Every finding on record at Aspirus Care & Rehab-Medford

Based on observation, interview and record review, the facility did not ensure that 2 of 2 residents (R) reviewed for pressure injuries (PI) (R7 and R30) received care consistently with professional standards of practice to prevent further deterioration and promote healing of an existing PI.R7 and R30 were at risk for PI development. The facility failed to provide complete comprehensive weekly assessments with staging of the PI. This is evidenced by Example 1 The standard of practice for staging pressure injuries is based on the NPIAP (National Pressure Injury Advisory Panel) system, which categorizes injuries from Stage 1 to Stage 4, along with Unstageable and Deep Tissue Pressure Injury (DTPI). Staging is based on the anatomical depth of tissue destruction (epidermis, dermis, muscle, bone). Facility's policy titled Pressure Ulcers and other Wounds Procedure effective date of 03/2023, documented in part. 2. Assessment .3. Characterize the wound and pressure ulcer when documenting. a. Document pertinent characteristics of existing pressure ulcers and other wounds including: i. Location, size depth, maceration, color, description of drainage, eschar, necrosis, odor, tunneling, undermining, tissue types, description of periwound. R7 was admitted to the facility on [DATE]. R7's diagnoses include palliative care, Parkinson's disease and heart failure. R7's admission Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status score of 7/15, meaning severe cognition impairment. R7 is dependent on staff to shower/bathe, lower body dressing, and personal hygiene. R7 is at risk of developing pressure injuries, with one stage 3 PI present on admission. On 01/19/26, a skin breakdown assessment was completed with a score of 17. A score of 15-18 is at mild risk for skin breakdown. Physician orders:03/06/26 treatment: Skin: Cleanse 2nd Right toe, Apply wet to dry dressing once daily. Remove dry, until resolved. Leave right shoe off if resident allows daily AM. 03/10/26 Treatment: Skin: Document on ulcer to right 2nd toe until resolved one time per week Wednesday AM FIRST Date: 01/21/26 Care Plan: 02/05/26 I: Have a skin injury. Because I: have an ulcer to my right 2nd toe.I need my nurses to Complete treatment as ordered. Update myself/responsible party as needed. Update Hospice as needed. I need my aides to report soiled or missing bandages to my nurse to be replaced. My goal is to : avoid infection Goal time: Three months Surveyor observed R7's right second toe on 04/07/26 at 9:22 AM when Registered Nurse (RN) C completed wound care. R7's toe appeared to have the tip of the toe curled down. The PI was dry with the wound bed with 100% eschar and with dark to black area on the left side of the toenail and under the toenail. R7's admission skin assessment dated [DATE] documented in part open lesion on foot, 2nd toe, right foot, Description: moist, macerated, fragile, non blanchable. Size: length (cm) 1.5, width (cm) 1.5, Drainage: Sero-sanguious, pink wound bed with white surrounding tissue. On 01/28/26, a weekly skin assessment documented No changes in appearance to the ulcer on right 2nd toe, remains pink and slightly moist. On 02/04/26, a general skin condition note, Right foot second toe, moist open area with bright pink wound bed, the edges are slightly rolled in and has some white tissue, size 1.4 cm x 1.5 cm, scant amount of sero-sanguious. On 02/11/26, a general skin condition note, Right foot second toe, moist open area with bright pink wound bed, some white tissues noted towards the edges, 1.4 cm x 1.5 cm, no drainage. On 02/18/26, no assessment of right foot second toe. On 02/25/26, a weekly skin assessment, Right foot second toe open area, the wound bed is dark brown and dry. The wound edges are slightly rolled in and slightly raised, 1.3 cm x 1.3 cm, no drainage. On 03/04/26, Right foot second toe, the edges are a little swollen and tender to the touch. The wound edges are also slightly rolled in and are pink. Wound bed has some white tissue, and the other part is dark brown, 1.4 cm x 1.4 cm, no drainage has pain to wound site. On 03/11/26, Right foot second toe 1 cm x 0.6 cm, sero-sanguious drainage, it appeared to have a small spot of yellow drainage noted under the corner of the toenail. On 03/18/26, Right 2nd toe, small open area, dry, red wound base, calloused built up areas surrounding open area, 1 cm x 0.5 cm x 0.2 cm depth, and no drainage. On 03/25/26, Right 2nd toe, size n/a, sero-sanguious drainage, yellow. On 04/01/26, Right 2nd toe, area around the nail is reddened, fragile, some scabbing noted. End of toe has eshar(sic) to wound bed, reddened skin around wound, white macerated tissue to planter side of wound, some serous drainage noted to dressing upon removal. Size n/a, and serous drainage. On 04/06/2026 at 1:27 PM, Surveyor interviewed Registered Nurse (RN) C and Director of Nursing (DON) B about R7's wound assessment to include staging and weekly measurements. RN C stated is wound care certified. RN C doesn't do much with staging and has no charting of staging of R7's PI. The area was scabbed filled for the vast majority of the time. DON B stated this would be unstageable. Surveyor asked when the area became unstageable. RN C stated there was a period of time on admission that was not scabbed over. Surveyor asked what the stage of the PI was at that time. RN C stated 2-3 if had to stage on admission, at that time it had a red wound bed. RN C stated she did not stage the wound, the MDS nurse staged the wound. Surveyor asked if MDS nurse observed the PI. RN C stated MDS nurse did not see the PI. RN C stated RN C would see the PI regularly to judge if it is getting larger. The PI is assessed every bath day that is every seven days. The hole itself has not changed much. The second toe is bent down so the tip of the toe is touching the floor and this is where the PI is located. On 04/07/2026 at 9:38 AM, Surveyor interviewed RN D, the MDS nurse, asking about R7's PI staging. RN D stated will look at the wound on the reference date and assess. Will talk with the nurses and DON B and talk about the stage of the wound. Nursing would document the PI on admission and chart what they see. Typically, the nurses don't put the stage on the assessment. We knew about the PI before R7 came to the facility. Felt it was a PI but R7 does have multiple factors that contribute to the wound like diabetes and pvd. On 04/07/2026 10:05 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about assessing and staging of PIs. NHA A felt RN C was doing good at assessing the PI weekly. Surveyor reviewed with NHA A of the assessments not being comprehensive to include description of location on toe, the amount of slough or eschar in the wound bed, the stage of the PI on the admission and weekly assessments, and missing measurements on two weekly assessments. NHA A stated understanding of needing staging of the PI on the assessments and accurate assessments. Example 2 Based on National Pressure Injury Advisory Panel (NPIAP): Calazime is suitable for application on denuded or weeping skin around a pressure injury to promote skin integrity.Instead of paste, the NPIAP typically recommend moisture-retaining dressings for Stage 2 wounds to promote healing, such as hydrocolloids: for low-exudate Stage 2 injuries. Foam dressings: for moderate-exudate Stage 2 injuries. Hydrogels: for dry-to-low exudate wounds. R30 was admitted to the facility on [DATE], after a hospitalization for exacerbation of congestive heart failure. R30's diagnoses included Stage 2 Pressure Ulcers to right and left buttock, per the hospital discharge summary. R30's Minimum Data Set (MDS) assessment was to be completed by 04/07/26. Surveyor was not able to review complete MDS data. R30's wound care notes from the hospital, dated 03/30/26 included diagnoses of Stage 2 Pressure Ulcers to left and right buttock. R30's skin assessment on 04/02/26 included: Coccyx, two left buttock pressure ulcers measuring 1.7cm x 1.7cm and 0.5cm x 1.6cm. Both ulcers appear epithelized with blanchable periwound, no signs of infection and no drainage. Note, skin assessment was not comprehensive and did not include staging of pressure ulcers. R30's wound orders included the following: 04/02/26, Buttock ulcer, apply barrier cream with calazime to area twice daily and as needed, do not cover with bordered foam. Right hip, cleanse with vashe, apply xeroform and bordered foam, change three times weekly and as needed. Check two left buttock pressure ulcers daily. Document two left buttock pressure ulcers weekly. Note, skin assessment did not indicate a wound to right hip or right buttock. Note, R30 did not have a diagnosis of two pressure ulcers to left buttocks upon discharge from the hospital, R30 diagnosis included Stage 2 Pressure Ulcers of left and right buttocks. On 04/07/26 at 9:57 AM, Surveyor interviewed Registered Nurse (RN) E. RN E reported she was not sure where R30's wounds were located, and she would be administering R30's wound care today. On 04/07/26 at 10:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F reported she assisted R30 this morning with cares and did not note any dressings to R30's hip or redness to buttocks or hips. On 04/07/26 at 10:11 AM, Surveyor interviewed R30. R30 reported having an open area to her buttock. R30 denied any wounds located on her hips. R30 stated she did not think the facility staff was applying any dressings to her hip or buttock. On 04/07/26 at 10:17 AM, Surveyor interviewed Director of Nursing (DON) B. DON B was unable to report the reason R30 had a wound treatment order for her right hip. DON B was unable to report if R30 had a treatment order for Stage 2 Pressure Ulcer to right buttock. DON B was unaware if R30 had one or two pressure ulcers to her left buttock. Surveyor asked DON B if R30's wound treatment orders followed a standard of practice for treatment of a Stage 2 Pressure Ulcer. DON B stated she would review R30's record. On 04/07/26 at 10:28 AM, Surveyor observed RN E administer R30's wound care. Surveyor observed R30 had a foam border dressing to her right lower hip, dated 04/05/26. RN E removed the dressing and noted a dark purple colored area, it appeared closed, without redness or drainage. RN E ran a gloved finger over the area and stated this area was indented and a Stage 2 Pressure Ulcer to right buttock or right hip. Surveyor observed that R30 had a pressure ulcer to inner left buttock, area was open and dark pink in color, moist, with small amount of serosanguinous drainage. The skin around the open area was flat, without redness or signs of infection, and darker in color, evidence of wound chronicity. RN E placed a foam dressing to area. RN E stated she would update the wound care nurse as the pressure ulcer to R30's left buttock, looks different today than the other day. On 04/17/26 at 11:00 AM, Surveyor interviewed DON B. DON B stated she thought the nurse who completed R30's admission skin assessment made a mistake and documented R30 had two pressure ulcers to left buttock and meant to document a pressure ulcer to both left and right buttock. Surveyor could not determine if R30's pressure ulcers had worsened due to inaccurate documentation and R30's limited time in the facility. Surveyor determined the following: R30's initial skin assessment was not comprehensive and was inaccurate. The facility's documentation did not support any areas of concern to R30's right buttock or hip, however R30 had a wound treatment order for right hip. The wound treatment order to R30's Stage 2 Pressure Ulcer to left buttock did not follow standards of practice for the condition of the wound.

Based on observation, interview and record review, the facility did not ensure that a resident (R) received treatment and care in accordance with professional standards of practice for 1 out of 13 residents sampled. (R172) The facility did not follow provider's orders, or the facility wound assessment procedures for R172, who was needing care and treatment for a post operative surgical wound. Findings include: The facility's policy titled, Pressure Ulcers and Other Wound Procedure last revised on 03/2023 states in part, . 2. Assessment 1. Frequency .b. A total skin assessment will be done on admission and weekly x 4 by a licensed nurse. R172 was admitted on [DATE] from the hospital with a pertinent diagnosis of hemiarthroplasty hip partial status post age related osteoporosis with fracture of the right femoral neck (this diagnosis was added to R172's record on 6/3/25- effective 5/29/25). Bilateral below the knee amputation, post hemorrhagic anemia, kidney disease- chronic, Type II diabetes w/ peripheral, long term use of insulin, anxiety disorder, and depression. R172's admission Minimum Data set (MDS) was not yet completed. Completed due date would be 6/5/2025. R172's care plan did not include wound care for R172's right hip incision status post hemiarthroplasty done on 5/25/25 at time of State Agency (SA) review on 6/2/25 and was not added to care plan until 6/4/2025. R172 had no documentation for surgical wound assessment, care, or treatment at the time of SA review on 6/2/2025. R172's hospital discharge after visit summary states, in part, Wound/incision care: keep incision clean and dry. Special instructions: call your doctor if you have any of these symptoms: . Increased pain not relieved by medication, Fever over 101 degrees for 24 hours, Increased redness/swelling around incision . Orthopedic discharge instructions: .Remove dressing in 7 days, ok to shower and leave incision uncovered if there is no drainage. On 6/02/25 at 10:19 AM, Surveyor interviewed R172, who reported a patch on right hip surgical site. R172 stated, As far as I can remember, they (facility staff) have not changed bandage or even looked at it, since admission on [DATE]. R172 showed Surveyor right hip area. Surveyor noted a white dressing approximately 4 x 10 adhered to R172's outer hip. Surveyor noted no redness, odor, drainage, or swelling. R172 reported minimal pain. Surveyor did a brief record review noting R172 had no diagnosis or orders for a post operative incision. On 6/02/25 at 12:24 PM, Surveyor interviewed Registered Nurse (RN) F, who stated she is not able to find any orders for incision care or documentation of R172's wound assessment since R172's admission on [DATE]. RN F stated, It should be in there. I will put it in there right now. RN F stated she would have expected an assessment with documentation of the incisional site and dressing change. On 6/02/25 at 1:48 PM, Surveyor interviewed RN F who reported she found R172's after-visit summery with surgical site directions. RN F stated R172's outer dressing was supposed to be removed in 7 days, which would have been yesterday, 06/01/2025. RN F reported she just removed R172's outer white dressing and assessed surgical incision. No concerns noted with incisional site and wound has a clear protective covering over it. RN F reported she was going to document on the wound before she leaves at the end of her shift today. Director of Nursing (DON) B came to nurses' desk during interview. DON B was updated by RN F regarding R172's lack of assessment and documentation of surgical wound. DON B stated, I will have to look into this. On 6/04/25 at 7:41 AM, Surveyor interviewed DON B, who stated the expectation of the facility nurses is to do a complete skin assessment on every resident upon admission. DON B stated when she asked the admitting nurse about the admission assessment, staff missed identifying R172's surgical incision. On 06/04/25 at 11:56 AM, Surveyor interviewed DON B after reviewing admission checklist. DON B acknowledged that because no wound was identified upon R172's admission, there was no treatment record with daily wound checks or skin care plan completed. DON B agreed there was no incisional site assessment or care performed or documented since R172's admission on [DATE] until 6/2/25. DON B stated the expectation is that professional standards of practice for incisional wounds would have been followed by facility nurses. DON B agreed that daily assessments would include dressing placement, assessing for bleeding and signs and symptoms of infection. DON B stated R172's discharge summary orders/after visit summary should have been followed by facility and was not.

Based on observation, interview and record review, the facility did not ensure implementation of person-centered care plan approaches for 1of 13 Residents (R1). This is evidenced by: The facility policy, titled Care Plan (Comprehensive, Temporary and Baseline) last reviewed 11/2020, states in part, The person-centered comprehensive care plan include: a) the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and including the resident's strengths, goals, life history and preferences. R1 was admitted to the facility on [DATE] and has diagnoses that include multiple sclerosis, seizure disorder, paraplegia. R1's Quarterly Minimum Data Set (MDS) assessment, dated 4/23/25, indicated that R1 has a BIMS of 15/15, indicating cognitively intact, and is dependent on staff for mobility and ADLs, including positioning while in bed/wheelchair. R1's care plan, dated 4/29/25, states, I can't complete my cares on my own because I have multiple sclerosis with paraplegia. Approach includes having a lateral support to use in the left side of wheelchair - whether it be a wedge, a rolled blanket, a pillow, etc. On 06/02/25 at 1:35 PM, Surveyor observed R1 leaning heavily to left side while in wheelchair with a loosely folded up blanket in place which was not maintaining upright positioning of R1. On 06/03/25 at 7:03 AM, Surveyor observed R1 in a motorized wheelchair leaning heavily to left side attempting to correct position independently but was unable to maintain upright position. Surveyor asked if R1 was comfortable. R1 stated, No, they don't have my wedge cushion in. I don't know where it is. R1 stated, I wish they would hurry up and get wedge. On 06/03/25 at 7:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding positioning devices for R1. CNA D stated, Yes, [R1] has a wedge cushion that should be in place. Did they forget? CNA D repositioned R1 with wedge cushion along left side and R1 confirmed feeling better. On 06/04/25 at 7:25 AM, Surveyor interviewed CNA C on how staff are informed of proper repositioning devices to use for R1. CNA C showed Surveyor R1's CNA care plan hanging in closet which indicated use of wedge cushion for positioning. On 06/04/25 at 10:52 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectations of implementing care plan approaches. DON B confirmed expectation of staff is to follow resident care plans.

Based on observation, staff interview and record review, the facility did not prepare distribute and serve food in accordance with professional standards for food service safety. This had the potential to affect 21 of 22 residents within the facility. Findings: Glove use The Wisconsin Food Code states in part, Applicability and Terms Defined 1?201.10 Statement of Application and Listing of Terms . Food-contact surface means: . (b) Onto a surface normally in contact with food. 4-904.11 Kitchenware and Tableware. (A) Single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that the contamination of food- and lip- contact surfaces is prevented. Facility's policy titled, Grooming and Personal Health revised 8/23, states in part: .Use tongs, spoons and forks when preparing foods rather than hands whenever possible. Wear sanitary disposable gloves if direct contact of food is necessary. On 04/30/24 at 11:42 AM, Surveyor observed Dietary Aide (DA) D serve hot food to plates with gloved hands. DA D leaned left gloved hand onto the service counter. DA D rested right gloved hand onto the counter. DA D grabbed a plate from plate warmer with contaminated gloved hand touching the food contact surface. DA D placed a piece of chicken onto cutting board with left contaminated gloved hand and cut the chicken in half. DA D put the half of chicken into the hot serve area with same gloved hand. DA D wiped gloves with a dry towel that was lying on the food service counter. DA D then rested both gloved hands on service counter. DA D took a plate holding a cold sandwich from other dietary aide and placed it on the tray and DA D told dietary staff, This one needs mayo. DA D picked up another plate from the warmer touching food contact surface. On 04/30/24 at 12:05 PM, Surveyor interviewed DA D regarding observations of contaminated gloves touching chicken and food contact surfaces. DA D replied, I know that I should have used the tongs for the chicken. I was just nervous. On 04/30/24 at 12:06 PM, Surveyor interviewed Dietary Manager (DM) C about observations made during hot food service with DA D. DM C replied, I'm thinking that I have to have the staff serve barehanded, so they know to use tongs for everything they touch. Sanitizer Bucket Logs The Wisconsin Food Code documents at 4-501.116 Ware washing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. On 04/30/24 at 12:07 PM, DM C showed the sanitization bucket log to Surveyor. Surveyor asked DM C, How often is the log supposed to be documented? DM C replied, The log is supposed to be completed daily. Surveyor informed DM C that there are dates missing from the log and asked for previous logs. Surveyor followed DM C into the office. DM C handed Surveyor logs back to 12/02/23 and stated, It looks like we are not doing a very good job of keeping these logs. On 04/30/24 at 12:30 PM, Surveyor reviewed the sanitization bucket log. Dates missing in December 2023 include: 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30. Dates missing in January 2024 include: 3, 4, 6, 7, 8, 10, 11, 14, 15, 16, 19, 20, 21, 26, 27, 28, 29, 30, 31. Dates missing in February 2024 include: 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 16, 17, 18, 20, 21, 22, 25, 26, 27, 28. Dates missing in March 2024 include: 1, 2, 3, 5, 6, 7, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 25, 26, 27, 29, 30, 31. Dates missing in April 2024 include: 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 26, 27, 28.

Based on observation, record review and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when warranted when providing care to 1 of 4 residents (R) R11. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Hand Hygiene Policy with most recent revision dated 03/2024. The policy in part reads: Purpose: To establish procedures for hand hygiene, which will cleanse the hands of contaminates and microorganisms for protection of everyone. General Instructions: Hand hygiene is the single most important means of preventing spread of infection. Perform hand hygiene with soap and water or alcohol based hand rub for at least twenty seconds: Before direct contact with patients Before donning gloves After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. After contact with the patients intact skin. Surveyor reviewed R11's most recent Significant Change in Status Minimum Data Set (MDS) completed 4/09/24 and noted R11 is dependent on staff for eating, dressing and bed mobility of rolling. R11 is always incontinent of bladder and bowel. On 4/29/24 at 12:37 PM, Surveyor observed Certified Nursing Assistant (CNA) G wash her hands in the dining room and obtain R11's lunch tray to take to R11's room. Once at R11's room CNA H donned a gown and gloves to enter resident room with her lunch tray. CNA G placed R11's lunch tray on her bed side table and raised R11's head of her bed. CNA G placed R11's glasses on resident and placed a towel around resident neck. CNA G brought a chair and bedside table to R11's bed and proceeded to end of bed to raise R11's bed further. CNA G raised R11's bedside table and proceeded to provide R11 drinks of liquids via a glass and attempted to feed R11 foods via a spoon. CNA G wiped R11's lips with a wet cloth and provided R11 cues to swallow. CNA G did not remove her gloves, perform hand hygiene and don clean gloves after touching R11's bed, R11's glasses, the chair in R11's room and the bedside table in R11's room and proceeded to assist R11 with eating. On 5/01/24 at 9:06 AM, Surveyor interviewed CNA G about the observation. CNA G expressed CNA G didn't think about it, but should wash her hands after touching anything dirty and before helping R11 eat. CNA G further expressed it is important because those items are dirty, and you should wash hands before helping residents eat. Example 2 On 04/30/24 at 7:47 AM, Surveyor observed CNA H assist R11 with morning care. CNA H is associated with R11's hospice service. CNA H donned a gown and gloves before entering R11's room without performing hand hygiene. CNA H went to R11's sink in her bathroom to turn on water by the faucet handles with same gloved hands. CNA H returned to R11's bed and adjusted R11's bed height with same gloved hands. CNA H went to R11 and rubbed her shoulder while talking with her. CNA H returned to the bathroom to adjust the water temperature by faucet handles with same gloved hands. CNA H went to R11's wardrobe closet and obtained clean clothes and returned to bedside to talk with resident touching her shoulders again. CNA H went back to the closet for more clothes and proceeded to the bathroom for basin and clean washcloths. CNA H returned to bed and adjusted bed height more. CNA H uncovered R11, removed pillows from in front and behind resident and placed the pillows on a chair in room. CNA H rolled R11 to back with pad that was under R11. CNA H removed heel device from under R11's legs and proceeded to assist R11 with undressing and removing cloths that were rolled into palms of R11's hands. CNA H removed R11's hospital gown and t-shirt. CNA H washed and dried R11's face, hands and underarms. CNA H applied lotion and hisop oil to R11 and proceeded to R11's dresser for clean t-shirt and clean socks. CNA H did not remove her gloves, perform hand hygiene and don clean gloves at any point after touching various presumably dirty items in R11's room or after washing R11. CNA H returned to R11 to don clean t-shirt and shirt. CNA H rolled R11 to window and washed R11's back and pulled down R11's shirts in the back. CNA H placed a clean brief under R11 while she was rolled to window with no change of gloves or hand hygiene. CNA H rolled R11 to her back to wash her peri area. CNA H removed her gloves and used gel on wall for hand hygiene and donned clean gloves. This is the first glove change and hand hygiene since entering R11's room and going from presumably dirty items to clean. CNA H rolled R11 in bed to window. CNA H informed Surveyor the pad underneath R11 is a little wet. CNA H removed the pad and donned a clean brief. CNA H asked R11 if R11 wanted to get up and R11 declined. Registered Nurse (RN) E entered the room to assist CNA H to boost R11 in bed. CNA H removed R11's socks and lotioned her legs. CNA H placed the heels up device on R11's bed, placed R11's legs on device and covered R11 with a sheet. On 4/30/24 at 8:23 AM, Surveyor spoke with CNA H about the observation and the expectation of hand hygiene when going from dirty to clean. CNA H explained CNA H was taught hand hygiene is needed to be done after peri care and denture care but it is Good to know she should perform hand hygiene every time when going from dirty to clean. On 5/01/24 at 10:50 AM, Surveyor spoke with RN I about the observations. RN I is the facility's Infection Control Coordinator. RN I indicated the facility's hand hygiene expectation and policy is based on Centers of Disease Control (CDC) guidelines. CDC guidelines directs staff to remove their gloves, perform hand hygiene and don clean gloves prior to feeding resident. RN I would expect staff to remove gloves, perform hand hygiene whenever touching things in resident room, the patient and equipment that is presumably dirty to prevent cross contamination. Anytime going from dirty to clean.

Based on record review and interview, the facility did not conduct a thorough investigation into allegation of abuse for 1 of 3 residents reviewed for neglect and abuse (R8). Example 1 This is evidenced by: Surveyor reviewed the facility policy titled Abuse, Neglect, Caregiver Misconduct Policy and Procedure with most recent date revision of 11/23. The policy in part reads: Conduct and document a thorough investigation: 1. All alleged violations involving resident mistreatment of injuries of unknown source must be thoroughly investigated and documented. A thorough investigation may include: Interviewing other residents to determine if they have been abused or mistreated. Surveyor reviewed the Facility Reported Incident (FRI) and noted on 3/06/24 R8 reported Someone threw him around last night. The facility interviewed staff and notified the police but did not interview other residents to ensure there were no other reports of potential abuse or mistreatment as part of the investigation. The facility identified an incident during the night shift with R8 being combative during cares with Certified Nursing Assistant (CNA) F. The facility concluded it is likely this incident is where R8's skin tear may have occurred. Surveyor reviewed R8's record and noted the most recent Significant Change in Status Minimum Data Set (MDS) dated [DATE] indicated he is understood, sometimes understands and has moderately impaired cognition. On 4/30/24 at 6:33 AM, Surveyor spoke with Registered Nurse (RN) E. RN E explained R8 made a comment to her someone throwing him around when she asked him about a skin tear on his wrist that was bleeding and needed bandaging. RN E explained R8 can be combative during cares because he doesn't know what staff are doing due to not seeing or hearing well. RN E further explained RN E reported the allegation to the Director of Nursing right away. R8 could not give a timeline of the incident or description of who threw him around. On 04/30/24 at 7:01 AM, Surveyor spoke with CNA F about the incident that occurred on the night shift on 3/06/24. CNA F explained at around 2-230 am she approached R8 to change his pants as he needed assistance to change. R8 was lying in bed and did not want to stand up. R8 wanted his pants changed because he was wet. CNA F moved R8 side to side in bed with bribe of snacks. R8 likes to curse when working with him and was calling her names. R8 was changed without incident, and she did not see a skin tear at that time. CNA F further expressed the day nurse found the skin tear and she is not sure how he got it. CNA F expressed R8 may have hit his end table or siderail while being changed but she did not see it that morning and the lights were on in room. CNA F explained R8 did try to hit her when attempting to pull up his pants and he may have hit his wrist at that time on walker or bedside table. On 04/30/24 at 11:08 AM, Surveyor spoke with Nursing Home Administrator (NHA) A about facility investigation process when abuse is reported and the FRI involving R8. NHA A indicated NHA A is the individual responsible for investigating allegations of abuse. NHA A indicated NHA A was informed of an abuse allegation involving R8 who reported being thrown against a wall last night. R8 did not have a report of a specific staff or time of incident. NHA A explained NHA A spoke with staff who worked the evening and night shift and called law enforcement. A police officer came on site to speak with R8 who changed his story a bit. The officer did not direct NHA A to conduct further interviews or to speak with residents. NHA A explained it is the facility's normal practice to speak with other residents as part of their internal investigation process. NHA A further indicated NHA A did not conduct other resident interviews as part of the investigation as R8's story changed when speaking to the police officer. R8 can be accurate at times and not accurate at times. The facility thought the likely cause of the skin tear to his wrist was a result of him becoming combative during cares on the night shift with CNA F. The facility updated R8's care plan and provided staff training related to combative cares.

Based on interview and record review, the facility did not ensure the medication regimen reviews were completed monthly for 1 of 5 residents (R) reviewed, (R22). R22's record was missing medication reviews for the months of November 2022, December 2022, January 2023, and March 2023 during his current stay at the facility. This is evidenced by: The facility policy, entitled Pharmacy Regimen Review Recommendations, dated 04/2023, states, in part, under the heading Policy, 4. The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist. This review includes a review of the resident's medical chart. R22 was admitted to the facility on [DATE] and has diagnoses including, in part, congestive heart failure (CHF), type 2 diabetes, bipolar disorder, long term use of oral hypoglycemic drugs and injectable non-insulin antidiabetic drugs, kidney disease, and manic depression. R22's Physician's orders include, in part, Spironolactone 25mg twice a day, Metformin 1000mg twice a day, Torsemide 20mg twice a day, Victoza 1.2mg/0.2ml subcutaneous injection daily, lamotrigine 200mg daily, and Aripiprazole 10mg daily. R22 receives high risk medications that include, in part, two different diuretics, and injectable and oral blood sugar lowering medication, an anticonvulsant/mood stabilizer, and an antipsychotic. R22's Minimum Data Set (MDS) assessment, dated 04/10/23, indicated that R22 has no cognitive impairment, has trouble falling or staying asleep nearly every day, receives injections, antipsychotic meds, and diuretics 7 days a week. R22's care plan, dated 11/17/22, states: The potential to feel depressed need medication management. I have depression, I have bipolar disorder. I have PTSD. Interventions include, in part, Administer medications as ordered. R22's care plans, dated 02/06/23, states: I receive insulin I receive an oral medication. I have the potential to experience hypo/hyperglycemia and fluid overload because I have a history of diabetes mellitus type 2 and CHF. Interventions include, in part, Administer medication as ordered registered dietitian and/or diabetic educator to review my chemstrips results as needed to make recommendation to my MD (medical doctor) as needed for my diabetic management. R22's care plans, dated 02/06/23, states: I have hypertension. I have edema. I have hyperlipidemia. I have angina. I have renal disease. I have a-fib. I have CHF because I need medication management. Interventions include, in part, Administer my medication as ordered. Update my MD as needed. Check my blood pressure as ordered. I am on a 2200cc fluid restriction. Surveyor reviewed the medical record and could not locate pharmacy medication reviews for November 2022, December 2022, January 2023, and March 2023. On 04/25/23 at 2:58 p.m., Surveyor interviewed Director of Nursing (DON) B and asked where the reviews were for the missing months. DON B stated, They were not done. The pharmacist stated that when he was trained, he was told he did not need to complete monthly medication reviews for unit 3 residents since they were short term stays. I did educate him that they need to be done if they are here longer than a month. He agreed to do that going forward. DON B provided email proof of conversation, dated 4/24/23, after Surveyors entered and asked questions about the pharmacy reviews. DON B agreed that R22 has high risk medication that places R22 at risk for adverse consequences.

Based on interview and record review the facility did not ensure that each resident's change in condition and injury was thoroughly assessed and documented. This was discovered for 1 of 5 residents sampled for a change of condition for a thorough nurse assessment and subsequent documentation of an injury of unknown origin. R1 (Resident) was found to have a fractured ankle which the facility's investigation into the injury did not discover the circumstances of the injury. The facility was unable to determine how and when the injury took place. However during the investigation it was discovered by the DON (Director of Nursing) and subsequently by the survey team that the injury was not thoroughly assessed and documented for at 2 days prior to updating the physician, getting x -rays, and treating the injury. This is evidenced by: R1 was originally admitted to the facility in (MONTH) of (YEAR). Her [DIAGNOSES REDACTED]. According to her last MDS (Minimum Data Set) assessment dated [DATE] R1 needs the extensive physical assistance of at least one person for all of her dressing, grooming, and hygiene needs. She does not walk and need a mechanical lift to transfer. She is unable to do the standard memory test and has both long and short term memory problems. She is however usually able to understand others and have others understand her needs. The facility submitted to the SA (State Agency) a summary of their investigation that on 11/3/19 R1 was diagnosed with [REDACTED]. The fracture was suspected when RN-E (Registered Nurse) found R1's left ankle to be swollen with yellow bruising on the inside and outside of her ankle. Bruises usually follow a color change as they are resolving with a yellow bruise indicative of an injury 5 to 10 days prior. In the summary the DON discovered during her investigation that on 11/1/19 CNA-D (Certified Nursing Assistant) found R1 expressing pain in her left ankle and reported this to RN-C (Registered Nurse). RN-C told the DON she had assessed the areas and R1 did not appear to be in any pain and did not notice any swelling. RN-C wrote a statement addressed to the NHA (Nursing Home Administrator) that stated, Was reported to me that R1 had pain during her range of motion with her legs. R1 usually when in her wheelchair takes her left leg off the pedals. I put it back on once she was in the wheelchair. She didn't yell out that time. When I had a moment I looked to check if her dressing (on her right calf) was on and I didn't notice any bruising or out of the ordinary swelling on either legs . On 11/25/19 at 11:33 a.m. Surveyor interviewed RN-C about her assessment of R1's leg and ankle after it was reported to her on the morning of 11/1/19. RN-C stated she had done a late entry of her assessment. RN-E stated R1 was up in her wheelchair by the time she was able to assess the area and put R1's left foot back on the foot pedal as it was off and while doing so she looked to see if R1 grimaced. RN-E stated she saw nothing out of the ordinary when she compared R1's legs. RN-E stated she took off the CAM boot on the right leg and compared the two and neither had redness or bruising. RN-E stated she did not recall what type of footwear R1 had on but thought it was a shoe on her left foot. RN-E was asked if during her assessment if she had palpated or manipulated R1's joints to assess their condition and if that would elicit any pain. RN-E stated she touched her ankle but did not go any further, I didn't do anything like that because I was told it hurt her and I didn't want to hurt her anymore. I just looked There is no evidence of this assessment or any assessment on 11/1/19. According to AMDA (American Medical Directors Association) guidelines titled Acute Change in Condition in the Long-term Care Setting dated 2003; an acute change of condition is a deviation from the resident's norm that is clinically important in that it may result in complications. The facility's policy for reporting a change of condition states it is the responsibility of the nurses to determine this. Surveyor's review of the Merck Manuel, Professional Version of 2014 the accepted way to assess the ankle joint for pain, besides a visual comparison to the unaffected side, is to feel gently to detect subtle swelling, palpate over the bones and ligaments and do passive range of motion in all directions to determine the extent of the pain and swelling. On 11/25/19 at 12:23 a.m. Surveyor interviewed the DON about the investigation and what would be considered a thorough assessment of pain and swelling of a joint. The DON stated the expectation is you can't just look at it you have to move it and touch it. Surveyor reviewed all of the documented nursing assessments for (MONTH) and (MONTH) and there are none recorded from 10/30/19 until the morning of 11/3/19. The 11/3/19 notations by RN-E notes that R1's ankle was noted to be swollen at least as far back as the evening of 11/2/19 however there is no evidence of any assessments all day on 11/2/19 either. On 11/3/19 RN-E found R1's ankle to be very swollen and some fading bruise noted on the inner and outer ankle. Resident yells out in pain when the area is touched. The note goes on to record her updating of the on-call physician and R1's decision maker. An x-ray was ordered, taken, and reviewed. The 3 fractures were discovered. The on-call physician them came to the facility and casted the injury and gave orders that R1 should be seen by a bone and joint specialist the next day.

Based on interview and record review the facility did not ensure that each possible abuse allegation was thoroughly investigated and measures were put in place to prevent a similar situation. This was found for 1 of 5 sampled residents. (R1) Resident presented with a significant injury of unknown origin. The facility did not explore measures to prevent issues discovered during their investigation. The DON (Director of Nursing) did not investigate why alleged assessments of the injury were not done, not thorough, and not documented. The facility in turn did not explore measure to prevent the apparent delay in [DIAGNOSES REDACTED]. This is evidenced by: On 11/3/19 R1 (Resident) was discovered with her left ankle fracture in 3 places. The DON (Director of Nursing) was unable to determine the cause, date, and circumstances of this significant injury. The interviews conducted during her investigation found that R1 had pain and swelling for at least 2 days and a fading yellow bruise that would indicate an injury 5 to 10 days old already. There is no evidence the DON or other facility staff investigated why there is no documentation of any assessments nor calls to a physician. This further investigation being an attempt to discover the root cause of the injury or why the nursing staff did not discover an injury that showed clinically significant signs of having been there for a week. On 11/25/19 at 12:26 a.m. Surveyor interviewed the DON about the investigation, her findings, and what had been done to try to prevent another injury and lack of a thorough assessment in a similar circumstance with other residents. The DON stated that she had interviewed all of the staff and no one had any definitive information as to the the cause of the injury. The DON stated she could find no identified incident and that a lot of the time after an investigation there is some whole house education or audits but not after this incident.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents reviewed (R23) for unnecessary medications were given the opportunity for a reduction in these medications. R23 is receiving [MEDICATION NAME] for anxiety with no attempts for a GDR (Gradual Dose Reduction) in over 4 years. This is evidenced by: R23 has medical [DIAGNOSES REDACTED]. R23's Minimum Data Set assessments from 10/19/16 through 4/7/19 indicates R23 has no behaviors with the exception of verbal behaviors occurring 1-3 days out of 7 on the 7/16/17 assessment. The surveyor then reviewed R23's medication regimen and noted R23 was currently receiving the following: - [MEDICATION NAME] 0.5 milligrams (mg), 1 tablet twice daily: First date: 3/31/15, latest order was 1/5/17. This was only a re-order of the medication. There was no GDR completed in that time frame. Note: Even though regulations require the facility to attempt a GDR at least annually, unless contraindicated, there have been no GDR attempts made in the [MEDICATION NAME]. R23's Behavior Monitoring includes target behaviors of anxiety/restlessness, kicking, hitting during cares, pinching/scratching during cares. - (MONTH) (YEAR) through (MONTH) (YEAR): no behaviors noted all shifts -July (YEAR): 1 instance of being somewhat resistive but not hitting staff with cares - (MONTH) (YEAR) through (MONTH) 2019: no behaviors noted all shifts - (MONTH) 2019: 1 instance of being resistive with cares - (MONTH) 2019: no behaviors noted all shifts On 7/12/17 the pharmacist recommended a GDR of the [MEDICATION NAME]. The doctor replied to the pharmacist request on 9/11/17. R23's physician placed a check mark next to a statement which states: Resident's functional and/or emotional status has been at optimal levels with current medication regime. GDR would likely reduce resident's functional and/or emotional status, well-being, safety, and/or quality of life; therefore the benefits of GDR do not outweigh the risks of functional/emotional decline. A review of the physician dictation notes going back to 1/6/17 revealed no mention of why the [MEDICATION NAME] should be continued and no mention of behaviors. The dictations repeatedly state that R23 is pleasant and cooperative. There were no further recommendations from the pharmacist. On 7/2/18, a GDR Assessment was completed and the facility requested a reduction. There is no further documentation. Several observations were made of R23 throughout the dates of survey and no behaviors were noted. On 6/05/19 at 2:07 PM, Surveyor interviewed the RCC (Resident Care Coordinator). She indicated there have been no reduction attempts made on the [MEDICATION NAME]. When asked if R23 displays behaviors, RCC stated, Not really. She hasn't had behaviors in a long time. When asked why the physician hasn't addressed this medication, RCC raised her hands up and said, We try .

Based on interview and record review the facility did not ensure 1 of 7 sampled residents (R11) maintained their weight within acceptable parameters. R11 had a weight loss of 8.2% or 12 pounds over a period of 6 months. While the facility identified the weight loss, there were no new interventions put into place to improve or maintain R11's weight. R11 subsequently continued to have weight loss. This is evidenced by: R11 had current [DIAGNOSES REDACTED]. R11's most current MDS (Minimum Data Set) was dated 2/28/17. The MDS indicated R11; ~Had a BIMS (Brief Interview for Mental Status) score of 4 indicating a severe cognitive impairment; ~Required extensive assistance of 1 to 2 staff persons for all aspects of care including eating; and ~Had no significant weight loss. R11 did not have a nutritional care plan. Under the problem identifying R11 could not complete care independently had an approach dated 4/20/18 which indicated, .I may need reminders to continue eating. I get a supplement . R11's care plan did not identify R11 had weight loss. According to R11's record, R11 had been on ensure 4 ounces three times a day since 10/16/16. Surveyor completed a review of R11's weights and noted the following. All weights are noted in pounds. ~11/13/17, 146 ~12/4/17, 143 ~1/8/18, 138. In a period of 2 months R11 lost 8 pounds. There were no new approaches added to R11's care plan to improve or maintain R11's weight. ~3/5/18, 135 ~5/7/14, 134. R11 continued to loss weight. Over a period of 6 months, R11 lost 12 pounds. There were no new interventions put into place to improve or maintain R11's weight. Surveyor completed a review of R11's dietary notes and noted the following. On 11/22/17 a dietary note indicated, .weight in a downward trend, weight changes not significant .no nutritional concerns . On 1/17/18 a dietary note indicated, .weight in a downward trend, weight changes not significant . The facility identified R11 was loosing weight. There were no new approaches added in attempt to maintain or improve R11's weight. On 3/1/18 a dietary note indicated, .weight in a downward trend, weight changes not significant .continue current approach . The facility continued to identify R11 had weight loss. There were no new approaches added in attempt to maintain R11's weight. On 4/25/18 a dietary note indicated, .weight .4/23/18: 134 lbs (pounds) .weight stable . On 05/16/18 at 8:38 AM Surveyor observed R11 in the dining room. R11 was noted to eat both independently with staff cues and with staff assist. R11 ate most of one pancake, no eggs, and bites of oatmeal. R11 was noted to drink all fluids. On 05/16/18 at 8:53 AM Surveyor spoke with CNA-A (Certified Nursing Assistant). CNA-A indicated when R11 is awake R11 can eat independently. CNA-A indicated sometimes R11 required cueing and if sleepy assistance. CNA-A indicated R11 really liked Ensure and stated, its the first thing she goes for. CNA-A indicated R11 really liked sweets. On 05/16/18 at 9:25 AM Surveyor spoke with RN-B (registered Nurse). RN-B indicated both nursing and the RD (Registered Dietician) monitored weights. RN-B stated normally the RD implemented supplements. On 05/16/18 at 9:28 AM Surveyor spoke with RN-C. RN-C indicated she worked on the unit where R11 resides. RN-C indicated weight loss was monitored by nursing and the RD. RN-D indicated if weight loss was identified the physician was updated as well as the RD. RN-C indicated the RD, many times, orders a supplement in response to weight loss. RN-C indicated R11 got Ensure at mealtime and typically drank it. Surveyor asked RN-C if R11 had been on any other supplements. RN-C stated they hadn't tried anything else to boost R11's weight. RN-C indicated R11 takes fluids much better than solid foods. The facility identified R11 had weight loss, readily accepted ensure, liked sweets, and drank fluids better than eating solid foods. Despite that, there were no changes made to R11's plan of care to improve R11's weight. On 05/16/18 at 10:34 AM Surveyor spoke with RD-D. RD-D indicated she reviewed weights weekly. RD-D indicated if a weight loss was noted she notified the MDS coordinator. RD-D indicated if a significant weight loss was noted she would look further into the weight loss. RD-D indicated a significant weight loss would be 5% loss over a period of 30 days, and 10% over a period of 180 days. RD-D indicated if a weight loss was identified she preferred using food including fortified foods to increase calories. RD-D indicated there were also multiple types of supplements that could be added including Ensure, Glucerna, Magic Cups, and fortified juice. Surveyor asked RD-D about R11's weight loss. RD-D indicated she felt R11 had declined and slept a lot. RD-D indicated she had been monitoring R11's weights however had not implemented any new strategies to improve R11's caloric intake including fortified foods or supplements.

Based on observation, record review, and interviews the facility did not prepare, store, and serve food under sanitary conditions. This has the potential to affect all 61 residents. The facility did not complete the cooling process properly. The facility did not check temperatures of hot food items properly to prevent cross contamination from one food item to another. The facility was not monitoring temperatures of any cold food items. The facility did not follow recipes to prepare puree foods thus changing the nutritive value. The facility did not properly sanitize a scissors that was contaminated from an employee cut and then used to cut open tarter sauce packets. This is evidenced by: COOLING PROCESS All cooked foods must be rapidly cooled to prevent bacteria growth and food borne illnesses. Food should be cooked to the required temperature then cooled to 70 degrees Fahrenheit within 2 hours and cooled to 41 degrees within an additional 4 hours. If either of the time frames are not met, food must be reheated to 165 degrees Fahrenheit and a final cool down attempt made before food should be discarded. On 03/20/17 beginning at 9:30 a.m., Surveyor conducted the initial kitchen tour with DL (Dietary Lead)-A. During the tour, Surveyor noted an incomplete cooling log. Surveyor asked DL-A what items were used as leftovers or cooled for another day service. DL-A stated raw pork, beef, turkey, and chicken roasts were cooked to temperature then cooled and served the following day. DL-A also stated soups were cooked almost daily then cooled for service another day. DL-A stated staff did not monitor or log the cooling down process of the soups. Surveyor noted 7 entries on the cooling log posted on the refrigerator during the initial tour. The first entry was dated 1/23/17 and the last entry was dated 3/16/17. Of the 7 entries, four of them were not cooled to 41 degrees or less within the six hour time period. Surveyor requested and reviewed all available cooling logs which included 5 pages of data. The entries began in 2/2016 through 3/2017. The entries were all turkey, chicken, beef, or pork roasts and there were no entries of soups or other leftovers. Of the 48 entries made, there were 12 entries that were incomplete or did not reach the proper temperatures within the time periods. On 03/20/17 at 5:15 p.m., Surveyor interviewed the CDM (Certified Dietary Manager) regarding the cooling process. The CDM stated staff have been educated monthly on the importance of completing the cooling process. The CDM stated staff will often interrupt the cooling process of the roasts and begin slicing or shredding the meat then return it to the refrigerator for service the next day. The CDM stated staff will be instructed to complete the cooling process before removing the meats from the refrigerator to slice or shred. The CDM confirmed staff were not checking temperatures of soups. TEMPERATURE OF HOT FOOD On 03/20/17 beginning at 11:44 a.m., Surveyor observed DA (Dietary Aide)-B set up and prepare to serve residents in the 2nd floor dining room. DA-B wheeled the steam table filled with hot food items to the 2nd floor dining room and began checking the temperatures of all food items on the steam table. DA-B first checked the temperature of the beef roast then proceeded to the baked fish without sanitizing the thermometer between food items. DA-B used a paper towel to wipe off the excess food, but never sanitized with an alcohol swab. DA-B continued to check all food items in the following order and again never sanitized the thermometer between food items: squash, puree beef, ground beef, rice, mashed potatoes, and gravy. DA-B noted the squash was 150 degrees Fahrenheit and stated to the Surveyor vegetables should reach 160 degrees or higher. DA-B requested another kitchen staff person to remove the squash and return it to the oven. When the squash was returned at 12:07 p.m., DA-B checked the temperature as 168 degrees Fahrenheit. On 03/21/17 at 11:10 a.m., Surveyor observed Cook-G check and record the temperatures of all hot food items on the 1st and 2nd floor steam tables. Surveyor observed Cook-G remove all hot food items from the steamer and place them directly into the steam table without checking the final cooking temperature. Cook-G cleaned the thermometer with an alcohol swab and immediately placed the thermometer into the noodles. Cook-G removed the thermometer, swiped the probe with the alcohol, then immediately inserted the probe into the chicken casserole. Cook-G repeated this procedure for all food items on both steam tables. By not allowing the thermometer to dry before inserting it into foods, Cook-G introduced a potential chemical contaminate into the food items. The other food items included cauliflower, mixed vegetables, toast, creamed chipped beef, mashed potatoes, gravy, puree chicken casserole, puree vegetables, and ground chicken casserole. On 03/21/17 at 11:25 a.m., Surveyor interviewed DL-A regarding proper procedure to check the food temperatures. DL-A stated staff have been trained to clean the thermometer with the alcohol wipes and allow to dry for 30-60 seconds before inserting thermometer probe into food. DL-A also stated staff have been trained to wipe off the thermometer probe with a paper towel to remove excess food before using the alcohol wipes to sanitize. DL-A also stated staff are to check the final cooking temperature of each item before placing the item on the steam table. DL-A stated the final check ensures the food was cooked to the required temperature. COLD FOOD TEMPERATURES On 03/20/17 beginning at 11:44 a.m., Surveyor observed DA-B check temperatures of the hot food items to be served for the residents on 2nd floor, but did not check the temperatures of the cold food items such as milk, juice, and fruit. These cold food/fluids were served by AA (Activity Aide)-H and consumed by all residents on the 2nd floor. On 03/21/17 beginning at 10:25 a.m., Surveyor observed DA-C and DA-F prepare cold food items such as lettuce salads, pickles, milk, juice, and fruit for the lunch service on both 1st and 2nd floor. Neither DA-C or DA-F checked the temperature of the cold food items. On 03/21/17 at 11:18 a.m., DA-C was about to deliver the cold food items to the 1st floor when Surveyor asked DA-C who checked the temperatures of the cold food items on the cart. DA-C stated the cold food items were not checked for temperature because they had just come out of the refrigerator. At 11:19 a.m., DA-F was about to deliver the cold food items to the 2nd floor when Surveyor asked DA-F who checked the temperatures of the cold food items on the cart. DA-F stated the cold food items were not checked for temperature. On 03/21/17 at 11:25 a.m., Surveyor interviewed DL-A regarding cold food temperatures. DL-A stated examples of cold food items frequently served would be pasta salads, potato salad, jello, fruit, milk, juices, and cottage cheese. DL-A stated prior to leaving the kitchen, the dietary aides are to check the temperature of cold food items. DL-A stated the cold food items should have the temperature checked again by the dietary aide at the point of service. DL-A stated staff do not log the temperatures of any cold food items. On 03/21/17 at 3:50 p.m., Surveyor interviewed the CDM regarding food temperatures. The CDM confirmed staff had not been checking the temperature of cold food items. Surveyor requested and reviewed the daily temperature logs and noted there were no entries for any cold food items since January, 2017. At the bottom of the daily temperature logs were temperature guides for serving and palatable temperatures. According to the log, the cold food items were able to be served at 50 degrees Fahrenheit and palatable at 65 degrees Fahrenheit. This information was inaccurate. Cold food items must be served at or below 50 degrees Fahrenheit. PUREE PROCEDURE On 03/21/17 beginning at 10:25 a.m., Surveyor observed Cook-G prepare the noon meal; however Cook-G had previously prepared the puree chicken casserole. On 03/21/17 at 11:15 a.m., Surveyor interviewed Cook-G regarding puree food procedure. Cook-G stated she takes the number of servings needed of any food item and puts that in the blender then adds water then thickener for proper consistency. Cook-G stated she did not follow any recipe for puree chicken casserole made for lunch on 03/21/17. Cook-G stated she had been employed for decades and had never used a recipe to prepare puree foods. On 03/21/17 at 3:50 p.m., Surveyor interviewed the CDM regarding puree diets. The CDM stated staff used to follow a recipe to puree foods; however those recipes are no longer available for staff. The CDM stated staff should use milk, gravy, or broth to thin food items to the proper consistency. The CDM stated staff should not use water to puree foods as this reduces the nutritional value of the food. Surveyor requested a list of all residents on a puree diet. The facility had 8 residents on puree diets. Of the 8 residents, five residents were selected as sampled residents. As part of phase I, weight loss was a category selected and 3 residents who received puree diets were reviewed for weight loss. The survey team did not find any concerns regarding weight loss. CONTAMINATED SCISSORS On 03/20/17 at 12:12 p.m., CNA (Certified Nursing Assistant)-D began serving the residents in the 2nd floor dining room. CNA-D was unable to open a packet of tarter sauce and retrieved a scissors from the kitchen drawer. CNA-D was washing the scissors with soap and water in the sink. The scissors were not sanitized prior to using on resident food items. CNA-E and CNA-D used the scissors throughout the meal service On 03/22/17 at 7:30 a.m., Surveyor interviewed the ICP (Infection Control and Preventionist) regarding the contaminated scissors. Surveyor asked the ICP what recommendations she made and the ICP stated she recommended to eliminate the use of any condiment packets and scissor use at the serving areas. The ICP also stated the CNA should have removed the scissors from the serving area to be properly sanitized using the kitchen sanitizing solution if the scissors was to be used for that purpose.

Based on observation and interview the facility did not ensure that their infection control procedures adequately contained infectious PPE (personal protective equipment). It is the facility's procedure to place open garbage cans containing gowns, gloves, and masks that are contaminated with infectious organisms outside the resident's rooms. This practice has the potential to affect all residents. This is evidenced by: On 2/18/16 at 7:45 a.m. Surveyor # observed 2 garbage cans outside 2 rooms, including Resident #17's room. These trash cans had black garbage bags but were the same beige short containers as the rest of the trash containers in the rest of the resident rooms. Next to these garbage cans were carts with PPE and signage that these two room had infection precautions. One of the garbage cans contained used gloves, masks, and gowns. At 7:50 a.m. Surveyor # asked CNA-A (Certified Nursing Assistant) about the precautions for Resident #17. CNA-A stated Resident #17 has a history of a multi-drug resistant organism. CNA-A stated that after caring for a resident with infection precautions, staff are to remove their PPE at the threshold of the room and deposit the PPE in the garbage can in the hall. At 9:10 a.m. Surveyor # spoke with RN-B (Registered Nurse) about the set up the the garbage cans for the disposal of infections PPE. RN-B indicated that the placement of the the garbage can was the facility's usual practice as there was no room in the residents' rooms to place the garbage can. At 10:00 a.m. Surveyor # interviewed the DON (Director of Nursing) and the ICP (Infection Control/Preventionist) about the facility's infection control procedure and practice. The DON and ICP also stated the practice was to put the open garbage cans outside the room as there was no room in the residents' rooms.

Based on observation, interview, and record review, the facility did not ensure that 1 of 17 sampled residents received medically related social services to attain the highest practicable physical, mental, and psychosocial well-being. Resident #16 had overwhelming feelings of sadness related to age and placement. While the facility identified some of the causative factors for Resident #16's sadness, there were no interventions to assist Resident #16 in coping. This is evidenced by: Surveyor # completed a review of Resident #16's clinical record. The record indicated Resident #16's current diagnoses include, but not limited to, arthritis, chronic pain, and high blood pressure. Resident #16's most current MDS (Minimum Data Set) was dated 8/11/13. The MDS indicated Resident #16: ~ Had a BIMS score (Brief Interview for Mental Status) of 8, indicating a moderate cognitive impairment; ~ Had mood indicators of feeling down, depressed, or hopeless, tired or having little energy, and difficulty with concentration; ~ Required the assistance from staff for all aspects of care except eating; and ~ Received no antidepressant medications. Resident #16's previous MDS, dated [DATE], was unchanged from the MDS dated [DATE] with the exception of Resident #16's BIMS score. The MDS dated [DATE], indicated Resident #16 had a BIMS score of 12. Resident #16's most current CAA (Care Area Assessment) summary was dated 2/18/13. The CAA summary triggered both psychosocial well-being and mood state. The CAA indicated, according to Resident #16 MDS, Resident #16 had indicators of minimal depression, however had no [DIAGNOSES REDACTED]. Resident #16's care plan did not contain a problem identifying Resident #16's sadness. There were no approaches on Resident #16's care plan which directed staff on how to manage Resident #16's sadness. On 10/2/13 at 1:10 p.m., Surveyor # spoke with CNA-L (Certified Nursing Assistant) about Resident #16. CNA-L indicated she did not feel Resident #16 had any symptoms of depression. On 10/2/13 at 1:12 p.m., Surveyor # spoke with the Activity Director about Resident #16. The Activity Director indicated she didn't feel Resident #16 had any symptoms of depression. On 10/2/13 at 1:30 p.m., Surveyor # spoke with LPN-K (Licensed Practical Nurse) about Resident #16. LPN-K indicated she felt Resident #16 was getting "more confused, edgy, didn't remember conversations, and felt ignored." LPN-K also indicated she didn't feel Resident #16 had symptoms of depression. On 10/1/13 at 1:30 p.m., Surveyor # spoke with Resident #16. Surveyor # noted Resident #16's speech was slow, movements were slow and Resident #16's face was drawn. Resident #16 indicated she did not feel happy. Resident #16 expressed several times she didn't know why, at her age, she was still alive and never thought things would end up as they have. Resident #16 also stated she was aware her memory was getting worse but she didn't care and was "just letting it go." Resident #16 also expressed she felt she had "lost a lot of life." On 10/3/13 at 8:45 a.m., Surveyor # spoke with the SW (Social Worker). The SW indicated meeting each residents psycho-social was a team effort. The SW indicated she counted on the nursing staff to inform her of changes in residents' moods. The SW indicated she saw Resident #16 frequently on a "casual basis," and spoke with her approximately monthly. The SW stated she felt Resident #16 didn't have mood indicators of depression. The SW stated she thought Resident #16 was showing signs of increased confusion and forgetting when staff had been in to talk with her. The SW stated Resident #16 had expressed to her several times that she would like staff to spend more time with her. The SW indicated her response to Resident #16's request was to remind Resident #16 that staff do not have that kind of time. The SW stated family was important to Resident #16, however her family was some distance from the facility. The SW indicated Resident #16's family would call, however they would have difficulty communicating as Resident #16 had a difficult time hearing. The SW stated Resident #16 had spoken to her about withdrawing into herself. The SW however stated she thought that was just Resident #16's personality.

Based on observations, interviews, and record reviews, the facility did not ensure 1 of 14 residents reviewed (Resident #4) for medication administration, was assessed as being appropriate to safely self-administer. A mixture of [MEDICATION NAME] and either water or juice was left in front of Resident #4 on two separate observations and the nurse did not remain in the area to ensure Resident #4 safely accepted the medication. This is evidenced by: The facility policy and procedure titled "Pharmacy Services," which was dated January 1998 and last reviewed April 2012, directs staff on the appropriate and safe procurement and dispensing of medications. This policy includes directives to staff on the administration of medications, and states: "12. Medications are never to be left at the resident's bedside or with the resident (i.e., on the table during mealtime) unless so specified by a Prescriber's Order and/or Care Plan based on document evaluations...B. If a resident elects to self-administer medications, the Interdisciplinary Team will evaluate the resident's ability to self-medicate. The team will need to evaluate the resident's ability to take their own medications without direct observation. That they understand the procedure, and would alert nurse or another staff member if task is not completed. If the Interdisciplinary Team agrees that the resident could take medication without direct observation the resident's prescriber is to be informed of resident's desire and an order will be obtained to allow self-administration of medications..." On 9/30/13 at 12:20 p.m. through 12:58 p.m., Surveyor # observed Resident #4 seated at her assigned place at the table in the main dining room on the Third Unit. The resident had a foam cup placed in front of her at the table, which contained approximately 6 ounces of clear liquid that resembled water but was slightly cloudy. There was an activity aide and several certified nursing assistants in the dining room assisting residents with the meal service. Resident #4 made no attempts to drink the liquid contained in the foam cup, she only accepted beverages from the clear glasses. At 12:50 p.m., Resident #4 was removed from the dining room. The cup remained untouched by the resident. At 2:50 p.m., Surveyor # approached RN-H (Registered Nurse) and questioned her if there was medication within the foam cup. RN-H stated there was 30 milliliters (ml) of [MEDICATION NAME] mixed in with water in the cup. RN-H stated, "She won't take it all right away. It takes her all day to drink it all, but she does take it at times. I really should go back and see if she accepted it." On 10/1/13 at 8:35 a.m. through 9:20 a.m., Surveyor # observed meal service for Resident #4. On the table in front of the resident sat a foam cup containing green liquid, approximately 8 ounces. The Surveyor approached RN-I and questioned her on the contents of the foam cup. RN-I stated, "I have [MEDICATION NAME] mixed with apple juice. She won't take it all at once, she savors it." It was noted that RN-I was in and out of the dining room, but did not remain with Resident #4 or within the dining room while the liquid was in front of the resident. At 8:45 a.m., RN-I approached Resident #4 and encouraged her to sip on the [MEDICATION NAME] liquid. Resident #4 did so but only one sip. RN-I then left the dining room and continued to pass medications down the hall with her medication cart. At 9:04 a.m., RN-I re-entered the dining room, checked on Resident #4, encouraged her to drink the liquid, then left the dining room once again to pass medications down the hall. Resident #4 did not take any sips of the [MEDICATION NAME] liquid. At 9:11 a.m., RN-I entered the dining room once again to encourage Resident #4 to drink her [MEDICATION NAME] mixture. The resident took one sip then placed the cup back down on the table. RN-I left the room and went down the hall. Surveyor # requested a Self-Administration of Medication Assessment for Resident #4 during the daily exit meeting. On 10/2/13, Surveyor # was informed that there was no such assessment completed for Resident #4. At 9:34 a.m., the Surveyor approached RN-I and questioned her on the leaving of medication in front of Resident #4 unattended. RN-I stated this morning she had given Resident #4 a straight shot of the 30 ml of [MEDICATION NAME] not mixed with anything, and "...she had accepted it willingly without any problems, took it all at once. I am writing it on the MAR indicated [REDACTED]." At 1:50 p.m., Surveyor # approached the Director of Nursing (DON) regarding resident self-administration of medications. The DON stated, "...all residents should have an assessment prior to nursing leaving any medication unattended." At 2:10 p.m., Surveyor # approached RN-I and asked her how she is made aware of a resident's ability to self-administer medications. RN-I stated the resident will have a Self-Administration Assessment completed. The MAR indicated [REDACTED]. RN-I provided another resident MAR indicated [REDACTED]. RN-I stated Resident #4 did not have an order or an assessment to self-administer medications. She stated, "That's where I messed up. We shouldn't leave it with her. Sometimes it's so hard to get her to accept it. But today, like I said earlier, it worked to give it like a shot without diluting it and she accepted it."

Based on observations, interviews, and record reviews, the facility did not ensure all staff consistently followed 1 of 17 residents' care plans. Resident #4 was left with medication diluted in either water or juice on two separate occasions with the nurse not present to ensure the medications were taken by the resident. The care plan created by the facility for Resident #4 specifically directs staff not to leave medications. This is evidenced by: Resident #4 has current medical [DIAGNOSES REDACTED]. The facility formulated a care plan for Resident #4 which states, "Potential for asking to have medications left at bedside with potential for being a danger to herself and others, wanting medications left for her to take when she is ready RELATED TO delusional behavior, MANIFESTED BY not completely consuming medications or forgetting to take them." This plan was dated 1/10/13. The approaches for the nurse state the following: "Firmly tell her she must take medications at the time nurse offers them, they cannot be left unattended to be taken later, if she doesn't take them at first offer try again in another 30 minutes or so. If not consumed at that time mark as refused and have medication destroyed, resident's POA (Power of Attorney) is ok with this as it presents a safety concern to other residents and resident herself if she collects medications she doesn't take at a given time..." There were two observations during the survey in which Surveyor # noted [MEDICATION NAME] being mixed with either water or apple juice and left on the dining room table, unattended by the nurse, for Resident #4 to take on her own. In both of these observations, Resident #4 made no attempt to drink the liquid except when coaxed by the nurse. These observations were: 1. On 9/30/13 from 12:20 p.m. through 12:58 p.m., in which the medication was left in water by RN-H (Registered Nurse). Resident #4 did not drink any of the medication mixture during the meal service. Resident #4 was left unattended and unsupervised by the nurse while Resident #4 had this medication in front of her. 2. On 10/1/13 at 8:35 a.m. through 9:20 a.m., Surveyor # observed meal service for Resident #4. On the table in front of the resident sat a foam cup containing green liquid, approximately 8 ounces, left by RN-I. The nurse did not constantly remain within the vision of Resident #4 but entered and left the room periodically. Note: RN-I stated the liquid was a mixture of 30 milliliters of [MEDICATION NAME] and 8 ounces of apple juice. The reader is referred to F176 for details and interviews.

Based on observation, record review, and interview, the facility did not provide necessary services to promote healing of a pressure ulcer for 1 out of 8 sampled residents reviewed for pressure ulcers. Resident #1 was observed twice without a pressure reducing device in the wheelchair which was part of the skin care plan. This is evidenced by: On 10/03/13, Surveyor # requested and reviewed the facility policy titled "Skin Care." Noted in the policy under the section titled "Pressure Reduction - Chair-Bound Patient" was "Use a pressure-reducing device in the chair. The pressure-reducing device should be matched to the individual patient/resident's need..." Resident #1 was admitted to the facility for long term care following a stroke in December 2009. The facility completed a quarterly MDS (Minimum Data Set) assessment for Resident #1 on 09/23/13 with the following data noted: ~able to make self understood and usually able to understand others; ~required extensive staff assistance for transfers, bed mobility, ambulation, dressing, hygiene, and toilet use; ~was at risk for pressure ulcer development; however had no pressure ulcers; ~had a pressure reducing device in chair, had an application of a nonsurgical dressing, and application of ointments/medications. Review of the care plan titled "Potential for Impairment of skin integrity..." initiated 01/31/13, noted a goal for Resident #1's skin to remain intact. The approaches for this care plan were "...cushion in wheelchair..." The facility completed a Braden scale, which identified pressure ulcer risk factors for Resident #1, on 08/30/13. The risk factors identified by the facility were mobility, friction/shear potential, and activity. The facility noted Resident #1 was at risk for skin breakdown. Review of the nurse's notes identified Resident #1 developed a stage II pressure ulcer on 10/18/12 on the left buttock. The pressure ulcers on Resident #1's right and left buttock area healed and reopened six times from October 2012 through present date. The facility made changes to the care plan and treatment plan with each reopening of the pressure ulcers. The facility also documented the progress of these ulcers in accordance with current standards of practice. As of 09/09/13, Resident #1 had 2 stage II pressure ulcers on her bilateral buttock area. During the initial facility tour conducted by Surveyor # on 09/30/13 at 10:45 a.m., RN-E (Registered Nurse) stated Resident #1 had pressure ulcers on the coccyx which would come and go. RN-E stated Resident #1 was currently being treated with a [MEDICATION NAME] dressing for pressure ulcers on the coccyx. On 10/01/13 at 9:30 a.m., Surveyor # observed CNA-F (Certified Nursing Assistant) and CNA-G assist Resident #1 to the bathroom. Surveyor observed no pressure reducing device in the wheelchair. At 9:45 a.m., RN-E entered the room and removed the [MEDICATION NAME] dressing on Resident #1's coccyx area. Surveyor # observed a stage II pressure ulcer on the right buttock which was approximately 0.5 cm (centimeters) by 1 cm. Surveyor # also observed a stage II pressure ulcer on the left buttock which measured approximately 4 cm by 3 cm. At 10:30 a.m., Surveyor # interviewed RN-E who stated Resident #1 has had a reoccurring pressure ulcer that has been treated with topical creams, [MEDICATION NAME] dressing, and a variety of other treatment choices. RN-E stated Resident #1 does not like to lie down to relieve pressure and spends most of the day in the wheelchair. On 10/02/13 at 1:15 p.m., Surveyor # observed CNA-D assist Resident #1 to the toilet. Surveyor # noted again no pressure reducing cushion in the wheelchair. On 10/02/13 at 1:40 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding Resident #1's pressure ulcer. The DON stated Resident #1 was to have a waffle air cushion in the wheelchair. The DON stated Resident #1 always had the waffle air cushion in the wheelchair. On 10/02/13 at 2:00 p.m., Surveyor # observed CNA-D place a waffle air cushion in Resident #1's wheelchair. Resident #1 did not object to the placement of the cushion.

Based on observation, interview, and record review, the facility did not ensure that 1 of 13 sampled residents reviewed for bladder incontinence received the necessary care and treatment to maintain and/or restore bladder function. Resident #6 was not prompted to use the bathroom after breakfast and before lunch as outlined in her individual toileting plan. This is evidenced by: The facility provided Surveyor # with a policy titled " Incontinence" which indicated the following: Policy: Residents who are incontinent of bladder and or bowel should receive the appropriate treatment and services to prevent urinary tract infections and to restore as much normal function as possible. Purpose: To evaluate environmental and cognitive risk factors for developing incontinence and to develop an appropriate treatment plan... Programs and Definitions: Incontinent Diagnosis: [REDACTED]. Toileting programs: Prompted Voiding: prompted voiding includes: 1. regular monitoring with encouragement to report continence status. 2. using a schedule and prompting the resident to toilet. 3. praise and positive feedback when the resident is continent and attempts to toilet. A. Contact with each resident every 2-3 hours from 8 am or arising to bedtime. B. Check resident for wetness and give feedback to the resident. C. Whether wet or dry, ask the resident if he or she would like to use the toilet... Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's annual Minimum Data Set assessment dated [DATE], indicated Resident #6 requires extensive assistance of 2 staff for transfers and toilet use, is frequently incontinent of bladder, and is on a toileting program. Resident #6's Care Area Assessment reads: Description of Problem: Is frequently incontinent or bladder, occasionally incontinent of bowel. Review of voiding diary indicates that current prompted toileting program is appropriate. She is able to answer staff when they ask her is she needs to use the bathroom at times, but not reliably. She will at times become restless. Risk Factors: bowel and bladder incontinence can lead to skin breakdown, increase fall risk, social isolation. Care Plan: continue current plan. Review of Resident #6's care plan for Potential for Functional Incontinence dated 05/14/13, goal reads: has two or less episodes of bladder incontinent a day. Approaches read: prompted toileting: following breakfast, before and after lunch, mid afternoon, after supper and as needed for agitation and restlessness or per demand. Review of Resident #6's Nursing Assessment/Evaluation of Incontinence dated 08/02/13, indicated Resident #6 experiences functional incontinence and her individual prompted voiding times are as follows: following breakfast, before and after lunch, mid afternoon, and after supper. Her scheduled toileting times are: a.m. and rounds at night. Comments read: toilet when restless/agitated or requests. On 10/01/13 at 5:45 a.m., Surveyor # observed Resident #6 sitting in her wheelchair at the 2nd unit nurses' station. Resident #6 remained at the nurses' station until taken to breakfast at 8:07 a.m. Resident #6 remained in the dining room until 9:40 a.m. when Resident #6 was taken back to the nurses' station on the 2nd unit. At 9:50 a.m., Surveyor # continued observation of Resident #6 who continued sitting at nurses' station until 10:18 a.m. when staff stood her up at and took her blood pressure. Resident #6 was seated back down in her wheelchair and continued to sit at nurses' station. At 11:00 a.m., Surveyor # resumed monitoring Resident #6 who continued to sit in her wheelchair at the nurses' station until 11:45 a.m. when she was transported to the dining room. At 11:53 a.m., CNA-A approached Resident #6 in the dining room and asked Resident #6 if she wanted to use the bathroom. Resident #6 responded, "No." CNA-A then responded, "Okay, we will try after lunch." On 10/02/13 at 9:55 p.m., Surveyor # interviewed CNA-B who indicated she has worked at the facility [AGE] years and is familiar with Resident #6's toileting program. CNA-B identified Resident #6's toileting plan as before and after meals or when she is "antsy." CNA-B explained when it is time for Resident #6 to go to the bathroom, staff will stand her up and tell her "let's go to the bathroom." CNA-B further explained if you ask Resident #6 if she needs to go to the bathroom she will say "no" as she no longer can tell you that she needs to go to the bathroom. On 10/02/13 at 9:30 a.m., Surveyor # interviewed RN-A who indicated she is the Resident Care Coordinator for Resident #6. RN-A explained she is the person who assessed Resident #6's incontinence and developed her toileting plan. RN-A explained Resident #6's plan as prompted toileting before and after meals or when she is restless or anxious, trying to stand up. RN-A also indicated Resident #6's scheduled toileting times as: 5:00 a.m. and during night rounds. RN-A explained prompted toileting as "asking Resident #6 if she needs to use the bathroom." RN-A expressed Resident #6 is not always receptive and may drop her feet and at times is difficult. RN-A further expressed Resident #6 can't always tell you she needs to use the bathroom or will say "don't know" when asked by staff.

Based on observation, interview, and record review, the facility did not ensure 1 of 17 sampled residents received adequate supervision to prevent accidents. Resident #8 had swallowing precautions due to dysphagia (difficulty swallowing) and associated concerns with aspiration. Observations revealed staff were not following Resident #8's swallowing precautions. This is evidenced by: Surveyor # completed a review of Resident #8's clinical record and noted the following. Resident #8's current [DIAGNOSES REDACTED]. Resident #8's most current MDS (Minimum Data Set) was dated 8/18/13 and indicated Resident #8: ~ Cognition was moderately impaired; and ~ Required the assistance of 1 to 2 staff persons for all aspects of care including eating. Resident #8's nutrition care plan, dated 8/21/13, directed staff to follow the swallowing precautions as follows. The swallowing precautions were dated 7/24/13. ~ Constant supervision; ~ Mechanically altered diet with nectar thickened liquids; ~ Liquids by either a teaspoon or tablespoon; ~ Monitor swallowing if a cup was used; ~ Alternate solids and liquids; and ~ Eat and/or assist to eat slowly with verbal cues to swallow. Surveyor # completed a review of the results of a swallowing study done 7/24/13. The swallowing study indicated, "...wife states he is having all sorts of trouble swallowing...has noticed a change in his ability to swallow...she thinks that he is aspirating...No obvious choking...episodes of coughing on some occasions when eating...severe oral dysphagia...Swallow precautions...Direct supervision. Alternate solid/liquid. Repetitive dry swallow...Present liquids by spoon if patient accepting - otherwise controlled drinks from cup with cues to swallow..." On 10/1/13 at 5:00 p.m., Surveyor # observed the evening meal and noted the following: ~ At 5:08 p.m., Resident #8 received his supper and began to eat independently. There were no staff present at the table Resident #8 was seated at. ~ At 5:15 p.m., CNA-J (Certified Nursing Assistant) sat down and assisted 2 other residents to eat who were also seated at Resident #8's table. ~ From 5:15 p.m. until 5:28 p.m., CNA-J assisted the 2 other residents. CNA-J did not cue or assist Resident #8. ~ At 5:28 p.m., Surveyor # noted Resident #8 had eaten most of his supper meal. Resident #8 however had not drunk any fluids. According to Resident #8's swallowing precautions, Resident #8 was to be cued to swallow as well as alternate solids with fluids. ~ At 5:28 p.m., CNA-J left Resident #8's table and began to assist other residents in the dining room. ~ At 5:58 p.m., Resident #8 reached for a glass of thickened liquids and took a drink. There were no staff present at Resident #8's table. ~ At 6:10 p.m., CNA-J sat down next to Resident #8 and assisted Resident #8 to drink fluids via a teaspoon. Surveyor # did not note Resident #8 to cough anytime during the meal. On 10/2/13 at 1:05 p.m., Surveyor # spoke with CNA-G regarding what constant supervision meant for residents with swallowing precautions. CNA-G stated staff needed to be seated at the same table in order to watch them eat and drink. On 10/2/13 at 1:10 p.m., Surveyor # spoke with CNA-L. CNA-L also indicated direct supervision meant seated at the same table and within reach of a resident. On 10/2/13 at 1:30 p.m., Surveyor # spoke with LPN-K (Licensed Practical Nurse) regarding residents with swallowing precautions needing constant supervision. LPN-K indicated a staff person needed to be seated at the same table to observe, cue, and/or assist the resident. On 10/3/13 at 9:45 a.m., Surveyor # spoke with ST-M (Speech Therapist) about Resident #8. ST-M stated because of Resident #8's diagnoses, Resident #8 held food in his mouth therefore needed cueing to swallow. ST-M stated some days Resident #8 did well and other days it took longer in which Resident #8 required more encouragement to swallow. ST-M stated Resident #8 required constant supervision which meant a staff person had to be physically present at his table to monitor his swallowing and cue him as needed.

Based on observation, record review and interviews, the facility did not ensure that 19 of 24 infra-red alarms were secured in accordance to the manufacturer's instructions. The facility uses infra-red Bedside Monitoring system. The manufacturer's recommendations indicate the alarm should be mounted to a surface that would not allow it to be moved. Observations of the 24 infra-red alarms in use in the facility found 19 of them were not mounted according to manufacturer's recommendations. In addition, during observations, Resident #4's infra-red alarm was not turned on, thus the potential for an accident to occur without staff being made aware. This is evidenced by: The facility has 24 residents on a Infra-red Bedside Monitor system. This system alerts the caregiver when a resident attempts to leave a bed. According to the instructions for the Infra-red Bedside Monitor IRM-1, Model , "the infra-red bedside monitor uses infra-red technology to discretely monitor any movement from a bed. There are no cumbersome pads or cushions. The device works by emitting a harmless infra-red signal which alerts the caretaker, either by triggering an audible alarm or by sending an electronic signal to a nurse's station at a remote location." The facility has the audible alarm. "The IRM-1 is designed to be attached to the side of a hospital bed frame. It works by emitting an infra-red signal along the length of the bed. If a patient either falls or attempts to leave the bed, the IRM-1 will be activated." On 8/7/13 at 11:15 a.m., Surveyor # spoke with the manufacturer representative/technical support who stated the infra-red alarm does not specifically have to be mounted on the bed but should be mounted in a secured way so the area covering is stable. He stated if the infra-red alarm box is on the floor it could be moved very easily, rendering the alarm ineffective. Surveyor # observed the 24 infra-red alarms in use in the facility. Three of the alarms are mounted to a movable pole, the rest are either on the floor or the bedside table, which could be easily moved and not be effective. This does not meet the manufacturer's instructions to be mounted in a secure way. On 8/7/13 at 11:00 a.m., Surveyor # spoke with the Director of Nurses who stated, "To tell you the truth, I just sent an email out this morning" regarding the infra-red alarms. The Director of Nursing and the Administrator both stated they did not know the alarms had to be mounted to keep secure. The Administrator stated the facility is in the process of having the infra-red alarms hooked up to a new call system. Example #2: On 8/7/13 at 10:35 a.m., Surveyor # observed residents who were in bed and have the infra-red alarms. Surveyor # observed Resident #4 in a low bed and asleep. The infra-red alarm was mounted to moveable pole but was not turned on. On 8/7/13 at 10:35 a.m., Surveyor # spoke with CNA-J who stated 3 staff laid Resident #4 down in bed so another staff must have not turned on the alarm. Surveyor # and CNA-J observed the infra-red alarm in the off position. The green light was not on which indicates the alarm is on.

Based on observations, policy review, record reviews and interviews, the facility did not ensure that 8 out of 15 sampled residents reviewed for incontinence received care and services designed to maintain or restore as much bladder function as possible. Resident #14 and #5 had declines in bladder function. The facility did not comprehensively assess the cause of the declines in bladder function, did not monitor the residents' usual voiding patterns, did not identify the types of incontinence, did not develop care plans to improve bladder function, and did not explore reversible causes of incontinence in order to assist each resident with restoring or maintaining as much bladder function as possible. For Residents #10, #8, #9, #16, #3, and #17, the facility did not comprehensively assess each resident's incontinence to determine an individualized toileting plan. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. The Long-Term Care Nursing Desk Reference states, " ... Incontinence is not a normal consequence of aging and can frequently be cured or improved. Many treatable problems contribute to incontinence. Some residents have several coexisting problems, and to successfully manage the incontinence, all must be identified and treated... Remember that the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom...Most believe that toileting residents every two hours is the best means of keeping them dry, when in fact this is a dated and ineffective method..." On 06/16/11 at 9:00 a.m., Surveyor # interviewed the DON (Director of Nurses) regarding the facility procedure for bladder assessments. The DON provided the Surveyor with copies of both forms used as well as the facility policy. The forms are titled "Bowel and Bladder Assessment" and "Bowel & Urinary Incontinence Evaluation." The DON stated that upon admission, all residents have a 5-day voiding diary, followed by a bowel and bladder assessment to determine the type of incontinence and a toilet program for each resident. The DON stated that no further bladder assessments are completed for residents even if there was readmission, a decline in bladder function or change in bladder devices such as Foley catheters. The DON stated that quarterly, every resident has an evaluation completed. Surveyor # reviewed the Bowel & Urinary Incontinence Evaluation form and noted the directions at the bottom of the form read "The Interdisciplinary Team is to evaluate residents quarterly and as needed for change in Bowel and Bladder incontinence by speaking with staff, evaluating C.N.A. documentation in Caretracker, and using 3 day diary form if needed. The I.T. (Interdisciplinary Team) will implement and modify, as needed, a treatment plan and toileting schedule. Anyone that has shown an increase in daytime incontinence on his/her MDS should have his/her toileting program reevaluated with discussion of other interventions. Resident should be assessed for symptoms of UTI (Urinary Tract Infection) and/or reversible or contributing factors if needed. Other possible interventions might include: Medications or urology consults, a post-void residual determination per bladder scanner for anyone at risk for urine retention, behavioral therapies such as Bladder Retraining Program and pelvic muscle strengthening, Therapy consults, Intermittent catheterization, or adjust dietary intake of foods/liquids that can cause increase frequency." Review of the facility policy titled "Incontinence" noted, "Residents who are incontinent of bladder and/or bowel should receive the appropriate treatment and services to prevent urinary tract infections and to restore as much normal function as possible." The policy outlined the procedure that was described by the DON. Example #1: Resident #14 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The Bowel and Bladder Assessment completed on 02/10/11, noted that Resident #14 was continent of bladder. The CNA (Certified Nursing Assistant) assignment card last updated on 05/18/11 for Resident #14 noted staff is to "have urinal in reach at night or when in recliner in room, offer to toilet before and after meals, mid morning about 10 and mid-afternoon 2-3 p.m. before bed." The care plan titled "Potential for Functional Incontinence..." last updated on 05/18/11, noted that Resident #14 asks for toilet assistance, has limited mobility, and utilizes large doses of diuretics (water pills) for his [MEDICAL CONDITION]. The goal listed for that care plan problem was that Resident #14 will be continent 50% of the time for waking hours. The facility completed an admission MDS (Minimum Data Set) assessment for Resident #14 on 02/18/11, and noted the following data: *Able to make self understood and understand others; *Requires extensive assist for toilet use; *No toilet program; and, *Occasionally incontinent of bladder (less than 7 episodes of incontinence in a 7-day period). The CAA (Care Area Assessment) summary completed for Resident #14 on 02/18/11, noted that Resident #14 has potential for functional incontinence and also urgency related to bladder control. The CAA did not reveal any voiding patterns or toilet program to be implemented for Resident #14. The facility completed a significant change in status MDS assessment for Resident #14 on 05/18/11, and noted the following data: *No change in ability to make self understood or understand others; *No change in toilet use assistance; *No toilet program; and, *Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding in a 7-day period). The CAA completed for Resident #14 on 05/18/11, noted that Resident #14 has urgency due to diuretic use and has functional incontinence due to immobility. The CAA did not reveal any voiding patterns or toilet program to be implemented. The Bowel & Urinary Incontinence Evaluation form dated 05/18/11, noted that Resident #14 has a decline in bladder continence. The toilet plan is to continue with toileting upon request and after meals and to keep the urinal at bedside. The note reflected an increase in pain medications utilized. The evaluation did not consider any reversible causes or contributing factors (such as infections, retention, medication side effects, urology consults, bladder scans, referrals to therapy, etc.) as described by the directions on the form. On 06/16/11 at 9:00 a.m., Surveyor # was referred to RN-M (Registered Nurse) by the DON regarding any questions for Resident #14. On 06/16/11 at 9:36 a.m., Surveyor # interviewed RN-M regarding Resident #14's bladder control. RN-M stated Resident #14 was usually continent but took large doses of diuretics which impacted his bladder control. The Surveyor asked RN-M what type of incontinence Resident #14 has and what is the toilet program. RN-M stated she is uncomfortable diagnosing the type of bladder incontinence as the physician has not noted a [DIAGNOSES REDACTED]. Of note: the determination of the type of incontinence is not a medical diagnoses. On 06/16/11 at 10:06 a.m., Surveyor # interviewed CNA-P (Certified Nursing Assistant) regarding Resident #14's toilet needs. CNA-P stated she has cared for Resident #14 3 days per week since his admission. CNA-P stated Resident #14 is usually incontinent upon rising in the morning. CNA-P stated that Resident #14 has had a decline in his bladder control since admission and is more incontinent and now requires 2 staff to toilet him. CNA-P stated that Resident #14 is assisted to the toilet upon rising, after breakfast, before and after lunch. On 06/16/11 at 11:50 a.m., Surveyor # observe CNA-P and CNA-Q assist Resident #14 to the toilet. Resident #14 requires 2 persons to transfer from the wheelchair to the toilet. Resident #14 was wearing a brief which was dry. Resident #14 sat on the toilet for approximately 10 minutes with the water running and CNA-P in attendance and did not urinate. Resident #14 was transferred back into the wheelchair with the assist of both CNA-P and CNA-Q. Example #2: Resident #5 was admitted to the facility on [DATE] and was readmitted on [DATE], following a fall with [MEDICAL CONDITION]. Additional diagnoses include, but not limited to: [MEDICAL CONDITION], diabetes, [MEDICAL CONDITION], anxiety, and dementia. Surveyor # was unable to locate any Bowel and Bladder Assessment in Resident #5's medical record. The Surveyor requested a copy of any Bladder Assessment completed since Resident #5 had been readmitted in 2008 and none was provided. The CNA assignment card for Resident #5 last updated on 01/07/11, noted that Resident #5 is to be toileted before and after meals, at bedtime and when she asks. The care plan titled "Potential for Incontinence" dated 01/05/11, noted Resident #5 has frequency and increase in urinary tract infections. The goal for Resident #5 is to be continent of bladder 50% of the time. The facility completed a quarterly MDS on 10/05/10 for Resident #5 and noted the following data: *Able to make self understood; *Usually able to understand others; *Requires extensive assist for toilet use; *Is occasionally incontinent; and, *No toilet program. The facility completed a significant change in status MDS on 12/31/10 for Resident #5 and noted the following data: *No changes in ability to understand others, make self understood, and toilet use assistance; *Frequently incontinent (decline); and, *No toilet program. The CAA for Resident #5 completed on 12/31/10, noted possible overflow incontinence, diuretics causing urge incontinence as well as mixed (stress and urgency) incontinence. There was no clear type of incontinence, rationale for incontinence, or toilet plan. The CAA did not reveal any voiding patterns or toilet program to be implemented. The facility completed a quarterly MDS for Resident #5 on 03/30/11 and noted the following data: *No changes in entry date, type of entry, ability to understand others, ability to make self understood, and toilet use assistance; *No toilet program; and, *Frequently incontinent (decline continued). The facility completed a Bowel & Urinary Incontinence Evaluation form for Resident #5 on 10/05/10, 01/04/11 and 03/28/11 and noted the following: *10/05/10 "less than daily episodes of incontinence. Worse 1-2 wks ago with UTI." The evaluation noted recent blood in urine and a pending urology referral. *01/04/11 Resident #5 had increased incontinence even after treatment of [REDACTED]. Resident #5 referral to urology was completed with no diagnostic examinations per family decision. The plan was to toilet before and after meals and activities. *03/28/11 Resident #5 was frequently incontinent of bladder even with toilet program. Resident #5 had chronic and acute UTIs. The evaluation did not consider any reversible causes or contributing factors (such as retention, medication side effects, bladder scans, referrals to therapy, etc) as described by the directions on the form. Of note: The toileting program Resident #5 was on, was a general before and after meals and before bed. There is no evidence that this plan was individualized to Resident #5's usual voiding patterns. On 06/16/11 at 9:36 a.m., Surveyor # interviewed RN-M regarding Resident #5's bladder control. RN-M stated that Resident #5 had a decline in bladder control in January, 2011 and was referred to urology. RN-M stated that the health care decision maker did not want to pursue any diagnostic examinations to determine possible causes of blood in urine, frequent UTIs, or decline in bladder function. RN-M stated that Resident #5 requests to go to the bathroom and she is assisted by staff; however, she was usually already incontinent. RN-M stated that no Bladder Assessment was done when Resident #5 returned to the facility in 2008. RN-M stated she was unable to determine type of incontinence for Resident #5. RN-M stated that Resident #5 had medication changes in the past 6 months to aide in bladder control. The evaluation form did not reflect any changes in medications. On 06/16/11 at 10:06 a.m., Surveyor # interviewed CNA-P regarding Resident #5's bladder control. CNA-P stated that she has cared for Resident #5 3 days per week since her readmission to the facility in 2008. CNA-P stated that Resident #5 has had a decline in bladder control over the past several months. CNA-P stated that Resident #5 requested toilet assistance every 30-45 minutes and was assisted. CNA-P stated that Resident #5 was usually wet upon rising in the morning, often dribbled urine, and voided in small amounts. On 06/16/11 at 11:53 a.m., Surveyor # observed CNA-Q assist Resident #5 to the toilet. Resident #5 was transferred from the wheelchair to the toilet and voided. Resident #5 was assisted back to the wheelchair with CNA-Q's help. Resident #5 was wearing an incontinent brief that was dry. Example #3: Resident #10 was admitted to the facility on [DATE]. Current medical Diagnoses include, but are not limited to, [MEDICAL CONDITION], Anxiety Disorder, and Diabetes Mellitus Type 2. Resident #10's Care Plan for Self-Care Deficit was dated 9/10/10 and was most recently updated on 6/9/11. According to the care plan, Resident #10 is on a prompted toileting plan for Functional Incontinence. He is to be prompted by staff in the morning, around meal times, at bedtime, and during the night to go to the bathroom. The MDS assessment dated [DATE], indicates that Resident #10 is frequently incontinent of bladder function and requires extensive assistance of staff for meeting his toileting needs. The MDS assessment dated [DATE], indicates no changes regarding toileting and bladder function. The assessment also indicates that a toileting program or trial was conducted, and that there are no improvements in his functioning at that time. In reviewing the data collection for the trial toileting program called the Continence Detail Report, Surveyor # noted inconsistent toileting being conducted for the time period of 2/2/11 through 2/14/11. There is no evidence that an hourly assessment of Resident #10 continence status was conducted. From 2/2/11 through 2/14/11, Resident #10's continence status was documented only 36 times with ranges in time from 3 to 19 hours between documentation. This sporadic toileting does not allow a resident to improve daily toileting function. There is no pattern of toileting to determine the best times to offer toileting in order to assist the resident to be as continent as possible. The facility completed a Quarterly assessment dated [DATE]. There were no changes in regard to bladder incontinence. However there were enough changes in Resident #10's function, that the facility completed a Significant Change in Status assessment dated [DATE]. According to the 6/6/11 MDS, there were no changes regarding toileting and bladder function. The assessment also indicates that a toileting program or trial was conducted, and that there were no improvements in his functioning at that time. In reviewing the data collection for the trial toileting program called the Continence Detail Report, Surveyor # noted that between 5/24/11 through 6/5/11, Resident #10's continence status was documented only 41 times with ranges in time from 3 to 12.5 hours between entries. This sporadic toileting does not allow a resident to improve daily toileting function. There is no pattern of toileting to determine the best times to offer toileting in order to assist the resident to be as continent as possible. On 6/14/11 at 9:14 a.m., Surveyor # interviewed CNA-T (Certified Nursing Assistant) regarding Resident #10's toileting needs. CNA-T stated that the resident is generally incontinent of bladder function, but staff are to offer toileting every two hours. On 6/22/11, during a telephone conference. Surveyor # asked the NHA and the DON if staff are documenting in the Care Tracker system each time a resident is toileted or changed. The NHA indicated that staff are "encouraged" to document as soon as something happens, but it is not always possible. Example #4: Resident #9 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicates that Resident #9: ~Usually is understood and sometimes understands; ~Extensive assistance of one staff for toilet use; and, ~Frequently incontinent and on a toileting plan. Review of the current plan of care dated 1/13/11, titled "Potential for Bowel and/or Bladder Incontinence" related to "dementia, visual and hearing deficits, DM, and impaired mobility. Approach: "Prompted toileting program, lead to bathroom rather than asking if he has to use as he will be resistive to going. Assist with pad change. Report changes in bowel, voiding pattern to nurse. Nurses...Monitor for changes in bowel, voiding pattern, update MD as needed. Soft touch call light." Review of the CNA Assignment Card dated 1/13/11 indicates, "Prompted toileting program, lead to bathroom rather than asking if he has to use as he will be resistive to going." Review of last Bowel and Bladder assessment dated [DATE] indicates that Resident #9 was incontinent upon admission, with occasional incontinence of bladder/bowel, wears incontinence products and the cause of incontinence is confused and doesn't make it at times. Review of the 5-day toileting study indicates that Resident #9 was wet 7 times out of the 5 days. However, the toileting study is not complete and is completed only once a shift. There is no evaluation of the toileting study to determine the type of incontinence and which toileting program will be affective. On 6/16/11 at 12:10 p.m., Surveyor # spoke with CNA-C who stated that the staff toilet Resident #9 before and after meals and in between if staff can get him to go. He often refuses to get up or go to the bathroom. CNA-C stated Resident #9 is mostly incontinent and staff try to just check and change him. Example #5: Resident #8 was readmitted on [DATE] with a Right [MEDICAL CONDITION] following a fall. Other [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] indicates that Resident #8: ~Usually is understood and makes poor decisions, requires cues; ~Extensive assist of two for toilet use, uses briefs; and, ~On a trial for prompted toileting. Review of Care Plan dated 4/28/11, titled "Potential for bowel and bladder incontinence, Related to: [MEDICAL CONDITION], s/p (status [REDACTED]. Nurse Aide:---Assist with cares as needed. Toilet per plan. Report changes in bowel/voiding pattern to nurse. Nurses---Administer medication per order, monitor effectiveness. Monitor for changes in bowel/voiding pattern. Update MD as needed. Goal: ...has some daytime bladder continence." Review of the CNA Assignment card states, "toilet per plan." Review of the Bowel and Bladder assessment dated [DATE], indicates incontinence on admission, dribbling and leaking, time of day is throughout and number of pad changes 8-10 times a day. Cause is [MEDICAL CONDITION]. On 6/15/11 at 8:40 a.m., Surveyor # observed Resident #8 request to use the bathroom. Resident #8 did not void into the toilet but when he stood up, urine ran out. CNA-T stated that Resident #8 will usually tells us when he has to go. On 6/16/11 at 7:25 a.m., Surveyor # spoke with CNA-X who works the night shift. CNA-X stated that they check and change Resident #8 or he will occasionally use the urinal. Surveyor # requested Resident #8's bladder evaluation and 3-day continence assessment. No evaluation or assessment was given to this surveyor. There was no toileting program as indicated on the MDS, no 3-day voiding to evaluate a need to place him on a program since he was mostly continent during the day and incontinent at night, and no type of incontinence was determined. Example #6: Resident #16 was admitted to the facility on [DATE]. According to her plan of care and [DIAGNOSES REDACTED]. A review of the clinical chart by Surveyor # found a "Bowel and Bladder Assessment" dated 12/3/10. This initial assessment states the "time of day" of incontinence "varies, when asleep." The assessment states that Resident #16 has "lack of control" and quotes the resident spouse as saying that he has to change her 1 to 2 times a day "if I don't catch her." There is no indication that a detailed and accurate bladder diary was conducted to determine if there was a pattern in her incontinence. The facility submitted to Surveyor # a copy of the CNA's (Certified Nursing Assistant) "5-Day Toileting Study Chart Detail Report." The report is incomplete as it does not have consistently recorded real-time data collection. For example, the record indicates that Resident #16 was "wet" at 8:29 p.m. on the night of her admission, but does not have any information as to when and if she was toileted prior and what were the results. The next time on the care-tracker records state that she was checked at 5:04 a.m. and was incontinent of urine There is no indication that she was checked more often, especially when the husband had reported that her incontinence occurs "when asleep." The rest of the record is similar in that it appears the resident was toileted only once a shift and she was incontinent 8 times and continent 6 times. There is no [DIAGNOSES REDACTED]. Resident #16's plan of care outlines for staff to check with her for incontinence every 2 to 3 hours. Surveyor # requested the comprehensive assessments that indicates an individualized toileting plan was attempted and none was received. There is no toileting plan to control her night-time incontinence. Example #7: Resident #3 was admitted to the facility on [DATE]. According to her plan of care and [DIAGNOSES REDACTED]. Her MDS assessments dated 4/13/10 through 4/5/11, indicate she is completely dependent on the physical assistance of staff for all of her transfers, dressing, hygiene, and toileting needs. The MDSs also indicate she has multiple daily episodes of urinary incontinence. A review of the clinical chart by Surveyor # found a "Urinary Incontinence Assessment" dated 7/10/08. This initial assessment is incomplete as it does not indicate the onset or duration of the incontinence, does not outline the usual pattern of incontinence, and does not outline the type and amount of fluids that the resident normally takes in. Resident #3's plan of care outlines for staff to check for incontinence with each position change. Surveyor # requested the comprehensive assessments which would indicate that an individualized toileting plan was attempted. Surveyor # was given a copy of the form "Bowel and Urinary Incontinence Evaluation." The form indicates no changes, and continuing to be "totally incontinent" for the last year. There is no evidence that a toileting plan was done for the past 3 years. Example #8: Resident #17 was admitted to the facility on [DATE]. According to her plan of care and [DIAGNOSES REDACTED]. Her MDS assessments dated 9/3/10 through 5/26/11, indicates that she is completely dependent on the physical assistance of staff for all transfers, dressing, hygiene, and toileting needs. The MDSs also indicate that she has multiple daily episodes of urinary incontinence. A review of the clinical chart by Surveyor # found a "Urinary Incontinence Assessment." This initial assessment is incomplete as it does not indicate the onset or duration of the incontinence, does not outline the usual pattern of incontinence, and does not outline the type and amount of fluids that the resident normally takes in. Surveyor # requested the comprehensive assessments which would indicate that an individualized toileting plan was attempted, but none was submitted.

Based on observation, record review, and interview, the facility did not ensure that 1 of 7 residents reviewed for pressure ulcers received the services to prevent the development of pressure ulcers. Resident #9 was admitted to the nursing home with a Stage II pressure ulcer of the right buttock which was healed on 1/27/11. On 3/20/11, the right buttock reopened and was again healed on 5/1/11. On 5/1/11 another open area developed on the left upper buttock and healed on 5/8/11. Then on 6/5/11, two open areas developed on the right and left inner buttock. The facility did not implement new measures to prevent pressure ulcers from reoccurring. In addition, Resident #9 sleeps in a recliner and was observed without any type of pressure-relieving device in the recliner. This is evidenced by: Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/30/10, the facility completed a Skin Assessment. The nurse completing the assessment documented that Resident #9 was admitted with a Stage II pressure ulcer on the right buttock measuring 0.5 cm (centimeters). The assessment indicates that Resident #9 is able to reposition self independently and that pressure reducing devices were not needed. A multi-vitamin was added on 1/4/11. The Wound Documentation Sheet indicates the following: ~1/6/11, Right buttock, Stage II measuring 0.5 cm. ~1/13/11, Right buttock, Stage II, measuring 0.5 cm. ~1/20/11, Right buttock, no stage documented, measuring 0.5 cm ~1/27/11, Right buttock, healed. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], does not indicate any pressure ulcers or any history of having one. On 6/16/11 at 12:03 p.m., Surveyor # spoke with the MDSC (MDS Coordinator) by phone who stated Resident #9 did not have a pressure ulcer upon admission and that she went and assessed Resident #9 herself, "I even check for blanching and everything." The MDSC stated the area was abraded. MDSC stated she is not on the Wound Care Team. Resident #9's care plan includes a problem of "Potential for Impairment of Skin Integrity" dated 1/13/11. Approaches dated 2/2/11 state, "Assist with cares as needed. Report changes in skin integrity, bruising to nurse. Sleeps in recliner, toilet per plan, barrier cream for redness..." Even though the facility was aware that Resident #9 sleeps in the recliner and there is a history of pressure ulcers, the facility did not implement any pressure relieving devices in Resident #9's chair. Wound Documentation Sheets continue: ~3/20/11, Right Buttock, no stage documented, 1.0 cm x 0.4 cm. No nurse's note seen. There were no changes made to Resident #9's care plan. There is no further documentation on this area until 5/1/11, when the Wound Documentation Sheet states, "Coccyx, healed." ~5/1/11, Left upper inner buttock, no stage documented, measuring 1.2 cm x 0.2 cm, wound bed dark pink, [MEDICATION NAME] dressing. Again, no pressure reducing cushion. Corresponding nurse's notes dated 5/1/11, "noted open area 1.5 cm by 0.2 cm on left inner buttock," and on 5/8/11 "area on left buttock appears healed but fragile. Barrier cream applied and open to air." The next entry on the Wound Documentation Sheet was on 5/19/11, "left upper inner buttock, healed." There are no updates to Resident #9's care plan to prevent recurrence/development of pressure ulcers. Wound Documentation Sheets continue: ~6/5/11, right inner buttock, Stage II, measuring 1.0 x 0.4 cm; left inner buttock, Stage II, measuring 0.3 x 0.2; wound bed dark pink, [MEDICATION NAME] applied. Resident #9's care plan was updated on 6/5/11 to include, "Assist with hygiene and general skin care. Gentle approach. Keep skin clean and dry." Resident #9 continues to sleep in his recliner but pressure relieving devices are not implemented. Wound Documentation Sheets continue: ~6/11/11, buttock, Stage II, Right measures 1.0 cm x 0.2 cm and Left measures 0.4 cm x 0.4 cm (larger). On 6/13/11, 6/14/11, and 6/15/11, Surveyor # observed Resident #9 either sitting or sleeping in his recliner with no cushion on the chair with feet elevated. On 6/14/11, the physician was asked to visit Resident #9 after Surveyor # was interviewing staff. New physician orders [REDACTED]. Please keep affected area dry and clean. OK to apply [MEDICATION NAME] until further recommendations from Wound Clinic. Please consult Wound Clinic." physician progress notes [REDACTED]. ~I have been requested to see Resident #9 by SNF (skilled nursing facility) nursing team as apparently he has developed two small ulcers on his buttocks. They have been applying barrier ointments over the affected areas but they appear unchanged..." Physical Exam: Skin: "On inspection of the skin of the gluteal area, there are two round shaped 2 cm diameter ulcers with minimal surrounding [DIAGNOSES REDACTED] in the medial area. The one on the left side appears open and the right closed. Of note the patient is wearing diapers and this are heavily soiled with feces. Other than those [MEDICAL CONDITION] skin appears intact." Impression: "1. Findings on examination are suggestive of decubitus ulcers or pressure ulcers stage I - II. Most likely this is secondary to his sedentary habits and the fact that he sleeps in same position in recliner. Will implement the following recommendations: ~Frequent repositioning at least every 2 hours. ~Modification of bowel regimen and cares. Recommend frequent checks for soiling and change diapers frequently to keep the area clean and dry. ~Consider starting lambs wool or pneumatic cushioning on recliner. ~Will start covering the ulcers with [MEDICATION NAME] or [MEDICATION NAME]. At the same time will have Wound Clinic visit the patient and follow their suggestions and recommendations." On 6/16/11 at 11:10 a.m., Surveyor # spoke with PT-H and asked if there was any discussion or referral for Resident #9. PT- H reviewed her notes and stated she had no notes on Resident #9. On 6/16/11 at 11:30 a.m., Surveyor # spoke with CNA-U about any new changes for Resident #9. CNA-U stated that she is a float today but she was in report this morning and said nothing was really new except Resident #9 now has open areas. Surveyor # and CNA-U reviewed the CNA assignment card and no new interventions were added despite physician orders.