Every finding on record at Care and Rehab - Boscobel

Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (R5, R10, and R48) reviewed for infection control with the potential to affect the census of 39.R5 did not receive the RSV (Respiratory Syncytial Virus) vaccine he requested.R10 was removed from COVID isolation before the required time.R48 was removed from COVID isolation before the required time.This is evidenced by:The facility's policy Infection Prevention and Control Program, dated 4/28/25, includes: 5. Isolation Protocol (Transmission-Based Precautions) A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Centers for Disease Control and Prevention) guidelines. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines.www.CDC.gov/covid guidelines for Duration of Transmission-Based Precautions for Patients with SARS-CoV-2 Infection states At least 10 days have passed since symptoms first appeared.Example 1R5 admitted to the facility on [DATE]. R5 has an APOA (Activated Power of Attorney).R5's Vaccination Information & Consent form, signed and dated on 6/18/26, indicates R5's APOA accepted the RSV vaccine.On 7/15/26 at 1:43 PM, Surveyor interviewed IP C (Infection Prevention Nurse) regarding R5's RSV vaccine. IP C indicated R5 should have received the RSV vaccine but has not.On 7/16/26 at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) regarding R5's RSV vaccine. DON B indicated resident should receive their requested vaccines timely.Example 2R10 admitted to the facility on [DATE].On 12/25/25, R10 exhibited symptoms and tested positive for COVID. R10 was placed on isolation. R10 was removed from isolation on 1/1/26.Of note, R10's isolation ended prior to 10 days.Example 3R48 admitted to the facility on [DATE]. On 1/15/26, R48 exhibited symptoms and tested positive for COVID. R48 was placed on isolation. R48 was removed from isolation on 1/23/26.Of note, R48's isolation ended prior to 10 days.On 7/15/26 at 1:43 PM, Surveyor interviewed IP C (Infection Prevention Nurse) regarding R10 and R48. IP C indicated residents should be isolated for 10 days for COVID. IP C indicated both residents were removed from isolation too early.On 7/16/26 at 8:33 AM, Surveyor interviewed DON B (Director of Nursing) regarding isolation. DON B indicated the facility should be following their infection control policies.

Based on interview and record review, the facility did not ensure residents were free from unnecessary medications in relation to excessive duration for 3 of 5 residents reviewed (R4, R7, and R35). R7 was prescribed Lorazepam every 4 hours as needed without a required end date. R35 had a PRN (as needed) psychotropic medication order that exceeded 14 days. R4 had a PRN medication that was being used as a psychotropic medication whose order exceeded 14 days. Findings include: Example 1 The facility's policy titled, Use of Psychotropic Medications, states, Psychotropic medications used on a PRN basis must have a diagonal specific condition an indication for the PRN use documented in the residence medical record and is subject to the limitations as noted.PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond the 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. R7 was admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. On 5/22/26, R7 was ordered Lorazepam 0.5 mg every 4 hours as needed for anxiety/air hunger. No end date was specified in the order. R7 received Lorazepam 37 times in June and 21 times in July. The facility was unable to provide any documentation indicating a physician had determined the PRN Lorazepam to be appropriate beyond 14 days of the 5/22/26 order. On 7/15/2026 at 3:16 PM, Surveyor interviewed DON B (Director of Nursing) who indicated that some doctors and hospice agencies sometimes will take it upon themselves to replenish a PRN order without consulting the facility or documenting a necessary extended duration for the medication. Example 2 R35 was admitted to the facility on [DATE] with diagnosis that include, in part: Unspecified Dementia unspecified severity without behavioral disturbance, anxiety disorder unspecified, and Depression unspecified. R35's Physician Orders include, in part: --Lorazepam HCL Oral Tablet 0.5 mg (milligram). Give 1 tablet by mouth every 4 hours as needed for anxiety. Start Date: 9/11/25. No end date. No documentation/justification indicating why R35's PRN lorazepam does not have a stop/end date. Example 3 R4 was admitted to the facility on [DATE] with diagnoses that include, in part: anxiety disorder. R4's Physician Orders include, in part: --Hydroxyzine HCL (hydrochloride) Oral Tablet 25 mg (milligrams). Give 25 mg by mouth every 6 hours as needed for anxiety. Start Date: 4/14/26. No end date. On 7/16/26 at 9:11 AM, Surveyor interviewed DON B (Director of Nursing) about PRN (as needed) psychotropic medications. DON B indicated that typically when a PRN order is entered into the system for 14 days with an end date, the floor nurses would notice that the 14 days was up and would follow-up with the provider. DON B stated that she also tries to watch the PRN end dates, but she was on vacation for some of them, and that hospice orders are a little more difficult to keep track of. DON B indicated that she thought that hospice was monitoring those, and that when a resident is admitted to hospice, some of those PRN medications were part of the hospice standing orders. DON B stated that she was going to be meeting with the hospice providers to streamline the process and ensure that the 14-day duration regulation was being followed. Surveyor pointed out that R4's hydroxyzine medication being used to treat anxiety would also need to follow the duration regulation of 14 days. DON B indicated that she has been educating the doctors on their responsibility when they order medications that are PRN and would do that with medications being used off label as well. The facility did not ensure that orders for PRN psychotropic medications did not exceed 14 days.

Based on interview and record review, the facility failed to ensure residents received adequate fluid and food intake to maintain acceptable parameters of hydration and nutrition for 1 of 3 Residents reviewed for nutrition (R1). R1's fluid intake was not documented or evaluated to ensure he was meeting his required daily fluid needs. R1's care plan was not updated with individualized approaches to increase fluid intake to prevent dehydration after it was revealed on 12/27/24 that he had elevated labs indicative of reduced kidney function. R1 was hospitalized with elevated lab value, dehydration, an acute kidney injury, hypernatremia, metabolic encephalopathy, and severe sepsis. The facility did not have a systematic process in place to monitor and assess R1's daily fluid intake or needs and implement corrective actions to prevent dehydration for R1. Despite R1 being his own person, the facility did not provide education and risks versus benefits to R1 about the risk of continuing to refuse food and drink. The facility failed to ensure residents receive adequate fluid intake to maintain acceptable parameters of hydration by its: * Failure to consistently record and assess fluid intake data being gathered; * Failure to accurately assess and complete assessments for signs and symptoms of dehydration (e.g., sunken eyes, cool/clammy skin, dry tongue, dark colored urine, and sticky saliva); * Failure to develop individualized care plan approaches for encouraging fluid intake. R1 lost 37.3 lbs. within a month following admission (almost 20% of body weight). Although the facility respected R1's right to refuse meals, the facility did not provide risks/benefits to the residents, did not immediately begin giving foods that he liked (e.g. ice cream), did not monitor the percentage of supplements consumed, and did not update R1's nutritional plan after admission. There was no assessment of why R1 refused to eat beyond, I don't like the food here. These failures to ensure R1 maintained acceptable parameters of nutrition and hydration created a finding of Immediate Jeopardy that began on 12/26/24. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were notified of the immediate jeopardy on 1/23/24 at 12:15 PM. The Immediate jeopardy was removed on 1/24/25; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. Findings include The facility's weight monitoring policy states the following: *Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance; unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. *The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: .developing and consistently implementing pertinent approaches . monitoring the effectiveness of interventions and revising them as necessary. * A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments could include the following information: a.) Height b.) Weight c.) Food and fluid intake d.) Fluid loss or retention e.) Laboratory/diagnostic evaluation *Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following, to the extent possible: a.) Identified causes of impaired nutritional status b.) Reflect the resident's personal goals and preferences c.) Identify resident-specific interventions d.) Time frame and parameters for monitoring e.) Updated as needed such as when the resident's condition changes, goals are met, interventions are determined to be ineffective or a new cause of nutrition-related problems are identified f.) If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. *Weight will be monitored at least monthly unless otherwise specified by physician orders. * Weight analysis: the newly recorded weight should be compared to the previous recorded weight. A significant change in weight is defined as: a.) 5% change in weight in one month (30 days) b.) 7.5% change in weight in three months (90 days) c.) 10% change in weight in six months (180 days). The facility's hydration policy states the following: * The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. * The facility will utilize the systematic approach to optimize the residence hydration status: a.) Identifying and assessing each resident's hydration status and risk factors b.) Evaluating/analyzing the assessment information c.) Developing and consistently implementing pertinent approaches d.) Monitoring the effectiveness of interventions and revising them as necessary. * Nursing staff shall assess hydration status upon admission and throughout the residence stay in accordance with assessment protocols. * The dietician will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission. * The dietician shall use data gathered from the nutritional assessment to the residence fluid needs and whether intake is adequate to meet those needs. A general guideline for oral hydration of the resident is: residents body weight in kilograms x 30cc = estimated fluid needs per 24 hours. * The resident will be monitored for signs and symptoms of dehydration including, but not limited to: . confusion or change in mental status .decreased urinary output .abnormal laboratory values (elevated hemoglobin hematocrit, potassium, chloride, sodium, albumin, transferrin, blood urea nitrogen (BUN), BUN/creatinine ratio, or urine specific gravity). * The resident will be monitored for signs and symptoms of electrolyte imbalance: .unexplained fatigue or lethargy. * The resident will be monitored for conditions that may increase fluid needs: .new cardiac medication or diuretic. According to Strategies for Ensuring Good Hydration in the Elderly, Dehydration is a frequent etiology of morbidity and mortality in elderly people. It causes the hospitalization of many patients, and its outcome may be fatal. Indeed, dehydration is often linked to infection, and if it is overlooked, mortality may be over 50%. Older individuals have been shown to have a higher risk of developing dehydration than younger adults. Modifications in water metabolism with aging and fluid imbalance in the frail elderly are the main factors to consider in the prevention of dehydration. Particularly, a decrease in the fat free mass, which is hydrated and contains 73% water, is observed in the elderly due to losses in muscular mass, total body water, and bone mass. Since water intake is mainly stimulated by thirst, and since the thirst sensation decreases with aging, risk factors for dehydration are those that lead to a loss of autonomy or a loss of cognitive function that limit the access to beverages. The prevention of dehydration must be multidisciplinary. Caregivers and health care professionals should be constantly aware of the risk factors and signs of dehydration in elderly patients. Strategies to maintain normal hydration should comprise practical approaches to induce the elderly to drink enough. This can be accomplished by frequent encouragement to drink, by offering a wide variety of beverages, by advising to drink often rather than large amounts, and by adaptation of the environment and medications as necessary. https://onlinelibrary.[NAME].com/doi/pdf/10.1111/j.1753-4887.2005.tb00151.x R1 was admitted to the facility on [DATE] and had diagnoses that included hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke; brain bleed, restricted blood flow to the brain), dysphagia (difficulty swallowing) following cerebral infarction, hypertension (high pressure in the arteries), COPD (Chronic Obstructive Pulmonary Disease; progressive lung disease that makes it difficult to breathe), and type 2 diabetes (problem in way the body regulates and uses sugar as fuel). His admission Minimum Data Set (MDS), dated [DATE], includes a Brief Interview for Mental Status (BIMS) score of 14, indicating R1 was cognitively intact. R1 had a power of attorney (POA), but this had not been activated and R1 was his own decision maker during his stay at the facility. R1's nutrition care plan states, Focus: nutritional status: potential for alteration in nutrition/dehydration related to stroke-left sided weakness, hypertension, anxiety, hypercholesteremia, gastroesophageal reflux disease, obesity, chronic obstructive pulmonary disease exacerbation, recently diagnosed type 2 diabetes, dysphagia manifested by altered texture diet, able to feed self .Goal: resident will consistently consume 75-100% of diet .Interventions: daily weights for 1 week, encourage fluids with and between meals, monitor resident food intake and record percentage for each meal, regular diet, minced and moist texture with ground meats, thin liquids, speech therapy as ordered, supplement per registered dietitian. All interventions on R1's care plan were put into place on 12/6/24. No further additions were made. Of note, R1's admission orders included Spironolactone 25 mg (diuretic; a medication that increases urine production, helping the body get rid of excess fluid and salt), once daily. Additionally, R1 had orders for Metformin 500 mg once daily for type 2 diabetes and Sennosides (laxative) 8.6 mg once daily for constipation. Facility Medication Administration Record (MAR) for R1 indicates these medications were dispensed daily. It should be noted R1's weights, in pounds (lbs.) during his stay at the facility (12/5/24 - 1/9/25) were as follows: 12/5/24 202.8 12/6/24 200.4 12/7/24 195.8 12/8/24 194.4 12/9/24 194.3 12/10/24 195 12/11/24 193.6 12/12/24 190 12/13/24 192.6 12/16/24 191.8 12/17/24 188.8 12/19/24 186.8 12/26/24 180 1/2/25 175.4 1/2/25 176 1/9/25 165.5 On 12/11/24 a progress notes for R1, written by RD C (Registered Dietician), states, Admission assessment . regular diet, minced and moist texture, thin consistency. Meal intakes are ~ 50% consumed. Resident reports he has had a decreased intake for a while even at home. Resident has permanent implants with no difficulties chewing or swallowing per resident report. Eats independently with set up assistance required. Has been eating meals in his room. Seeing speech language pathology until 1/7 with no recent changes to diet order. Estimated needs: 1880 Kcal/day, 88 to 106 g protein/day, one mL/Kcal recommended . resident is somewhat sleepy on visit, had just had therapy period resident is tolerating current minced and moist texture at this time period he reports his appetite is down but is happy with the weight loss he has had (10 pounds since admit). This writer reviewed his weight could gradually come down another 5 to 10 lbs. and be considered appropriate for him, but not at a rapid rate. Current BMI 29.4 is normal for age with a gradual decline to 25-30 acceptable. Resident reports he does not drink milk. He was living at home alone prior and preparing food for himself. He did not drink supplements and does not wish to have them here. He was interested in a snack of ice cream. Will review the option to offer a snack at HS (hour of sleep) for resident. RD C also conducted a mini nutrition assessment on 12/11, which R1 put R1 at risk for malnutrition due to a decrease in food intake and a weight loss greater than 3 kg (6.6 lbs.) in the last 3 months. On 12/12/24 at 2:14 PM, an electronic note was sent to R1's physician, stating Resident has lost 8 pounds since admission on 12-5-24. Stated nothing looks or sounds good. Talked over menu items and a salad that has eggs for proteins was chosen for supper. Resident thinks colder lite foods are most appealing at this time. Will notify dietary. Lungs are clear and no edema. This note was acknowledged and signed by R1's physician on 12/19/24, but no recommendations were made. On 12/16/24, RD C noted, Resident is reviewed for monthly skin weight. Current weight 12/16 191.8 lbs. are decreased 5% since admission 2 weeks ago. It is noted resident is pleased with weight loss and did want to lose some weight. BMI is 29.2 which is the upper end of acceptable for his age. Meal intakes have been scattered, 0-100% over the past week. Will consider supplementation if resident experiences further loss (will have to be Boost Breeze/Ensure Clear as he does not drink milk). No new recommendations at this time. On 12/18/24, it was noted that R1 was coughing up brown sputum (mucus). R1's physician was notified, and orders were placed for Azithromycin and Cefdinir for 10 days. Additional progress notes for R1: * 12/20/24 at 7:15 AM: Refused breakfast and lunch today stating, I don't like the food here and I can stand to lose a few pounds. * 12/25/24 at 6:48 PM: Resident has been refusing most meals. Drinks some liquids. * 12/26/24 at 11:11 AM: Has lost 22 pounds since admission and 6 pounds in the last week. Has refused meals. Continues to drink cola and orange juice .Resident declined for any medications or treatments. Is own person. Dietary updated. * 12/26/24 at 11:35 AM: It was reported that resident has had recent weight loss and refuses meals .Resident states he does not care for food, which is why he doesn't eat. Write offered to have other options provided for meal, but resident stated he will eat when he gets hungry .Resident did begin to get a little agitate when asked about all of these concerns, as well as the offer for a medication to help with appetite/mood, stating he is tired of being prodded with questions all the time and wants staff to understand he is fine and feels good . * 12/26/24 at 1:34 PM: Spoke with RD and we are going to do a trial of Boost Breeze, and she is going to check on what is going on, RD will do further charting on this resident. He refused to talk to me about his dislikes. States he will eat when he is hungry. R1's physician was notified on 12/26/24 of the 6 lb. loss in one week and 22 lb. loss since admission. A document titled, Diet History/Food Preference List, dated 12/27/24 states, Resident stated I will eat when I am hungry. Stated he liked all fruits .resident to get fruit daily .refused to give me any other food choices. An RD note, dated 12/26/24 at 1:38 PM states, Resident has continued to lose weight since admission weight of 202 lbs. Upon admit, resident stated he was happy with some weight loss. He has, however, lost weight rapidly 20 lbs. over 3 weeks. He does not drink milk and refused the milk based Ensure. He has refused any appetite stimulants and reports he eats when he is hungry and decides when to eat. The resident's rights will be honored while offering snacks. Please offer him ice cream or another option at HS as he said he likes ice cream. He also agreed to trial Boost Breeze so these will be provided to nursing to see if and when he might accept these. The dietary manager has offered to take preferences and individualized meal selections. A physician's order was placed on 12/27/24 to offer R1 ice cream at HS. This was started on 12/28/24 and tracked on R1's Treatment Administration Record (TAR). Additionally, Boost Breeze was documented in the progress notes but not tracked to include how much or how often it was being offered. A meal ticket for R1 (no date) was provided to surveyors showing fruit daily and Boost Breeze daily for each meal. No documentation was provided showing this was being tracked, how much was being drank, or if/when it was refused. It should be noted the facility tracks food and fluid intake in percentages from 0, 1-25, 26-50, 51-75, and 76-100. According to this documentation, R1 refused breakfast lunch and dinner from December 21-29. Additional meal refusals: Breakfast: December 17, 20, 30, 31 and January (2025) 1, 2, 3, 4, 6 and 9 Lunch: December 17, 18, 19 and January 1, 2, 4, 6, 7, 8 Supper: December 12, 13, 17, 19, 20, 30 and January 1, 3, 4, 7, 8 R1 also refused or drank 0% of fluids for breakfast lunch and supper from December 22-31 and January 3-8, with additional refusals or 0% intake as noted: Breakfast: December 19, 21 and January 2 Lunch: December 12-15, 17-21 and January 1 Supper: December 10, 11, 13, 16, 17, 20 and January 1 Routine labs were conducted for R1 on 12/27/24 showing R1's BUN (blood urea nitrogen- waste product created when your liver breaks down protein) was 43 mg/dl (Normal range is between 8-23 for adults 60 and over in age). R1's creatinine (a level test that measures the amount of creatinine in your blood or urine. Creatinine is a waste product created when your muscles break down. It determines how well your kidneys are functioning) was 1.57 mg/dl (Normal creatinine level for men is between 0.7 and 1.3). On the labs, PA F (Physician's Assistant) wrote (and dated 12/30/24), Decrease in kidney function, was recently on 2 antibiotics. Any edema or change in fluid status? A 12/30/24 (11:37 PM) progress note replies to this, stating, .Resident already being monitored for edema. Additional progress notes for R1: *12/27/24 at 5:23 AM: resident agitated this AM due to running out of Pepsi. Explained to resident we carry cola and Shasta. Resident said he doesn't like either of those. Gave resident vanilla ice cream and Boost Breeze. Resident consumed alternative snacks until Pepsi can be purchased. *12/27/24 at 10:22PM: resident was offered an ice cream cup with HS meds. Resident agreed and said he liked vanilla ice cream. Resident was given a vanilla ice cream cup and ate the whole thing. *12/28/24 at 10:12 AM: refuses all meals. Will only drink liquids. Boost Breeze given and has only taken sips thus far after being prompted. *12/28/24 at 4:37 PM: resident drank 1 carton of Boost Breeze. Sipped on it until gone. *12/29/24 at 10:11 AM: continues to refuse meals. Has snacks in room and does not eat. Is sipping on boost breeze with much encouragement. Drinks regular Pepsi and juice. *12/31/24 at 5:46 PM: Has been requesting and receiving pineapple for snack. *1/1/25 at 4:14 AM: resident is reviewed for weight changes in December. Weight on 12/26 180 lbs. is documented as a significant loss from admission. Interventions include offering the resident various snacks especially at HS, offering Boost Breeze as resident allows. He has been accepting both of these. Resident's family expresses resident may take extra fruit sent on tray. 1/1/25 at 10:15 AM: Refuses meals. Drinks liquids. 1/1/25 at 1:26 PM: Refused meals. Accepted liquids to sip on during day. 1/2/25 at 10:15 AM: Resident had 4 LB weight loss in one week. Dietary notified. Physician notified. Resident often refuses meals. 1/2/25 at 3:53 PM: Poor appetite/likes fruit On 1/2/25 at 10:50 PM, a progress notes for R1 states, Resident started on Levaquin 500 mg four times a day times 10 days for coughing up phlegm. Tolerated antibiotic without ill effect. Chest X-ray to be done tomorrow. Additional progress notes for R1: *1/3/25 at 2:07 PM: Poor appetite. Eating fruit. *1/3/25 at 6:21 PM: Does accept fruit dishes. Drank 1 Boost Breeze with encouragement. *1/4/25 at 4:55 AM: .Has 8 three fruit cups . *1/4/25 at 10:02 PM: Refused supper but did eat some fruit cups. *1/5/25 at 3:46 PM: Poor appetite, likes fruit *1/5/25 at 10:11 PM: Resident refused supper tray, but writer did get him a bowl of cut up pineapple around 8 PM. A progress notes for R1, dated 1/9/25 at 8:36 AM states, Resident is very weak this morning. Three staff for a transfer. Skin color pale. No complaints of pain. No shortness of breath. Resident has refused most meals and will only eat a bite or two of fruit or ice cream. Weight down 10.5 lbs. in one week. Continues on antibiotic for excess phlegm. Call place to clinic to update and will wait on a call back. R1 was sent to the ED (emergency department) at approximately 9:00 AM. R1's ED Notes, dated 1/9/25, states, in part: . Date of Service: 1/9/25 . Assessment & ED/UC Department Course: . Leukocytosis (a high level of white blood cells in the blood) . . Acute renal failure (a condition in which the kidneys suddenly can't filter waste from the blood) . . Hypernatremia (condition that occurs when the level of sodium in the blood is too low) . . Lactic acidosis (a condition that occurs when lactate builds up in the blood and lowers the body's pH balance) . . Altered mental status . . Weight loss Patient presenting from nursing due to concerns about weakness, altered mental status, not eating, 40-pound (lb.) weight loss in 1 month. Per the report patient went to rehab after a stroke. He has not been wanting to eat . Patient appears very dry. Initial blood pressure in the 70s systolic. Given 2 liters intravenous (IV) fluids. Patient noted to but in acute renal failure with creatinine 4.76 this is increased from baseline of 1.57. Patient with sodium of 150. Patient with white count of 22.73 (normal range between 4,500 - 11,000) with leukocytosis. Patient started on empiric antibiotics ceftriaxone and vancomycin. Foley catheter placed no urine output initially, bladder scanned and nothing in the bladder .Most concerning of all is lactic acid (a chemical produced by the body when it breaks down carbohydrates for energy) of 7.3 repeat of 5.3 (normal range between 0.5 and 2.2 millimoles per liter (mmol/L). Creatinine Phosphokinase (CPK) (enzyme that helps your muscles produce energy, can help diagnose and monitor muscle, heart, or brain injuries and diseases) is 297. (normal range is between 10 and 120 micrograms per liter (mcg/L)). Family informed of plan to transfer and that this is a serious condition . Labs Reviewed: Glucose- 133 (average range between 70 and 100mg) . BUN 127 . Sodium 150 (average range between 135 and 145) . Lactate Sepsis with 4-hour reflex (refers to a medical situation where a patient with sepsis (a severe systemic infection) has significantly elevated lactate level in the blood) 7.4 (normal level below 2 mmol/L) . Lactate (chemical produced by the body when cells break down food for energy) 5.3 (normal level is less than 2 mmol/L) .9:18AM- Arrived . 1:49PM discharged . R1 was transferred to another hospital. R1's Discharge Summary, dated 1/16/25, states, in part: . Date of Admission: 1/9/25. Date of Discharge: 1/16/25 . Principal Diagnosis: Acute metabolic encephalopathy (a brain condition that occurs when there's a lack of oxygen, glucose, or vitamins in the body) . Resolved Hospital Problems- Diagnosis - Acute metabolic encephalopathy -Hypovolemic shock (form of shock caused by severe dehydration or blood loss) -UTI (urinary tract infection) -Acute kidney injury -Severe sepsis (life-threatening condition that occurs when the body's immune response to an infection damage organs) due to staph epidermidis UTI . Summary of Admission . Patient presented to an outside ED from [Boscobel] skilled nursing facility for worsening weakness and altered mental status. Reportedly he had not been eating or ranking for past 3 weeks. He was initially admitted [DATE] to the nursing home and weight 202-pound, patient today weighs 165.5 pounds . Hospital Course: Patient was admitted for management of UTI, AKI, and metabolic encephalopathy. Patient was also hypernatremia (a high concentration of sodium in the blood) at presentation. AKI thought to be due to prerenal which improved slowly with antibiotics and fluids. Hyponatremia was managed with 100 mL/h D5W (dextrose 5% in water that treats dehydration, low blood sugar, and insulin shock). UTI was managed with ceftriaxone . ciprofloxacin total 7-day course . Acute metabolic encephalopathy improved, though his dementia is advanced . R1's hospital notes, encounter date 1/9/25, states, in part: . BUN 1/9/25 - 127 mg/dl (12/27/24 - 43 mg/dl) Creatinine 1/9/25 - 4.76 mg/dl (12/27/24 - 1.57 mg/dl) WBC 1/9/25 - 22.73 (11/11/24 - 11.11) Magnesium 1/9/25 - 3.7 (2/1/24 - 2.2) HS-cTnT, Baseline (a measurement of the amount of troponin T in the blood, a level of above 14 indicates a likelihood of heart damage) 1/9/25- 48 11/11/24 - 13 . R1's family submitted a grievance to the facility regarding weight loss to which NHA A (Nursing Home Administrator) responded, documenting: Concern about resident's weight loss since admission. RD progress notes 12/16, 12/26, and 1/1/25. MD updated on weight loss 12/19 and 1/8/25. This writer discussed weight loss and resident's refusal to eat, take in fluids and supplements given. Fruit offered .Resident is own decision maker .Refusals of cares monitored on the TAR began 12/31/24. Dietician reviews and resident had desire to lose weight. Resident was provided supplements. Resident stated he desires fresh fruit. On 1/22/25 at 9:00 AM, Surveyor interviewed RN D (Registered Nurse) who stated that a significant weight loss would be 3 pounds in a day or 5 pounds in 1 week, 10% in 30 days. RN D stated that if such a weight loss would occur, he would notify POA, physician. On 1/22/25 at 9:26 AM, Surveyor interviewed LPN E (Licensed Practical Nurse) stated that if there were weight loss she would update the MD the day it is found, send a slip to dietary- it has lung sounds, edema, medications. LPN E stated that she would notify physician of 3 lb. or greater in 1 week, 5% in 1 month, 10% in 6 months. Additionally, LPN E stated that R1 did feed himself but refused to eat. They tried all different foods. LPN E stated they offered to assist him with eating-he refused all. R1 would say I will eat when I am hungry. LPN E recalled R1 stating, Nothing looked good. LPN E stated R1 would eat fruit and ice cream at first but then stopped. Facility tried Boost and Breeze supplements. It would take a very long time to get him to drink a breeze. We would have to keep coming back throughout day to get him to drink whole breeze. LPN E stated R1 struggled with eating ever since he came to the facility. LPN E also stated R1 would say I will eat when I am ready and that he would eat pineapple and ice cream but that wasn't enough; he would not allow staff to assist him. LPN E stated that when R1 would not eat, alternatives were offered but specific items were not charted, only alternatives refused. LPN E stated the facility tried the Breeze for a while and offered ice cream at night but stated the ice cream did not get documented; nursing would not put stuff on the MAR until something was found that he liked or they would be constantly charting refusals. LPN E stated fluid amounts did not get documented, just percentages. When asked for a resident with that amount of weight loss in such a short period of time if she would expect to see specific amounts of fluid and food intakes to be charted, LPN E stated, He was his own person, but she would update MD on the weight loss. Surveyors conducted additional interviews with CNAs (Certified Nursing Assistant) interviews on 1/22/25: *At 9:52 AM, CNA G stated R1 refused meals often and would keep fruit off his tray and not eat it. CNA G stated R1 was able to feed himself and was on a regular diet, not mechanically altered. CNA G stated she would document refusals for meals and fluids or document percentages. Additionally, CNA G stated that when R1 refused she and the other CNAs would let the nurse know and offer alternatives. CNA G stated she was not sure if R1 received a supplement but if a resident received a supplement, CNAs could chart the resident was given the supplement, but not the amount taken or consumed and if a supplement was given during medication pass, CNAs check yes or no if they drank it- but no specific amount. CNA G stated snacks do not get documented, but they report to the nurse that they were offered. *At 10:00 AM, CNA H stated R1 fed himself but refused a lot of meals and this would be documented and reported to the nurse. CNA H stated R1 refused a lot. CNA H stated when a resident is weighed, if there is a 5 lbs. or more weight loss, CNAs are to tell the nurse and reweigh. CNA H stated R1 lost a lot of weight and was a daily weight. On 1/22/25 at 2:49 PM, Surveyor interviewed RD C who stated that she sends her recaps about residents to facility administration and indicated she had sent her admission assessment of R1 to the DON (Director of Nursing). When asked why R1's interest in ice cream on 12/11/24 was not put into practice until the 12/28/24 or why it had not been used more given R1's weight loss, RD C stated, It's only 150 calories. RD C stated the initial weight loss could have been fluid loss after coming from the hospital. RD C stated that tracking fluid amounts for R1 would not have mattered as it only would have confirmed what they already knew that he was refusing. Additionally, RD C stated that when tracking fluids the way the facility currently does it with entering percentages, Percentage of what? indicating that unless there was a defined or documented amount of fluids given, percentages do not detail how much fluid is taken in. On 1/23/25 at 10:25 AM, Surveyor interviewed PA F (Physician's Assistant) who stated that she never did get a reply when she asked about the fluid status of R1 on 12/30/24 and was not sure if that had been relayed to R1's physician as he (R1's physician) is currently on medical leave. On 1/22/25 at 3:10 PM, Surveyor interviewed DON B (Director of Nursing), along with NHA A (Nursing Home Administrator.) DON B stated that normally the physician will recommend additional daily weights, but the RD could also do that. DON B stated that there was no discussion of continuing daily weights after the initial admission orders and the facility had not talked about documenting intakes and output amounts of fluids for R1, even after his reduced kidney function was known on 12/27/24. When asked if R1 had been given a clear risks vs benefits describing the extreme risks of continuing to refuse snacks, meals and fluids, DON B indicated that had not been done. DON B stated that snacks were not tracked as to how much they are given or how much was consumed and, additionally, the Boost Breeze that was given with meals was not documented or observed for success or failure. DON B stated that they will be tracking snacks and supplements better moving forward. DON B stated the facility had not considered any sort of IV (Intravenous Fluids) or advanced hydration for R1 NHA A stated that R1 was his own person and allowed to refuse. R1 was admitted to the facility and immediately began losing weight. R1's admission nutrition assessment was not completed until 12/11/24 at which time he had lost 9.2 pounds. At this time, R1 indicated would enjoy ice cream, but this was not put into orders until 12/27/24 after R1 had lost an additional 13.6 lbs. Daily weights were discontinued on 12/13/24. R1's physician was notified on 12/26/24 regarding a 22-lb weight loss since admission and 6 lbs. in the previous week. Ice cream was added to R1's orders in addition to a trial of Boost Breeze and added fruit at each meal. These items were not tracked as to how much was consumed. The ice cream was noted as being given staring on 12/28, but not how much was consumed or if it was consumed. R1 was taking a diuretic and there is no documentation of a discussion with the physician regarding the continued use of the diuretic in light of the resident's decreased food and fluid intake. When labs came back [TRUNCATED]

Based on interview and record review the facility failed to ensure that all residents were able to formulate an advance directive, specifically related to code status, for 9 of 12 residents (R7, R185, R8, R22, R13, R28, R11, R17, & R10) reviewed for code status of total sample of 34 residents. R7's Provider Orders for Scope of Treatment (POST) form is dated and signed by the physician but not the resident or resident representative. R185's POST form is dated and signed by the physician but not the resident or resident representative. R185 does not have Advance Directives in place and no documentation to show the facility spoke with R185 regarding Advance Directives. R8's POST form is dated and signed by the physician but not the resident or resident representative. R8's Power of Attorney for Healthcare does not have the two required witness signatures and dates. R22's POST (Provider Orders for Scope of Treatment) form did not match his CNA (Certified Nursing Assistant) Kardex in the closet of his room; POST form said Full code and Kardex in closet said DNR (Do Not Resuscitate). R22's POST form is not signed by his Court-appointed Guardian. R22 only has his code status on file, no further advance directives. R13 did not have a POST form in the POST form book at the Nurse's Station until the afternoon of [DATE]. R13's POST form is not signed by herself or her representative. R11 and R28 POST (Provider Orders for Scope of Treatment) form was not signed by the resident or representative. R10 and R17's POST (Provider Orders for Scope of Treatment) was not signed by the resident or representative. This is evidenced by: The facility's policy entitled Resident Rights Regarding Treatment and Advance Directives, dated [DATE], states, in part: . Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . The facility's policy entitled, Respiratory and/or Cardiac Arrest-Code Blue Procedure, dated ,d+[DATE], states, in part: . POLICY: It is the policy of Care & Rehab Boscobel to provide immediate medical attention as needed for our residents who become pulseless and breathless unless: 1) The resident has a do not resuscitate (DNR) order; . Code status will be addressed by social worker upon admission. PROCEDURE: . 2. Call for help- The staff member is to determine if resident is Full Code indicators for full code: Full Code sticker inside the resident's closet, and in Point Click Care - Care Profile- Special Instructions . Example 1 R7 admitted to the facility on [DATE]. R7's Provider Orders for Scope of Treatment (POST), dated [DATE], indicates R7 is a Do Not Attempt Resuscitation/DNR. The POST form is signed and dated by physician. The resident or resident representative did not sign and date the form. Example 2 R185 admitted to the facility on [DATE]. R185's POST, dated [DATE], indicates R185 is a Do Not Attempt Resuscitation/DNR. The POST form is signed and dated by physician. The resident or resident representative did not sign and date the form. On [DATE] at 10:48 AM, Surveyor interviewed SW C (Social Worker) and asked what the facility's process is for Advance Directives. SW C indicated the staff talks to the residents on admission, during care conferences, and nurses on the floor talk with residents also. Surveyor asked SW C for R185 if there is documentation on a discussion with R185 regarding Advance Directives. SW C indicated no. Surveyor asked if there should be and SW C indicated yes. On [DATE] at 4:05 PM, Surveyor asked R185 if the facility spoke with him regarding Advance Directives on admission and R185 indicated he does not remember being talked to here at the facility but at the hospital he does remember a conversation. He remembers signing something at the hospital. Example 3 R8 admitted to the facility on [DATE]. R8's POST, dated [DATE], indicates R8 is a Do Not Attempt Resuscitation/DNR. The POST form is signed and dated by the physician. The resident or resident representative did not sign and date the form. R8's Power of Attorney for Healthcare, dated [DATE], does not have the two required witness signatures and dates; therefore, the form is not valid. On [DATE] at 4:20 PM, Surveyor interviewed RN D (Registered Nurse) and asked where she would look for a resident code status and RN D indicated first, she would look at the paper the nurses carry with all the residents' code statuses listed. RN D indicated the residents' closets also have code status's along with PCC (Point Click Care). RN D indicated and showed Surveyor the list of all residents' code status' that is kept hanging in the medication room. RN D indicated in the dining room there possibly might be a list as well with residents' code statuses. On [DATE] at 12:15 PM, Surveyor interviewed SW C and asked what the process is for obtaining code status for new residents. SW C indicated the facility looks at the hospital code status and have a discussion with the resident to see if the resident would like to keep that status or change it. If resident chooses to stay the same, the facility keeps the hospital form. If the resident wishes to change status, the facility completes a new the code status form. Surveyor asked who is required to sign the code status forms and SW C indicated the physician signs, and the facility gives the resident the option to sign the form. Surveyor asked SW C how one would know by looking at the form not signed by resident or resident representative if it was the resident's choice. SW C indicated the SW knows. Surveyor asked SW C is the facility uses the POST form as the main form to determine code status that is entered in various areas such as PCC and SW C indicated yes, the other forms and places are formed from the POST. Surveyor asked if the resident/resident representative should sign the POST forms and SW C indicated the facility is reviewing the policy and will be changing the policy. Surveyor asked SW C if R8's Advance Directives is valid without the required two witness signatures and SW C indicated no not without the signatures. Surveyor asked if residents should be asked about Advance Directives and SW C indicated yes. Surveyor asked if there should be documentation showing these conversations and SW C indicated yes. 38725 Example 4 R22's POST form is dated [DATE] with Physician signature only, there is no resident/resident representative/guardian signature present. R22's POST form, banner in Electronic Health Record (EHR), Order, on Nurse Report sheet, and Code status list in medication room all document Full Code. R22's CNA Kardex in R22's closet had DNR sticker on it. R22 only has code status on file, he does not have any other advance directive in place. Example 5 R13's POST form is dated [DATE] with Physician signature only, no resident/resident representative/guardian signature present. On [DATE] at 11:03 AM, Surveyor observed POST form book at Nurse's Station. R13 did not have a POST form in binder. On [DATE] at 10:47 AM, Surveyor observed POST form book at Nurse's Station. R13 did not have a POST form in binder. On [DATE] at 4:36 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E where he would look to find a resident's code status, LPN E said in our computer system and POST book. Surveyor asked LPN E if all residents should have a POST form in the POST book, LPN E stated yes, they should. Surveyor asked LPN E when is the POST form completed, LPN E replied on the day of admission. Surveyor asked LPN E who completes the POST form, LPN E said I think Social Worker does that. Surveyor asked LPN E if there are any other places where a resident's code status is documented, LPN E explained it is on our report sheet- typed on there, list in medication room, and in room in closet. On [DATE] at 5:32 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who obtains residents' code status upon admission, DON B said Social Service. Surveyor asked DON B how a residents' code status is determined, DON B explained there's a discussion with resident/family and Social Services. Surveyor asked DON B where you would expect your staff to look for code status in the event of an emergency, DON B stated in the EHR if they are in the hallway or in residents' closet on the CNA Kardex, there's a sticker; it's also on their report sheets that they carry. Surveyor asked DON B who ensures all areas where code status is documented are up to date, DON B said our MDS (Minimum Data Set) Coordinator. Surveyor asked DON B if all areas that code status are documented should match, DON B replied yes. Surveyor asked DON B are you aware of any residents that don't have matching code status, DON B stated no. It is important to noted that in the event of an emergency in R22's room, if staff looked in his closet and did not provide Cardiopulmonary Resuscitation (CPR; can help save a life during cardiac arrest), they would not have been following his code status order. On [DATE] at 5:33 PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C how a resident's code status is determined, SW C explained there's a discussion with resident/family where I ask the resident, complete POST form, take to the clinic and have Physician sign. Surveyor asked SW C how discussion is had if family isn't able to be present in person, SW C said I'd call them and if there's a guardian company, we email. On [DATE] at 10:55 AM, Surveyor interviewed LPN F. Surveyor asked LPN F if all residents should have a POST form in the POST book, LPN F said yes. On [DATE] at 11:16 AM, Surveyor interviewed DON B. Surveyor asked DON B if all residents should have a POST form in the POST book, DON B stated yes. On [DATE] at 12:04 PM, Surveyor interviewed SW C. Surveyor asked SW C if all residents should have a POST form in the POST book, SW C replied yes. Surveyor asked SW C if R22 had any further advance directive information on file, SW C said she would look and come back. On [DATE] at 1:06 PM, SW C came back to Surveyor to say that R22 does not have any other advance directive on file here. SW C stated I called his Corporate Guardian and asked her if they had anything that we didn't have, and she stated they did not. 36253 Example 6 R11's POST form, indicating her wish to be a Do Not Resuscitate (DNR), was signed by the physician on [DATE]. The form was not signed by R11 despite the form indicating that she was of capacity to do so and had not indicated she did not wish to sign. Example 7 R28's POST form, indicating her wish to be a DNR, was signed by the physician on [DATE]. The form was not signed by R28 despite the form indicating that she was of capacity to do so and had not indicated she did not wish to sign. On [DATE] at 12:10 PM, Surveyor interviewed DON B (Director of Nursing). When asked if she would expect the POST form to be filled out thoroughly and signed by all the parties, DON B stated that she would leave that to SW C (Social Worker) as that is her job to complete. When asked how she knows what the wishes are of the resident, DON B stated that the facility has electronic orders for their code status. When asked where those electronic orders come from, DON B stated it was the POST form. 50228 Example 8 R10's POST form, indicating her wish to be a DNR, was signed by the physician on [DATE]. The form was not signed by R10 despite the form indicating that she was of capacity to do so and had not indicated she did not wish to sign. Example 9 R17's POST form, indicating her wish to be a DNR, was signed by the physician on [DATE]. The form was not signed by R17 despite the form indicating that she was of capacity to do so and had not indicated she did not wish to sign.

Based on observation and interview, the facility did not ensure a resident who is fed by and receives medications by enteral means (also known as tube feeding, a way of sending nutrition and / or medications directly to the stomach or small intestine) receives the appropriate treatment and services. This affects 1 (R2) of 5 residents observed during medication pass. The facility did not properly check placement, ensuring the marking on the tube has not changed, of R2's jejunostomy tube (tube placed through the skin of the abdomen into the small intestine for nutrition, hydration, and/or medication administration) prior to administering medications. This is evidenced by: The Facility's policy entitled Verifying Placement of Feeding Tube dated 5/22/24, documents in part: It is the practice of this facility to ensure proper placement of feeding tubes prior to beginning a feeding, flushing the tube, or before administering medications via feeding tube.Procedure for verifying placement of feeding tubes: . Verify tube placement: for gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube.If unable to confirm placement, notify supervisor and/or physician. Consider alternative verification methods such as x-ray. Do not proceed with feeding, flush, or medication administration until tube placement is verified. On 07/01/24 at 4:39 PM, surveyor observed RN G (Registered Nurse) perform medication administration with R2. RN G performed hand hygiene, prepared medications, again performed hand hygiene, applied gown and gloves, and took medications, water flush, and prune juice to R2's bedside. RN G placed the tube feeding on hold, palplated R2's abdomen, attached the bulb of the syringe to the tube and poured water flush into syringe to instill by gravity. RN G administered medications one at a time through the syringe with water flush in between. RN G poured prune juice the syringe after the last medication, and followed this with an additional water flush. RN G removed the syringe from tube and restarted the tube feeding. Surveyor asked RN G, when placement of a feeding tube is verified. RN G stated, Good question. I do not do it. On 7/2 24 at 4:44 PM, Surveyor interviewed LPN E (Licensed Practical Nurse). Surveyor asked LPN E if placement of a feeding tube is verified. LPN E stated, Yes, we measure the tube prior to any administration; the measurement is listed on the pump. LPN E showed surveyor a sticker on the top of R2's tube feeding pump that stated 23 cm. On 7/02/24 at 5:27 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when would you expect staff to check placement of the tube feeding? DON B stated before giving meds, feeding, or flushes. Surveyor asked DON B, how do you expect staff to check placement? DON B stated measure the tube.

Based on observation, interview and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 34 residents (R) in the facility. The facility allowed staff who had tested positive for COVID-19 to return to work after a 5 day quarantine without evidence of being in a contingency staffing situation and the facility has not been tracking/trending the areas in which an ill employee last worked prior to illness to increase monitoring of those residents potentially exposed. R132 was observed multiple instances with food or beverages sitting on the floor with no barrier to reduce the risk of infection Staff observed providing wound care did not wash hands between glove changes Staff did not shut the door of a resident receiving an aerosol generating procedure This is evidenced by: The CDC (Center for Disease Control) document, Work Restrictions for HCP (Healthcare Personnel) with [CONDITION(S)]-CoV-2 (COVID-19) Infection and Exposures, dated 1/7/22, indicates for those with vaccination status of both up to date and not up to date, when the facility is in conventional staffing mode, work restriction for HCP (Health Care Personnel) with COVID-19 infection is 10 days OR 7 days with negative test, if mild to moderate illness (with improving symptoms). If a facility is running on contingency staffing, work restriction for HCP with COVID-19 infections is 5 days with/without negative test, if asymptomatic or mild to moderate illness (with improving symptoms). The facility policy titled, Return to Work Policy, no date listed, reads: General Principles: - Work at home: Office and management staff may work from home only when unable to come to work due to symptoms. All other times, they should report to work as their responsibilities include assisting floor staff, interviewing residents, monitoring care delivery, and assisting in the office to answer phones, etc. - Authorization from Infection Control/ MDS (Minimum Data Set) Nurse/Director of Nursing: All staff must report symptoms to their manager or charge nurse in a manager's absence, or directly to Management Nurses above, if they have any symptoms. This nurse will provide instructions on next steps such as taking a COVID test or staying home until symptoms subside. This facility addresses Assessing Health Risk, as well as the Procedure for Employees with COVID-19 Symptoms, which reads: 1. COVID-19 Positive Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. COVID-19 Symptoms- Employees with symptoms should self-quarantine and consult with their physicians. 3. Return to work after positive COVID-19 Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms must have improved and no fever for more than 72 hours with fever reducing medications, improved cough or shortness of breath, and at time line is followed by CDC guidelines on a specific date of return. Return to Work after diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Facility will determine when a staff member is allowed to return to work. This is based on how our staffing needs are defined below: 1. Contingency staffing (an employee may return after 5 days of asymptomatic or mild symptoms, as outlined in CDC guidance). This is defined as when management would have to cover the floor hours. 2. Crisis staffing is defined when with management working all the floor hours and we still can't cover all the hours needed. *Subject to change based on CDC and CMS (Center for Medicare Services) guidelines. The facility policy titled, Infection Surveillance - Overview, last revised 9/21, indicates methods of surveillance including, but not limited to: - Employee illness questionnaire - individual illness questionnaire will be filled out on each employee that calls in ill or leave in the middle of their shift. The staff member receiving the call will document the illness start date and symptoms. - The infection control nurse or designee will provide monitor [sic] of staff illness. When a staff member calls in or leave due to illness the IC (Infection Control) nurse will provide follow up calls to monitor symptoms and end dates/times. The IC nurse will inform the staff member when they will be allowed to return to work. This policy also provides the following regarding documentation: - Facilities may use various approaches to gathering, documenting, and listing surveillance date. The facility's infection control reports describe the types of infections and are used to identify trends and patterns. - Descriptive documentation provides the facility with summaries of the observations of staff practices and/or the investigation of the causes of an infection and/or identification of underlying cause(s) of infection trends. - It is important that the infection prevention and control program define how often and by what means surveillance data will be collected . The facility policy titled, Infection Prevention and Control Program, no date listed, states, The infection prevention and control program exist to assure a safe, sanitary and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of communicable disease and infection. It reads, in part, . The facility establishes a program under which it: - Prevents, identifies, reports, investigates and controls infections and communicable diseases in the facility for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement based upon the facility assessment; - Provides a system of surveillance to identify possible communicable diseases or infections before they can be spread in the facility. This policy indicates steps included in preventing the spread of infection include, The facility must prohibit employees with a communicable disease or infected skin [CONDITION(S)] from direct contact with residents or their food, if direct contact will transmit the disease. (And) The facility must require staff to clean their hands after each direct resident contact using the most appropriate hand hygiene professional practices. This policy states, An effective infection control program is therefore, necessary to control the spread of infections. Infection control program components critical to the operations of the healthcare facility may include but are not limited to: . - Prepare lists of persons who are ill and try to identify recent human and environmental contacts of each resident to facilitate an infection management plan; The Department of Health Services (DHS) memo BCD 2021-11, release date 12/13/2022, states in part .A fit tested N95 respirator and eye protection should be worn when caring for any residents with suspected or confirmed COVID-19 and during any AGP performed on those residents .staff present during the procedure should be limited and the door should remain closed. The Occupational Safety and Health Administration temporary emergency standard, 19.10.502(b), of June 21, 2021, defines an (AGP) aerosol-generating procedure in part as: Commonly performed medical procedures that are often considered AGPs, or that might create uncontrolled respiratory secretions, include: open suctioning of airways, sputum induction, cardiopulmonary resuscitation, non-invasive ventilation (e.g., [CONDITION(S)], [CONDITION(S)]) . The facility's policy, entitled [Facility Name] Policy and Procedure Clean Dressing Change, undated, states, in part: .Procedure .10) Loosen tape and remove dressing. Dispose of soiled dressing and gloves in appropriate receptacle. 11) Wash or sanitize hands. Donn (put on) disposable gloves . The facility's policy, entitled [Facility Name] Policy Hand Hygiene, dated 6/1995, states, in part: .Objectives *To outline the required, minimum hand hygiene procedures to be followed within [Facility Name] to prevent the transmission of micro-organisms, reduce the incidence of infection and promote the health and safety of staff, medical staff, Volunteers, residents, and visitors .Procedure *Always wash your hands: -After contact with a residents intact skin .-After removing gloves -Before donning gloves .-Before moving from a contaminated body site to a clean body site during patient care .-Before and after direct resident care . Example 1 Surveyor reviewed the facility's Staff Infection Surveillance - January 2022 form which revealed 6 staff members had returned to work earlier than CDC recommendations for HCP. The facility's staff line list indicates the following COVID-19 positive staff and their return to work: - DON B (Director of Nursing) left work early 1/12/22 for headache and general malaise. She completed a POC (point of care/rapid test) at that time which was negative. On 1/13/22 she comes in for scheduled shift stating she feels 'way better' but continues to have a hoarse voice. POC for COVID-19 obtained and was positive. PCR sent to [Contracted Lab] for review. DON B will remain off work for a 5 day quarantine through 1/18/22. On 1/19/22, facility was notified that DON B's PCR test collected on 1/13/22 was positive for COVID-19. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/nursing department was operating on contingency staffing at this time. - CNA J (Certified Nursing Assistant) - On 1/15/22, facility was notified by [Contracted Lab] that CNA J's PCR test for COVID-19 collected on 1/10/22 was positive. CNA J was made aware and denies any symptoms. May return to work on 1/16/22. CNA J worked on 1/18/22 from 10:00 AM to 10:00 PM and on 1/19/22 from 10:15 AM to 10:30 PM. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/nursing department was operating on contingency staffing at this time. - CNA K was sent home early due to nausea on 1/17/22 and reported headache, increased nausea, and vomiting later that day. On 1/18/22, CNA K states she has had no further GI (gastrointestinal) symptoms but does c/o (complain of) body aches and fatigue. She denies a fever. 1/19/22 CNA K reports improvement in body aches and fatigue and has had no further GI sx (symptoms) since the morning of 1/17/22. May return to work on 1/20/22. On 1/21/22, the facility was notified by [Contracted Lab] that the PCR collected on 1/17/22 was positive for COVID-19. CNA K was notified at that time. She states her symptoms have completely resolved. Notified that she will have to remain off work until 1/23/22. *Note - it is not documented on the line list if CNA K took a POC test prior to returning to work on 1/20/22. CNA K worked on 1/20/22 from 6:00 AM to 2:45 PM and on 1/24/22 from 3:00 AM to 2:45 PM. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/nursing department was operating on contingency staffing at this time. - Dietary Cook L - On 1/19/22, facility was notified by [Contracted Lab] that Dietary Cook L's PCR test collected on 1/13/22 was positive. Dietary L was made aware of her test results and denies any symptoms consistent with COVID-19. May return to work as scheduled. *Note - Dietary Cook L worked on 1/19/22 from 5:15 AM to 2:30 PM, 1/20/22 from 5:30 AM to 2:15 PM, 1/22/22 from 5:15 AM to 1:45 PM, and 1/23/22 from 5:30 AM to 2:15 PM. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/dietary department was operating on contingency staffing at this time. - NA M (Nurse Aide) - On 1/21/22, the facility was notified that PCR test for COVID-19 that was collected on 1/17/22 was positive. NA M informed and denies symptoms. Informed of 5 day quarantine and instructed to call facility if she develops symptoms. May return to work for scheduled NOC (night) shift on 1/23/22. *Note - NA M worked on 1/23/22 from 11:00 PM to 7:30 AM on 1/24/22, 1/25/22 from 11:00 PM to 11:15 AM on 1/26/22. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/nursing department was operating on contingency staffing at this time. - CNA N - On 1/21/22, the facility was notified that PCR test for COVID-19 that was collected on 1/17/22 was positive. CNA N was informed of positive results and need for 5 day quarantine. She denies symptoms fever, cough, and GI sx. Instructed to notify facility if she does develop sx. Ma return to work as scheduled 1/24/22.' *Note - CNA N worked on 1/24/22 from 11:00 PM to 7:45 AM on 1/25/22 and on 1/25/22 from 11:00 PM to 7:45 AM on 1/26/22. *Note - After payroll review and infection control review the facility failed to have evidence to support the facility/nursing department was operating on contingency staffing at this time. On 1/25/22, at 1:30 PM, Surveyor met with Infection Prevention Nurse I (IP) and DON B. Surveyor asked IP I and DON B about the facility's return to work policy and requested a copy. DON B indicated to Surveyor, Contingency staffing is when management is on the floor at times and we are doing that right now. Surveyor asked DON B how long the facility had been considered to be operating on contingency staffing, and she stated, In December and early January we were definitely running on contingency. Surveyor asked who determines when an ill staff member can return to work, and IP I indicated she makes the determination. On 1/25/22, at 3:38 PM, Surveyor asked IP I to indicate who was considered management staff and she indicated NHA A is able to work as a CNA, and DON B, IP I, and MDS/RN O (Minimum Data Set Registered Nurse) area able to work on the floor in the nursing department. Surveyor requested a copy of January schedules and assignments. Per staff assignment sheets, the last date a staff member considered management was assigned to the floor was 1/10/22, which was DON B noted on the PM shift on the facility assignment sheet from 7-11 (PM). DON B's time clock punches on 1/10/22 does note her time out punch at 10:00 PM. DON B also worked on the floor on 1/9/21 from 6:45 AM to 7:00 PM. On 1/26/22, at 8:53 AM, Surveyor spoke with DON B about staffing levels and asked what she considered the facility to be operating with right now, and DON B stated, Right now I would almost say we are contingency because you're here and we're not able to do all of our usual tasks. Surveyor asked DON B what the staffing status last week prior to survey, and DON B stated, I would say contingency because of us being out on the floor. We have to have a balance to be out on the floor and also be able to do our jobs. We're also working CNAs 12 hour shifts and they are getting burned out and we have no one else to pull or to call so we would be out pulling trays and helping on the floor last week. Surveyor asked what instruction staff were given if allowed to return to work after 5 day quarantine, and she stated, To make sure they wear PPE correctly, and we don't allow them to work with non-vaccinated residents, we are out on the floor all the time and help as we can with trays, picking up, toileting, etc. I would say for our staff we are really good about PPE use. On 1/26/22, after speaking with DON B, Surveyor spoke with IP I and asked if the staff was operating as contingency staffing. IP I stated, Not for nurses. For CNAs right now the night shift is staying over and working 12s. They are getting burned out. Since we got agency Licensed Practical Nurse (LPN) licensed staffing has significantly improved. On 1/26/22 at 2:25 PM, Surveyor spoke with IP I to discuss staff returning to work after a 5 day quarantine when testing positive for COVID-19 and how the facility determined when it was operating on contingency staffing. IP I indicated the facility discusses staffing at their morning stand up meeting but does not document the staffing discussion or status anywhere. Surveyor asked IP I if the facility was documenting and tracking/trending where ill employees had last worked prior to illness, and she stated, We definitely talk about it, but it should be on that list. Surveyor asked IP I if she documented past working assignments are talked about anywhere besides the line list, and she did not. Example 2 R132 (Resident) was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R132's Care Plan indicates because of her involuntary movements, she feels safest near the floor and often in squatting position - choreiform movements noted to be less in this position. R132's Care Plan for Nutritional Status notes she will eat on the floor-barrier to be provided, at times the resident will remove items from provided barrier. The Care Plan focus Cognitive: Documented Safety Concerns, resident can be impulsive as well as compulsive. Needs supervision. Makes decisions on own behalf, has no designated health care agent but does involve father in decision making as needed was initiated on 1/24/22 and revised on 1/25/22 includes the intervention, - Provide towels or tray to place food items on when sitting on the floor. Date initiated: 1/24/22, Revision on 1/24/22. On 1/24/22, at 11:37 AM, Surveyor observed R132 sitting on floor in hallway outside of her room eating yogurt, pudding, and with three drinks covered with lids and straw in them. Noted a cloth towel and paper towels next to resident, but food and drink items are sitting directly on floor. Observed staff walk past R132 and not provide or encourage use of barrier for food and drinks. On 1/24/22, at 11:56 AM, Surveyor asked CNA P (Certified Nursing Assistant) what staff does to reduce the risk of infection for R132 since she prefers to eat and drink on the floor. CNA P stated, We are putting mats down and food on trays and she is usually pretty good about leaving it there. On 1/24/22, at 01:27 PM, Surveyor observed R132 sitting on floor between her room and the nurses station with a Styrofoam cup sitting on the floor without a barrier. No barrier was observed within sight on the floor around R132. On 1/25/22, at 2:15 PM, Surveyor spoke with DON B (Director of Nursing) and IP I (Infection Prevention) and asked what steps the facility was taking to keep R132 free from infection. DON B and IP I indicated R132 now has a mat which will go on the floor at meals and will get put up and cleaned between meals. Both DON B and IP I stated they try to give R132 barriers, but she usually removes them. On 1/25/22, and 2:30PM, Surveyor spoke with Director of Housekeeping Q (DOH) to inquire of housekeeping was doing anything different for R132. DOH Q stated she has instructed her staff to increase cleaning in the areas R132 spends the most time in and to check if she has she spilled anything. My staff is aware they may need to do hers more often. On 1/26/22, at 9:31 AM, Surveyor observed R132 in her room sitting on the floor with a Styrofoam drink cup and an ice cream cup sitting directly on her floor with no barrier. The floor was visibly smudged and dirty. R132 was eating her magic cup with a plastic spoon. Surveyor observed resident hit her spoon on the floor due to her choreiform movements and continued to eat her ice cream. On 1/26/22, at 9:37 AM, Surveyor spoke with CNA R and both observed R132 sitting on the floor in her room. Surveyor asked CNA R if the floor she was sitting on looked clean and if there should be a barrier under her food and drink. CNA R stated, No, it doesn't look clean. And, Yes, she should. She had a paper towel, but she sometimes picks that up and wipes her mouth with it and tosses it aside. No paper towel was observed in the room on the floor around R132 at this time. On 1/26/22, at 9:44 AM, Surveyor spoke with IP I and both observed R132 sitting on the floor in her room. Surveyor asked IP I if the floor looked clean, and IP I replied, Not particularly. Surveyor asked IP I if R132 should have a barrier between her food/drink and the floor, and IP I stated, Yes, and it is care planned that way that she should. On 1/26/22, at 10:15 AM, IP I approached Surveyor with a typed note and stated it was a plan for R132 eating/drinking on floor. IP I said, The dirty floor bothered me, but we talked about it and have a plan. We are going to order a second mat to have one for her room and one for the dining room. We moved the dining room mat to her room for now while she is in there. On 1/26/22, at 10:58 AM, Surveyor observed resident sitting on floor near Nurse's station, opposite the side of her room as previously observed. R132 was sitting on the side closer to where visitors and employees enter the building. Surveyor observed R132 with one Styrofoam cup sitting directly on the floor and no barrier in sight. The floor in this area was visibly dirty with footprints from people entering the building. Example 3 R30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/25/2022 at 8:55 AM, Surveyor observed R30 receiving a medicated nebulizer breathing treatment with the door to the room open. R30 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA G (Certified Nursing Assistant) entered the room and closed the door. CNA G exited the room [ROOM NUMBER] minutes later and left the door open. R30 continued to take the nebulizer treatment. On 1/25/2022, at 9:09 AM, LPN H (Licensed Practical Nurse) entered the room, turned the nebulizer off, and exited the room. On 1/25/22 at 9:02 AM, Surveyor asked CNA G, have you had any training in regards to what to do with the room or environment when a resident is receiving a nebulizer? CNA G stated, No. On 1/25/22 at 9:10 AM, Surveyor asked LPN H, is there anything to do with environment when administering a nebulizer treatment? LPN H stated, Close the room door. Surveyor asked LPN H, would the CNA's know this? LPN H stated, I don't know. On 1/25/22 at 9:22 AM, Surveyor asked IP I, (Infection Preventionist) what precautions does one take when administering an AGP? IP stated, Keep the door closed, no one else in room. Surveyor asked IP I, would the CNA's know this? IP I stated, Yes, I believe so. Example 4 On 01/25/22, at 10:00 AM, Surveyor observed LPN (Licensed Practical Nurse) F provide wound care on R30's left ischial. LPN F set clean barrier on bedside table with supplies needed for treatment and pushed over to the side of the bed. LPN F placed a clean towel on bedding and up against R30's backside as a barrier. Without performing hand hygiene LPN F donned gloves. LPN F removed old dressing and discarded into clear plastic bag set at foot of the bed. LPN F doffed gloves and then donned new gloves without performing hand hygiene. LPN F proceeded with treatment by taking soapy water in syringe and irrigated wound. LPN F placed syringe into garbage. LPN F then irrigated wound with water in a syringe and discarded that syringe into the garbage. LPN F removed towel that had been placed on top of bedding and against resident's backside. LPN F doffed gloves and donned new gloves without performing hand hygiene. LPN F placed a new clean towel on bedding and up against R30's backside and then packed wound by pushing in gauze wet with normal saline with a cotton tipped applicator. LPN F discarded applicator into garbage and took a new cotton tipped applicator with Vaseline on it and spread it around the wound. LPN F discarded applicator into the garbage and took finger and spread the Vaseline more evenly onto the skin surrounding the wound. LPN F doffed gloves and donned new gloves without performing hand hygiene. LPN F applied new dressing to cover wound, doffed gloves, and gathered supplies and garbage. LPN F then performed hand hygiene. On 01/25/22, at 10:30 AM, Surveyor interviewed LPN F and asked if hand hygiene should be performed before donning gloves and in between doffing dirty gloves and donning new gloves. LPN F indicated yes. Surveyor asked LPN F if hand hygiene was performed at those times during R30's wound treatment. LPN F indicated no. LPN F indicated she should have but only performed hand hygiene before and after the treatment. On 01/25/22, at 3:41 PM, Surveyor interviewed DON B (Director of Nursing) and asked what her expectation is of hand hygiene during a wound treatment. DON B indicated before applying gloves and in between doffing dirty gloves and donning new gloves.

Based on observation and interview, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 34 residents. Surveyors observed moldy strawberries in the refrigerator. Findings include On 1/24/22 at 9:19 AM, Surveyor observed 4 individual 1 quart containers of strawberries. The four containers had a date of 1/6/22 stickered on them. Each container had strawberries with visible mold (white and green mossy appearing substance). At 9:21 AM, Surveyor interviewed DA D (Dietary Aide) while showing the strawberries to her. DA D stated the strawberries had mold on them and the date on containers is the received date. DA D stated the kitchen staff usually keep fruit until it looks bad. On 1/26/22 at 10:59 AM, Surveyor interviewed DM C (Dietary Manager) who stated that any resident can request fresh strawberries, in addition to other fruits like apples and bananas. Usually the staff look at fruit daily to see if it is still fresh, but typically it is good for about a week.

Based on interview and record review, the facility did not provide residents with a written bed-hold notice to those residents who were transferred from the facility. This has the potential to affect all 34 residents as the facility did not have a system in place to ensure bed holds were being offered to residents after the facility social worker was no longer employed at the facility. The facility did not offer bed holds to any resident since January of 2021. Findings include On 1/26/22 at 8:58 AM, Surveyors requested a list of resident hospitalization s from the previous 12 months and if those residents had been offered a bed hold when discharging. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) both stated at this time that they had not been providing bed holds to any residents going to the hospital nor were they aware of this being offered to any resident. NHA A stated they had lost their full-time social worker in January 2021. Although the facility had teamed up to provide other social services related functions, the facility was not offering bed holds. DON B stated the facility had not denied any resident a return to the facility. The facility provided Surveyors with the last known bed hold offered, which was dated 1/11/21. The facility had lost their social worker and did not have a system in place to ensure any resident discharging to the hospital was offered a bed hold.

Based on interview and record review, the facility did not ensure a notice of transfers or discharges was sent to a representative of the Office of the State Long-Term Care Ombudsman. This has the potential to affect all 34 residents. The facility did not have a system in place to provide the Office of the State Long-Term Care Ombudsman with a notice of transfers or discharges when the facility was without a social worker. Findings include On 1/26/22 at 8:58 AM, Surveyors requested a list of resident discharge and transfer notices the facility had provided to the Office of the State Long-Term Care Ombudsman. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) both stated they had no record of providing such notices, nor were they aware of the notices being sent. NHA A stated they had lost their full-time social worker in January 2021. Although the facility had teamed up to provide other social services related functions, the facility was not providing the Ombudsman with discharge and transfer notices. On 1/26/22 at 2:01 PM, Surveyor interviewed OMB E (Ombudsman), who is the Ombudsman for the facility. OMB E stated she had not received any resident transfer and discharge notices dating back to January of 2021. The facility had lost their social worker and did not have a system in place to ensure the task of providing notices of resident discharges and transfers to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety as the facility served unpasteurized, poached eggs that were not thoroughly cooked to 1 of 44 residents (R25). Failure to ensure that eggs served were pasteurized or fully cooked placed this resident at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) which started on 1/8/20. The facility administrator was made aware of the findings of IJ on 1/8/2020 at 10:42 AM, which was removed on 1/8/2020. The deficiency continues at a scope/severity of D (potential for more than minimal harm that is not IJ/isolated) as the facility continues to implement its removal plan. Findings include: According to the (YEAR) FDA (Food and Drug Administration) Food Code: 3-302.13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; The facility does not have a policy regarding the use of unpasteurized eggs or the safe handling and/or cooking of shell eggs. On 1/7/20 at 9:51 AM, during the initial tour of the facility's main kitchen with DM C (Dietary Manager), Surveyor observed 2 crates of unpasteurized eggs in the main kitchen's cooler. DM C stated she knew that Surveyors would see that the facility did not currently have pasteurized eggs, but there currently was a shortage. DM C stated the kitchen had not had pasteurized eggs in 1 or 2 weeks. On 1/7/2020 at 3:00 PM, R25 stated, during the resident council meeting, that she regularly receives poached eggs for breakfast and had, in fact, had one this morning. R25's most recent Minimum Data Set (MDS), dated [DATE], shows a Brief Interview for Mental Status (BIMS) score of 15, which indicates R25 is cognitively intact. On 1/8/2020 at 8:33 AM, Surveyors observed R25, in her room, eating 2 poached eggs with visibly runny yokes. On 1/8/2020 at 8:49 AM, Surveyor interviewed DA D (Dietary Aide). DA D stated she had cooked poached eggs this morning for R25, as she does every morning. DA D stated the eggs were not pasteurized and did not check the yokes before sending the eggs to R25. Surveyor then immediately interviewed DM C, who stated the facility should not be serving unpasteurized eggs with runny yokes. DM C also stated she did not have a policy related to pasteurized and/or unpasteurized eggs. On 1/8/2020 at 1:03 PM, Surveyor interviewed R25, who stated she was unaware the facility did not have pasteurized eggs for the past 2 weeks. Serving unpasteurized eggs that were not fully cooked created the potential that residents could contact Salmonella. This created a finding of I[NAME] The IJ was removed, on 1/8/20, when the facility began implementing the following: *All unpasteurized eggs were removed from the facility and discarded, by the Dietary Manager, on 1/8/2020 at 12:00 PM. *The resident (R25) who received the eggs that were soft or cooked to order will be monitored for signs of food borne illness, including fever, abdominal pain, nausea, vomiting, diarrhea every shift for 72 hours then daily for an additional 48 hours. The monitoring of these conditions was set up in the eMar (electronic medication administration record) system on 1/8/2020 at 12:30 PM. Any identified signs will immediately be reported to the attending physician or nurse practitioner. The Medical Director and attending physician/nurse practitioner for the residents involved were notified of the potential hazard related to egg consumption. *Education was immediately provided, on 1/8/2020, to all kitchen staff who were working regarding the proper use of pasteurized and unpasteurized eggs, how to identify the difference, and direction to only use pasteurized eggs when making breakfast eggs to the residents' choice. Education will be conducted with all other dietary staff prior to beginning next shift. *The dietary manager will monitor tray line every breakfast that serves unpasteurized eggs, beginning 1/9/20, looking for soft or not hard cooked eggs. The issue will be addressed as a Quality Assurance and Performance Improvement (QAPI) project, beginning on 1/8/20 and will be discussed and reviewed at the facility's quality assurance meetings in (MONTH) and (MONTH) 2020.

Based on interview and record review, the facility did not implement their policy and procedures to ensure labs were not performed and antibiotics were not started unless resident's meet criteria per standards of practice for 4 of 44 residents (R39, R12, R23, and R31). - R39 received an order for [REDACTED]. - R12 received an order for [REDACTED].>- R23 received an order for [REDACTED].>- The facility did not follow its policy or procedure for R31 receiving an order to test urine, which resulted in an order for [REDACTED].>This is evidenced by: The facility policy titled, Antibiotic Stewardship Policy, states, in part: This facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The policy also states it is essential for success of the program that it be a collaborative effort between the resident/resident representative, interdisciplinary team, practitioners, Medical Director, pharmacist and leadership team. The procedure includes the following steps, in part: 1. When the nurse suspects that the resident has an infection, the nurse will perform an evaluation of the resident that includes: a. Resident signs and symptoms i. Complete set of vital signs ii. Interview of resident for symptoms iii. Assessment 2. The Nurse will utilize the (facility identified/approved tools) infection criteria protocol to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. 3. Notify physician/practitioner of resident change of condition and evaluation information. The nurse to communicate to physician of infection criteria protocol to treat the respective infection. 4. When diagnostics are ordered by the practitioner, the nurse will contact the lab/radiology to notify of physician order. a. Physician will be notified of results of diagnostics to ensure resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. 5. If indicated, based upon (identified) criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. a. In the event that the prescribing physician orders [REDACTED]. The Medical Director will be contacted for further direction. According to The Core Elements of Antibiotic Stewardship for Nursing Homes, from the Center for Disease Control and Prevention (CDC), Inappropriate use of microbiology tests in nursing homes may drive unnecessary antibiotic treatment. It notes that, Identifying and reducing inappropriate use of laboratory testing may be a high-yield effort for improving antibiotic use and reducing other management costs. Example 1 On 1/9/20 at 9:46 AM, Surveyor spoke with RN F (Registered Nurse), the facility nurse manager who serves as infection preventionist in the facility. RN F indicated that the facility uses McGeer's criteria for all infections, except urinary tract infections (UTIs). RN F stated that for UTIs, the facility uses the Healthcare Associated Infections (HAI) criteria. RN F stated staff have a binder at the nurse's station with this information, along with the When to Test Urine - Nursing Tool and scripts for when to contact providers. Copies of these were requested and provided. According to R39's medical record and infection control data, on 10/23/19, the facility sent a fax to R39's provider stating Per family request would like a UA/UC. It notes that urine is foul smelling and that R39's temperature is 98.0 degrees orally. The provider returned the fax and approved of the lab work. On 10/24/19, R39 received an order for [REDACTED]. According to R39's medical record and infection control data, on 11/17/19, facility staff sent another communication sheet via fax to provider stating that R39's daughter was visiting and was concerned that urine still has a very strong odor. Daughter requesting a follow U[NAME] Can we have an order for [REDACTED]. No other symptoms were noted in documentation. Temperature on 11/18/19 was 97.1. An antibiotic, [MEDICATION NAME] 100mg (milligrams) PO (by mouth) BID (twice a day) x7 days was ordered when culture results were complete. According to the facility used criteria and When to Test Urine - Nursing Tool, criteria was not met for urine to be tested . On 1/9/20 at 1:31 PM, Surveyor spoke with RN F to review infection related orders and criteria for R39 as noted above. Regarding R39's order for labs and the antibiotic in October, RN F stated, Her daughter wanted it due to foul smelling urine and there is no telling her no. Surveyor asked if the resident had met criteria for contacting the provider or if it was appropriate for lab work to be ordered. RN F stated that R39 is difficult to assess with her dementia. Documentation was charted that provider who ordered the antibiotic prior to having culture results was educated and declined to wait for them prior to starting the antibiotic. Surveyor asked if the Medical Director was then updated or contacted and RN F said the Medical Director was not and she may have been out on a medical leave at that time. Surveyor asked RN F if R39's symptoms, as documented, were appropriate indications for lab work and antibiotic orders according to the facility policy and criteria used. RN F stated, No. Example 2 According to nurse's notes, on 4/7/19, charting indicated that R12 had bloody discharge that was able to be visualized as coming from vaginal opening, and R12 denied pain. On 4/8/19, provider was in the building and saw R12 on rounds. A urinalysis and transvaginal ultrasound was ordered for occasional vaginal bleeding. The UA was collected at 9:35 PM that day and charted as being clear with no foul odor. On 4/9/19 at 5:00 AM, R12's temperature was 98.3. Later that day at 2:00 PM, charting notes no frequency, no complaints of pain or burning with urination, temperature 98.0. On 4/10/19 at 5:45 AM, R12's temperature is charted at 98.3 degrees, denies pain or discomfort with urination this AM. Did report stomach a little sore. Minimal bleeding noted x1 with urination. The following entry in R12's chart is also on 4/10/19, with no time indicated, and indicates provider reviewed urine culture and [MEDICATION NAME] daily x 5 days for UTI. On 1/9/20 at 1:31 PM, Surveyor spoke with RN F and reviewed urinary related orders for R12 as above. Surveyor asked, if according to the charting, was it appropriate for a urinalysis and culture to be ordered for the symptoms charted. Regarding the (MONTH) 2019 charting, RN F stated, I probably wouldn't have asked for that, but the doctor was in the building and had seen R12 and ordered it. Surveyor asked if the provider was educated or asked for reasoning for the order to collect urine sample without meeting the criteria before doing so, and RN F stated, It's not charted so I don't know. (Provider) will do UAs for other reasons, too and if it is positive, they automatically culture it. Per the symptoms, I would say it was not appropriate. Example 3 According to medical record and infection control data, on 4/14/19 at 3:00 PM, R23 was yelling out in pain. R23 refused medications and repositioning. Charting reads, in part . Complaints of pain are in resident's back. Writer ?'d (questioned) possibility of UTI. (Medical Doctor (MD)) was called and MD gave order to straight cath (catheter) resident to collect urine sample for UA . At 10:00 PM, the specimen was collected and charting reads R39's temperature was 97.8, axillary. According to the facility guide When to Test Urine - Nursing Tool, the action that should have been taken would have been to contact the provider with Script 4 and observe/monitor the resident for 24-48 hours. After the 24-48 hours of observation, the facility is to contact the provider again using Script 5, 6, 7 as indicated. If the resident had improved, no urine testing is necessary. On 4/15/19 at 3:30 AM, charting indicates the resident was resting quietly that night without calling out or yelling and temperature is charted at 98.0. No other symptoms are documented up to 4/17/19 at 1:30 PM, when it is noted that the lab work was received and R23 was started on [MEDICATION NAME] 250 milligrams twice a day x 5 days. On 1/9/20 at 1:31, Surveyor reviewed R23's symptoms with RN F for appropriateness of order received on 4/17/19. RN F stated, I would probably say no to testing with this one. She had back pain and her screaming out is blood curdling. RN F indicated R23 did not have any localizing urinary symptoms or warning signs present. Example 4 According to R31's medical record, on 12/5/19, the facility sent a faxed communication form to provider to update on R31's decline in physical abilities since admission and asked if any labs or tests were recommended. No vital signs were included. On 12/6/19, the provider responded with orders to check urinalysis and other lab orders for blood work. On 12/11/19, R31 was started on [MEDICATION NAME] 100 milligrams by mouth twice a day x 10 days. On 1/9/19 at 1:31 PM, Surveyor spoke with RN F regarding whether R31's urine met the criteria followed by facility for testing. RN F indicated R31 had a huge functional decline and behavior changes. Reviewed the flow chart used on the facility's When to Test Urine - Nursing Tool. R31 did not have localizing urinary signs or symptoms in Box B or any warning signs in Box D; therefore, observing and monitoring for 24-48 hours was indicated as the next step according to the protocol used. At that point, the facility would move to Script 5, 6, or 7 for consulting the provider, depending on if resident is worse, no change, or improved. The facility did not follow protocols for ordering lab testing and antibiotic use that address unnecessary or inappropriate antibiotic use which increases the risk of adverse events, including the development of antibiotic-resistant organisms.

Based on observation, interview, and policy review, the facility did not establish and maintain an Infection Prevention and Control Program to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 44 residents (R31, R9, R8 and R37). The facility did not complete hand hygiene as required, did not ensure that equipment used by multiple residents was cleaned in between each individual use, did not handle and transport linens so as to prevent the spread of infection, and did not complete hand hygiene during meal assistance after direct contact with a resident prior to assisting another resident. - R31 was observed during personal cares and transfers and staff did not follow facility policy and professional standard of practice for hand hygiene and infection control measures. - Mechanical lifts were used for more than one resident without being cleaned between uses. - Staff was observed transporting used linens in the hallway without gloves and dirty linen was not placed in bags prior to being transported through the hallway. - Staff did not perform hand hygiene when appropriate when assisting with meals. This is evidenced by: The facility policy, Infection Prevention and Control Program, states, in part: . the program exists to assure a safe, sanitary and comfortable environment for residents and personnel. It is designed to help prevent the development and transmission of communicable diseases and infection. This program, in part . provides standard transmission-based precautions to be followed to prevent the spread of infections . A key component of preventing the spread of infection listed in the policy states: The facility must require staff to clean their hands after each direct resident contact using the most appropriate hand hygiene professional practices. The facility policy, Infection Control Standard Precautions - Hand Hygiene, states, in part: Appropriate hand hygiene is essential in preventing transmission of infectious agents. The policy indicates that hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn; immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and/or the environment. Specific examples include but are not limited to: . 3. Before touching medication or food to be given to a resident . 5. Before and after providing personal cares for a resident (Peri-care, bathing, oral cares) 6. After removing gloves. 7. After touching any item or surface that may have been contaminated with blood or body fluids, excretions or secretions (e.g. measuring graduate, commode) . 9. Between contacts with different residents in high-risk areas . Example 1 On 1/7/20 at 10:09 AM, Surveyor observed CNA [NAME] (Certified Nursing Assistant) transfer R31 from wheelchair to bed in order to use the bedpan. Surveyor observed CNA [NAME] remove R31's incontinent pad and place the bedpan under R31's bottom, then remove gloves. CNA [NAME] did not perform hand hygiene after removing gloves. CNA [NAME] then moved the EZ Stand lift back into R31's bathroom and placed the call light in R31's reach. CNA [NAME] then washed her hands in R31's bathroom prior to leaving room. At 10:15 AM, R31 turned on her call light. CNA E, who had just come out of another resident's room, entered the room without performing hand hygiene, turned off call light, and spoke to R31 who then stated she did not think she was finished with the bedpan. At 10:27 AM, R31 turned on call light when finished with bedpan. With gloves on, CNA [NAME] removed the bedpan and noted R31 leaked urine outside of the bedpan and onto her sheets. CNA [NAME] set the bedpan on R31's side table. Surveyor observed wet bed linens and soaker pad under R31. CNA [NAME] took the bedpan into the bathroom, then removed her gloves and did not complete any form of hand hygiene. CNA [NAME] positioned R31 to a sitting position on the side of the bed, touching R31's hands to guide resident to hold onto the side rail of bed and EZ stand. CNA [NAME] connected sling, put straps on R31's legs, and maneuvered the EZ Stand to transfer R31 back to the wheelchair. At 1/7/20 at 10:34 AM, CNA [NAME] stripped the wet bedding from R31's bed. CNA [NAME] did not place soiled laundry into a bag and did not wear gloves. CNA [NAME] carried the bedding from R31's room and walked through the hallway to the dirty utility room. CNA [NAME] opened the door of the dirty utility room, discarded the laundry, and returned to R31's room, entering without performing hand hygiene. CNA [NAME] placed R31's side table next to her wheelchair and placed R31's call light across the side table within R31's reach. On 1/8/19 at 9:19 AM, Surveyor observed R31's side table, which appeared to have a film/residue on it. Surveyor also noted a used towel and soaker pad sitting on the toilet seat in the bathroom. At 9:52 AM, Surveyor observed a housekeeper completing cleaning tasks in R31's room. At 9:56 AM, after room cleaning was complete, Surveyor observed the side table, which appeared unchanged from the previous observation. Surveyor spoke to R31 regarding cleaning of the side table. R31 stated, I don't think they cleaned it today. R31's most recent BIMS (Brief Interview of Mental Status) score was 15, indicating intact cognition. On 1/8/20 at 10:02 AM, Surveyor spoke to HL J (Housekeeping/Laundry) and asked who is responsible for cleaning a resident's side table. HL J stated, Well, ultimately everyone should be responsible if it was dirty. I cleaned the bedside table, but R31 is kind of particular on what you move and what she wants done. She has papers and books that she doesn't usually want moved. Surveyor asked HL J if a staff member was to set a dirty item on the side table, would you expect them to clean it after removing the item HL J stated, Yes. I wouldn't know it was dirty unless they told me. On 1/8/20 at 10:47 AM, Surveyor spoke with CNA [NAME] regarding handwashing, transportation of laundry, and cares performed on R31 the previous day. Surveyor asked CNA [NAME] what training or education the facility provides on handwashing. CNA [NAME] stated she has been working in the facility since (MONTH) (2019), so she was not sure of all of the education provided, but it was discussed in her initial training and that it is often re-emphasized, especially now with flu season. Surveyor asked CNA [NAME] when hand hygiene is required, and CNA [NAME] indicated, When you enter a room, anytime you do cares, anytime you touch something dirty, and when you leave a room. Surveyor asked if hand hygiene should be completed after removing dirty gloves, and she said, Yes. Surveyor asked CNA [NAME] if she washed her hands after removing her gloves with cares while working with R31. CNA [NAME] stated, No, and I should have. Surveyor asked CNA [NAME] who was responsible for cleaning a resident's side table. CNA [NAME] stated, Housekeeping, unless it is visibly soiled. Surveyor asked CNA [NAME] if she would clean it if she knew she had set something dirty on it, and she stated, Yes. Surveyor discussed the dirty bedpan that was set on the side table during cares the previous day. CNA [NAME] acknowledged that she had not cleaned the side table afterwards and that she knew urine had leaked outside of the bedpan, since the linens had to be changed. Surveyor asked CNA [NAME] what the facility policy was on transporting laundry outside of resident rooms. CNA [NAME] stated, It's taken out in bags and I use gloves most of the time. I probably should have bagged the laundry before I took it out yesterday. Surveyor asked if she should have used gloves to carry dirty linens through the hallway as well, and she said, Yes. Example 2 On 1/8/20 at 1:58 PM, Surveyor observed CNA G pushing an EZ Stand lift through the hallway and returning it to R31's room. Surveyor asked CNA G about the cleaning of lifts between residents. CNA G requested to get back to Surveyor. CNA G discussed with another staff member and returned to Surveyor, indicating that it should be cleaned between each resident. CNA G stated he had just used the lift with R9 prior to returning it to R31's room. Surveyor asked CNA G if he had cleaned it after using it with R9, and he said, No. CNA G also stated that he did not clean it prior to use with R9. CNA G states there are at least five residents who use the stand lift on the second floor, but there are only two stands available. CNA G indicated the facility keeps wipes on the Hoyer lift machines for cleaning after use, but was not sure why they were not kept on the EZ Stand lifts. On 1/8/20 at 10:47 AM, Surveyor had also asked CNA [NAME] when lifts are cleaned. CNA [NAME] stated she was not sure, but that she would clean it if she was going to use it on another resident. Example 3 On 1/8/20 at 10:08 AM, Surveyor spoke with HL I for review of laundry services. While in first floor dirty utility room to observe laundry collection process, HL I indicated that laundry was to be brought into that room in bags. Surveyor and HL I then observed CNA K, who was not wearing gloves, bring in a blanket that was not in a bag and place it in the dirty laundry bin. Example 4 On 1/7/20 at 12:34 PM, Surveyor observed CNA [NAME] feeding R8. CNA [NAME] stopped and got up to intervene when R37 started moving R9's pie plate and coffee cup. CNA [NAME] touched R37's hand and moved the items out of her reach. CNA [NAME] returned to feeding R8 without performing hand hygiene. On 1/9/20 at 9:46 AM, Surveyor spoke with DON B (Director of Nursing) and RN F (Registered Nurse), the facility Nurse Manager who oversees Infection Control Program, regarding handwashing and linen transportation policies and observations. RN F indicated that staff, would hold it away from the body with one gloved hand carrying linens and another free hand because they shouldn't have two gloves on in the hallway. DON B and RN F agreed they did not believe staff was instructed to bag linens unless it was dripping. Surveyor asked RN F if they performed regular handwashing audits. RN F indicated they are always watching and monitoring staff and providing feedback, but at least since the implementation of the electronic charting program, (MONTH) 2019, they have not done any formal audits of handwashing. Surveyor asked when the facility would expect staff to perform hand hygiene, and RN F stated, When going into and out of rooms, when clothes are removed, before touching food, after using a bathroom, when visibly soiled, and before and after any direct resident contact. Surveyor reviewed observation of CNA [NAME] cares, on 1/7/20, with DON B and RN F who agreed CNA [NAME] missed multiple opportunities for hand hygiene. Surveyor asked what the facility policy or cleaning schedule was for transfer lifts. DON B and RN F stated and agreed that, Nights do it on a schedule, but they should be cleaned in between each resident use, at least where they touch, too. The facility did not follow its policies and procedures related to infection prevention and control in order to provide a safe, sanitary, and comfortable environment which helps prevent the development and transmission of communicable diseases.

Based on observation and interview, the facility did not ensure food palatability for 1 of 1 dining observations for 1 of 44 residents (R39). R39's hot meal was sitting in front of her for approximately 20 minutes and her meal was not warmed up. This is evidenced by: On 1/7/2020 at 12:11 PM, Surveyor observed that all 2nd floor dining room trays had been passed out. On 1/7/2020 at 12:15 PM, Surveyor observed R39 sitting at the dining room table with her meal sitting in front of her, while others at her table received help from CNA [NAME] (Certified Nursing Assistant). On 1/7/2020 at 12:32 PM, Surveyor observed CNA [NAME] turn to assist R39 with her lunch meal. CNA [NAME] did not heat up or offer to heat up R39's meal at this time. Surveyor stopped CNA [NAME] at this time and asked her to get R39 a new meal tray. CNA [NAME] called down to the kitchen at 12:33 PM and was able to get R39 a new tray. On 1/7/2020 at 12:34 PM, Surveyor used R39's previous tray as a test tray with the following results: Half piece of toast with pureed chipped beef and gravy had a temperature of 88.9 degrees F (Fahrenheit) and tasted cool and salty. The wax beans had a temperature of 97.7 degrees F and tasted cold. All other food items were okay. On 1/8/2020 at 3:20 PM, Surveyor interviewed Cook H regarding R39's meal tray. Cook H indicated that the chip beef and wax beans are not at a hot enough temperature for consumption.

Based on observation, interview and record review, the facility did not ensure safe and secure storage (limited access, and mechanisms to minimize loss or diversion) for scheduled medications in 1 of 2 medication rooms. R9's liquid [MEDICATION NAME] concentration was not double locked in the 2nd Floor medication room fridge. This is evidenced by: Facilities Pharmacy policy entitled '5.3 Storage and Expiration of Medications, Biological's, Syringes and Needles' states, in part: Procedure .3. General storage procedures: 3.1. Facility should store Schedule II controlled substances and other medications deemed by facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device.12. Controlled Substance Storage: 12.1 Facility should ensure that Schedule II - V controlled substances are only accessible to licensed nursing, pharmacy, and medical personnel designated by facility. 12.2. After receiving controlled substances and adding to inventory, facility should ensure that schedule II - V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with applicable law). 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security. Example 1: On 3/25/19 at 10:38 AM, Surveyor and RN D (Registered Nurse) conducted an observation of the 2nd floor medication room. Surveyor observed R9's bottle of liquid [MEDICATION NAME] concentrate to be opened and in an unlocked refrigerator, no locking mechanism on fridge and not in a lockable box. Surveyor interviewed RN D at this time regarding liquid [MEDICATION NAME]. RN D indicated that liquid [MEDICATION NAME] should be double locked and that it is not double locked at this time. RN D indicated that the refrigerator does not lock, but the medication room door does. R9's order indicates [MEDICATION NAME] 2 mg (milligram)/ml (milliliter) oral concentrate (30 ml container) to give 0.25 ml (to equal 0.5 mg) by mouth every six hours as needed for agitation. On 3/25/19 at 2:16 PM, Surveyor observed RN D indicated the [MEDICATION NAME] should be double locked and would have to check with DON B.

Based on 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 and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 46 residents. Multiple observations of staff not using personal protective equipment (PPE), not using personal protective equipment appropriately when in droplet/contact precautions. The facility did not follow recommendations from Public Health to test and treat residents with an [MEDICAL CONDITION] medication, subsequently more residents became ill. Evidenced by: The facility's Infection Control - Outbreak Management policy, dated 2013, states, in part: Definitions: For any given circumstance, the facility's Medical Director and Infection Preventionist, and/or State Guidelines will determine the threshold for determining whether or not an outbreak exists. An Outbreak is Generally Defined as: 1. Three (3) or more cases of clinically significant, facility acquired infections caused by the same organism occurring in the same general area within a period of seven (7) days. OR 2. Twice the normal number of these infections per month observed for a period of three (3) consecutive months. OR 3. The identification of one (1) unusual or highly contagious infection (e.g. Influenza, Scabies, E. Coli 0.157, Salmonella). III. Define and Identify Cases: 1. When a commonality of symptoms is evident among residents or staff who have other factors in common such as a person, place, time, or event, suspect an outbreak, b. Verify the diagnosis; review each possible case to determine if it meets the definition or if definition should be changed. V. Educate Staff, Residents, and Visitors: 1. Notify all staff about the existence of an outbreak, their responsibilities and potential risk for them, and methods to prevent transmission. 3. Reinforce and monitor compliance and hand hygiene and compliance with control measures. VI. Enforce Controls 1. It is the responsibility of all employees to enforce proper precautions in each other, residents, and visitors. The facility also provided the State of Wisconsin Division of Public Health memo entitled Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities, dated 10/19/17, states, in part: Definitions of Terms Used: 2.2 Acute respiratory illness (ARI) is defined as illness characterized by any two (2) of the following: Fever, Cough (new or worsening, productive or nonproductive), Rhinorrhea (runny nose) or nasal congestion, Sore throat, Myalgia (muscle aches) greater than the resident's norm. 2.2.1 Fever may be difficult to determine among elderly residents. Therefore, the definition of fever used for ARI is defined as temperature two degrees above the established baseline for that resident. 2.4 A respiratory disease outbreak in a LTCF (Long Term Care Facility) is defined by DPH (Department of Public Health) as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other and who have: Pneumonia, or ARI, or Laboratory-confirmed [MEDICAL CONDITION] or bacterial infection (including influenza). 3.0 Prevention and Control of Respiratory Outbreaks in LTCF 3.2 Laboratory Testing: When an outbreak of acute respiratory illness is suspected, consider collecting nasopharyngeal swabs (preferred) or oropharyngeal swabs from up to three ill residents or staff and, with DPH approval, send specimens to the Wisconsin State Laboratory of Hygiene (WSLH) for influenza and respiratory pathogens panel (RPP) testing. Testing will be done free of charge. 3.2.1 Specimens should be collected within five days after the onset of illness and placed in [MEDICAL CONDITION] transport media to assure optimal test results. 3.3 [MEDICAL CONDITION] Treatment and [MEDICATION NAME] during Influenza Outbreak: 3.3.1 Ideally, within 48 hours of the onset of illness, teat residents with confirmed or suspected cases of influenza with oseltamivir ([MEDICATION NAME]) or Zanamivir (Relenza), to reduce the severity and shorten the duration of illness. 3.3.3 Influenza [MEDICAL CONDITION] may prevent further spread of infection during outbreaks of influenza in a LTCF. 4.0 Infection Control: Caregivers and visitors should adhere to the appropriate precautions when in the presence of a resident with suspected or confirmed respiratory illness. Until the cause(s) of an ARI outbreak is determined, both droplet and contact precautions should be initiated in addition to standard precautions. 4.1 Droplet Precautions: 4.1.1 Health care personnel should wear a mask for close contact with an ill resident. The mask is generally donned immediately prior to room entry. 4.1.2 Residents on droplet precautions who must be transported outside of their room should wear a mask if tolerated and practice respiratory hygiene/cough etiquette. 4.2 Contact Precautions: 4.2.1 Health care staff should wear a gown and gloves for all interactions that may involve direct contact with the resident or potentially contaminated areas in the environment. 4.4 Duration of Contact and Droplet Precautions 4.4.1 When a resident has confirmed or suspected influenza, the resident should remain on droplet precautions for seven days after onset of illness or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. 4.4.2 For other respiratory illnesses, after resident should remain on appropriate precautions for the duration of illness, defined as 24 hours after resolution of fever without the use of fever-reducing medications and without respiratory symptoms. Example 1 On 2/14/18 at 9:00 AM, DON B provided a list of residents on droplet/contact precautions. The list included R3, R28, R37, R10, R2, and R35, who reside on first floor and R17, R33, R24, and R13 who reside on the second floor. February, (YEAR), 1st floor Resident Illness Log indicates the following: 2/10/18 - R2 has NP cough, clear nasal drainage, T 98.3 2/11/18 - R35 has nausea, small emesis, LS clear, T 99.7 2/11/18 - R28 has NP cough, LS clear, no temperature 2/11/18 - R37 has cough, LS clear with expiratory wheezing, T 98.9 2/13/18 - R3 has NP cough, LS clear, T 100.3 2/12/18 - R10 has NP cough 2/19/18 at 9:00 AM, DON B provided an updated 1st floor Resident Illness Log, which indicates the following addition: 2/18/18 - R39 has nasal drainage, sore throat, cough, sneezing, T 99.3 February, (YEAR), 2nd floor Resident Illness Log indicates the following: 2/10/18 - R24 has NP cough, T 100.2 2/11/18 - R17 has NP cough, nasal drainage, hoarse voice, T 99.1 2/11/18 - R13 has NP cough, fatigue, confusion, T 99.7 2/13/18 - R33 has NP cough, T 100.2 2/15/18 - R9 has NP cough, nasal drainage, T 99.5 2/19/18 at 9:00 AM, DON B provided an updated 2nd floor Resident Illness Log, which indicates the following addition: 2/18/18 - R31 has NP dry cough, wheezes, fatigue, decreased BP (blood pressure) T 102.9 The facility Outbreak Line Listing includes, in part, the following staff information: 2/11/18 1745 (5:45 PM) Staff (LPN Q (Licensed Practical Nurse)) - Last worked second floor on 2/9/18 - PM shift. T 102, NP cough, sore throat, congestion. On 2/14/18 at 9:11 AM, Surveyor was informed by DON B that all residents are staying in their room, due to an outbreak in the facility. All residents, who have active signs and symptoms, have a sign outside their room to indicate the need to use mask, gown and gloves and kitchen staff is to deliver carts to the floor, going no further than the elevator. On 2/14/18 at 12:12 PM, Surveyor observed CNA G (Certified Nursing Assistant) enter R2's room to deliver a meal tray wearing only a mask. On 2/14/18 at 12:16 PM, Surveyor asked CNA G what PPE was needed in R2's room. CNA G stated she would only need to wear a mask, as long as I don't come in contact with R2. On 2/15/18 at 12:34 PM, Surveyor observed CNA H inside R13's room with no PPE on. R13 was in the room. On 2/19/18 9:05 AM, Surveyor observed DA L (Dietary Aide) walking down 2nd floor hallway to get the meal cart. Surveyor interviewed DA L regarding coming onto the unit, as it is quarantined. DA L stated she was not told she could not go onto the units. On 2/14/18 at 2:45 PM, Surveyor spoke with DON B about the outbreak. DON B stated she had called Public Health on Monday (2/12/18) morning and left a message and contacted MD I (Medical Director), who is the facility Medical Director. DON B stated she asked MD I for direction regarding swabbing resident to test for influenza and MD I told her she did not see any reason why, it wouldn't change what we would do. DON B stated all residents who presented with symptoms were kept in their rooms as soon as they presented with symptoms and the entire facility was put into quarantine on Monday morning (2/12/18). DON B stated staff was educated at the beginning of their shift to increase handwashing and to wear gown, gloves and mask in all rooms of residents with symptoms. On 2/15/18 at 12:51 PM, Surveyor spoke with MD I regarding the outbreak. MD I stated she was informed the symptomatic residents had low grade fevers, nasal congestion, and cough. MD I stated she told the facility to continue to monitor the residents and let her know if there were any more concerns and how the outbreak was going. On 2/15/18 at 1:15 PM, Surveyor spoke with RN J. RN J works with Grant County Public Health. RN J stated she spoke with DON B on Monday and was informed of the symptoms presented in the facility. RN J stated she suggested to DON B that the residents should be tested for influenza; the testing could be done thru Public Health at no cost. DON B informed RN J that after talking with MD I it was decided the facility was not going to test for influenza. RN J stated she informed DON B that it was also suggested that the residents who presented and/or were at risk could be treated with [MEDICATION NAME], this was also declined. RN J stated she would talk with the State Epidemiologist and let DON B what he suggested. On 2/15/18 at 4:25 PM, Surveyor asked DON B if she had informed MD I that Public Health had suggested symptomatic residents should be tested and residents should be treated with [MEDICATION NAME]. DON B stated she did not inform MD I. On 2/20/18 at 11:00 AM, DON B provided Surveyor with a letter from Grant County Public Health, dated 2/20/18 that includes, in part, the following: The documented communications between (RN J) and (Facility) relating to the ARI outbreak reported on 2/12/18, as of 2/20/28 at 8:45 AM, are as follows: 2/12 TC (telephone call) from (DON B) who states that they have 1 staff member and 6 residents with cough, low grade temp, congestion and clear nasal drainage that started 2/10. Staff member with body aches, T 101, cough and congestion. (DON B) states that staff member unable to be tested due to medical history, but was started on [MEDICATION NAME]. (DON B) reports that they have been in discussion with their MD and lab and have decided not to test at this time. Writer advised that state would recommend testing. Writer advised (DON B) that she would contact state and be in touch. Writer was able to reach staff member at the state who recommends testing at this time. Left message for (DON B) at 3:30 PM on 2/12 to return phone call to writer. 2/13 (DON B) attempted TC at 10:01 (AM) leaving message stating that employee was started on [MEDICATION NAME] and that the MD does not believe that residents have influenza at this time and that they are not going to be tested . Writer attempted TC back at 4:27 PM. 2/14 Missed TC to writer at 12:48 (PM) stating that there (sic) are an additional 2 residents with cough/congestion. One resident continues with low grade T of 99.0. MD continues to not recommend testing at this time. State at facility per (DON B). Writer states that state does recommend testing, but that they can make the decision not to if they choose to do that. 2/19/18, 11:43 (AM) Voicemail left on main line at 12:09 (PM) on 2/18 stating that they have 2 new residents with symptoms. They state that they will be testing for influenza at this time 2/19/18, 17:48 (5:48 PM) Error in documentation on 2/14: Corrected: Message left on writer's voicemail from (DON B) at 12:48 (PM) stating to add 2 residents, 1 resident continues with low grade temp of 99 and cough/congestion. Writer did not speak with (DON B) on 2/14 with stte recommendation as no return phone call was made until 2/15. On 2/20/18 at 2:07 PM, DON B informed Surveyor the influenza tests came back positive for Influenza A for R31 and R39. Example 2 On the morning of 2/14/18, when Surveyors entered the building, they were informed the facility has a respiratory illness outbreak and to wear gowns, gloves and masks when going in any resident rooms, who are on precautions. Surveyors were told which residents had symptoms and that there were signs posted outside each ill residents door. On 2/15/18 at 7:28 AM, Surveyor observed HSKP P (Housekeeper) restocking paper towels in resident bathrooms on first floor. Surveyor observed HSKP P go in R37's room with only gloves on. No gown or mask on. R37 is on droplet precautions related to a respiratory illness. There was a sign just outside R37's door identifying this. On 2/15/18 at 7:30 AM, Surveyor spoke with HSKP P and asked if she knew about residents being ill and on precautions. HSKP P said yes, she did. Surveyor explained she saw HSKP P go in R37's room with just gloves on and not a gown and mask. HSKP P said she put a mask on when she got in the room and only went as far as the bathroom to check the paper towels. On 2/15/18 at 7:32 AM, Surveyor observed HSKP P enter R35's room to check paper towels and was wearing gloves, no mask or gown. R35 was on droplet precautions for a respiratory infection at that time. On 2/25/18 at 7:41 AM, Surveyor shared her observation of HSKP P going in rooms of residents who are on precautions with only gloves on, no mask or gown. Surveyor asked RN/ICP F if HSKP P should have a mask and a gown on also, when entering rooms of residents on precautions. RN/ICP F said, Yes, I will educate her. On 2/15/18 at 8:12 AM, Surveyor observed CNA M go into R35's room without any PPE, gowns, gloves or a mask. R35 is on droplet precautions, which require staff to don a gown, mask and gloves prior to entering the room. On 2/15/18 at 08:16 AM, Surveyor spoke with CNA M and shared the above observation with her. Surveyor asked CNA M, since R35 is on precautions, should you go in the room without a gown, mask and gloves on. CNA M said, No.

Based on interview and record review, the facility did not ensure each residents drug regimen is free from unnecessary drugs in 2 of 18 residents reviewed and 3 of 3 residents supplemented (R3, R39, R9, R24, and R17). An unnecessary drug is used in the presence of adverse consequences, which indicate the dose should be reduced or discontinued, or without adequate indications for use. R3 was prescribed an antibiotic ([MEDICATION NAME]) for an URI (upper respiratory infection) without meeting criteria, the facility did not consult with the provider about this. R39 was prescribed an antibiotic ([MEDICATION NAME]) for an URI without meeting criteria, the facility did not consult with the provider about this. R9 was prescribed an antibiotic ([MEDICATION NAME]) for an URI without meeting criteria, the facility did not consult with the provider about this. R24 was prescribed an antibiotic ([MEDICATION NAME]) for an URI without meeting criteria, the facility did not consult with the provider about this. R17 was prescribed an antibiotic ([MEDICATION NAME]) for an URI without meeting criteria, the facility did not consult with the provider about this. Evidenced by: The facility uses McGeer's criteria for infection surveillance, which includes, in part: Respiratory Tract Infections: B. Influenza-like illness (both criteria 1 and 2 must be present): 1. Fever. 2. At least 3 of the following influenza-like subcriteria: a. Chills. b. New headache or eye pain. c. Myalgias or body aches. d. Malaise or loss of appetite. e. Sore throat. f. New or increased dry cough. Wisconsin Division of Public Health Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities memo, dated 10/19/17, includes, in part, the following: 2.0 Definition of Terms used 2.2.1 *Fever may be difficult to determine among elderly residents. Therefore, the definition of fever used for ARI (Acute Respiratory Illness) is defined as temperature two degrees (2 degree Fahrenheit) above the established baseline for that resident. The facility's Antibiotic Stewardship Policy, undated, states, in part: Procedure: 2. The Nurse will utilize the infection criteria protocol to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made. 5. If indicated, based upon criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. a. In the event that the prescribing physician orders [REDACTED]. The Medical Director will be contacted for further direction. 10. The Infection Preventionist will track antibiotic use and monitor adherence to evidence-based criteria . Example 1 R30's Nurse's Notes include, in part, the following: 2/13/18, 10:15 (AM): VSS (Vital Signs): . T (temperature) = 102.7 . Lung sounds clear to auscultation. Occasional non-productive cough. No nasal drainage noted this AM shift. 2/13/18 1505 (3:05 PM): . (Physician) responded re (regarding): T/cough, to monitor - if SOB (shortness of breath) or productive (with) yellow or green sputum get CXR (chest x-ray). 2/13/18 3 - 11 PM Summary: Awaken alert has harsh non-productive cough. Clear nasal drainage. LS (lung sounds) clear. T @ (at) 1700 (5:00 PM) 98.4 / @ 1830 (6:30 PM) 100.5. Didn't eat supper, juice taken, very groggy. harsh cough continues at 2000 (8:00 PM) 101.7. Awakens easily, lung sounds unchanged, loose cough, swallowing secretions. @ 2200 (11:00 PM) T 100.7. No SOB . 2/14/18 4 AM (4:00 AM) . Non-productive cough noted. T 98.3 oral. 2/16/18 0330 (AM) . Cont (continues) to have occ (occasional) loose moist cough. Lungs clear, T 98.8 orally. No nasal drainage. Denies pain or SOB. 2/16/18 (no time) Discussion with (Physician) updated on continued NP (non-productive) cough, (no) T - congestion - New orders. Resident updated. R3's Telephone Order, dated 2/16/18, includes, in part, the following: [MEDICATION NAME] 250 mg po (orally) daily x (times) 5 days for URI Example 2 R39's Nurse's Notes include, in part, the following: 2/18/18 11:05 (AM) Resident had c/o (complained of) nasal drainage, which is clear, upon further assessment at 0930 (AM) T 99.3 orally . Lungs clear. Denies SOB. Non-productive cough noted, Resident also c/o sore throat and sneezing. (Medical Director aware). N.O. (new order) Lab: influenza. 2/18/18 12:45 (PM): (Physician) returned call updated on influenza test and agreeable (with) order. Per (Physician) N.O. [MEDICATION NAME] 500 mg PO daily x 5 days . R39's Telephone Order, dated 2/18/18, includes, in part, the following: [MEDICATION NAME] 500 mg PO daily x 5 days for URI . Example 3 R9's Nurse's Notes include, in part, the following: 2/15/18 1830 (6:30 PM) T 99.5 . has non-productive cough. Lungs clear. (No) SOB. Nasal drainage. 2/16/18 05:30 (AM) T 97.5 . L/S clear occ moist cough (no) nasal drainage noted . hoarse voice. 2/16/18 1300 (1:00 PM) T 100.1 . occ moist cough; cough is productive, clear nasal drainage present - voice hoarse. Denies pain or SOB. Will begin [MEDICATION NAME] 250 mg PO daily x 5 days. R9's Telephone Order, dated 216/18, includes, in part, the following: [MEDICATION NAME] 250 mg po daily x 5 days URI Example 4 R24's Nurse's Notes include, in part, the following: 2/12/18 11:15 (AM) T 98.5 . LS/CL (lung sounds clear) bil (bilateral) occ NP (non-productive) cough, voice hoarse, clear nasal drainage. States feels stuffy . 2/12/18 1800 (6:00 PM) . T 99.6. Just feeling tired et (and) has a headache today. Ate fair for supper. 2/13/18 05:00 (AM) T 99.8. c/o headache and muscle aches. Clear nasal drainage. Occ cough. Occ non-productive cough. Lungs clear. 2/13/18 09:30 (AM) T 99.3 . Lung clear bilateral . Dry non-productive cough . Complains of body aches. 2/14/18 03:30 (AM) . T 98.8 . L/S clear, non-productive cough noted c/o nasal drainage clear. 2/16/18 09:20 (AM) (Physician) updated on cont NP cough, (no) temp, congestion, new order R24's Telephone Order, dated 2/16/18, includes, in part, the following: [MEDICATION NAME] 250 mg po daily x 5 days URI Example 5 R17's Nurses Notes include, in part, the following: 2/11/18 1630 (4:30 PM) T 99.1, resident has non-productive cough, nasal drainage, hoarse voice. Denies sore throat, (No) redness/ (No) swelling to throat. Lungs clear. 2/12/18 11:30 (AM) T 99.1 / o (oral), hoarse, occ NP cough, LS clear . ate only bites at breakfast, drank 75% of liquids. At lunch ate 25% & drank 75% . 2/13/18 1600 (4:00 PM) T 100.1. Hoarse, occ non-productive cough, lungs clear. Denies SOB.rechecked T 98.8 at 2000 (8:00 PM). 2/14/18 1605 (4:05 PM) T 99.4, . occ non-productive cough noted, Hoarse voice. Lungs clear. Denies SOB. Rechecked T 98.0 at 2000. 2/15/18 0045 (12:45 AM) T 98.3 oral . dry cough notes L/S clear, . 2/15/18 2000 T 99.2 . has non-productive cough. Lungs clear. Denies SOB. Hoarse voice. 2/16/18 12:25 (PM) (Physician) called, updated on cont NP cough, (no) T, congestion. New order. R17's Telephone Order, dated 2/16/18, includes, in part, the following: [MEDICATION NAME] 500 mg po daily x 7 days for URI On 2/20/18 at 4:05 PM, Surveyor interviewed RN/ICF F. RN/ICF F stated the facility uses McGeer's Criteria for the use of antibiotics. RN/ICF F stated she thought that all the residents who were ordered [MEDICATION NAME] for URI met the McGeer's Criteria and the physicians ordered the [MEDICATION NAME], because they did not think the symptoms were Influenza. RN/ICF F stated she would have to review the documentation.

Based on observation, interview, medical record review, and facility policy and procedure review, the facility did not develop comprehensive policies and procedures or a Comprehensive Care Plan, to ensure that residents who require [MEDICAL TREATMENT], receive services consistent with professional standards of practice (including in part; ongoing assessment of the resident's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments, implementing appropriate interventions, and using appropriate infection control practices .), for 1 of 1 resident (R28), reviewed for [MEDICAL TREATMENT] care, out of a total sample of 18. R28 receives [MEDICAL TREATMENT] three days per week. R28's care plan did not include necessary interventions for monitoring and assessing a resident receiving [MEDICAL TREATMENT]; nor did R28's care plan include interventions for an emergency situation, such as bleeding from the fistula site. The facility policy and procedure related to [MEDICAL TREATMENT] only addressed transportation to the [MEDICAL TREATMENT] facility. R28 was ill with respiratory symptoms and was on droplet/contact precautions. The facility was experiencing a respiratory illness outbreak. The facility had not communicated that information to the [MEDICAL TREATMENT] facility This is evidenced by: During the entrance conference conducted with NHA/SW A and DON B, on 02/14/18 at 11:06 AM, Surveyor asked for a copy of the facility's [MEDICAL TREATMENT] policy and procedures. Surveyor was told the facility does not have [MEDICAL TREATMENT] policy and procedures, because we do not do [MEDICAL TREATMENT] here. Surveyor was provided with a facility policy, with the revised date of 10/31/17, entitled [MEDICAL TREATMENT] Transportation. This policy addressed how a resident would be transported to and from [MEDICAL TREATMENT]. No other policies and procedures were provided until 2/20/18, that policy was written on 2/15/18, after Surveyors had asked about their [MEDICAL TREATMENT] policies and procedures. On the morning of 2/14/18, Surveyor noted R28 was experiencing respiratory illness symptoms and was on droplet/contact precautions and was remaining in his room. On 2/15/18 at 10:19, Surveyor asked R28 about his [MEDICAL TREATMENT]. R28 said he goes three times a week and he has been on it for a while. Surveyor asked R28 which arm his fistula is in. R28 raised his sleeve of his left arm and Surveyor saw his fistula site. R28's Physician Orders identify R28 is on Aspirin 81 mg per day and [MEDICATION NAME] (an anti-platelet) 75 mg per day. These medications put R28 at increased risk for bleeding. R28's care plan does not include [MEDICAL TREATMENT] standards of practice for: assess auscultation (listen)/palpation (feel) of the AV (arteriovenous) fistula (pulse, bruit and thrill) to assure adequate blood flow of R28's [MEDICAL TREATMENT] or emergency interventions in the event of bleeding from the fistula site. R28's care plan does not identify how communication is to occur between the [MEDICAL TREATMENT] facility and the Care and Rehab facility. R28's care plan does identify R28 has [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) and receives [MEDICAL TREATMENT] three days per week. An approach under the care plan category Pressure Ulcer includes the approach of Remove dressing from fistula L arm M-W-F (Monday-Wednesday-Friday at HS (hour of sleep) - he generally removes and is placed after [MEDICAL TREATMENT]. Approaches under the category Dehydration / Fluid Maintenance include: [MEDICAL TREATMENT] as ordered. And VS (vital signs) weekly and weight and PRN (as needed). R28's care plan nor CNA (Certified Nursing Assistant) Care Guide identify that a blood pressure should not be taken in his L arm due to the fistula. Surveyor reviewed R28's Physician Orders and a Treatment Order reads: REMOVE DRESSING FROM FISTULA 3X WEEKLY-MON/WED/FRI-HS (RESIDENT DOES). There are no Physician Orders for assessment and monitoring of R28's fistula site. Surveyor reviewed R28's TARs (Treatment Administration Records) and MARs (Medication Administration Records) and these do not include direction to assess and monitor R28's fistula site or that a blood pressure should not be obtained in R28's L arm. On 2/15/18 at approximately 11:20 AM, Surveyor asked RN K how it is handled for R28, when he goes out for [MEDICAL TREATMENT], since he is on precautions, because of his respiratory illness. RN K said he wears a mask, until he gets outside. Surveyor asked what about at [MEDICAL TREATMENT]. RN K said she didn't know, that would be up to them. Surveyor asked RN K how they would let the [MEDICAL TREATMENT] facility know that someone is sick and is there a communication book that you send back and forth or did someone call the [MEDICAL TREATMENT] facility to let them know R28 is ill. RN K said she didn't know. On 2/20/18 beginning at 10:53 AM, Surveyor interviewed RN/ICP F, who is the facility's Infection Control Preventionist (ICP) and asked if they use a communication book for R28 for [MEDICAL TREATMENT]. RN/ICP F said the [MEDICAL TREATMENT] facility R28 goes to, do not use communication books anymore. Surveyor asked how the [MEDICAL TREATMENT] facility would let this facility know if there is a concern, or the other way around. RN/ICP F said they would call. Surveyor asked how it is communicated that R28 is ill with respiratory symptoms and is on droplet precautions here. RN/ICP F said they do their own assessment and if they notice a cough, would have him wear a mask. Surveyor asked, since this facility has identified an outbreak and R28 was identified as having respiratory illness symptoms and was on precautions, was that communicated to the [MEDICAL TREATMENT] facility. RN/ICP F said she didn't know, she would have to look at the chart. No further information was provided. State of Wisconsin Division of Public Health memo entitled Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities, dated 10/19/17, reads, in part: 4.1 Droplet Precautions: 4.1.1 Health care personnel should wear a mask for close contact with an ill resident. The mask is generally donned immediately prior to room entry. 4.1.2 Residents on droplet precautions who must be transported outside of their room should wear a mask if tolerated and practice respiratory hygiene/cough etiquette. R28 was identified as having respiratory illness symptoms starting on Sunday, 2/11/18. R28 went to [MEDICAL TREATMENT] on Monday, 2/12/18, Wednesday, 2/14/18, Friday, 2/16/18 and Monday, 2/19/18, while on droplet precautions. R28 was taken off precautions on 2/20/18. The facility had not tested any residents identified in the outbreak for influenza until 2/18/18. On 2/20/18, two residents were confirmed to have tested positive for influenza.

Based on observation, interview and medical record review, facility staff did not provide care and treatment in accordance with professional standards of practice for 1 of 18 sampled residents (R45). R45 has a draining wound on his toe. A nurse started a treatment with products not indicated for use with a draining wound, then requested a Physician order [REDACTED]. This is evidenced by: On 2/14/18 at 11:16 AM, R45 told Surveyor he has had infection in a sore on his middle toe of his left (L) foot. R45 said he is going to the foot doctor this afternoon. On 2/19/18, Surveyor reviewed R45's medical record and noted R45 has [DIAGNOSES REDACTED]. Surveyor read a Physician Communication Sheet, dated 12/23/17, that identified R45's L third toe was red and tender. A Physician order [REDACTED]. It was identified as an old blister to the tip of R45's L third toe and it was now blackened. A Physician Communication Sheet for R45, dated 12/27/17, no time identified, read: When I checked today: squeezed toes for sensation (R45) states a little bit but I have diabetic [MEDICAL CONDITION]. Upon squeezing 3rd toe noted serosanguinous drainage from under discolored tip. Epsom salt soak done /c (with) A & D oint (ointment) & BA (Band Aid) applied. Do you want this tx (treatment) continued BID (two times per day)? Yes was checked by the physician. There was no time identified when the physician signed the sheet, the signature was dated 12/27/17. On 12/29/17, R45 was started on an antibiotic, [MEDICATION NAME] 875 mg (milligrams), two times per day for seven days for his L third toe ulcer. On 1/03/18, R45 saw the podiatrist and the podiatrist identified R45's L third toe wound as an ulcer with [MEDICAL CONDITION]. New orders were written; discontinue the Epsom foot soaks and the A & D ointment. The podiatrist ordered to start iodine ([MEDICATION NAME]) to R45's L third toe wound, cover with gauze and secure with tape and to continue the [MEDICATION NAME]. On 2/20/18 at 10:26 AM, Surveyor observed RN K perform the treatment for [REDACTED]. There was a small amount of drainage on the BA removed. RN K cleansed the area, applied [MEDICATION NAME] and a BA. Prior to the [MEDICATION NAME] and the new BA being applied, Surveyor observed R45's L third toe and noted an approximate 0.5 cm (centimeter) circular, superficial open area on the end of R45's toe. On the afternoon of 2/20/18, Surveyor met with DON B and RN O and shared the above concern of the nurse starting the Epsom salt soaks and A & D ointment treatment for [REDACTED]. 2/20/18 at 3:56 PM, NHA/SW A told Surveyor, they have no policy and procedure or standard of practice for nurses starting treatments before getting the Physician order [REDACTED]. Indications for use from an Epsom salt container read in part: Most commonly used as an aid in soaking minor sprains & bruises. And Warning: Where prompt relief is not obtained or where there is evidence of irritation or infection, discontinue use and consult a doctor. Do not use if pregnant or diabetic, unless advised by a doctor. Indications for use of Vitamin A & D ointment: This medication is used as a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations (e.g., diaper rash, [MEDICAL CONDITION] . The information for Vitamin A & D ointment does not include for use on draining, open wounds.

Based on observation, interview and medical record review, the facility did not revise care plans, to accurately reflect the comprehensive needs for 2 of 16 residents, out of a total sample of 18 (R40 and R5). R40's care plan had not been revised to address the death of her son. R5 has hearing loss. R5's care plan did not include individualized approaches for staff to use to compensate for her hearing loss. This is evidenced by: On [DATE] at 10:00 AM, R40 told Surveyor her son died recently and it has not been easy dealing with that. He had been sick for a while; he had Alzheimer's. R40 also said, Then days like this, when we are shut in, I get awfully lonely. (Due to a respiratory outbreak in the facility, residents were remaining in their rooms.) [DATE] at 8:32 AM, Surveyor reviewed R40's medical record and identified R40's son had died on [DATE]. Surveyor reviewed R40's care plan and did not find any information identifying R40 had lost her son or any approaches related to grieving, loss or coping. Surveyor asked RN/ICP F (Registered Nurse/Infection Control Preventionist) if they had a temporary care plan related to R40's son's death. RN/ICP F said that would be a Social Worker thing. Surveyor reviewed Social Service's notes and identified there were no notes related to R40's loss of her son. The last note by Social Services was on [DATE], which was a care conference note. Surveyor noted a nursing note for [DATE] that read: Granddaughter (name) in et (and) informed resident son (name) passed away. All staff notified to provide extra support. Tearful but does openly converse about feelings. A nursing progress note on [DATE], read in part: Teary and sad due to loss of son. Continues to cooperate with staff . A nursing progress note on [DATE], read in part: Flat affect noted. States I'm ok to? of how she is feeling . No other nursing notes addressed R40's son's death or how R40 was coping with that loss. Surveyor reviewed R40's most recent mood assessment (PHQ-9), completed on [DATE], and was scored at a 2, indicating minimal depression. No further PHQ-9 assessment had been completed. On [DATE] at 8:52 AM, Surveyor spoke with NHA/SW A (Nursing Home Administrator/Social Worker), and explained Surveyor was unable to locate a grieving/loss care plan related to R40's son passing away on [DATE]. Surveyor asked NHA/SW A to look to see if she could find anything on R40's care plan that addresses the loss of her son. NHA/SW A looked and did not locate anything. NHA/SW A said, I do not believe her care plan was updated. Surveyor asked if a temporary care plan was done and would be located somewhere other than R40's chart. NHA/SW A said, we do not have one. Surveyor explained she did not find any Social Service notes identifying they have met with R40 or other approaches have been done for R40 regarding the death of her son. NHA/SW A said, I know if it is not documented it wasn't done, but we have been offering her extra support. SSC C said R40 is invited to a support group tonight and she may attend. SSC C said she has spent time with R40, but has not documented it. Surveyor told NHA/SW A, she did not find that another PHQ-9 had been done with R40 after her son's death. NHA/SW A said, SSD/LPN N (Social Service Designee/Licensed Practical Nurse) does the MDS (Minimum Data Set) assessments and progress notes. Surveyor asked NHA/SW A to check with SSD/LPN N and ask if she has any further information. On [DATE] at 9:12 AM, NHA/SW A said she had spoken with SSD/LPN N and she did not have anything either, related to R40's care plan, notes or mood assessments regarding the loss of her son. Example 2 On [DATE] at 10:41 AM, Surveyor interviewed R5. Surveyor observed R5 had a hearing aid (HA) to the right (R) ear. R5 was having a hard time hearing our conversation. R5 stated staff has put a new battery in. On [DATE] at 7:52 AM, Surveyor interviewed R5. R5 had a hard time hearing this AM. Surveyor interviewed RN E who stated that the HA battery had been checked this AM and was working. RN E stated resident relies on lip reading. RN E was unsure of last audiologist appointment. On [DATE] at 8:30 AM, Surveyor reviewed R5's medical record. Surveyor read the care plan for R5 with problem start date of [DATE] and long term goal target date of [DATE]. The care plan listed monthly ear checks and HA to R ear as interventions. No other approaches were documented for R5's hearing loss. On [DATE] at 8:38 AM, Surveyor interviewed SSC C who stated that the facility is in the process of assisting R5 to get a new HA when she qualifies in (MONTH) or (MONTH) of this year. On [DATE] at 9:03 AM, Surveyor interviewed DON B (Director of Nursing) about R5's care plan for hearing loss. DON B stated she would expect that there would be something in the care plan about it. DON B stated that AD D (Activities Director) does that part of the care plan. On [DATE] at 9:13 AM, Surveyor interviewed AD D. AD D reviewed the care plan to see if she could locate any additional information about hearing loss. AD D said that R5's hearing was pretty good when she was first admitted (in 2009) and it has slowly declined over the years. AD D said they have all adjusted to her over the years. AD D agreed that there isn't anything in the care plan as to R5's hearing loss and what to do to compensate for this.

Based on interview, medical record review and policy review, the facility did not provide pharmaceutical services, including acquiring, receiving and dispensing medications to meet the needs of 1 of 18 sampled residents out of a total sample of 18 (R45). R45 received a Physician order [REDACTED]. The facility did not have the antibiotic in their contingency supply, the pharmacy did not deliver the antibiotic and a physician was not consulted, until 2/15/18. This is evidenced by: The facility's pharmacy policy and procedure, dated 5/1/10, entitled 5.2 Receipt of Interim/Stat/Emergency Deliveries reads, in part: Procedure 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions: 2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or 2.2 For Pharmacy delivery by contract courier, or 2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt. On 2/14/18 at 11:16 AM, R45 told Surveyor he has had infection in a sore on his middle toe of his L foot. R45 said he is going to the foot doctor this afternoon. On the afternoon of 2/14/18, R45 went to an appointment with podiatry. The progress note from that appointment reads, in part: .He is still having pain in the toe he rates as a 5 on a scale of 1-10 . Patient has return of discolored callus at the distal tip of his L 3rd toe. After paring, he does have a full-thickness small wound, 2 mm (millimeter) in diameter. It does not probe deeply . Unfortunately, he continues with significant [MEDICAL CONDITION], [DIAGNOSES REDACTED] to the toe. It does extend to the dorsum of the foot in comparison to the R side. He has increased [MEDICAL CONDITION] and warmth to the leg as well, but no [DIAGNOSES REDACTED] in the leg . The Podiatrist ordered to Start [MEDICATION NAME] (an antibiotic) 500 mg BID x 10 days. On 2/15/18 at 10:50 AM, Surveyor spoke with RN K about R45 not getting started on the [MEDICATION NAME] that was ordered on [DATE]. RN K indicated that R45's [MEDICATION NAME] was not started on 2/14/18, because it wasnt in our backup supply. Surveyor asked if a doctor was called on 2/14/18, to be informed that the facility did not have the [MEDICATION NAME] and was unable to start R45's antibiotic yesterday (2/14/18). RN K said she did not know, because he returned from his appointment at the change of shift. RN K learned that the [MEDICATION NAME] was not started for R45 during report on the morning of 2/15/18. Surveyor asked about the pharmacy the facility uses and what time they deliver medications. RN K said their pharmacy delivers anywhere from 11:00 PM to 2:00 AM. Surveyor asked RN K, if they don't have a medication in their contingency supply, do they have a local pharmacy as back up so they can get medications needed for residents. RN K said she is not sure. RN K said she faxed the order as soon as she got it yesterday. The pharmacy didn't bring it. Surveyor shared her concern regarding the delay in treatment for [REDACTED]. RN K said she received an order this morning (2/15/18), for a different antibiotic, [MEDICATION NAME] 500 mg four times a day, that they have in their contingency supply and it will start today with the noon med pass. On 2/19/18 at 2:35 PM, Surveyor spoke with DON B and RN O and shared the above concern of R45's antibiotic not getting started until 2/15/18, when it had been ordered on [DATE]. DON B said their pharmacy delivers between 11:00 PM and 1:00 AM. Surveyor asked if they have a backup system with another local pharmacy. DON B said no, there is a rush thing with (pharmacy name), but that is not a whole lot quicker. On 2/20/18, Surveyor reviewed R45's MAR and confirmed the [MEDICATION NAME] was started on 2/15/18, and has been given as ordered.