to the use of apixaban medication. On 03/12/25 at 2:28 p.m., Surveyor interviewed DON B about a plan of care for R3's depression with use of an antidepressant and for R9's risk of bleeding with the use of apixaban. DON B indicated DON B will look to see if there is a care plan. On 03/12/25 at 3:11 PM, DON B stated there was no care plan for R3's depression and no care plan for R9's risk of bleeding. DON B stated care plans will be initiated for both R3 and R9.

Based on observation, interview and record review, the facility did not ensure proper glove use with ready to eat foods and hand hygiene was performed in accordance with professional standards for food service safety, when food was prepared and served to the residents (R). This affected 16 of 18 residents (R10, R9, R73, R16, R15, R3, R11, R12, R72, R13, R5, R14, R7, R2, R18, and R6). This is evidenced by: The facility policy, entitled Dietary Department, states: .Dietary staff practice proper food handling procedures, including but not limited to hand washing .using utensils to reduce hand contact with food, wearing disposable gloves to perform certain food handling tasks . On 02/12/24 at 11:37 AM, Surveyor observed lunch service in the dining room served by Chef I. Surveyor observed Chef I wash hands and put on gloves. With the same gloves on, Chef I grabbed bread and placed into the toaster, pushed down the toaster handle, grabbed a scoop, butter knife and the bread bag. With the same gloves on, Chef I grabbed the toast out of the toaster and placed on a plate. Chef I put on new gloves. With gloves on, Chef I grabbed a scoop and then with the same gloved hand, grabbed potato chips. Chef I removed the gloves and performed hand hygiene. With new gloves, Chef I grabbed a plate, a spoon, a scoop, and opened the freezer to grab ice cream. Chef I removed gloves and touched a pen, cupboard, and a plate. Chef I applied new gloves and grabbed a hamburger bun with the gloved hand, along with cheese, tongs, and placed the food on a plate. Chef I placed new gloves and grabbed chips with gloved hand. Chef I did not perform hand hygiene in between glove changes. Surveyor observed Chef I pick up bread, hamburger buns, and chips to place them on resident plates using the same gloved hands that touched multiple potentially contaminated surfaces, along with not performing appropriate hand hygiene. Surveyor observed Chef I touch the ready to eat food with the contaminated gloves to place on R13, R72, R7, R3, R6, R5, R18, R14, R2, R15, R16, and R73's plate. On 02/13/24 at 8:01 AM, Surveyor observed breakfast service in the dining room served by Chef I. Chef I washed hands and applied gloves. With gloves on, Chef I touched the countertop and then grabbed with the same gloved hand bread to place in the toaster and pushed down the handle. Removed the gloves and place new ones to grab the toast, butter knife to butter the toast and placed into holding area. Chef I with same gloves on opened the fridge and then grabbed new bread to place in the toaster with the same gloved hand. Chef I applied new gloves and repeated the process. No hand hygiene in between glove changes. Surveyor observed Chef I pick up bread to make toast using the same gloved hands that touched multiple potentially contaminated surfaces, along with not performing appropriate hand hygiene. Surveyor observed Chef I touch the ready to eat food with the contaminated gloves to place on R13, R11, R12, R9, R72, R3, R6, R5, R15, R16, R7, R18, R10, R73, and R14's plate. On 02/13/24 at 1:15 PM, Surveyor interviewed Dietary Manager (DM) G and asked what the expectation was for staff handling ready to eat food. DM G said staff were to use tongs or gloved hands. Surveyor asked DM G if staff could use gloved hand that was used to touch other objects and then touch ready to eat food. DM G said no, that was not appropriate. Surveyor asked DM G about the expectation for hand hygiene between glove use. DM G said to do hand hygiene with each change of gloves. On 02/14/24 at 10:53 AM, Surveyor interviewed Director of Nursing (DON) B asking about what the expectation was for staff handling ready to eat food. DON B said staff should not touch food with gloves that had touched other items. Hand hygiene was to be done after each glove change.

Based on observation, interview and record review, the facility did not ensure the resident environment remains as free of accident hazards as is possible to prevent accidents. Water temperatures were recorded above a safe temperature of 110 - 115 degrees for 4 of 4 residents (R2, R10, R11, and R12). This is evidenced by: The facility document, entitled Legionella and other water pathogens monitoring control measures, states: .Weekly water temps taken in three rooms, per wing, per week. Temp (Temperature) range 105-120 degrees . The facility obtained this temperature range from the Centers for Disease Control and Prevention (CDC) Guidance for Monitoring Building Water for Legionella which states, .When state regulations or codes do not allow hot water temperatures above the range of 105-120 degrees Fahrenheit (F) for hospitals or 95 - 110 degrees F for nursing care facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow either of these alternative preventive measures to minimize the growth of Legionella in water systems . Wisconsin State Regulation DHS 132.83 (7)(a)2 states: .The temperature of hot water at plumbing fixtures used by residents may not exceed the range of 110-115 degrees F . R2 was admitted to the facility on [DATE] and had diagnoses that include in part diabetes with neuropathy and peripheral vascular disease. R10 was admitted to the facility on [DATE] and had diagnoses that include in part dementia and diabetes. R11 was admitted to the facility on [DATE] and had diagnoses that include in part cognitive communication deficit and parkinsonism. R12 was admitted to the facility on [DATE] and had diagnoses that include in part mild cognitive impairment, diabetes, and peripheral vascular disease. On 02/13/24 at 8:38 AM, Surveyor washed hands in R10's sink using the hot water. Surveyor was unable to keep hands under the water due to the temperature being very hot. On 02/13/24 at 9:00 AM, Surveyor calibrated the digital thermometer with ice water to 32 degrees F as per manufacturer's guideline. On 02/13/24 at 9:03 AM, Surveyor measured R10's hot water temperature by placing the thermometer in the stream of water until the highest temperature was maintained for 15 seconds. The water temperature read 133 degrees F. On 02/13/24 at 9:07 AM, Surveyor measured R2's hot water temperature by placing the thermometer in the stream of water until the highest temperature was maintained for 15 seconds. The water temperature read 131 degrees F. On 02/13/24 at 9:14 AM, Surveyor spoke with R10 about the faucet hot water temperature in his room. R10 said he does wash his hands in the sink sometimes and had noticed that it was hot. R10 said R10 had not burned himself when using the water. On 02/13/24 at 9:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN) H, and asked if LPN H had concerns with the water temperature. LPN H said the water had been the appropriate temperature. LPN H had not noticed it being too hot. If LPN H did find the water to be too hot, LPN H said LPN H would call the Maintenance Supervisor (MS) E, who takes care of the water temperature, to come in and adjust it. Surveyor asked LPN H if any residents had been burned by hot water. LPN H said no burns from any reason while she has been working here. On 02/13/24 at 9:25 AM, Surveyor measured the faucet water temperature for room [ROOM NUMBER], an unoccupied room. The water temperature read 132 degrees F. On 02/13/24 at 9:31 AM, Surveyor measured the faucet water temperature for R11 and R12's room. The water temperature read 131 degrees F. On 02/13/24 at 9:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F, and asked if CNA F had concerns with the water temperature. CNA F said sometimes the water gets a little warm but was not bad. A few residents wash their hands independently. CNA F said CNA F was not aware of any residents getting burns from any reasons including water. On 02/13/24 at 9:40 AM, Surveyor interviewed MS E and Maintenance Tech (MT) D concerning the water temperature. MS E said he checks the water temperature in three rooms, per wing, per week with a pocket non-digital thermometer and records the results. MS E said if the water temperature was out of range, MT D would change the temperature at the mixing valve (used to adjust the water temperature). The facility has only one mixing valve located at the holding tank in the maintenance room on the ground floor. MS E and MT D said we have not had to change the water temperature because the temperatures had been in the range we follow of 105-120 degrees F. Surveyor asked both MS E and MT D if any residents or staff had complained of too hot of water, or any injury due to hot water. Both said no. On 02/13/24 at 9:50 AM, Surveyor asked MS E to check the water temperature at the faucets of the resident rooms. MS E went into the kitchen on the first floor to obtain a non-digital thermometer to use for temping the water. Surveyor asked MS E if he wanted to get the thermometer that he normally used to check the water temperature. MS E said no, this one was just like the one he would use. On 02/13/24 at 9:55 AM, Surveyor and MS E went to the unoccupied room [ROOM NUMBER] to check the hot water coming out of the room's faucet. MS E placed the non-digital thermometer under the running hot water. MS E said the temperature read under 100 degrees F. Surveyor placed the calibrated digital thermometer under the running water at the same time and obtained a temperature of 130 degrees F. Surveyor asked MS E if he wanted to get a different thermometer to verify what was the correct temperature. MS E said no, he believed the reading from the Surveyor's thermometer. Surveyor asked if MS E wanted to temp the water in a different room to verify they were high also. MS E said no need as this was a loop system and only one mixing valve to change the temperature. If one room was hot, the other rooms would be hot too. Surveyor and MS E felt the water, and both agreed that the water felt too hot and were unable to keep hands under the water. MS E said the current water temperature was a danger to the residents and will decrease the temperature at the mixing valve to decrease the temperature at the faucets. Surveyor asked MS E how he calibrated the thermometer they use. MS E said he had never calibrated the thermometer and he did not know how to calibrate it. MS E said he should calibrate the thermometer to know that it was reading an accurate temperature. Surveyor was unable to determine accuracy of MS E's thermometer as the thermometer has not been calibrated. Review of the facility's weekly documentation of water temperature log of resident rooms indicated temperatures ranging from 110 to 120 degrees F. The temperature log documented on the top of the page for a water temperature range of 105 to 120 degrees F. On 02/13/24 at 12:17 PM, Surveyor interviewed R11 and R12 concerning the water temperature. Both residents stated they did use the sink and had noticed it to be hot, but never burned them. On 02/14/24 at 11:31 AM, Surveyor interviewed R2 and asked if he used the sink in his room. R2 stated that he used it to wash his hands and brush his teeth. Surveyor asked if R2 had any concerns with the temperature of the water. R2 stated that the water gets too hot, so he just turns the cold water on. When asked, R2 stated that he had never burned himself and there were no burns noted on his hands. On 02/14/24 at 11:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A to ask if any residents had any injury from hot water. NHA A said no. On 02/14/24 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B to ask if any residents had any injury from hot water. DON B said no.

Based on observation, interview and record review, the facility did not ensure a medication administration error rate of less than 5%. Errors occurred when staff did not follow physician order for administration of nebulizer and removal of lidocaine patch. The two errors from 31 opportunities, yielded a medication error rate of 6.45% affecting 2 of 6 residents (R) (R20 and R73). This is evidenced by: The facility policy titled, Medication and Treatment Orders, states, .Drug and biological orders must be recorded on the Physician's Order sheet in the resident's chart . Drugs.com states the following in relation to Lidocaine Patches: . After you take lidocaine patch off, do not put another one on that area of skin for 12 hours . Example 1 On 02/13/24 at 1:06 PM, Surveyor observed Licensed Practical Nurse (LPN) J administer a nebulizer treatment via handheld nebulizer kit to R20. During medication reconciliation, Surveyor noted an after-visit summary dated 02/05/24 that states, .CHANGE how you take: ipratropium-albuterol (DUONEB) .administer nebulizer by mask 4 times per day . The after-visit summary was noted and signed by facility Registered Nurse (RN) K; however, RN K did not transcribe the updated order onto the physician's order sheet in the resident's chart. On 02/13/24 at 1:14 PM, Surveyor observed R20 falling asleep during the nebulizer treatment while R20 was holding the handheld nebulizer kit. The handheld nebulizer kit moved away from R20's mouth on 3 occasions and this would cause R20 to not receive the entire dose of medication. LPN J was in the hallway and asked R20 if R20 would like LPN J to hold the nebulizer kit. When LPN J spoke to R20, he would wake and put it back in his mouth. On 02/13/24 at 1:19 PM, Surveyor asked LPN J if LPN J was aware of R20's order to receive nebulizer treatments via mask which LPN J stated, No I was not aware. On 02/13/24 at 1:40 PM, Surveyor interviewed Director of Nursing (DON) B and read the current nebulizer order on the MAR and the new order on the after-visit summary dated 02/05/24. DON B stated that adding the mask should have been added to the order. DON B stated that it will be fixed immediately, and the order was reviewed by RN K, however, was not transcribed in the electronic health record under orders. Example 2 On 02/13/24 at 8:10 AM, Surveyor observed LPN J administer a lidocaine patch to R73. When LPN J moved R73's shirt to place the lidocaine patch on R73, there was already a lidocaine patch on R73's right shoulder dated 02/12/24. Surveyor asked LPN J when lidocaine patches are to be removed. LPN J stated they are supposed to be removed at night. Surveyor asked LPN J to show where the patch removal was shown on the medication administration record (MAR). LPN J stated it is not on there. The directions on the box for the lidocaine patches indicated the patch should be removed after 12 hours. 02/14/24 9:30 AM, Surveyor interviewed DON B asking what the expectation is for applying and removing lidocaine patches. DON B stated that the patches should be off after 12 hours. Surveyor reported the concern that R73 still had the previous lidocaine patch on with the date of 02/12/24. DON B agreed the patch should have been removed.

Based on observation, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when Enhanced Barrier Precautions (EBP) with appropriate Personal Protective Equipment (PPE) was not followed for 1 of 1 resident (R10). This is evidenced by: The facility utilizes the Centers for Disease Control and Prevention (CDC) sign for EBP that states: Everyone must: .wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter . R10 was admitted to the facility on [DATE], and had diagnoses that included in part dementia, benign prostatic hyperplasia (BPH), chronic cystitis, obstructive and reflux uropathy, chronic kidney disease (CKD), urogenital implants, renal and perinephric abscess, and nephrolithiasis. R10 had a urinary catheter. Outside R10's door was the CDC sign for EBP and a PPE cart that included gloves and gowns. On 02/14/24 at 10:07 AM, Surveyor observed Certified Nursing Assistant (CNA) F wearing gloves, but not wearing a gown, empty R10's urinary catheter bag. Surveyor interviewed CNA F and asked if CNA F should be wearing a gown when emptying R10's urinary catheter bag due to the EBP that R10 was on. CNA F said CNA F did not need to wear the gown to empty the urinary catheter bag. CNA F said CNA F only needed to wear gloves and gown when doing peri care or activities of daily living (ADL) cares for R10. On 02/14/24 at 10:29 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked what PPE staff were to wear and when for R10's EBP. ADON C said staff were to wear gown and gloves when doing any high contact cares such as peri cares, urinary catheter care, or emptying the urinary catheter bag. On 02/14/24 at 10:31 AM, Surveyor interviewed Director of Nursing (DON) B asking what staff should wear when emptying the urinary catheter bag for R10. DON B said staff should wear gown and gloves because R10 was on EBP. Surveyor notified DON B what was observed when staff emptied R10's urinary catheter bag. DON B said when staff empty any urinary catheter bag, staff need to wear gown and gloves. DON B said staff should know this as staff had been educated on what EBP requires. Surveyor asked for the facility policy on EBP PPE use. On 02/14/24 at 11:13 AM, DON B provided a copy of the CDC EBP sign that was outside R10's door and said they follow CDC guidelines for EBP.

Based on observation and interview, the facility did not ensure that kitchen surfaces and dishes were properly sanitized. This had the potential to affect all 22 residents. On 09/27/21, at 08:50 a.m., during an initial kitchen tour, Surveyor asked Culinary Supervisor (CS) E to test the sanitizing solution used to fill the three compartment sink and wipe down the kitchen counters and kitchen surfaces which included the carts used to transport food to the resident rooms. A test strip is used to check the parts per millimeter (ppm) of the sanitizing solution, after it is added from the pre-measured dispenser. A bucket is marked with a line, indicating the amount of water to be added, to ensure the correct amount of sanitizing agent and water are accurate. The test strip read zero, indicating that the amount of sanitizing agent ppm in the water that had been used to clean the surfaces was zero. Surveyor confirmed this with CS E. CS E said that the Culinary Aide (CA) fills the bucket with the sanitizing agent and water before breakfast and lunch, and the solution is to be tested at that time. The three compartment sink is filled and tested 3 times a day. Surveyor interviewed CA J. CA J said she added sanitizing agent to the sanitizing solution, and does not know why there is no sanitizing agent in the sanitizing solution (bucket). Surveyor interviewed Chef K. Chef K stated that she did not know why the sanitizing agent was not added to the water. On 09/29/21 at 10:30 a.m., Surveyor observed the kitchen dishwasher process. The container of sanitation solution was sitting on a counter, next to a sink. Surveyor asked CS E to perform a test of the solution. The sanitizing agent again read zero ppm. Surveyor asked CS E to perform a test of the sanitizing solution in the 3 compartment sink. The sanitizing ppm read zero. Surveyor interviewed CS E. CS E stated that she did not know why the sanitizing solution in both areas was zero. CS E showed Surveyor a sanitizing log of the three compartment sink for September. All areas read 300-500 ppm. CS E said that there is no log kept to record the ppm for the solution (bucket) that is used to wipe down the kitchen surfaces. CS E stated that she has not supervised the kitchen staff to ensure that staff are interpreting and performing the sanitizing solution ppm tests correctly.

Based on observations and interviews the facility failed to prevent or contain COVID 19 for 1 of 1 unvaccinated residents (R11,) maintain an infection prevention and control program to help prevent transmission of infection by not providing catheter care in a sanitary manner for 1 of 1 residents (R7,) and did not provide peri-care in a sanitary manner for 1 of 1 residents (R24) during personal care observations. R11 is on covid precautions. Staff did not remove PPE when leaving R11's room or the covid unit. R7's catheter bag was drained; staff did not use an alcohol wipe to disinfect the tubing. R24 received personal cares; staff did not remove gloves and wash hands or wash R24 in a hygienic manner. This is evidenced by: The facility's COVID unit had a pink sign outside the door that read, You are now entering a COVID wing. Correct PPE must be worn at all times. The rooms on the COVID unit have signs outside the resident rooms stating Contact Precautions and Droplet precautions, room. The sign on the door states . remove gown, then gloves (throw away in room) sanitize hands. On 09/27/21 at about 12:05 p.m., Resident Transportation Worker (RTW) F was transporting R11 back to his room on the COVID unit from the hospital. RTW F was wearing full PPE when he came on the unit with R11; when RTW F left the unit, he left with the same full PPE on. RTW F did not doff the PPE before leaving the covid unit. On 09/27/21 at about 2:05 p.m., Surveyor interviewed Registered Nurse (RN) G and asked her what staff are to be wearing when entering the unit. She indicated a surgical mask and goggles, if they are going into a resident room they should have full personal protective equipment (PPE) on and remove their PPE before leaving the resident's room. Surveyor asked where RTW F would have taken off his PPE when he left the COVID unit. RN G was not sure where he would have disposed of it. RN G did indicate that she knew they had to wear full PPE when transporting a resident that is positive with COVID. On 09/27/21 at 2:45 p.m., Surveyor interviewed Plant Operations Manager (POM) H and asked him if he supervised RTW F and he said he did. Surveyor asked POM H what RTW F should be wearing for PPE when transporting residents. POM H indicated if the resident does not have COVID they should be wearing a surgical mask and goggles; if the resident is COVID positive they should be wearing full PPE and they should put it on to get the resident and they should remove PPE before leaving the COVID unit. On 09/27/21 at about 4:05 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) A about the above observations and she indicated that RTW F said that he discarded his PPE in the soiled utility room that is located outside the double doors of the COVID unit to the left of the elevator. Surveyor did not observe RTW F come into contact with any residents or staff when leaving the covid unit. R7 was admitted to facility 11/11/2019, and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7 receives hospice services, and has an indwelling urinary catheter ordered through hospice provider. On 9/29/2021 at 11:38am, Surveyor observed Certified Nursing Assistant (CNA) C empty R7's urinary drainage bag. Prior to entering R7's room, CNA-C stated she needed to get alcohol wipes because she didn't think there were any in the room; CNA-C went into the supply closet and then came back out. Upon entering R7's room, CNA-C used ABHR and donned clean gloves. CNA-C placed paper towel on floor and set clean collection container on top. CNA-C then raised R7's pant leg up to reveal drainage spigot. CNA-C unclamped spigot and drained yellow urine into container. When container was full, CNA-C clamped spigot, carried container into bathroom, and poured urine into toilet. CNA-C then returned and placed empty container back on paper towel and unclamped spigot to complete draining of urinary drainage bag. CNA-C then turned to Surveyor and stated, Normally I would wipe this with an alcohol wipe now, but I couldn't find any in here. CNA-C clamped spigot and replaced R7's pant leg over bag. CNA-C discarded urine into toilet, doffed gloves and isolation gown, washed hands, and exited room. Following observation, Surveyor interviewed CNA-C. Surveyor asked if CNA-C had encountered a situation such as this before, where there were no alcohol wipes available when emptying urinary drainage bag. CNA-C stated yes, quite frequently. Surveyor asked where staff could get refills of supplies when needed. CNA-C stated she did not know; she stated she looked in the supply closet, but couldn't find any in there. Surveyor asked who CNA-C could ask for more supplies. CNA-C shrugged shoulders and stated it is the night shift's responsibility to replenish supplies. On 9/29/2021 at 3:30pm, Surveyor reviewed observation concerns with Director of Nursing (DON) B. DON-B stated the expectation would be for CNA-C to use an alcohol wipe to cleanse drain spout when emptying urinary drainage bag. DON-B stated there were alcohol wipes in R7's room in the drawer, however CNA-C did not look there. DON-B stated if staff need refills of supplies, they can ask the nurse on duty. R24 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Minimum Data Set (MDS) dated [DATE], indicated that R24 is frequently incontinent of bowel and bladder. O 09/29/21, at 07:34 a.m., CNA M and CNA L performed hand hygiene, donned gloves, and assisted R24 to the edge of the bed after transferring R24 onto the bed using the sit to stand lift. CNA M removed R24's wet brief. After performing hand hygiene and donning gloves, CNA M cleansed R24's meatus, from front to back. Then cleansed R24's groin area, then re-cleansed the meatal area using the same cloth. Cleaning from the dirty area back to the clean area. CNA M next re-cleansed the groin area, using the same cloth. Without changing gloves or performing hand hygiene, CNA M applied a clean brief with contaminated gloves, CNA M obtained a tube of A and D ointment (a topical, over the counter mild vitamin based ointment), with contaminated gloves and applied a small amount to R24's right hip area. CNA M removed gloves and performed hand hygiene after touching clean objects with contaminated gloves. At 08:25 a.m., Surveyor interviewed CNA M, who acknowledged the gloves should have been removed and hand hygiene performed before going to clean areas. At 10:30 a.m., Surveyor interviewed DON B. Surveyor shared findings with DON B. DON B agreed that there should not be breaks in infection control during hygiene cares.

Based on interview and record review, the facility failed to provide needed care and services that are in accordance with the resident's preferences, goals for care, and professional standards of practice. Daily weights were not obtained according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility policy entitled Weight Assessment and Intervention, dated 10/25/2019, states 1. The nursing staff will measure resident weights on admission, the next 2 days for a total of 3 consecutive weights, and weekly thereafter unless MD order otherwise. 2. Weights will be recorded in the individuals medical record. R19 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's care plan dated 8/19/21 states in part . R19 will show no signs and symptoms of exacerbation of cardiac status (weight or vital sign changes, SOB, etc.) through next review. Interventions include . monitor and document weight, report weight changes to dietician and health care provider as ordered. Sudden unexplained weight gain, sudden decrease in activity, decreased output, change in mental status. R19's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor requested R19's recorded weights from 08/16/2021 through present. Daily weights were recorded on 08/16/21 through 09/20/21. There were no weights recorded after 09/20/21 per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 09/29/21 at 7:42 am, Surveyor interviewed RN G and asked how often R19 is weighed. RN G indicated his weight is supposed to be daily, but due to COVID he hasn't been weighed for a week. On 09/29/21, Surveyor asked DON B for a policy and procedure on obtaining daily weight for residents with CHF. She indicated there isn't one per se, but if a resident has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B showed Surveyor the CHF charting document that she schedules the residents for a day of the week to be monitored. DON B indicated that if a residents weight is up or down 3 pounds in a day or 5 pounds within a week, they monitor signs and symptoms. If the weight gain or loss can not be explained, they will recheck the weight the next day and notify the doctor within 24 hours. Upon review of the CHF charting document, Surveyor observed R23's name on the chart who is also on the COVID unit. R23 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's care plan states: R23 will show no signs and symptoms of exacerbation of cardiac status (weight or vital sign changes, SOB, etc.) through next review. Interventions include: monitor and document weight, report weight changes to dietician and health care provider as ordered. Monitor for signs/symptoms of cardiac exacerbation: [CONDITION(S)], distended neck veins, sudden unexplained weight gain, respiratory congestion, decreased output, change in mental status. R23's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor requested R23's recorded weights from 09/02/2021 through present. Daily weights were recorded 09/02/21 through 09/20/21. The last daily weight recorded was 09/20/21. On 9/29/21 at about 1:30 pm, Surveyor interviewed DON B and asked about weights being done on the COVID unit for residents with CHF. DON B indicated they do not have a scale that is portable, they are working on getting one. DON B indicated the daily weights have not been done to assess for fluid weight gain for the [CONDITION(S)] patients as ordered by the physician.

Based on observation and interview, the facility did not honor resident's food choices for 1 of 1 sampled residents. Resident (R) R14. R14's choice in food items was not honored during the meal observation. This is evidenced by: R14 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's care plan, no date listed, with a goal date of 09/30/21, states R14 has a potential for alteration in nutrition/hydration related to [CONDITION(S)], requires a textured modified diet per Speech Therapy. Interventions include offer dietary likes and preferences .encourage more fruits and vegetables when requesting more foods at meals . On 09/28/21, at 12:30 p.m., Surveyor observed R14 during the noon meal. R14 asked Chef K for a second helping of chili. Chef K said No. Your sister wants you to have more fruits and vegetables. Surveyor interviewed R14. R14 stated that he would have wanted more chili, and did not want anything else. Chef K did not offer or bring R14 any fruits or vegetables or chili. At 12:45 p.m., Surveyor interviewed Chef K. Chef K stated, I hate telling him no. He typically requests more protein. His sister, who is his Power of Attorney for Health Care, says we are supposed to offer him more fruits and vegetables instead of the protein, but he doesn't like them .my supervisor told me that we are supposed to tell him 'No' when he asks because the sister has the final say. He wanted more meat last week, and the other cook felt terrible when she had to tell him no. On 09/29/21 at 08:19 a.m., Surveyor interviewed Culinary Supervisor (CS) E. CS E stated that she has instructed the staff, that when R14 asks for more entree, the staff are to offer him fruits and vegetables because that is what the Health Care Power of Attorney wants. On 09/29/21, at 9:20 a.m., Surveyor interviewed NHA A. NHA A stated that the facility is offering R14 food choices by offering him fruits and vegetables. However, this is not what R14's preference in food choice is.

Based on observation and interview, the facility did not treat 1 of 12 sampled residents (R20) with respect and dignity. Dietary Staff did not treat R20 in a dignified manner during two meal observations. This is evidenced by: R20 admitted to facility on 4/17/2018, and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's Minimum Data Set (MDS) dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 2, meaning R20 has severe cognitive impairment. MDS indicated supervision is needed for eating. R20's Care Plan read: Encourage R20 to come to the dining room for all meals. R20 needs some encouragement to continue eating meal. On 9/28/2021 at 9:20 AM, Surveyor began observing the breakfast meal in the dining room. R20 was seated at a table by himself; R20 had a plate with eggs, breakfast meat, and cake, a small bowl of peach slices, a glass of orange juice, and a glass of milk. R20 held fork in right hand and was slowly feeding himself; R20 used left hand to take occasional drinks of beverages. R20 often became preoccupied with wiping/rubbing table with his left hand; passing staff offered verbal cues, which prompted R20 to continue eating meal. At 9:53 AM, Culinary Aide (CA) D approached R20's table and asked to take empty bowl R20 was holding in left hand. At 9:57 AM, CA-D reapproached table and asked if R20 was going to finish eating. R20 responded, What? What? CA-D left the table and R20 picked up milk with left hand and drank, and continued to eat with fork. At 10:11 AM, Certified Nursing Assistant (CNA) I approached table and asked if R20 was done eating. R20 said no. CNA-I then asked Are you going to eat it or play with your milk? CNA-I then left dining room, and CA-D approached R20's table. CA-D stated, What do you think (R20), can I take your plate now? R20 was holding milk in left hand and fork in right hand. CA-D left table and went to refrigerator; meanwhile, R20 took two more bites of peaches. CA-D returned to table with a cold cup of milk and orange juice from refrigerator; CA-D took the old cups and told R20 they are too warm to drink. CA-D then told R20 the food was now too cold to eat. CA-D took R20's plate of food, placed the cake on a new plate and discarded the rest of the food. CA-D then left the dining room. R20 remained in dining room with a plate of cake and a glass of milk and orange juice until 10:38am, when a staff member brought him back to his room with his beverages. On 9/28/2021 at 1:06 PM Surveyor observed part of the lunch meal in the dining room. R20 was seated at a table with a plate of food. CA-D approached R20's table and asked, Are you going to eat that or play with it? CA-D took R20's plate and discarded the food; CA-D then wiped R20's table and stated, Ok, now drink these up. Gesturing to the glasses of milk and orange juice left on the table. R20 finished drinking the milk. CA-D took the milk cup, and said, finish that one up for me and left the table. R20 sipped the orange juice. CA-D returned to R20's table. CA-D remained standing at table with hands on hips saying: Can you drink that up for me? Drink it down just like a shot, you can do it Drink it up so I can take it. At that time, R20 had drunk approximately half of the glass of orange juice. When R20 finished drinking, CA-D took the cup and left the dining room. Surveyor was unable to obtain interview with CA-D. On 9/29/2021 at 10:51 AM, Surveyor interviewed Culinary Supervisor (CS) E. CS-E stated all dietary staff receive on-the-job training as well as computer-based quarterly training. CS-E stated customer service training goes over things like how to take resident's meal orders. Surveyor asked when and how dietary staff determine a resident is finished with a meal. CS-E stated, staff should wait to clear the table until the resident leaves the dining room or until a resident is able to tell them they are finished. Surveyor asked how staff determine if a resident is finished if they are unable to verbalize. CS-E stated dietary staff should ask the CNA or nurse for direction. CS-E provided Surveyor with a log of CA-D's computer-based training which included, in part: Effective Communication on 6/20/21, Protecting Resident Rights in Nursing Facilities on 3/26/21, and Teepa Snow: Dementia 101 on 3/4/21. CS-E also provided a blank checklist entitled, JumpStart for Food & Nutrition Staff, which included a segment entitled Customer Service. Goal: To provide standards for establishing a dining room that is attractive, homelike, adequately staffed, dignified and pleasant. CS-E stated they just recently received this and will soon be implementing this training for all dietary staff upon hire, as well as annually, or more often, as needed.

Based on record review and interview, the facility did not immediately consult with the resident's physician upon a significant change in resident condition for 1 of 3 sampled residents, Resident (R) R1. The facility did not notify or consult with R1's physician when R1 had a choking/coughing episode, followed by an episode of weakness and dysphagia. This is evidenced by: R1's [DIAGNOSES REDACTED]. R1's Brief Interview for Mental Status (BIMS) is 11, indicating moderate cognitive deficits. On 07/15/20 at 9:30 a.m., Surveyor interviewed Registered Nurse (RN) C. RN C told Surveyor on 07/02/20, at 5:30 p.m., the Certified Nursing Assistants (CNAs) came to the nurses' desk and informed her R1 was choking. RN C stated when she entered the dining room, R1 was coughing a little and slouching in her wheelchair. R1 was unable to keep her eyes open or hold her head up. RN C stated, That was kind of concerning. RN C brought R1 to the nurses' station, where Director of Nursing (DON) B was sitting, and informed DON B that, Something wasn't right with R1. R1 could not keep her head up. RN C told Surveyor DON B told her that R1's neurological signs were normal, even though R1 could not hold up her head, and was slouching in her wheelchair. RN C told Surveyor that RN C and DON B, Thought maybe R1's MS ([MEDICAL CONDITION]) was acting up. RN C told Surveyor that she instructed the CNAs to assist R1 with lying down. RN C stated the CNAs informed her that R1 was unable to transfer via pivot transfer due to this onset of weakness. The CNAs used a partial lift to assist R1 with lying down. RN C told Surveyor that she did not inform or consult with R1's physician about the choking/coughing incident or R1's subsequent symptoms. At 10:30 a.m., Surveyor interviewed CNA D. CNA D stated CNA I came to her and said, I need you in the dining room. R1 is choking. CNA D stated when she entered the dining room, R1 was not choking. R1 was slouched down in her wheelchair, and could not hold up her head. CNA D stated, We kept asking her to hold her head up, but she couldn't. CNA D stated this was not normal for R1, and she reported this to the nurse. At 11:50 a.m., Surveyor interviewed CNA F. CNA F stated, Me and CNA J were in the dining room helping with the residents when R1 starting coughing. We asked her if she was okay and she was not able to talk. We ended up patting her on the back, and she coughed up the food .I think it was a green bean. CNA F stated the episode lasted about 2 minutes. CNA F told Surveyor that R1, Was out of it (after the choking/coughing episode). She was not at baseline. We had to use a lift to transfer her. She kept saying she was okay, but she wasn't. I told the nurse. At 1:00 p.m., Surveyor interviewed R1. R1 was sitting up in her wheelchair with normal posture. R1 told Surveyor that she remembers choking but the staff helped her when this happened. R1 stated, I was so scared. At 3:00 p.m., Surveyor interviewed CNA J. CNA J stated, CNA F and I were in the dining room for the evening meal when R1 said she was choking. R1 was sliding down in her chair during this time and when we boosted her up, she spit out a green bean. We tried to feed her some mandarin oranges and water, but she could not hold her head up. R1's eyes kept closing. The oranges and water just slid out of her mouth. She couldn't hold her head up or keep her eyes open. I told DON B this and she stated, 'She is fine.' At 3:15 p.m., Surveyor reviewed R1's clinical record. The Minimum Data Set ((MDS) dated [DATE] indicated R1 does not have chewing or swallowing problems. R1 requires set up and supervision with eating a regular diet. R1 transfers with assist of one. The clinical notes state, in part, that on 07/02/20, at 4:49 p.m.: Resident was eating dinner when she choked on a green bean. Writer was alerted by staff. Writer assessed resident. Resident coughed up green bean. VSS (Vital Signs Stable). O2: 96% on room air. Lung sounds clear throughout. Neuros within baseline. Resident unable to stand, keep eyes open or head up. Hand grasps equal. Resident then requested to use the restroom. Resident unable to stand with one assist, so she transferred via sit to stand with assist of one. Resident stated she was ok, but nauseated. Blood sugar was 160. Resident was also assessed by DON. DON stated resident was baseline. At 3:45 p.m., Surveyor interviewed DON B. Regarding the above incident, DON B stated, R1 really didn't choke. She swallowed a green bean and it went down the wrong pipe. RN C did an assessment. After R1 was able to cough it up, she was alert and oriented and back to her old self. DON B reviewed the clinical notes from 07/02/20 at 4:49 p.m. DON B stated that RN C should have notified R1's physician if R1 was unable to stand, keep her eyes open, hold up her head and was nauseated. DON B stated, I went back and looked at the notes .RN C should have notified the physician. Yes, it was a change of condition.

Based on observations, interviews and record review, the facility did not implement interventions to promote healing and prevent infection of pressure injuries for 1 of 3 sampled residents with pressure injuries, Resident (R) R24. R24 has facility acquired pressure injuries on the left and right heel. Staff had breaks in infection control while performing wound care for R24. R24 wears prevalon heel boots as an intervention to promote healing. The manufacturer's recommendations were not followed for proper care of the boots to maintain their function to promote healing of the current pressure injuries. This is evidenced by: R24 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Staff identified unstageable Deep Tissue Injuries (DTIs) on both of R24's heels on 4/30/19. R24's Minimum Data Set ((MDS) dated [DATE] indicated R24 is at risk for development of pressure injury, having one unhealed stage II pressure injury. The MDS also indicated R24 had a Brief Interview for Mental Status (BIMS) score of 9, which means moderate cognitive impairment. The MDS functional assessment indicated R24 required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. Current Physician orders [REDACTED]. Left heel borderd gauze or foam. Change every other day .Right heel: Cleanse with saline. Pat dry. [MEDICATION NAME] to ulcer bed, top with saline amount of saline to activate [MEDICATION NAME]. Bordered gauze or foam. Change every other day and prn (as needed). 10/29/19 On 11/04/19 at 9:32 AM, Surveyor observed R24 resident up in wheelchair at 8:30 a.m. R24 was still up in wheelchair at 9:35 a.m. R24 was repositioned at 9:50 a.m. and the heel boots were on. On 11/04/19 at 11:12 AM, Surveyor observed heels were elevated off the mattress with prevalon boots. The right foot was turned slightly outward, as the wedge of the boot was not in the right position. Care plan, (Resident name) is at risk for or currently has skin breakdown issues R/T: -Current pressure ulcers. -impaired mobility ., weakness, LE (lower extremity) [MEDICAL CONDITION], cognitive impairment, noncompliance with care interventions, chronic pain, bowel & bladder incontinence, depression, receives antidepressant, narcotic, diuretic, cathartic & hypnotic medications, Arthritis, C.V. disease, D.M., Dementia, .Depression, [MEDICAL CONDITION], Obesity. R24 requires extensive assistance with bed mobility, transfers, hygiene and toileting needs, Current skin impairments will resolve with no evidence of further skin breakdown through next review. Will comply with nursing interventions . Complete skin and Braden assessments quarterly and as needed, document findings in resident's record. See Braden scale to determine level of risk and if at risk follow the appropriate interventions . If resident uses devices that can cause pressure, such as respiratory devices, indwelling cath, TED hose, cast, splint, assess for redness/irritation . Prevalon boots at all times except hygiene, air mattress added to bed per incident report on 5/8/19 .Resident is being seen at the wound clinic as ordered by wound MD. Surveyor reviewed the medical record that documents weekly measurements and assessment of the right and left heel since 4/30/19. The right heel is documented as healed on 10/02/19. On 10/10/19, the right heel is open 1.0 cm x 1.5 cm length x 0.1 cm depth, Stage II. On 10/23/19, the right heel has moderate drainage, and redness surrounding the wound. The physician is contacted and a wound culture is completed. R24 is diagnosed with [REDACTED]. On 11/06/19 at 7:30 a.m., Surveyor went into R24's room with Certified Nursing Assistant (CNA) [NAME] and Registered Nurse (RN) C. Surveyor asked if the heel boots had been in use for a long period of time. RN C did not know. CNA [NAME] indicated they take the boots to the laundry and wash them, then put them back on the resident. Surveyor observed the boots which have worn looking areas. The wedge on the bottom is not keeping the foot in alignment; it is pressing down allowing the right foot to rotate externally. The wedge is not holding its form to keep the foot straight. Surveyor noted the boots are Prevalon, model 7533. The boots are not dated as to whose boots, or how long the boots have been in use. Surveyor asked for manufacturer recommendations on use of the prevalon boots. The information for cleaning instructions given to Surveyor indicated boots are only to be wiped off with a damp cloth. Observation wound care, On 11/06/19 at 8:10 AM, Surveyor observed RN C perform wound care on the pressure injuries. RN C applied gloves and removed the old dressing from the left heel. The skin was intact with an approximate 0 .5 cm dry callous area. RN C kept the same gloves on, went into R24's drawer for supplies, opened the package of island dressing and set it on the bed. A barrier for the supplies was not used. RN C applied a new clean island dressing to the left heel with same gloves. RN C then moved the cart with supplies to the right side of R24. RN C took the gloves off, took new gloves from the box by the sink and set them on R24's newspaper which was lying on the overbed table. RN C then put on new gloves without washing or sanitizing her hands. RN C touched the tray table edges with the gloved hands as she moved the table. RN C removed the right boot, went to the paper towel holder, got paper towels and put paper towels on the bed under R24's foot. RN C removed the boot and sock. RN C removed the old dressing that was soiled with a dark colored drainage. The pressure injury was open and black in color, with no redness surrounding this. RN C took her gloves off, sanitized hands and applied new gloves. RN C put the dressing package on the bed with no barrier. RN C applied wound wash to 4 x 4 gauze, lifted right leg, cleansed the heel wound. RN C kept the same gloves on, took scissors from the basin, did not sanitize the scissors. RN C opened a new dressing ([MEDICATION NAME]) with the contaminated gloves that had cleansed the wound and drainage. RN C cut the dressing with contaminated scissors, then laid the scissors on the bed with no barrier in place. RN C dampened the [MEDICATION NAME], applied this to the wound while still wearing the contaminated gloves. RN C then, with contaminated gloves, opened the island dressing and applied the dressing to the right heel. RN C removed the gloves and washed hands appropriately after wound care was completed. The scissors were still lying on bed. RN C picked up the scissors and put them back in the basin of supplies, without sanitizing the scissors. Surveyor did not observe cleansing of scissors before or after the wound care. Facility policy for Dressings, Dry Clean, dated 06/17/19, in part, Steps in the Procedure 1. Clean bedside stand. Establish a clean field. 2. Place clean equipment on the clean field . 6. Put on clean gloves. loosen tape and remove soiled dressing. 8. Wash and dry your hands thoroughly. 11. Using clean technique, open other products 12. Wash hands thoroughly 13. Put on clean gloves . On 11/6/19 at 9:30 a.m., Surveyor called SAGE products manufacturer and spoke with Customer Representative (CR) F and asked how the Prevalon Heel Protector III boot is to be laundered. CR F states the boot is not to be laundered only wiped off with a damp cloth. If the boot is laundered it is no longer effective and not backed by the company. Surveyor asked if the boots are for individual use. CR F stated, Yes. Surveyor asked how long the boots are to be used before manufacturer recommends they be replaced. CR D states for length of hospital stay not for long term use. At 9:36 a.m., Surveyor went to CNA [NAME] to ask about the boot laundering. CNA [NAME] stated boots are sent to laundry weekly on bath day. Surveyor asked what R24 wears when they are at the laundry. CNA [NAME] stated they take another pair of boots out of the linen closet that are used; no specific boots are labeled for any resident. On 11/06/19 at 1:15 p.m., Surveyor interviewed Director of Nursing (DON) B asking about the right heel documented as healed and then reopening. DON B indicated R24 went to the wound clinic on 10/10/19 where the physician debrided the right heel. DON B stated she was upset by this and did not agree. DON B stated approximately 10-11 days later, R24 had signs of infection and the heel was getting worse. R24 was started on antibiotics, and the heel is improving. Surveyor shared the wound care observation with breaks in infection control that could contribute to introducing infection. Surveyor asked what was expected. DON B stated a barrier and clean field is to be used. Any time the gloves are removed, the hands need to be washed, especially between clean and dirty parts of the dressing change. Surveyor asked if DON B knew the laundering instructions for the Prevalon boots. DON B indicated the boots are sent to the laundry to be washed. Surveyor shared the manufacturer's information on how to clean the boots. Surveyor shared the observation of the wedge not staying firm when on R24's heel, allowing some external rotation possibly putting pressure on the outside of the right heel. The pressure injury is on the outside of right heel, where the heel would get pressure if externally rotating. The heel suspension boots are to prevent this. DON B was not aware of this.

Based on observation, interview and record review, the facility did not ensure pain management services were provided according to residents' goals and preferences. This occurred for 3 of 3 residents reviewed who experience pain, Resident (R) R18, R1, and R5. R18 experiences pain on a daily basis. R18 reports his pain is not relieved by current medications in place which are scheduled two times a day. R18's medical record frequently documents pain at a high level prior to scheduled medication being given. The scheduled medications and pattern of high pain ratings prior to treatment has not been reviewed and revised. R18's care plan does not include interventions for pain. R1 reports she has pain all over at times, especially in the evenings. R1 states she would like to have medication scheduled so she doesn't have to wait until she hurts in order to have the medication. R1's MAR indicated [REDACTED]. This pattern of use has not been reviewed or revised. R5's pain management program was not reassessed when using prn pain medications on a regular basis with no scheduled pain medication. Most recent pain assessment had pain level of 10 without reassessment or new interventions to pain protocol. This is evidenced by 1. R18 was admitted with [DIAGNOSES REDACTED]. Interview with R18 reveals, R18 experiences pain on a daily basis. R18 reports his pain is not relieved by current medications in place. R18 also stated at times his pain interferes with his sleep and daily functioning. When asked about taking a prn medication along with scheduled medications, R18 said Tylenol is the only PRN currently ordered, and it doesn't help much. R18 states he doesn't take it, especially after taking the scheduled doses already. R18's scheduled physician's orders [REDACTED]. R18 also has an as needed order for Tylenol 650 mg every 6 hours. According to R18's medical record, R18 is asked to rate pain two times a day, on a 0-10 scale, prior to scheduled medication for pain being given. Results of this rating over the past month indicate R18 rated pain from 0-5, 36 times (2 times pain was it rated as a 0, indicating no pain- or complete pain relief) and rated pain from 6-10, 36 times (3 times rating it a 10, the worst level of pain). Review of R18's pain data collection - comprehensive assessment dated [DATE] states the resident pain scale goal is 0, to sleep comfortably, have comfort with movement and to stay alert. R18's pain data collection dated 11/06/19 at 7:00a.m. states R18 has pain in arms and legs. The level of pain is indicated as a 6, chronic, aching. When asked if this level of pain is acceptable it indicates no. Review of R18's care plan does not include a care plan for pain, or any interventions used for pain. Surveyer conducted interview on 11/06/19 at 2:19 pm with Registered Nurse (RN) C and Licensed Practical Nurse (LPN) H. When asked how often R18's pain is evaluated, they responded two times a day and the information is documented in the Medication Administration Record [REDACTED]. When asked if R18 ever complains at times his pain is not relieved by the scheduled medication, they responded yes. When asked if a resident has a scheduled medication and they report their pain at high levels prior to the medication being used, is the medication use ever reviewed and re-assessed. Both reported the medication use is reviewed on a quarterly basis. The nurses added some residents report a high number on the pain scale, but then have no other visualized symptoms or some residents report pain is a 6 and then say it is mild pain. Staff report they do education on the pain scale to teach the residents to use the scale. During an interview with Director of Nursing (DON) B on 11/06/19 at 3:00 pm., Surveyor asked if a resident who experiences pain daily should have a pain care plan, DON B stated she would expect them to have a pain care plan. When asked if residents on scheduled pain medications frequently rate their pain at a high levels prior to receiving the medications should be re-assessed and looked at for adjustments to their pain relief program, DON B stated, Yes. DON B added if residents are asking for more pain medications they would look at that too. When asked how soon this re-evaluation should be completed, DON B stated she would expect it to be reviewed if someone has rated their pain at high levels in one week, if not sooner. When asked about R18's pain, DON B stated she thought there was a cream to use for pain also at one point, but doesn't see it on the physician's orders [REDACTED]. 2. R1 was admitted to the facility with [DIAGNOSES REDACTED]. Interview with R1 on 11/04/19 at 12:09 pm revealed R1 experiences pain, R1 reports has pain all over at times, and especially in the evenings. R1 states she has as needed medications to use for pain. R1 states she would like to have medication scheduled, so she doesn't have to wait until she hurts, in order to have the medication. R1's physician's orders [REDACTED]. Review of R1's MAR indicated [REDACTED]. The use occurs mostly around or after 7:00 p.m. This pattern of use has not been reviewed or revised. R1's care plan indicates R1 has pain related to a left wrist fracture. The goal is 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 include assess and document location, quality, intensity, and duration of pain. Assess effectiveness of pain medication and notify health care provider if pain not well controlled. Assist R1 to reposition as needed for comfort, and monitor factors affecting discomfort. Interview on 11/06/19 at 2:19 pm with RN C and LPN H. When asked about R1's pain, they indicated R1 likes a couple of Tylenol at bedtime as she is achey and has pain then. R1 also experiences occasional headaches. Interview with DON B on 11/06/19 at 3:00 p.m., revealed R1's care plan for pain has not been revised to include pain in the evening time prior to bed. When asked if R1's medication for pain usage had been reviewed due to frequent evening use, DON B was unsure. DON B did indicate if a PRN medication for pain is frequently used, it should be reviewed, and looked at for possible scheduling of the medication. No evidence of R1's as needed pain medication being reviewed for possible scheduling, as R1 desires, was located or provided. 3. According to the Journal of the American Medical Directors Association, It is essential that physicians and midlevel practitioners who care for residents in long-term care facilities be proficient in the recognition, assessment, and treatment of [REDACTED]. pain. (Winn, Peter [NAME] S., Dentino Andrew N. (2004) Effective Pain Management in the Long-Term Care Setting. Volume 5 (Issue 5), pp. 342-352). R5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] has a Brief Interview for Mental Status, (BIMS) score of 8 meaning mild cognitive impairment. The pain is documented as occurring frequently with a pain level of 9. R5 currently has the following orders for pain management: Tylenol 650 mg q (every) 6hr prn (as needed) [MEDICATION NAME] 50 mg q 6 hr prn Biofreeze 4% every 4 hr prn Surveyor reviewed R5's comprehensive care plan, dated 05/15/19. The care plan states the following, in part: (R5's name) has pain r/t (related to) weakness, secondary to car accident many years ago .Interventions: Assess effectiveness of pain medication and notify health care provider if pain not well controlled .assist to reposition for comfort .offer pain medication prior to therapy. (R5 is not in therapy). Goal: 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 through next review . The care plan does not identify what R5's acceptable pain level and goal is. Surveyor reviewed the MAR for as needed use of pain medications from 10/01/19 to present. R5 is using the [MEDICATION NAME] (Tylenol) twenty four times with pain levels ranging 7-10. A rate of 3-4 was used 3 times since 10/01/19. R5 has used the prn [MEDICATION NAME] approximately thirty two times since 10/01/19 with pain levels 6-9 for pain in his hips. The 9 entries describe where the pain location is, the others do not tell the location. Pain data collection comprehensive assessments were reviewed from 09/04/19 to present. 09/04/19 pain level was 9 (8-9 severe) 09/12/19 pain level was 8 (8-9 severe) 09/18/19 pain level was 8-9 severe pain 09/25/19 pain level was 4-5 (mild) 10/02/19 pain level was 8-9 (severe) 10/10/19 pain level was 3 (1-3 discomfort) 10/16/19 pain level 8-9 (severe pain) 10/24/19 pain level 1-3 (discomfort) 10/25/19 pain level 4-5 (mild) 10/30/19 pain level 10 (worst pain imaginable) The assessments document R5 is frequently using prn (as needed) pain medication and the pain management program is effective with pain scales for 6 of the 10 assessments having pain levels 8 -10. The care plan has had no revisions with updates for non-pharmacological interventions. The pain medications have not been reassessed or changed during this time. The facility policy, Pain Assessment and Management, dated 10/25/19, in part, General Guidelines 2. Pain management is defines as the process of alleviating the resident's pain to a level that is acceptable to the resident . 3. g. Monitoring for the effectiveness of interventions; and 3. h. Modifying approaches as necessary . Defining Goals . 1. The pain management interventions shall be consistent with the residents goals for treatment . Implementing Pain Management Strategies b. Administering medications around the clock rather than PRN. On 11/06/19 at 7:15 a.m., Surveyor interviewed RN C asking about R5's pain. RN C stated R5 has worse pain on cold days like today. R5 rated pain at 8 this morning. RN C stated she will be giving 50 mg [MEDICATION NAME] and Tylenol from the prn order. Surveyor asked what R5 has for scheduled pain medication. RN C replied, Nothing scheduled, (Resident name) has a history of drug seeking. Surveyor observed R5 near nurses station at approximately 8 a.m., moaning as he tried to stretch his arm and reach across his chest. R5 got up from a seated position and moaned as he reached for his walker. On 11/6/19 at 9:45 a.m., Surveyor interviewed R5 asking about his pain. R5 stated the pain was in his neck and shoulders this morning. Surveyor asked about pain medication. R5 said, I have to ask for it. Surveyor asked if that is working for R5. R5 said, No, every day I get up and get going it is worse. Surveyor asked his current pain level. R5 stated, 8. Surveyor asked if the pain medication he took earlier had helped much yet. R5 indicated it takes a while because it gets really achy before he gets the medicine. Surveyor asked if having a scheduled pain medication would work better for him. R5 stated, I think that would be much better. I have had hip replacements and a knee replacement. My left hip hurts every day. On 11/06/19 at 1:20 p.m., Surveyor interviewed DON B. Surveyor asked when they would re-assess pain management if R5 had high pain levels. DON B indicates they check on it pretty often. Surveyor shared the prn pain medication use, the pain levels and interview with R5.

Based on record review and interview, the facility did not permit each resident to remain in the facility and not transfer or discharge the resident from the facility. This occurred for 1 of 3 residents, Resident (R) 130. R130 was discharged from the facility by a facility-initiated discharge which R130 did not verbally, or in writing, request to be discharged from the facility. The facility did not provide R130 with a written notification of discharge from the facility. The facility did not document the specific resident needs the facility was unable to meet and any attempts made or not made to meet the needs for R130. R130's physician did not provide documentation when the discharge from the facility was necessary. A plan of care for discharge was not completed. This is evidenced by: Surveyor reviewed R130's medical record. R130's current diagnoses, in part: chronic diastolic (congestive) heart failure , hypertensive heart and [MEDICAL CONDITION] with heart failure and stage 1 through stage 4 [MEDICAL CONDITION], or unspecified [MEDICAL CONDITION], type 2 diabetes mellitus with other circulatory complications, neuromuscular dysfunction of bladder, unspecified anxiety disorder, unspecified, major [MEDICAL CONDITIONS] and [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side. The medical record documented the original admission date of [DATE]. R130 has been transferred to the hospital multiple times. Transfers included: [DATE] transfer to hospital with return anticipated and was re-admitted on [DATE]; [DATE] transfer to hospital with return anticipated and was re-admitted on [DATE]; and [DATE] transfer to hospital with return anticipated and was re-admitted on [DATE]. The most recent discharge to hospital with return anticipated was on [DATE]. The facility completed a discharge from the facility on [DATE]. The medical record documented a completed and signed bed hold notice given on [DATE]. The BED-HOLD POLICY & NOTICE OF TRANSFER OR DISCHARGE with the revision date or ,[DATE], read in part: Bed-hold refusal or discontinuation: .If readmission to ALH is desired upon the completion of leave, and the resident continues to be eligible for skilled nursing services, the resident will be admitted to the first available bed in an appropriate room. The bed hold notice is checked for The Resident is in need of medical care which cannot be provided in the long-term care environment and a transfer to a hospital of the resident's choice is medically necessary for the resident's welfare. The notice is not checked for resident's request for a transfer or for the health or safety of individuals at facility being endangered by the resident's presence in this facility. This notice did not specify a complete discharge from the facility and did not provide an explanation of why the discharge from the facility on [DATE]. On [DATE], the care conference note documents R130 does not want a referral to another facility and wants to stay in facility long term. Review of the comprehensive care plans did not document a plan of care for discharge. Review of the progress notes dated [DATE] at 9:42 a.m. Hospital discharge planner called to ask about a possible return, resident was on IV antibiotics 2 times per day, facility not able to readmit resident at this time due to IV antibiotic frequency, entered by Nursing Home Administrator (NHA) [NAME] Review of R130's chart identified the physician documentation did not document a discharge summary with specific resident needs the facility could not meet and the facility efforts to meet those needs. Review of the Facility Wide Resource Assessment For ALH-Mondovi with the approved date of [DATE], read in part: Types of Services: .Rehabilitative Therapy, Orthopedic, Stroke/Neuro, Medical, Wound Care, Pharmacy, Lab/Diagnostic Testing, Pain Management, IV Medications, Hospice .Competencies Required: Pain Management, Medication Management, IV Medication, Wound care, PT, OT, ST, Ortho Care, Lift mechanics, Glucometer . On [DATE] at 9:37 a.m., Surveyor interviewed Registered Nurse (RN) C and asked about residents with IVs. RN C indicated the facility has had one or two residents recently with IVs. RN C stated, It depends on the RN coverage if we take residents with IVs. Surveyor asked if the physician orders [REDACTED]. RN C indicated the facility has only two RNs on, herself and the Director of Nursing (DON). The facility has one RN that is a flex nurse and a new RN started today. RN C indicated the facility always has an RN on call each day of the week and the on-call RN would come in to administer the medication. On [DATE] at 2:36 p.m., Surveyor interviewed DON B and asked about R130. DON B indicated R130 is no longer a patient of the facility. R130 was sent to the hospital for IV antibiotics. The facility does not have enough RN coverage and R130 has a lot of issues with diabetes and other co-morbidities. Surveyor asked if a discharge care plan was developed for R130. DON B indicated after looking in the computer that a discharge care plan was not developed. At 2:36 p.m., Surveyor interviewed NHA A about R130 not being readmitted to the facility. NHA A indicated the facility felt R130's refusal of medication, treatments and cares, R130's behaviors, frequent re-hospitalization s and being non-compliant is self-harming. Surveyor asked if R130's physician reviewed R130's current status to make the determination R130 was not able to return to the facility and the facility was not able to provide the needed care. NHA A indicated the physician did not review R130. The facility team did the review of the referral and made the determination as a team that the facility could not meet his needs. NHA A indicated the facility usually does not consult a physician for referrals. NHA A indicated DON B went to the hospital to visit R130 and talk with the hospital nurses. DON B indicated the hospital reported behaviors and refusal of medication and cares. NHA A indicated R130 had bad [MEDICAL CONDITION] and co-morbidities. Surveyor asked when DON B went to the hospital to assess R130, did DON B talk with R130 and give verbal notification of discharge to the facility. DON B was not able to recall the date of the visit, and DON B indicated she did not tell R130 he was discharged from the facility as the decision was not yet made. Surveyor asked NHA A if a discharge notice was given to R130. The NHA A indicated the bed hold notice had expired. Note: transfer to the hospital is a transfer, not considered a discharge. Surveyor asked why the discharge Minimum Data Set (MDS) documented on [DATE], R130 was discharged from the facility. Surveyor asked if the bed hold notice given to R130 included documentation that when the notice expired, R130 would no longer be considered a resident at the facility or why the facility cannot meet R130's needs. NHA A indicated no. Surveyor asked for any documentation from the hospital for re-admission that documents the care R130 would require. No further information was provided.

Based on interview and medical record review, the facility did not complete a Level II PASARR (Preadmission Screen and Resident Review) for 2 of 2 sampled residents reviewed for PASARR screens. This occurred for 2 of 19 sampled residents, Resident (R) R5 and R20. R5 and R20 have [DIAGNOSES REDACTED]. A Level II evaluation and determination was not conducted. This is evidenced by: 1. R5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility Preadmission Screen and Resident Review (PASRR) Level I screen form reads, in part: . if the resident is suspected of having a serious mental illness or a developmental disability, and therefore, will require a Level II Screen . R5's Level I screen section A, questions 1-2 were all checked yes. And section B questions 2 was checked yes for emergency placement - 7 day maximum short term exemption. Additional Directions Note: For emergency placements a signed F- form is not required prior to admission, however a request for the F- should be made on the first business day following admission. If during the short term stay, it is established that the person will be staying for a longer period of time than permitted above, the person must be referred for a Level II screen . On 11/06/19 at 9:10 a.m., Surveyor interviewed Social Services Supervisor (SSS) D to ask if R5 has the F that is required if a 7 day emergency placement is marked on the facility level 1 PASRR. SSS D stated she would look. On 11/06/19 at 10:40 a.m., Surveyor interviewed SSS D asking if the Level II PASARR paperwork had been initiated. SSS D stated she was new to this position and was not here when R5 was admitted . SSS D has looked but can find no PASARR level II or F screen completed. 2. Surveyor reviewed R20's medical record. R20 was admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] documented R20 as having a Brief Interview for Mental Status score of 11 which identifies as having moderately impaired cognition. Review of the PASARR I completed on 9/26/19 documents in Section A, R20 having current [DIAGNOSES REDACTED]. Surveyor did not find documentation of PASARR II being completed in the chart. On 11/05/19 at 3:18 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) A and the Social Services Supervisor (SSS) D and asked if a PASARR II was completed for R20. NHA A and SSS D indicated the facility had sent the PASARR to the state she had lived in prior to moving into this facility. After being directed to other offices in that state, they said it didn't need a level II completed. At 3:24 p.m., SSS D indicated she has no documentation from the other state and only talked with three different people then one gentlemen indicated that he was unsure what to do and looks like a level II is not needed. SSS D indicated a PASARR II was not filled out.

Based on observations, interviews and record review, the facility did not implement interventions to prevent the development of pressure injuries to 1 of 4 sampled residents (R3). The facility did not implement pressure relief for R3's heels upon admission. R3 developed deep tissue injuries (DTIs) to both heels 10 days after admission. This is evidenced by: R3 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Staff identified unstageable DTIs on both of R3's heels on 4/30/19. physician's orders [REDACTED]. R3's Minimum Data Set ((MDS) dated [DATE] indicated R3 was at risk for development of pressure injury, but did not have any unhealed pressure injuries at that time. The MDS also indicated R3 had a Brief Interview for Mental Status (BIMS) score of 10, which means she had moderate cognitive impairment. The MDS functional assessment indicated R3 required extensive assistance with bed mobility, transfers, toileting, dressing and personal hygiene. Braden Scale for Predicting Pressure Sore Risk tool completed 04/21/19 showed a score of 15, indicating R3 was at risk for developing a pressure injury. R3's Care Card dated 04/29/19, prior to the DTIs being identified, states: Transfers: extensive assist- Sit-to-Stand (A1+1) Walk: Does not walk Locomotion: Total dependence Positioning: None Bed Mobility: Extensive Bathing, Grooming, Dressing Devices: TEDS-Knee High. The Care Plan identifies no interventions prior to 04/30/19 to prevent pressure on R3's heels when she is identified as being at risk for pressure injury upon admission due to impaired cognitive function, weakness related to recent pneumonia infection, being overweight, inability to move herself, and dependence upon staff for repositioning. R3's Care Card dated 08/14/19 states: Positioning: Wheelchair cushion Bathing, Grooming, Dressing Devices: Podus Boots/Heel Protectors. R3's Care Plan dated 08/14/19 states: Resident to lay down between meals and to reposition/toilet every two hours. Standard reducing pressure relieving cushion/mattress unless otherwise indicated Complete skin and Braden assessments quarterly and as needed .if at risk follow the appropriate interventions Update resident and family as needed; provide education regarding prevention of pressure wounds, rationale for interventions, risk factors. IDT (inter-disciplinary team) referral as indicated, implement treatment/P[NAME] (plan of care) with signs and symptoms of skin breakdown. Current Physician orders [REDACTED]. This intervention is implemented after the DTIs were discovered. Puracyn moist-to-dry gauze dressing BID to right heel ; two times daily starting 8/2/19 Continue [MEDICATION NAME] to left heel; one time daily starting 8/2/19. On 08/14/19 at 2:04PM, Surveyor observed R3 lying on back in bed with boots on; heels were not in contact with mattress. On 08/14/19, Surveyor interviewed interim Director of Nursing (DON) regarding R3's DTIs. DON stated that R3 is now on a repositioning schedule of every 2 hours. DON stated she is the person responsible for completing the wound assessments at this time, and does so weekly. Surveyor asked which professional standard of practice the facility uses to guide prevention and treatment interventions for resident's at risk of pressure injury. DON stated she is unsure, but could probably find out. Surveyor asked if there was any further documentation that interventions to prevent development of pressure injuries had been in place prior to the discovery of two DTIs for R3 on 04/30/19. DON stated facility did not get an order for [REDACTED]. These interventions were also put in place after the DTIs were discovered. No further evidence offered to indicate any other interventions were in place prior to the development of the heel pressure injuries.

Based on record review and staff interviews, the facility did not provide pharmaceutical services, including services that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of 2 of 2 sampled residents (R) receiving insulin. The facility did not administer fast acting insulin in accordance with accepted standards of practice for R1 and R2. Findings include: On 08/14/19 at 10:41 AM, the Surveyor reviewed R1's medical record. A complaint had been received alleging that R1 was not given insulin at the correct time the week of (MONTH) 12th, 2019. The record indicates R1 has a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. It has a range of times that are signed out. Surveyor interviewed Licensed Practical Nurse (LPN) A and asked how staff know what time the insulin was given before the meal. LPN A was not sure but searched in the computer to try to determine that information. On 08/14/19 at 2:30 p.m., Surveyor asked the interim Director of Nursing (DON) how staff know what time the insulin was given before a meal. The DON could not determine how staff know when the insulin was given. On 08/14/19, Surveyor asked the Nursing Home Administrator (NHA) how to determine what time the insulin was given. The NHA stated she would have to do some checking. At 3:00 p.m., the NHA brought back a report that did indicate times of administration. [MEDICATION NAME] manufacturer information accessed at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/ 6s082lbl.pdf, indicates: [MEDICATION NAME] starts acting fast. You should eat a meal within 5 to 10 minutes after you take your dose of [MEDICATION NAME]. The documented times R1 received his insulin prior to the recommended 5-10 minutes before a meal the week of (MONTH) 12th are: The morning dose of Novalog was given at 7:04 a.m. on 04/17/19 approximately one hour before breakfast is served at 8 a.m. The evening dose of insulin was given on 04/14/19 at 4:03 p.m., 04/18/19 at 4:04 p.m., 04/19/19 at 3:27 p.m. The supper meal is served between 4:45 p.m. and 5:00 p.m. R1 received the insulin 45 minutes to 1 hour and 15 minutes before the scheduled meal. Example 2 R2 has been in the facility since 2010. R2 has [DIAGNOSES REDACTED]. The physician orders [REDACTED].>Humalog Mix 75-25 insulin subcutaneous suspension 65 units one time daily dosing in the AM Humalog Mix 75-25 Insulin subcutaneous suspension 40 units one time daily dosing in the PM. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR p.m. dose of insulin has a range of 3:00 p.m. - 7:00 p.m. The time the insulin is given is not on the MAR. The times the insulin was given were not identified on the MAR. At 3:00 p.m., the NHA came to the Surveyor with times of administration. The documented times R2 received the morning insulin during this time frame on 08/10/19 at 7:12 a.m. (approximately 45 minutes before the breakfast meal). The evening dose of insulin was given on 08/08/19 at 3:16 p.m., 08/09/19 at 3:35 p.m., 08/10/19 at 3:10 p.m., 08/13/19 at 3:16 p.m. R2 received the fast acting insulin 1 hour and 15 minutes to 1 1/2 hours prior to the supper meal that is served at 4:45 p.m. - 5:00 p.m. Humalog information accessed at https://www.humalog.com/fast-acting-mealtime-insulin/ How should I use Humalog, Humalog Mix75/25, or Humalog Mix50/50? These insulins start working faster than other insulins that contain regular human insulin. You should take Humalog within fifteen minutes before eating or right after eating a meal. You should take Humalog Mix75/25 and Humalog Mix50/50 within fifteen minutes before eating. On 08/14/19 at 3:32 p.m., Surveyor interviewed LPN C who was doing the p.m. medication pass. Surveyor asked if you can tell what time the insulin is given. LPN C indicated she is not able to see that. Surveyor was observing LPN C start her medication pass down the hallway. Surveyor asked what time LPN C starts the evening med pass. LPN C indicated around 3:30 and showed the Surveyor the time range of 3 p.m. - 7 p.m. that they have to administer medications. Surveyor asked when blood sugars and insulin are checked. LPN C said she could check blood sugar at any time, but would wait closer to 4:00 p.m. to do the insulins. On 08/14/19 at 4:20 p.m., Surveyor interviewed the NHA and DON about the above concern. The NHA acknowledged the insulin administration times for R1 and R2 are not in accordance with the recommended timing for administration of fast acting insulin.

Based on observation and interview, the facility did not ensure that an infection prevention and control program was implemented to provide a safe, sanitary environment and to help prevent the development and transmission of infections for 1 of 2 residents (R4) whose personal cares were observed. R4 received personal cares where hands were not washed after removing gloves following perineal care, staff placed soiled linens on the sink countertop by oral care supplies, staff walked through urine and wheeled the(NAME)Stedy assistive device through urine during cares. This is evidenced by: On 08/14/19 at 10:10 a.m., Surveyor observed Certified Nursing Assistant (CNA) B assist R4 with toileting and personal cares. R4 was seated on the commode, Surveyor could observe a large puddle of liquid under the commode. R4 indicated he needed his sweat pants changed because they were all wet. CNA B washed her hands and donned gloves. CNA B had R4 stand up and lean on the(NAME)Stedy Stand. R4 had a bowel movement. CNA B wiped R4's backside front to back, then provided R4 the urinal to void. CNA B wiped R4's frontal area with the same gloves that had cleansed the feces. CNA B then touched the handles of the(NAME)Stedy Stand with the contaminated gloves to move the assistive device into a better position. At this time, CNA B walked through the puddle on the floor, and wheeled the(NAME)Stedy through the wet puddle in several directions while positioning R4 to get into bed. CNA B removed the soiled incontinent pad and R4's wet pants. CNA B then touched the privacy curtain with the contaminated gloves to pull it back. CNA B proceeded to wipe the frontal area with a wipe using the same gloves since the start of cares. CNA B went into the closet to get a clean incontinent pad, touching the handle of the closet with the contaminated gloves. R4 then asked CNA B if CNA B could see the water on the floor. Surveyor asked R4 if he had spilled water. R4 indicated that he had not spilled water, that it was urine that went on the floor when he could not control his bladder. CNA B continued to walk through the urine as she performed cares. CNA B put on the clean incontinent pad with the contaminated gloves. CNA B removed R4's wet pants and shoes. CNA B carried the wet items to the drawer by the sink and opened the drawer with the contaminated gloves to get a garbage bag. After putting the soiled items in the bag, CNA B removed the gloves, did not wash her hands or use sanitizer, and donned a new pair of gloves. CNA B went back to the bedside and walked through the urine as she rolled R4 side to side to pull up his clean pants. At this time, the package of disposable wipes fell into the garbage can that contained the soiled incontinent pad and wipes that had been used on R4. CNA B took the wipes from the garbage and set it on R4's recliner CNA B then got the(NAME)Stedy Stand rolling it through the urine again to transfer R4 back into his wheelchair. CNA B again was walking through the urine. CNA B removed the gait belt from R4. As CNA B was rolling up the gait belt, the end of it was on the floor touching the urine areas. CNA B then tied up the garbage bag containing all of the soiled items and set it on the sink by R4's oral care supplies. CNA B went to clean out the commode bucket that had visible BM on the top of the seat and bucket. CNA B wiped these areas off and rinsed out the bucket. CNA B removed the gloves, and did not wash or sanitize her hands. CNA B then opened the drawer by the sink to put away supplies. At this time, CNA B washed her hands for 20 seconds. CNA B took sanitizing wipes and disinfected the handles, seat and foot rest of the(NAME)Stedy Stand. CNA B did not disinfect or clean the wheels or the bottom of her shoes. CNA B wiped the floor two times with the sanitizing wipes. CNA B then took the lift into the hallway, parked it in the storage area and went on break. On 08/14/19 at 11:43 a.m., Surveyor interviewed CNA B asking if she had disinfected the wheels of the(NAME)Stedy Stand. CNA B acknowledged she had not done that or disinfected her shoes before walking to other places. Surveyor asked CNA B when she is to wash her hands during cares. CNA B indicated she should have removed her gloves after washing up R4 and anytime she removed her gloves she was trained she is to wash her hands. CNA B acknowledged she had not done so. On 08/14/19 at 3:55 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) and the Interim Director of Nursing (DON). Surveyor asked what the expectations were for glove use. The NHA indicated staff are to wash hands any time they remove gloves. Surveyor asked what the CNA should have done when there was urine on the floor. The DON indicated the urine should have been cleaned up and disinfected before cares were provided.

Based on observations, record review and interviews, the facility did not complete a thorough assessment to determine the root cause of decline in bladder function or offer appropriate interventions which would allow the residents to maintain or restore their bladder function for 2 of 9 residents reviewed for a decline in bladder function (Residents #5 and #3). The facility did not follow standards of practice for catheter changes for 1 of 1 residents reviewed for catheters (Resident #2). As evidenced by: Bladder decline: The facility policy titled: Bowel & Bladder Assessment, undated, includes in part: Purpose: 1. Identify history and patterns of bowel and bladder function 2. To identify type of incontinence 3. To identify mobility limitations which affect elimination. 4. To review medications and [DIAGNOSES REDACTED]. 5. To identify appropriate treatment plan for the resident 8. To improve the morale and restore the resident's dignity and respect 9. To restore optimum level of bowel and bladder function 10. In to include interdisciplinary approach with individualized care plan. Policy Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel and/or bladder will receive appropriate treatment and services to restore as much normal bowel or balder functioning as possible. Procedure Each resident will be assessed for 72 hours for bowel and bladder voiding patterns on admission, quarterly and with a significant change in elimination patterns with evaluation for feasibility in retraining for bowel and/or bladder control. 2. The licensed nurse will gather information from the chart, the resident's family/representative, staff members, from resident observations, and from review and analysis of the 72 hour voiding patterns. 4. The resident's plan of care will be developed to address the issue, goals, and appropriate interventions for elimination program. 1. Surveyor # reviewed Resident #3's medical record on 01/14 -1/16/14. Resident #3 had a decline in bladder function without a complete assessment of contributing factors or measures put into place to restore her bladder function. Resident #3 has [DIAGNOSES REDACTED]. On 05/22/13, the quarterly Minimum Data Set (MDS) documents Resident #3 is occasionally incontinent of bladder, on 08/21/13, the quarterly MDS documents a decline in bladder function to frequently incontinent of bladder, and on 11/13/13, the resident is still frequently incontinent of bladder. The MDS also documents the resident needs extensive assist with toileting and two person assist. The resident care card identifies under Toileting: Incontinent bladder/Incontinent Bowel. Extensive assist commode, ...barrier cream with peri cares, briefs. The care plan problem titled: (Resident #3) has a self care deficit- extensive assistance of 1 staff required with bathing...two staff and mechanical lift for all transfers.... Goal: (Resident #3) will not have UTI or skin breakdown due to incontinence. Interventions in part: Use incontinence products to protect dignity and clothing. Bowel and Bladder assessment quarterly and prn. The history of stage II pressure ulcer care plan includes these interventions in part: Provide hygiene after voiding/BS to prevent skin breakdown. Apply moisture barriers. Surveyor reviewed the quarterly bowel/bladder assessments that were completed on 08/30/13 and 11/26/13. The assessment on 08/30/13 identifies the resident voids correctly? Yes - at least once a day, that she is completely immobile, is forgetful but can follow commands, is usually aware of toileting needs, and identifies predisposing diseases as, absent. The summary on 08/30/13 states: Unaware of toileting needs at times due to lewy body advanced dementia. Staff anticipate needs. Barrier cream applied. The assessment on 11/26/13 identifies the resident voids correctly? Yes - at least once a day, that she is completely immobile, is forgetful but can follow commands, is sometimes aware of toileting needs, and identifies predisposing diseases as, serious. The summary on 11/26/13 states: Unaware of toileting needs at times due to [DIAGNOSES REDACTED]. Staff anticipate needs by toileting before/after meals and every 2- 3 hours, prn. Surveyor was unable to locate a voiding patterning assessment for Resident #3 when she had a decline in her bladder continence on the 08/21/13 MDS. On 01/15/14 at 2:20 p.m. Surveyor informed Registered Nurse (RN) A that the Surveyor reviewed Resident's #3's medical record and noted Resident #3 had a decline in her bladder continence that was identified on the quarterly MDS on 08/21/13. Surveyor # informed RN A that the Surveyor was unable to locate an assessment or patterning of normal voiding patterns when the decline was identified. On 01/16/14 at 12:30 p.m., Surveyor and Surveyor met with RN A and the Director of Nursing (DON) to discuss the bladder decline. RN A stated that the Resident Care Technicians (RCTs) document in the Kiosk when a resident voids. The Director of Nursing indicated that the RCTs should go right after a resident has voided and input this information into the Kiosk. Surveyor was provided with the bladder detail report for Resident #3. Upon reviewing the information, several incontinent bladder episodes were documented at the same time. RN A stated, "The RCTs are to document live, as it happens, but they are waiting until the end of the shift to enter all the information. Surveyor asked if this was the bladder patterning for Resident #3. RN A stated, "This is what we have since her admission; on the admission I did a tracking but I cannot locate the paperwork. I do not consider the RCT charting the tracking information." RN A stated the reason Resident #3 has a decline is because she has [DIAGNOSES REDACTED], and is on hospice. Surveyor stated that in order to help restore bladder continence, a regular schedule for elimination needs to be based on previous patterns of bladder elimination, so that an individualized program can be established for the resident. The DON stated, "We have our standard toileting schedule for all residents, which is before and after meals, A.M. and bedtime, and before activities." Surveyor stated that the medical record does not document that any interventions were offered to maintain the bladder function for Resident #3. Surveyor stated that the facility policy identifies that when a decline occurs, the resident will be re-evaluated for bladder patterns. The policy also identifies the types of bladder programs that are to be offered, based upon the resident's ability. The quarterly assessment completed was not a comprehensive assessment for Resident #3's decline in bladder continence. It does not identify the type of incontinence, or address medications, or patterns of voiding. Further information was not obtained or assessed when the decline in bladder function was reported on the quarterly MDS, dated [DATE]. Review of this information indicates that the facility had not comprehensively assessed and reviewed all factors that contributed to Resident #3's change in status and develop a comprehensive plan of care based upon the results of the assessment; including review of a three day pattern related to bladder continence status, or offer an individualized toileting program. Review of documents indicate that Resident #3 went from being occasionally incontinent of bladder to frequently incontinent of bladder in the time span of May 2013 to August 2013. 2. Resident #5 On 01/15/14, Surveyor reviewed the MDS bladder continence section for Resident #5, dated 09/16/13, which stated Resident #5 was occasionally incontinent of bladder. This surveyor reviewed MDS bladder continence section for Resident #5, dated 12/11/13, which states Resident #5 is frequently incontinent of bladder. The facility's bowel and bladder assessment does not indicate type of incontinence the resident had or address individualized toileting program needs. On 01/15/14, Surveyor reviewed Resident #5's Bowel and Bladder assessment, dated 09/09/13. The following was noted on the assessment: Resident #5 always voids correctly, is never incontinent of bladder, can walk to bathroom or transfer self to toilet alone with reasonable speed, is alert and oriented, is always alert and oriented, has no redness to skin on genital, perineal or buttocks area and is considered "minor" for predisposing disease. The Bowel and Bladder assessment summary is not completed by facility staff and was left blank. On 01/15/14, Surveyor reviewed Resident #5's Bowel and Bladder assessment dated [DATE]. The following was noted on the assessment: Resident #5 voids correctly at least once a day, is incontinent of urine 1-3 times per week, is completely immobile or needs assist to the bathroom or toilet, is forgetful but can follow commands, usually is mentally aware of toileting needs, has no redness to skin on genital, perineal or buttocks area and is considered "minor" for predisposing diseases. The Bowel and Bladder assessment summary states, "[MEDICAL CONDITION] and dementia have limited his awareness of toileting needs @ times." On 01/15/14, Surveyor reviewed Resident #5's Care Card dated 01/14/14. Resident Care Card states, "Comprehensive bladder assessment on annual and as needed basis to track incontinence patterns." This surveyor reviewed Resident #5's Comprehensive Care Plan, dated "09/19/13 - Present," which stated, "Check for incontinence; change if wet/soiled." On 01/15/14 at 2:25 p.m., Surveyor and Surveyor interviewed Registered Nurse (RN) A. RN A stated she is responsible for assessing residents for bowel and bladder function. RN A states bowel and bladder tracking is done quarterly and annually unless there is a significant change in condition which would warrant additional assessment. RN A stated facility does not have a specific toileting program for residents other than residents being toileted every two to three hours, after meals and activities, in the morning and at bedtime. RN A stated facility does not have individualized bowel and bladder programs that are designed to meet the individual needs of each resident. RN A stated facility was paper tracking bowel and bladder activity of the residents prior to new computer system and changes in MDS may be due to computer capturing a more accurate image. RN A stated, "A lot of changes occurred this past summer...possibly why such a big change in MDS coding." RN A stated Resident #5 had a decline in bladder function due to having a [DIAGNOSES REDACTED]. RN A stated no individualized bladder plan needed due to Resident #5 being on Hospice and bladder function is expected to decline. On 01/16/14 at 12:25 p.m., Surveyor and Surveyor interviewed the DON and RN A. RN A stated Kiosk charting by RCTs is not considered bowel and bladder tracking. RN A stated three day bowel and bladder tracking is done upon admission, annually and with significant changes in condition. Surveyor asked DON what Standard of Practice the facility used for monitoring bowel and bladder patterns for all residents and DON stated, "The facility has been using the same standard of practice for years" and we take bits and pieces out of the corporate policy to best meet the needs of this facility. No further information was provided to this surveyor. No bladder assessment was provided to Surveyor which correlated with the MDS dates which indicated the change in bladder function for Resident #5. No completed three day bowel and bladder tracking assessments, which correlated with the MDS dates, was provided to this surveyor. No further information was provided. Catheter Care 3. Resident #2 Surveyor reviewed current Healthcare Infection Control Practices Advisory Committee (HICPAC) standards in a document entitled, "Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009" which states: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. (Category II) (Key Question 2C) On 01/15/14, Surveyor reviewed facility policy and procedure titled, "Standing Order," undated, which stated, "12. Replace Foley catheter q (every) 4 weeks, unless otherwise ordered." On 01/14/14, Surveyor reviewed Resident #2's medical record and it was noted that Resident #2 has a supra-pubic catheter. Resident has a current [DIAGNOSES REDACTED]. Review of Resident #2's [DIAGNOSES REDACTED]. On 07/12/13, an order was obtained to change supra-pubic catheter monthly. The medical record did not reveal a physician's documented rationale for changing the catheter monthly. No description of the size of catheter or balloon was indicated on physician order. On 01/15/14, Surveyor reviewed catheter change from 10/22/13 - 12/25/13. The following catheter changes were noted on the following dates: - 10/22/13 - 10/29/13 - 11/06/13 - 11/12/13 - 11/17/13 - 11/29/13 - 12/15/13 - 12/25/13 On 01/15/14, Surveyor reviewed documentation which stated, "Next scheduled change: 1/25 (will be requesting orders from Dr. Stoughton to change as needed vs. q month)." On 01/15/14 at 2:20 p.m., Surveyor interviewed the DON. The DON stated catheters are changed every four weeks for Resident #2 "partly because of mucus and that is typically how catheters are ordered...we (facility) are trying to get away with having catheters changed every four weeks...we (facility) are currently still changing every four weeks but it is our goal is to change to as needed per the best practice." The DON stated she is aware that changing every four weeks is not the standard of practice and will be changing this policy soon.

Based on observations, record review and interviews, the facility did not complete a thorough assessment to determine the root cause of decline in bowel function or offer appropriate interventions which would allow the residents to maintain or restore their bowel function for 4 of 9 residents reviewed for a decline in bowel function (Residents #4, 5, 1, 3) As evidenced by: The facility policy titled: Bowel and Bladder Evaluation and Retraining, dated 2010 includes in part: Policy: It is the policy of this facility that based on the resident's comprehensive assessment the facility will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much bowel and bladder function as possible. Each new resident will be monitored for 72 hours for bladder and bowel patterns and incontinence and then evaluated for feasibility in retraining for an individualized, resident-centered toileting program or trial for bladder and bowel control. When a significant change affecting elimination occurs (i.e. decline or improvement), the resident will be re-evaluated. Procedure: 4. Based on the bowel and bladder data collection, the type of retraining program will be determined based on the assessment. 5. Training program will be evaluated for effectiveness at a minimum of quarterly with MDS. Types of toileting Programs with indications for Participation: Scheduled/habit toileting plan- scheduled toileting at regular intervals on a planned basis to match voiding habits, for cognitively impaired functionally disabled, caregiver dependent. 1. Surveyor reviewed Resident #1's medical record on 01/14 - 01/16/14. Resident #1 was admitted in February of 2013. The admission Minimum Data Set (MDS), dated [DATE], identifies she is always continent of bowel. On 05/22/13, the quarterly MDS documents Resident #1 is continent of bowel, on 08/21/13, the quarterly MDS documents a decline in bowel function to frequently incontinent of bowel, and on 11/13/13, the quarterly MDS documents the resident is always incontinent of bowel. The MDS also documents the resident needs extensive assist with toileting and two person assist. The resident care card identified under Toileting: Continent bladder/Incontinent Bladder. Continent Bowel/Incontinent Bowel commode, bed pan, barrier cream with peri cares, briefs. The care plan problem titled: (Resident #1) is occasionally incontinent due to limited mobility, need for extensive total assist with toileting from staff due to advanced dementia. Goal: (Resident #1) will not have UTI or skin breakdown due to incontinence. Interventions read in part: Check for incontinence; change if wet/soiled. Check for incontinence and/or offer toileting if awake every 2 hours on NOC (night). Bowel and bladder assessment on quarterly basis. Surveyor reviewed the quarterly bowel/bladder assessments that were completed on 08/30/13 and 11/27/13. The assessment on 08/30/13 identified the resident is incontinent of stool one to three times per week, that she is completely immobile, is forgetful but can follow commands, is usually aware of toileting needs, and identifies predisposing diseases as minor. The summary on 08/30/13 states: ...will at times request toileting, staff anticipate needs by toileting before/after meals/activities. Barrier cream applied. The assessment on 11/27/13 identified the resident is incontinent of stool four to five times per week, that she is completely immobile, is forgetful but can follow commands, is sometimes aware of toileting needs, and identifies predisposing diseases as absent. The summary on 11/27/13 states: Due to advanced dementia is not always aware of need to void. Staff toilet before and after meal/activities and prn (as needed). Surveyor # was unable to locate a bowel patterning assessment after Resident #1 had a decline in her bowel continence. On 01/15/14 at 2:20 p.m., Surveyor informed Registered Nurse (RN) A that the Surveyor reviewed Resident #1's medical record and noted Resident #1 had a decline in her bowel continence that was identified on the quarterly MDS on 08/21/13 and 11/13/13. Surveyor informed RN A that the Surveyor was unable to locate an assessment or patterning when the decline was identified. When asked about doing a bowel patterning or tracking log, RN A stated, "Upon admission, and then yearly we do the tracking, or if there was a significant change." Surveyor asked why RN A thought there was a decline in bowel function. RN A stated, "We went to computer charting this summer, so I think we are collecting more accurate information that is being charted when it happens." The quarterly assessment completed was not a comprehensive assessment for Resident #1's decline in bowel continence. Further information was not obtained or assessed when the decline in bowel function was reported on the quarterly MDS 08/21/13 and 11/13/13. Review of documents indicates that Resident #1 went from being continent of bowel to always incontinent of bowel in the time span of February 2013 to November 2013 without being comprehensively assessed by the facility to determine contributing factors, or offering an individualized toileting program to the resident that would help to restore/maintain her bowel continence. 2. Surveyor reviewed Resident #3's medical record from 01/14 - 1/16/14. Resident #3 has [DIAGNOSES REDACTED]. The brief interview for mental status (BIMS) was completed by the staff and documents she is severely impaired. Resident #3's admission MDS, dated [DATE], identifies that she is occasionally incontinent of bowel. The quarterly MDS on 08/21/13 documents Resident #3 is occasionally incontinent of bowel. The quarterly MDS on 11/13/13 documents a decline in bowel function to frequently incontinent of bowel. The MDS also documents the resident needs extensive assist with toileting and two person assist. The resident care card identified under Toileting: Incontinent bladder/Incontinent Bowel. Extensive assist commode, ...barrier cream with peri cares, briefs. The care plan problem titled: (Resident #3) has a self care deficit - extensive assistance of 1 staff required with bathing...two staff and mechanical lift for all transfers.... Goal: (Resident #3) will not have UTI or skin breakdown due to incontinence. Interventions in part: Use incontinence products to protect dignity and clothing. Bowel and Bladder assessment quarterly and prn. The history of stage II pressure ulcer care plan includes these interventions in part: Provide hygiene after voiding/BS to prevent skin breakdown. Apply moisture barriers. Surveyor reviewed the quarterly bowel/bladder assessments that were completed on 08/30/13 and 11/26/13. The assessment on 08/30/13 identified the resident is never incontinent of stool, that she is completely immobile, is forgetful but can follow commands, is usually aware of toileting needs, and identifies predisposing diseases as absent. The summary on 08/30/13 states: Unaware of toileting needs at times due to Lewy body advanced dementia. Staff anticipate needs. Barrier cream applied. The assessment on 11/26/13 identified the resident is incontinent of stool one to three times per week, that she is completely immobile, is forgetful but can follow commands, is sometimes aware of toileting needs, and identifies predisposing diseases as serious. The summary on 11/26/13 states: Unaware of toileting needs at times due to [DIAGNOSES REDACTED]. Staff anticipate needs by toileting before/after meals and every 2- 3 hours, prn. Surveyor was unable to locate a bowel patterning assessment after Resident #3 when she had a decline in her bowel continence on 11/13/13 MDS. On 01/15/14 at 2:20 p.m., Surveyor informed RN A that the Surveyor reviewed Resident #3's medical record and noted Resident #3 had a decline in bowel continence that was identified on the quarterly MDS in November, and was unable to locate an assessment or patterning when the decline was identified. On 01/16/14 at 12:30 p.m., Surveyor and Surveyor met with RN A and the Director of Nursing (DON) to discuss the bowel decline. RN A stated that the Resident Care Technicians (RCTs) document in the kiosk when a resident has a bowel movement. The DON indicated that the RCTs should go right after a resident has a bowel movement and input this information into the kiosk. On 01/16/14 the facility provided Surveyor with additional information to review with regard to Resident #1's bowel continence status. Within this information, the facility indicated that Resident #1's change in continence status is related to changes in her [DIAGNOSES REDACTED]. Surveyor reviewed bowel/ bladder notes from 09/02/13 - 09/14/13, that were given to support the gastrointestinal issues. The notes document some increase in soft unformed stools. The medical record does not contain a bowel patterning assessment at this point and time to help restore bowel continence. In addition, the care plan was not individualized to assist the resident in restoring her bowel function. Review of this information indicates that the facility had not, prior to Surveyor expressing concerns related to Resident #1's bowel continence status, comprehensively assessed and reviewed all factors that contributed to Resident #1's change in status and developed a comprehensive plan of care based upon the results of the assessment, including review of a three day pattern related to bowel continence status. Surveyor was provided with the bowel and bladder kiosk detail report for Resident #1 and #3. Upon reviewing the information, several incontinent bowel movements were documented at the same time. RN A stated, "The RCTs are to document live, as it happens, but they are waiting until the end of the shift to enter all the information. Surveyor asked if this was the bowel patterning for Resident #1 and #3. RN A stated, "Yes, this is what we have since their admission; on the admission I did a tracking but I cannot locate the paperwork, this is not what I use but this is what I have for documentation." RN A indicated, the reason Resident #3 has a decline in bowel function, is because she has [DIAGNOSES REDACTED] and is on hospice. Surveyor stated that in order to help restore bowel continence, a regular schedule for bowel elimination needs to be based on previous patterns of bowel elimination so that an individualized program can be established for the resident. The DON stated, "We have our standard toileting schedule for all residents, which is before and after meals, and before activities." Surveyor stated that the medical record does not document that any interventions were offered to maintain the bowel function for Resident #1 and #3. Surveyor stated that the facility policy identified that when a decline occurs the resident will be re-evaluated for bowel and bladder patterns. The quarterly assessment completed was not a comprehensive assessment for Resident #3's decline in bowel continence. Further information was not obtained or assessed when the decline in bowel function was reported on the quarterly MDS, dated [DATE]. In addition, the care plan was not individualized to assist the resident in restoring her bowel function. Review of this information indicates that the facility had not comprehensively assessed and reviewed all factors that contributed to Resident #3's change in status and developed a comprehensive plan of care based upon the results of the assessment, including review of a three day pattern related to bowel continence status. This is the information that the facility needed to utilize to be able to work to restore Resident #3's continence status back to being occasionally incontinent of bowel. Review of documents indicates that Resident #3 went from being occasionally incontinent of bowel to frequently incontinent of bowel in the time span of August 2013 to November 2013. 3. On 01/15/14, Surveyor reviewed the MDS section for Resident #4, dated 07/24/13, which stated Resident #4 was always continent of bowel. This surveyor reviewed MDS section on Bowel continence for Resident #4, dated 10/09/13, which stated Resident #4 was occasionally incontinent. A significant change MDS was completed on 01/7/14. This MDS idenfied the resident is now frequently incontinent of bowel. On 01/15/14, Surveyor reviewed Resident #4's Bowel and Bladder assessment, dated 10/22/13 (this was not completed when the decline was identified). The following was noted on the assessment: Resident #4 voids correctly at least once a day, is incontinent of stool 1-3 times per week (x1 small in pad), needs assistance from one side when being assisted to bathroom or toilet, is forgetful but can follow commands, is usually mentally aware of toileting needs, has no redness to skin on genital, perineal or buttocks area, is considered "minor" for predisposing diseases. The Bowel and Bladder assessment summary states Resident #4 has a history of UTI's - none this quarter and needs assist due to Lewy Bodies and [MEDICAL CONDITION]. The facility's bowel and bladder assessment does not indicate type of incontinence or address individualized toileting program needs. The facility did not complete 72 hour monitoring following identification of the decline (per facility policy). On 01/15/14, Surveyor reviewed Resident #4's Bowel and Bladder assessment, dated 01/13/14. The following was noted on the assessment: "Resident #4 voids correctly at least once a day, is incontinent of stool 1-3 times per week, is completely immobile or needs assist from more than when needing to use bathroom or toilet, is confused and needs physical prompting, is usually mentally aware of toileting needs, has no redness to skin on genital, perineal or buttocks area and is considered "minor" for predisposing diseases. The Bowel and Bladder assessment summary states "[DIAGNOSES REDACTED] and [MEDICAL CONDITION] make (Resident #4) unable to voice toileting needs at times. Rather he stands up (attempts) on own wherever he is to eliminate. Toileted immediately after every meal to (decrease) falls and incontinence." The facility's bowel and bladder assessment does not indicate type of incontinence or address individualized toileting program needs. The facility did not complete 72 hour monitoring following identification of the decline (per facility policy). On 01/15/14, Surveyor reviewed Resident #4's Care Card, dated 01/14/14. Resident #4's Care Card stated, "Comprehensive bowel assessment on annual and as needed basis to track incontinence patterns." This surveyor reviewed Resident #4's Comprehensive Care Plan dated "07/16/12 - Present" which stated, "Toilet immediately after meals to decrease fall and incontinent risk...assist (Resident #4) to the toilet and with toilet hygiene, barrier cream...Anticipate toileting needs if behaviors and self transfer attempts are arise." The care plan had no changes following a decline in bowel continence. 4. On 01/15/14, Surveyor reviewed the MDS bowel continence section for Resident #5, dated 09/16/13, which stated Resident #5 was always continent of bowel. This surveyor reviewed quarterly MDS bowel continence section for Resident #5, dated 12/11/13, which states Resident #5 is frequently incontinent. On 01/15/14, Surveyor reviewed Resident #5's Bowel and Bladder assessment, dated 09/09/13. The following was noted on the assessment: Resident #5 always voids correctly, is never incontinent of stool, can walk to bathroom or transfer self to toilet alone with reasonable speed, is alert and oriented, is always alert and oriented, has no redness to skin on genital, perineal or buttocks area and is considered "minor" for predisposing disease. The Bowel and Bladder assessment summary was left blank. On 01/15/14, Surveyor reviewed Resident #5's Bowel and Bladder assessment, dated 12/27/13. The following was noted on the assessment: Resident #5 voids correctly at least once a day, is incontinent of stool 1-3 times per week, is completely immobile or needs assist to the bathroom or toilet, is forgetful but can follow commands, usually is mentally aware of toileting needs, has no redness to skin on genital, perineal or buttocks area and is considered "minor" for predisposing diseases. The Bowel and Bladder assessment summary states, "[MEDICAL CONDITION] and dementia have limited his awareness of toileting needs @ times." The facility's bowel and bladder assessment does not indicate type of incontinence or address individualized toileting program needs. The facility did not complete 72 hour monitoring following identification of the decline (per facility policy). On 01/15/14, Surveyor reviewed Resident #5's Care Card, dated 01/14/14. Resident Care Card states, "Comprehensive bladder assessment on annual and as needed basis to track incontinence patterns." This surveyor reviewed Resident #5's Comprehensive Care Plan, dated "09/19/13 - Present," which stated, "Check for incontinence; change if wet/soiled." The assessment dated [DATE] states the resident is usually aware of toileting needs, yet no patterning or individualized plan to try to improve continence is identified. On 01/15/14 at 2:25 p.m., Surveyor and Surveyor interviewed RN A. RN A stated she is responsible for assessing residents for bowel and bladder function. RN A states bowel and bladder tracking is done quarterly and annually unless there is a significant change in condition which would warrant additional assessment. RN A stated facility does not have a specific toileting program for residents other than residents being toileted every two to three hours, after meals and activities, in the morning and at bedtime. RN A stated facility does not have individualized bowel and bladder programs that are designed to meet the individual needs of each resident. RN A stated facility was paper tracking prior to new computer system and changes in MDS may be due to computer capturing a more accurate image. RN A stated, "A lot of changes occurred this past summer...possibly why such a big change in MDS coding." RN A stated Resident #4's disease process has progressed and due to his [MEDICAL CONDITION], Lewy Bodies Disease and recent placement on hospice is why there is a change in bowel function. RN A stated because Resident #4 is on hospice there is not a need for an individual bowel program, "It is expected for the resident to decline when on hospice." RN A stated Resident #5 had a decline in bowel function due to having a [DIAGNOSES REDACTED]. Again, RN A stated no individualized bowel plan due to Resident #5 being on hospice and bowel function is expected to decline. On 01/16/14 at 12:25 p.m., Surveyor and Surveyor interviewed the DON and RN A. RN A stated Kiosk charting by RCTs is not considered bowel and bladder tracking. RN A stated three day bowel and bladder tracking is done upon admission, annually and with significant changes in condition. Surveyor asked the DON what Standard of Practice the facility used for monitoring bowel and bladder patterns for all residents and DON stated, "The facility has been using the same standard of practice for years" and we take bits and pieces out of the corporate policy to best meet the needs of this facility. No further information was provided to this surveyor. No bowel assessment was provided to Surveyor which correlated with the MDS dates which indicated the change in bowel function for both Resident #4 and Resident #5. No completed three day bowel and bladder tracking assessments, which correlated with the MDS dates, was provided to this surveyor.

UNCORRECTED AT VERIFICATION VISIT (Previous survey Event ID: K88C11) Based on interview and record review, the facility did not complete a thorough assessment to determine the root cause of a decline in bowel function or offer appropriate interventions, which would allow the resident to maintain or restore his or her bowel function. This occurred for 1 of 6 sampled residents (Resident #17) reviewed for a decline in bowel function. This is evidenced by: During the facility's recertification survey from 01/14/14 to 01/16/14, Surveyor reviewed the facility policy, entitled, "Bowel and Bladder Evaluation and Retraining," which is dated 2010. The policy states, in part: "Policy: It is the policy of this facility that based on the resident's comprehensive assessment the facility will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much bowel and bladder function as possible. "Each new resident will be monitored for 72 hours for bladder and bowel patterns and incontinence and then evaluated for feasibility in retraining for an individualized, resident-centered toileting program or trial for bladder and bowel control. When a significant change affecting elimination occurs (i.e. decline or improvement), the resident will be re-evaluated... "Procedure: 4. Based on the bowel and bladder data collection, the type of retraining program will be determined based on the assessment. "5. Training program will be evaluated for effectiveness at a minimum of quarterly with MDS..." Example: On 02/24/14 at 10:44 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the facility's "Bowel and Bladder" policy (as stated above) remains the same, but the facility is now trying to follow it. The DON indicated the facility is now monitoring bowel and bladder incontinence for eight days, and will be doing this for all residents who show a decline with incontinence since the resident's admission to the facility. After the eight day tracking is complete, and the resident's voiding pattern is assessed, the facility then completes a month-long tracking for the resident's elimination patterns. On 02/24/14 at 10:50 a.m., Surveyor reviewed Resident #17's medical record. A Minimum Data Set (MDS), dated [DATE], indicates under section H: Bowel and Bladder Functioning, Resident #17 was continent of her bowels. An MDS, dated [DATE], indicates, under Section H, Resident #17 is occasionally incontinent (one episode of bowel incontinence in a week). There is no documentation in Resident #17's medical record which indicates the cause of the decline in bowel incontinence and what interventions the facility will attempt, in order to promote the resident's bowel continence. Resident #17's "Bowel & Bladder Assessment," dated 01/20/14, identifies the following information, in part: 1...Voids correctly? Yes--at least once a day 2...Is incontinent of stool (bowel movement)? No--never 5...Mentally aware of toileting needs? Usually. Inc (incontinent) at NOC (nighttime) Summary: Aware of toileting needs @ (at) times, has functional incontinence...Inc at NOC and unaware of those @ times. Staff check incontinent product every 2-3 hrs (hours) (and) offer toileting if (Resident #17's first name) awake during check." The "Bowel & Bladder Assessment" is not a comprehensive assessment to determine the cause of Resident #17's decline in bowel function, as identified on the MDS, dated [DATE]. The assessment does not identify the interventions which will be attempted, in order to promote the resident's bowel continence. This assessment was also completed 20 days after Resident #17's MDS identified a decline in the resident's bowel function. On 02/14/14 at 12:30 p.m., Surveyor interviewed the DON, along with Registered Nurse (RN) A. The DON indicated the facility has not been monitoring Resident #17's elimination and incontinence patterns, as this tracking will occur in April to coincide with the resident's quarterly MDS. Surveyor then asked the DON and RN A what was the extent of Resident #17's bowel incontinence for the MDS, dated [DATE]. RN A then reviewed and counted Resident #17's bowel incontinence documentation on the computer. After review, RN A indicated Resident #17 had one small soft "wet fart" during the time period of the MDS, dated [DATE]. RN A indicated Resident #17 has had one watery bowel movement so far in February 2014, but the resident is believed (by the DON and RN A) to be on an antibiotic. An antibiotic could contribute to a resident having bowel incontinence, but this is not documented in the resident's medical record.

UNCORRECTED AT VERIFICATION VISIT (Previous survey Event ID: K88C11) Based on interview and record review, the facility did not complete a thorough assessment to determine the root cause of a decline in bladder function or offer appropriate interventions which would allow the resident to maintain or restore his or her bladder function. This occurred for 1 of 4 residents (Resident #18), who were reviewed for a decline in bladder function. This is evidenced by: During the facility's recertification survey from 01/14/14 to 01/16/14, Surveyor reviewed a facility policy, entitled, "Bowel & Bladder Assessment." The undated policy states the following, in part: "Purpose: 1. Identify history and patterns of bowel and bladder function 2. To identify type of incontinence 3. To identify mobility limitations which affect elimination 4. To review medications and [DIAGNOSES REDACTED]. 5. To identify appropriate treatment plan for the resident 8. To improve the morale and restore the resident's dignity and respect 9. To restore optimum level of bowel and bladder function 10. In to include interdisciplinary approach with individualized care plan. Policy: Based on the resident's comprehensive assessment the facility will ensure that each resident with bowel and/or bladder will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible. Procedure: Each resident will be assessed for 72 hours for bowel and bladder voiding patterns on admission, quarterly and with a significant change in elimination patterns with evaluation for feasibility in retraining for bowel and/or bladder control... 2. The licensed nurse will gather information from the chart, the resident's family/representative, staff members, from resident observations, and from review and analysis of the 72 hour voiding patterns... 4. The resident's plan of care will be developed to address the issue, goals, and appropriate interventions for elimination program..." Example: On 02/24/14 at 10:44 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the facility's "Bowel and Bladder" policy (as stated above) remains the same, but the facility is now trying to follow it. The DON indicated the facility is now monitoring bowel and bladder incontinence for eight days, and will be doing this for all residents who show a decline with incontinence since the resident's admission to the facility. After the eight day tracking is completed and the resident's voiding pattern is assessed, the facility then completes a month-long tracking for voiding patterns. On 02/24/14 at 11:00 a.m., Surveyor reviewed Resident #18's medical record. A Minimum Data Set (MDS), dated [DATE], indicates under section H: Bowel and Bladder Functioning, Resident #18 was occasionally incontinent of her bladder. The coding guideline for a resident being occasionally incontinent, is defined as having one episode of bladder incontinence in a week. Resident #18's MDS, dated [DATE], indicates, under Section H, the resident is frequently incontinent (two or more episodes of incontinence, but at least one continent episode in a week). There is no documentation in Resident #18's medical record which indicates the cause of the decline in bladder function, or the interventions the facility will implement, in order to promote the resident's bladder continence. Resident #18's "Bowel & Bladder Assessment," dated 01/24/14, indicates the following information, in part: 1...Voids correctly? Yes--at least once a day 3...Can walk to bathroom or transfer self to toilet. (Can manage clothing, wipe, etc.)? Needs assistance from one side 5...Mentally aware of toileting needs? Usually. (Not) @ (at) NOC (nighttime) 7...Predisposing disease--diabetes (diabetes was underlined by nurse), bladder or prostate, frequent UTI's (Urinary Tract Infections), spinal cord injuries, [MEDICAL CONDITION]? Minor Summary: (Resident's first name) is unaware of need to toilet at NOC at times (does not wake up when she gets the urge to void), which leads to incontinence. During the day is able to recognize the need to toilet, but at times does not recognize the need to alert staff that she has to void which leads to incontinence while she is searching for a bathroom. Staff is aware to offer toileting to her when (Resident #18's first name) 'wandering' as she may be looking for a toilet..." The "Bowel & Bladder Assessment" is not a comprehensive assessment to determine the type of Resident #18's incontinence, the cause of her decline in bladder function, as identified on the MDS, dated [DATE], and the interventions attempted, in order to promote the resident's bladder continence. This assessment was also completed 16 days after Resident #18's MDS identified a decline in the resident's bladder function. On 02/14/14 at 12:30 p.m., Surveyor interviewed the DON, along with Registered Nurse (RN) A. The DON indicated the facility has not been monitoring Resident #18's elimination and incontinence episodes, as this tracking will occur in April to coincide with the resident's quarterly MDS. Surveyor asked if the facility assessed the cause of Resident #18 decrease in bladder function, as indicated on the MDS, dated [DATE]. RN A then reviewed Resident #18's medical record on the computer. After review, the DON and RN A stated Resident #18 had a decrease in her antipsychotic medication, which was the only change at the time of the MDS assessment. Medications which have been shown to affect continence, such as antipsychotic medications, may cause overflow or functional incontinence. A dosage decrease in an antipsychotic medication may improve bladder incontinence in residents. The facility did not identify potential causes in the assessment, or document this in the resident's medical record. On 02/24/14, during a separate interview, Surveyor asked RN A what the frequency was regarding Resident #18's bladder incontinence for the MDS, dated [DATE]. RN A indicated Resident #18 was incontinent of her bladder 15 times during the MDS assessment period of 01/08/14. RN A further indicated Resident #18 is currently incontinent of her bladder eight times per week. The reason for the resident's decline and change in bladder function is not documented in the resident's medical record.