Every finding on record at Care & Rehab - Ladysmith 2

Based on record review and interview, the facility did not ensure to accurately code the Minimum Data Set (MDS) assessments for 1 of 1 resident (R) reviewed. (R1) R1's comprehensive MDS assessment indicated a PASARR level 2 screen had not been completed. R1's medical record included a PASARR screen was completed on 2/17/25. This is evidenced by: On 05/05/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including depression, post-traumatic stress disorder, dementia with anxiety, adjustment disorder, anxiety disorder, and other psychotic disorders.Annual MDS (Minimum Data Set) dated 12/30/25 documented section A1500 as No for currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Active diagnoses listed in Section I were coded for Non-Alzheimer's dementia, anxiety disorder, depression, and Post Traumatic Stress Disorder (PTSD).On 05/05/26 at 12:12 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about a PASARR level 2 being completed. NHA A stated there was a level 2 completed and the MDS was coded in error, the MDS will be corrected. NHA A provided R1's PASARR level 2 screen that was completed on 02/17/25.

Based on observation, record review and interview the facility did not provided the needed services and assistive devices. The facility practice had the potential to affect 1 of 5 residents (R) (R17) observed for transfer and ambulation This is evidenced by: Surveyor reviewed the facility policy titled Gait belts dated 7/24. The policy in part read: Policy: A gait belt provides a firm, grasping surface for the caregiver, protects the resident from accidental trauma to the skin, provides a sense of security to the resident, and protects the caregiver and resident from injury while transferring or ambulating. Suveyor reviewed the facility policy titled Fall Risk Management Policy dated 11/24. The policy in part read: Policy: It is the policy of Care and Rehab-Ladysmith to promote resident safety by identifying residents at risk for falling; assessing fall risk factors: provide guidelines for fall and repeat fall preventative interventions and to outline documentation and communication procedures to minimize the number of falls with major injury as well as implement appropriate interventions to prevent continued/repeated falls. R17 was admitted [DATE] with diagnoses that included non-Alzheimer dementia, weakness and hemiplegia. R17's Admission Minimum Data Set (MDS), dated [DATE], indicates R17 is understood, usually understands and has impaired cognition. R17 can walk 150 feet: once standing, the ability to walk at least 150 feet in a corridor or similar space: partial staff assistance required. R17 has fall history prior to admission and has fallen in the facility with no injury. R17's Fall Risk Assessment, dated 1/9/25, notes resident at risk for falling with the following risk factors: 3 or more falls in past 3 months, intermittent confusion, poor vision, 1-2 predisposing diseases, change in condition in past 14 days, balance problem with standing/walking, requires use of assistive device, takes 1-2 medications. Score: 19 (10 or higher equals high risk for falls) R17's care plan includes in part: Potential for falls/injury: cognitive deficit, history (Hx) of falls prior to admission, Hx fall since admission. I am at risk for falls due to balance issues, poor judgment in safety, continued self-transfers with assistance is needed Mobility change due to recent stroke including abnormal involuntary movements, new environment. Goal: Initiated: 1/02/25 . Intervention Intervention to lessen my risk for falls/injury: 1) Remind me to call for help rather than to get up by myself. 2)Anticipate my needs. 3) Report pain indicators. 4) Keep items/devices in reach. 5) Encourage use of non-slip footwear. 6)Follow toileting schedule. FALL RISK: I am at a High Risk for falls due to poor judgment in safety, self-transfers, attempts to complete tasks independently when assistance is needed, history of falls prior to and since admission, balance issues, and involuntary movement. Assess fall risk and implement fall reduction measures as indicated. Assure adequate pain management. Invite, encourage, and assist me to participate in activities that promote exercise, physical activity for strengthening and improved mobility and balance. Monitor that alarms are on at all times Please see self-care deficit care plan. Every 2 hour toileting with staff education. Alarms in place. Seek order for OT Evaluate/treat as indicated. Seek order for PT Evaluate/treat as indicated. CONCERN: SELF CARE DEFICIT: Cognitive and physical limitations: I will allow completion of cares that I am unable to do myself. Initiated: 1/02/25 Revised on 1/29/25 Target Date: 4/23/25 TRANSFER/LOCOMOTION/AMBULATION: Assist of 1 with FWW and gait belt. Does not use call light for assistance and will self transfer. Sign in room for reminder to use call light and to use walker. Ambulate with FWW (front wheel walker), gait belt, assist of one with wheelchair to follow in hallway. He may need cueing, occasional assistance to steer walker correctly. On 3/04/25 at 7:33 AM, Surveyor observed R17 ambulating from dining room with Certified Nursing Assistant (CNA) C with walker. R17 did not have a gait belt around his waist to allow staff to maintain contact guard assistance with walking. Surveyor observed a gait belt hanging from R17's walker. CNA C was observed walking beside resident to his room where he was seated in chair. Surveyor observed no wheelchair following behind R17 by staff. On 03/04/25 at 11:43 AM, Surveyor observed R17 in his bathroom with Licensed Practical Nurse (LPN) D in R17's room just outside the bathroom. LPN D entered R17's bathroom, cued him to stand from the toilet and walked beside R17 to his bed. LPN D did not apply a gait belt to R17's waist to maintain contact guard assistance when she walked beside him to his bed. Surveyor again noted a gait belt on R17's walker. CNA E, who was in R17's room, assisted R17 to stand from his bed to walk to his recliner to sit. Again no gait belt was applied to R17's waist to maintain contact guard assistance when assisting him to stand and walk to his recliner. Following the observation Surveyor spoke with LPN D and CNA E about R17's fall risk and use of gait belt, when walking and use of wheelchair following behind R17 when walking. LPN D indicated R17 is at risk for falls; using a gait belt would give staff something to hold onto to maintain contact guard which would be better than grabbing his arm. LPN D expressed R17's care plan should be followed. On 03/04/25 at 12:50 PM, Surveyor spoke with CNA C about the observation. CNA C indicated R17 is at risk for falling; not using the gait belt, contact guard assistance and following behind him with wheelchair places him at risk for falling. Staff should use gait belt, should maintain contact guard with R17 and should use a wheelchair close behind R17 when walking. On 3/04/25 at 12:55 PM, Surveyor spoke with Director of Nursing (DON) B about the observations. DON B indicated R17 is high risk for falls. R17 fell at home prior to his admission and has fallen at the facility. R17 has involuntary movements which increases his risk for falling. The approaches for safe ambulation are via therapy and should be followed. DON B expressed she would expect staff to follow therapy recommendations to use a gait belt for ambulation as noted in his care plan.

Based on random observation, record review and interview, the facility did not distribute foods in a sanitary manner. The facility practice affected one of one resident's (R) tray line service observed, (R17). This is evidenced by: Surveyor requested and reviewed the facility policy titled Food Handling Techniques For All Staff. which is not dated. The policy in part read: 1. What foods may not be touched with your bare hands? Answer: READY-TO-EAT FOODS Examples include: .Bread, toast, rolls, baked goods 2. What methods may be used to handle READY TO EAT FOODS? Answer: Utensils, tongs, napkins or disposable gloves. 3. Why is bare hand contact prohibited with READY-TO-EAT FOODS? Answer: Employees may transmit disease through unwashed or poorly washed hands. Wearing Gloves or using utensils protects the resident from germs the employee may be carrying on their hands. On 3/03/25 at 12:10 PM, Certified Nursing Assistant (CNA) F was observed picking up R17's hamburger bun with her bare hands to apply ketchup to the bun. CNA F placed the bun back on top of R17's burger and served it to R17. R17 immediately took a bite of the hamburger and bun. On 03/05/25 at 7:03 AM, Surveyor spoke with CNA F about the observation. CNA F indicated she should have worn gloves when handling R17's hamburger bun to apply the ketchup. Surveyor asked CNA F why wearing gloves when handling resident foods is important. CNA F responded to prevent the spread of bacteria or infections such as norovirus. On 03/05/25 at 7:26 AM, Surveyor spoke with Infection Control Preventionist (ICP) G. Surveyor shared the observation with ICP G. Surveyor asked about the facility expectation regarding bare hand food handling of resident foods. ICP G indicated staff should wash their hands and don gloves before handling any resident foods to not contaminate the resident foods. It is important to prevent the spread of infection.

Based on observations and interviews, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection as evidenced by the following observations. The facility did not ensure 12 of 16 residents (R) (R3, R6, R9, R12, R15, R16, R17, R18, R20, R23, R24, R25) were given the opportunity to conduct hand hygiene prior to meal services. The facility staff did not perform sanitization of durable medical equipment to prevent the spread of infection when warranted between resident transfers affecting 2 of 2 resident (R7 and R12). This is evidenced by: The Facility Policy entitled Hand Hygiene - Skilled Nursing Facility Resident, revised 01/24, states: Hand washing is considered to be the single most important task that can be done to help prevent the transmission of infection. Employees should educate the residents as to the importance of performing hand hygiene, provide the resources needed to do so (soap and water or alcohol-based hand sanitizers) and aid those who are unable to independently carry out this task. Facility policy under the section Procedure has a bullet point that states: Staff should pay special attention to those residents who wheel themselves to the dining area. Provide the opportunity to wash their hands or use hand sanitizer before eating. Facility policy entitled Mechanical Lift Slings - Types, Use & Cleaning, revised 07/23 states in part .all lifts will be wiped down following each use, using Super Sani-cloth disinfectant wipes and sling is to be used on one resident only, not used on multiple residents. Example 1 On 02/08/24 at 7:22 AM, Surveyors observed residents going to Atrium Dining room via walker or wheelchair for breakfast. No residents were offered hand hygiene prior to receiving breakfast meal. During observation, Surveyor observed R6, R9, R12, R15, R16, R17, R18, R20, R3, R23, R24 and R25, who all received toast and bacon and used bare hands to consume all or part of the food items. On 02/08/24 at 7:40 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding resident hand hygiene prior to meals. CNA D stated that residents get washed up in the morning before coming to breakfast. CNA D was asked about hand hygiene prior to lunch. CNA D stated, I am not really sure. CNA D confirmed that resident hand hygiene was not offered prior to meal service. On 02/08/24 at 8:04 AM, Surveyor interviewed CNA C regarding resident hand hygiene prior to meal. CNA C stated usually we do before meals, but most of the residents just got up for breakfast. CNA C confirmed that all 11 residents either use their hands to move or propel wheelchair or utilize a walker independently at least part if not all day. CNA C confirmed this could be an issue if resident hand hygiene was not offered prior to meal service. On 02/08/24 at 11:34 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation of no hand hygiene offered to residents prior to meal. DON B stated the expectation would be hand hygiene offered prior to receiving meals per policy. Example 2 On 02/08/24 at 7:16 AM, Surveyor observed CNA D bring mechanical stand lift and body sling out of R7's room after transferring R7 to wheelchair. No sanitization of lift or sling was observed by Surveyor. On 02/08/24 at 10:36 AM, continuous observation by Surveyor noted CNA D used the mechanical stand lift and body sling to transfer R12 on and off the toilet. Surveyor observed CNA D remove the mechanical lift and place it in the hallway, draping the used sling over the lift. Observation of sanitizing lift, sanitizing sling, or obtaining a clean sling prior to transferring R12 on and off the toilet was not observed by Surveyor. On 02/08/24 at 11:03 AM, Surveyor followed CNA C and CNA D to R7's room pushing the sit to stand lift and used sling to transfer R7 to and from the toilet. Observation of sanitizing lift, sanitizing sling, or obtaining a clean sling prior to transferring to toilet or after toileting was not observed by Surveyor. On 02/08/24 at 11:13 AM, Surveyor interviewed CNA C and CNA D regarding expectation of sanitization of lifts. Both CNA C and CNA D stated the expectation is to sanitize lifts between residents. CNA D stated that there should be a tub of wipes in bag hanging from lift, but there isn't any. On 02/08/24 at 1:05 PM, Surveyor interviewed CNA C regarding sanitization expectation of mechanical sit to stand lift sling between residents. CNA C stated, I don't really know what we are supposed to do. I know each resident should have their own sling, but we have 2 sit to stand lifts and each only have 1 sling available. On 02/08/24 at 11:34 AM, Surveyor interviewed DON B, regarding observation of no sanitization of lifts during resident transfers. DON B stated the expectation would be lifts are sanitized between each resident and resident should each have their own sling per policy.

Based on observations, interviews, and record review, the facility did not establish and maintain an Infection Control Program designed to prevent the development and transmission of disease and infection, such as Covid-19, which has the potential to affect all 29 residents in the facility. Throughout the survey, observations were made in which staff did not wear appropriate Personal Protective Equipment (PPE) such as eye protection of goggles or face shields while in resident care areas, when the community transmission rate was high for Covid-19. This is evidenced by: The State of Wisconsin Department of Public Health memo BCD 2021-11, dated December 13, 2021 guidelines include in part, .When the County community transmission level is substantial to high levels (regardless of whether the facility currently has Covid-19 cases), staff should wear the following as part of CDC (Centers for Disease Control and Prevention) guidance for the universal use of PPE during the Covid-19 Pandemic: eye protection for all resident encounters . The Centers for Disease Control and Prevention (CDC) last revised memo dated 9/10/21 for Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (Covid-19) Pandemic, directs HCP under the section Implement Universal Use of Personal Protective Equipment for HCP: If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . Survey Team entered the facility for the Recertification Survey on 01/10/2022. During completion of the screening process, and throughout the survey, the team noted that staff were not wearing protective eye equipment, such as goggles or face shields, while in resident care areas. Surveyor then reviewed Centers for Disease Control and Prevention Data Tracker. The facility County was noted to have High Community transmission rate (calculated on January 10, 2022,) 141 cases with 25.38%. Surrounding Counties for 1/3/22 included the following: County bordering to the South: High with 392 cases and 24.56% positivity County bordering to the South East: High with 141 cases and 25.38% positivity County bordering to the North: High with 170 cases and 30.51% positivity County bordering to the North East: High with 105 cases and 27.82% positivity County bordering to the West: High with 422 cases and 28.25% positivity On 1/12/22 at 9:56 AM, Surveyor interviewed Housekeeper (HK)-D regarding her training and use of PPE while on duty. HK-D stated that she was required to wear N95 masks with any resident positive cases in the building and was directed to not enter any positive Covid resident rooms. With no positive resident cases, HK-D stated she was not required to wear goggles or visors but is required to wear a surgical mask at all times except when eating. At 10:03 AM, Surveyor interviewed LPN-E (Licensed Practical Nurse) regarding the use of PPE. LPN-E stated at this time, she is only required to wear a surgical mask, .but we need to look at it like you could be carrying it or they could be, so we need to be mindful of that and practice hand sanitizing and always keep the mask on. I know we went back and forth with eye protection. We do have goggles and face shields available, but they are only worn in the rooms of Covid positive cases . We haven't been given any direction to wear goggles/visors at this time . On 1/12/22 at 10:30 AM, Surveyor interviewed the Infection Control Preventionist, Registered Nurse (RN)- C, regarding the infection control practices of the facility. RN-C stated that the County in which the facility resides, as well as the surrounding counties have been high .forever, even when we were lower, we were high . RN-C stated the staff are directed to wear eye protection when the facility is in outbreak mode, as well as N95 masks. The facility was in an outbreak mode which ended three weeks ago. Outbreaks for this facility are currently monitored by the DON of this facility, (DON-B), who is working at home related to active Covid-19 infection. RN-C stated that at this time, staff do not wear goggles or visors. I admit, that I read and operated under the premise of the memo prior and did not revisit the current memos . On 1/12/21 at 1:47 PM, Surveyor interviewed DON-B via telephone. DON-B stated that she was unaware of the guidance for staff to wear protective eyewear whenever in resident care areas, only that masks were to be worn at all times. This practice of not donning protective eye wear when the County and those counties surrounding the facility are at a high community transmission level, places residents, staff, and visitors at risk of contracting Covid-19 infection.

Based on observations, interviews, and record reviews, the facility did not provide necessary treatment and services, consistent with professional standards of practice, related to comprehensive weekly assessments of Pressure Injuries (PI) for 1 of 1 residents (R28) reviewed. R28 was admitted to the facility with an Unstageable PI to her right bunion on 12/8/21. The facility documented this wound as a Stage IV PI. The wound documentation indicated that it has worsened with the additional development of slough. There were no comprehensive assessments completed of the wound, nor did the treatment change when additional slough developed. Note: Slough is necrotic, or dead tissue that needs to be removed from the wound in order for healing to take place. This is evidenced by: According to the NPIAP (National Pressure Injury Advisory Panel) a PI is considered unstageable when the depth of a wound is unknown and is described as .Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed . Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage cannot be determined . The NPIAP also states that a comprehensive wound assessment should be completed weekly and should consist of the following information: - location of the wound; - category/stage of the wound; - size of the wound; - tissue type(s); - description of the wound bed and periwound; - a description of the wound edges; - the presence of any sinus tracts, undermining, or tunneling; - the presence of exudate or drainage; - the presence of necrotic tissue or slough; - the presence of odor; - the presence/absence of granulation tissue and/or epithelialization; and - the current treatment being utilized. *According to the NPIAP/EPUAP, Weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. The NPIAP also directs that the professional should reevaluate the pressure injury assessment plan if the pressure injury does not show signs of healing within two weeks and adjust the treatment accordingly. The facility's Policy and Procedure for Wound Assessment, which is undated, includes the following that should be required in the assessment: - the location of the wound - the size of the wound measured in centimeters Length x Width, and Depth - the presence of undermining or tunneling - the stage of the wound or if wound is unstageable - the presence or absence of drainage - the description of the wound bed, including the presence of eschar, slough, or granulation tissues - the condition of surrounding skin (redness, maceration, denuded tissue, the description of the wound edges) - any signs of infection present (changes in skin temperature or color, redness, warmth, [CONDITION(S)], or increase in exudate/drainage) - Pain R28 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Physician documentation of a mandated visit as well as a transitional assessment to another facility, dated 11/23/21, R28 was being followed by a Podiatrist for the right bunion wound while at previous facility. According to the most recent Minimum Data Set Assessment completed for R28, which was an admission assessment dated [DATE], R28 is fully cognitive and is independent to requiring supervision of her daily tasks of bed mobility, transfers, toileting, dressing, eating, and personal hygiene. She requires limited assistance of one staff for bathing. On 1/11/22, at 7:06 AM, Surveyor interviewed R28 regarding various aspects of her life in the facility, as well as her wound. R28 stated that she has a sore on her right bunion, and is unsure how it developed but that it was present prior to transferring to this facility. R28 indicated that the wound appears to not be healing, as she has had it for some time, but could not state when the wound developed. At 8:30 AM, Surveyor observed LPN-F (Licensed Practical Nurse) complete the treatment to R28's bunion wound. The wound was slightly smaller than a dime sized coin, approximately 1.3 cm (centimeter) diameter, with redness surrounding the wound approximately 0.5 cm out. The wound bed was covered in 80% slough from 1 o'clock to 8 o'clock and granulation tissue from 8 o'clock to 12 o'clock. LPN-F stated that the wound was cultured two weeks ago and the culture indicated normal skin bacteria. Surveyor then reviewed the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound culture was then reviewed and dated 12/23/21 and was determined to be normal skin bacteria. The wound notes completed by nursing staff were reviewed and the following was noted: - 12/10/21: Right Bunion: 1.4 cm x 1.3 cm x 0.3 cm with maceration to outer edges that measures 0.1 cm; 25% slough, 75% pinkness; treatment was [MEDICATION(S)] to wound bed covered by [MEDICATION(S)] dressing. - 12/17/21: no documentation of the wound on this week - 12/20/21 (located in another area of the record): Pressure ulcer stage 4 on admission to facility to right bunion - 12/22/21: 1.1 x 1.7. The documentation indicated that the old dressing contained a moderate amount of serous drainage. Note: Serous drainage is clear to slightly yellow in color. There were no other assessment criteria noted in the documentation. - 12/25: 1.1 x 1.7 with a medium amount of serous drainage to old dressing; slough present to wound base. Note: Again, no further wound descriptions were given. The amount of slough covering the wound is critical in determining if a wound is worsening and a major factor in the decision for a change in a treatment related to the ineffectiveness of the currently used treatment plan. - 12/29: 1.1 x 1.5; large amount of serous drainage noted on old dressing; slough present to wound bed. Note: Again, no further wound descriptions were given. Without an accurate description, the nurse is unable to accurately determine if a wound is healing or worsening, which is critical information to complete a plan for healing. - 1/5/22: 1.2 x 1.2; moderate amount of serous drainage; slough present to wound bed. Note: Again, the documentation is missing critical assessment information. On 1/12/21 at 9:18 AM, Surveyor again interviewed LPN-F, as LPN-F works frequently with R28. LPN-F stated many changes have occurred with the new ownership. There is no wound nurse on duty and all the treatments are the responsibility of the nurses on the floor. The weekly wound assessments are the responsibility of whichever nurse is assigned to the resident on the date they are due. When asked what criteria should be included in a weekly, or comprehensive wound assessment, LPN-F stated, Well, you need to look at size, drainage, peri-wound, wound bed, appearance, dressing in place/treatment, location of wound, if the resident is on any protein or supplements, the culture results, if one was ordered. The expectation is that if the wound shows no improvement or worsens, we call the doctor and request a treatment change. Sometimes they refuse, but you need to try. Also on this date, after notifying the facility of the concern, Surveyor was given an assessment of the wound time stamped 1:46 PM. According to this new assessment, R28's wound was now 100% covered in .firmly adherent slough . The treatment was changed on this date to [MEDICATION(S)] Blue followed by a [MEDICATION(S)] dressing.

Based on record review and interview the facility did not have a RN (Registered Nurse) working for 8 consecutive hours every day of the week. Surveyor reviewed facility schedules over a 6 months period beginning 07/28/19 through 02/15/2020 and found eight days when no RN had worked for 8 consecutive hours. This has the potential to affect all 30 residents. The facility census was from 27-30 residents during this time period. This is evidenced by: Surveyor requested staff postings and nurse schedules for a 6 month period. The facility provided nurse schedules beginning 07/28/19 through 02/15/20. The Surveyor reviewed all schedules and noted the following days with no RN coverage: Saturday, (MONTH) 28. Sunday, (MONTH) 29. Saturday, (MONTH) 12. Sunday, (MONTH) 13. Saturday, (MONTH) 26. Saturday, (MONTH) 7. Sunday, (MONTH) 8. Sunday, (MONTH) 5, 2020. On 02/11/20 at 11:20 a.m., Surveyor interviewed the Scheduler-D and the Assistant NHA (Nursing Home Administrator)-C. The Scheduler-D checked schedules and time cards and confirmed that no RN had worked on the eight days identified by the Surveyor. ANHA-C stated the facility has been struggling with RN coverage due to the nurse shortage. ANHA-C stated the facility is working with 4 different agencies in an attempt to staff RNs, but with no success. The ANHA-C stated the facility had also implemented recruiting efforts for RNs, but again without success. The ANHA-C confirmed the facility employed RNs that worked only Monday through Fridays. The ANHA-C stated the Payroll Based Journal reporting submitted quarterly would also confirm days without RN coverage.

Based on observation, interview, and record review, the facility did not ensure it maintained an infection prevention program designed to prevent the transmission of disease and infection. This had the potential to affect all residents. Beginning 1/7/19 residents in the facility began to exhibit symptoms of an ARI (Acute Respiratory Infection). By 1/17/19, 7 of the 30 residents (R3, R6, R15, R18, R21, R26, and R27) were ill with symptoms of an ARI. The facility did not: ~ Identify the threshold for an ARI outbreak had been met. ~ Implement infection outbreak management strategies. ~ Notify local Public Health officials of the respiratory outbreak. ~ Notify the Medical Director. ~ Consistently implement appropriate PPE (Personal Protective Equipment). This is evidenced by: A respiratory illness includes: ~ Pneumonia; ~ ARI with symptoms including fever, cough, nasal congestion, sore throat, or muscle aches; or ~ Laboratory confirmed [MEDICAL CONDITION] or bacterial infections including influenza. A respiratory disease outbreak is defined by CDC (Centers for Disease Control) and DPH (Division of Public Health) as 3 or more staff or residents on the same unit with illness onsets within 72 hours of each other. Outbreak management includes: ~ Laboratory testing to determine the presence of influenza and/or other respiratory viruses. ~ [MEDICAL CONDITION] and treatment for [REDACTED]. ~ Implementing both droplet and contact precautions. ~ Considerations for moving residents into private rooms. ~ Posting signs informing visitors of the outbreak. ~ Considerations for whether or not to admit new residents. ~ Limiting staff movement within the facility. ~ Excluding staff ill with symptoms of an ARI from work at least 24 hours after they no longer have a fever without the use of fever reducing medication. ~ Notifying the Medical Director. ~ Reporting the outbreak to the local health department. The facility had two distinct households, Wetland and Grove. On 1/15/19, on entrance to the facility for the facility's recertification survey, there were 3 residents on Wetland household (R3, R26, and R27) on enhanced precautions for an ARI. On 1/17/19 Surveyor reviewed the facility's surveillance logs. All of the following residents were noted on Wetland household: ~ On 1/7/19, R6 was ill with respiratory symptoms including fever, cough, and changes in lung sounds. ~ On 1/10/19, R3 was ill with respiratory symptoms including fever, cough, and nasal congestion. ~ On 1/12/19, R26 was ill with respiratory symptoms including fever, cough, body aches, and fatigue. ~ On 1/12/19, R27 was ill with respiratory symptoms including fever, cough, nausea, and fatigue. On 1/12/19 the facility met the threshold of 3 residents indicating a respiratory outbreak. The facility did not identify the outbreak, implement outbreak management strategies, contact the Medical Director, or contact their local health department. ~ On 1/14/19, R18 was ill with respiratory symptoms including a fever, cough, and nasal congestion. Beginning 1/17/19 the surveillance logs indicated residents on Grove household were symptomatic with an ARI. All resident listed below were on Grove household. ~ On 1/17/19 R21 was ill with respiratory symptoms including fever, cough, and congestion. ~ On 1/17/19 R15 was ill with respiratory symptoms including fever, cough, and sore throat. Despite that the ARI continued to spread, the facility did not implement outbreak strategies in attempt to control the transmission of the ARI. On 1/15/19 at 3:15 PM Surveyor observed CNA-F (Certified Nursing Assistant) in R18's room. R18 was in enhanced precautions due to a respiratory infection. Surveyor noted CNA-F had not donned PPE including a gown, gloves, and mask prior to entering R18's room. Surveyor noted CNA-F approached R18's bed and began speaking to R18. R18 was noted to be coughing during CNA-F's and R18's conversation. It was critical for all staff to don appropriate PPE in order to prevent the transmission of R18's respiratory infection to other residents and/or staff in the facility. On 1/17/19 at 9:30 AM, Surveyor spoke with the EDON (Executive Director of Nursing) who is also the ICP (Infection Control Practitioner). The EDON indicated she had spoken with their medical director on 1/17/19 regarding the residents ill with respiratory symptoms. The EDON stated the Medical Director felt there was no need to implement their outbreak strategies. Surveyor reviewed the surveillance logs with the EDON noting the threshold had been met for an ARI outbreak on 1/12/19. The EDON concurred. On 1/17/19 at 10:30 AM Surveyors spoke with the NHA (Nursing Home Administrator) and EDON. The NHA indicated she was notified on 1/12/19 of residents ill with respiratory symptoms. The NHA indicated she directed staff to implement outbreak strategies including enhanced precautions, residents ill were to stay in their rooms, and no movement of staff from one unit to another. The NHA indicated she lifted the outbreak strategies on 1/13/19 when the residents they checked for influenza laboratory results came back negative. The NHA indicated retrospectively she should not have lifted their outbreak strategies. Surveyor also asked the EDON about the observation as noted on 1/15/19. The EDON indicated all staff should be donning the appropriate PPE prior to entering ill resident rooms.

Based on interviews and record review the facility did not obtain follow up vision services for 1 of 12 sampled residents (R19). R19 has a [DIAGNOSES REDACTED]. There is no evidence an appointment was made. This is evidenced by: Resident's most recent MDS (Minimum Data Set Assessment) dated 12/11/18 shows that the resident has a BIMS (Brief Interview of Mental Status) of 15/15 and has impaired vision. R19 is his own decision maker. Review of R19's medical record finds a [DIAGNOSES REDACTED]. Surveyor reviewed R19's most recent vision consult dated 12/08/17, .Follow up in 6 months or sooner with concerns. Surveyor asked the DON for any follow-up from the 12/08/17 eye exam. No additional information was received. On 01/17/19 at 9:29 AM, Surveyor reviewed an Occupational Therapy note dated 07/27/18 which indicated that R19 had said that he would like to see the in-house eye doctor. The note states nursing was informed to try and set up There was no evidence R19 was seen by an optomotrist or opthamologist for the 6 month follow-up apppointment or per his request.

Based on observation, resident and staff interviews and record review staff did not ensure 1 of 6 residents (R4) was transferred properly with the mechanical lift. CNA D and CNA E (Certified Nursing Assistants) did not fasten the lower leg strap prior to moving R4 in the sit to stand lift. The facility did not have evidence that they had assessed that R4 did not need to use the lower leg strap. This is evidenced by: Review of the manufacturers instructions for the volaro sit to stand mechanical lift includes the following on page 4: Section 3: Attaching sling to the lift . the knee rest has a built in safety support strap to be used on one who does not have much control or experiences muscle spasms . 01/15/19 at 3:08 PM, R4 told Surveyor she had fallen in (MONTH) (YEAR) in the bathroom and broke her left ankle. R4 said staff are now using a sit to stand lift to transfer her. Surveyor review of R4's physician progress notes [REDACTED]. The physician ordered an xray of ankle and tib/fib on R4's left after continued pain. An xray completed on 07/18/18 indicated oblique fracture of distal fibular shaft with minimal displacement. On 01/16/19 at 8:24 AM, Surveyor observed CNA D and CNA E transfer R4 with the sit to stand lift. Neither staff attached the strap behind R4's lower legs. On 01/16/19 at 2:22 PM, Surveyor spoke with CNA D about the sit to stand lift. CNA D said you always attach the strap that goes behind legs. On 01/16/19 at 3:00 PM, Surveyor spoke with the facility Training and Development Coordinator who stated she teaches the CNA Class and stresses the use of the lower leg unless it's care planned to not for some particular reason. On 01/17/19 at 08:11 AM, Surveyor spoke with the DON (Director of Nursing). The DON said staff are supposed to use the leg straps for the Sit to Stand Lifts. The DON said if a resident declines, there would be a therapy screen and it would be care planned. The DON said no residents have been care planned to not use the leg strap. On 01/17/19 at 10:34 AM, the DON told Surveyor R4 has not been assessed to not use the lower leg strap on the sit to stand.

Based on observation, record review and interviews the facility did not ensure a medication error rate of 5% of less. Surveyor observed two errors out of 39 medication opportunities for an error rate of 5.13%. R3 was given Humalog insulin 34 minutes prior to R3 eating brunch. Humalog is a rapid acting insulin to treat diabetes and should be given 15 minutes or less prior to a meal to prevent [DIAGNOSES REDACTED] (low blood sugar). R3 received [MEDICATION NAME] 2% eye drops to treat IOP (intraocular pressure). RN-B (Registered Nurse) did not apply pressure to the bridge of the nose following eye drop instillation. Omitting this action reduces the absorption of [MEDICATION NAME] and increases systemic absorption. This is evidenced by: Example 1: Surveyor reviewed the physician orders [REDACTED]. On 1/16/19 at 10:49 a.m., Surveyor observed LPN-A (Licensed Practical Nurse) administer 23 units of Humalog to R3. At 11:23 a.m., R3 was served brunch and began eating independently. R3 went 34 minutes between receiving the Humalog and eating. Again, Humalog should be given 15 minutes or less prior to a meal. On 01/16/19 at 12:39 p.m., Surveyor interviewed LPN-A regarding Humalog and its effects. LPN-A stated she never gave R3 insulin before eating because R3 was a brittle diabetic (having blood sugars that are hard to control; increase and/or decrease rapidly). LPN-A stated R3 can go low with the blood sugar dropping quickly. LPN-A stated Humalog was a fast acting insulin and that residents who receive it must eat within 15 minutes of the injection. LPN-A stated she thought R3 had already eaten due to the time of day and R3 being in the resident's room and not the dining room. Example 2: Surveyor reviewed R3's physician orders [REDACTED]. On 1/17/19 at 7:04 a.m., Surveyor observed RN-B administer one drop of [MEDICATION NAME] 2% eye drops into R3's right eye. After administration, R3 wiped away excess medication with a tissue. Neither RN-A nor R3 applied pressure to the inner canthus of R3's right eye to prevent the medication from being absorbed systemically. [MEDICATION NAME] is an eye drop used to treat IOP. Following instillation of [MEDICATION NAME], you must apply pressure to the inner canthus of the eye or bridge of the nose to reduce systemic absorption. Omitting this action reduces the absorption thus effectiveness to treat IOP and also increases the likelihood of systemic absorption causing side effects such as low blood pressure. On 01/19/19 at 8:06 a.m., Surveyor interviewed RN-B regarding eye drop instillation. RN-B confirmed she did not apply pressure to R3's inner canthus to prevent systemic absorption. RN-B stated she remembered some training on eye drop instillation, but did not remember when it was necessary to apply pressure.

Based on observations, staff interviews and record reviews, the facility did not serve food under sanitary conditions for all 30 of the facility residents. Dietary staff did not perform hand hygiene at appropriate intervals while moving from dirty to clean dishes. Staff also did not protect their clothing from contamination while working with dirty dishes. Staff serving drinks at the evening meal of 12/1/15 were noted to consistently hold the residents' cups and glasses at the top of the glass, where one's lips would touch the glass, when carrying them and setting them on the table. This is evidenced by: Example #1: On 12/1/15 beginning at 10:55 a.m., Surveyor # observed DA-G go into the dish room in the kitchenette area. DA-G put on a pair of cloth gloves and then a pair of rubber gloves on top. DA-G did not have an apron on. DA-G began to spray the dirty dishes from the Grove and Wetlands dining rooms and put them through the dish machine. Dirty water from the dishes was splashing onto her clothes. At 11:05 a.m. DA-G removed her gloves and did not wash her hands. DA-G then went onto the clean side of the dishwasher and began removing clean dishes from the trays. DA-G then pushed up her eye glasses and took a rag and wiped a cart. DA-G then took a second tray of clean dishes and removed the clean dishes without washing her hands. DA-G then put on a second pair of cloth gloves and rubber gloves over the top of them and went back onto the dirty side of the dish room and began spraying the dirty dishes and putting them into the dish machine. DA-G then went over to the clean side of the dishwasher and removed another tray of clean dishes and stacked them. DA-G had her same dirty gloves on when she did this. DA-G then went and got a bottle of Clorox spray and sprayed a utility cart and wiped it with a cloth. DA-G then proceeded to move clean dishes with the same dirty gloves and put them into the cupboards and areas for future use. DA-G then proceeded over to the dirty area of the dish machine and began more dirty dishes to put into the dish machine. Example #2: On 12/1/15 at 3:55 p.m., Surveyor # observed the meal service of the residents that dine in the Wetlands and Grove dining areas. CNA-A (Certified Nursing Assistant) served 12 residents in the Wetlands dining room. CNA-A was observed to pick up and carry each coffee cup and each glass of juice she served by the lip of the glassware. CNA-B was observed doing the same with the glasses to nine residents served in the Grove dining room. She would however, carry the coffee cups by the handles. On 12/2/15 at 1:07 p.m., Surveyor # interviewed CNA-D and CNA-E about how staff were to handle glassware, silverware and dishware when serving the meals to the residents. CNA-D stated they were told never to hold them where the residents put their mouth. CNA-E stated less than three weeks ago they had an in-service on exactly the same thing and staff were shown how to do it. On 12/2/15 at 3:00 p.m., the SDC (Staff Development Coordinator) told Surveyor # that on 11/12/15 there was an in-person education of staff regarding several aspects of food safety and the handling of glassware with demonstrations by the DM (Dietary Manager). Review of the attendance record found CNA-A and CNA-B had not attended. On 12/01/15 at 1:15 p.m., Surveyor # interviewed DM-I (Dietary Manager). DM-I indicated staff should be using a disposable apron when in the dish room and should be removing the apron when moving between dirty and clean. DM-I said staff should be removing their dirty gloves and washing their hands before going onto the clean side of the dish machine and moving clean dishes. DM-I said when staff are serving liquids and food in the dining room, they should be holding the glasses, cups and plates on the bottom not on the top to prevent contamination.

Based on observation, interview and record review, the facility did not develop a plan of care or clarify to nursing staff which residents could safely self-administer medication and what medication the resident can safely self-administer. This was discovered for 2 of 11 sampled and supplemental sampled residents. Resident #6 and Resident #11 are identified by the nursing staff as being able to self-administer medications. However, which medication and who is responsible had not been determined by the Interdisciplinary Team nor was it care planned. This is evidenced by: The facility has no policy and procedure to ensure that each resident's desire to self administer medications was addressed on their plan of care and that those residents are: 1. Clearly identified, and, 2. The actual medications are clearly identified. Example #1: On 11/30/15 at 8:37 p.m., Resident #6's oral medications were left unattended for her to take on her own by LPN-F (Licensed Practical Nurse). LPN-F also allowed the resident to take her own metered dose inhalers (MDI) in a manner contrary to manufacturer's directions to administer the correct dose and minimize negative side effects. Resident #6 took her MDIs in rapid succession and did not rinse and spit afterwards to minimize the instance of thrush (a yeast infection in the mouth.) LPN-F told the surveyor she had forgotten to remind her to rinse and spit, and went back to do so. On 12/1/15 Surveyor # observed LPN-H also give Resident #6 her medications. Resident #6 again took her MDIs in rapid succession and did not rinse her mouth. While Resident #6 took her oral medications, LPN-F stood by and watched her do so. Resident #6 questioned LPN-F why she was standing there. LPN-F stated, I have to wait here until you take them. When asked afterwards why LPN-F had not coached her on the proper procedure to take the MDIs, LPN-F stated, I've talked to her many times and I let her dictate how to do it. This transfer of medication responsibility was not addressed on Resident #6's plan of care until questioned by Surveyor # . On the afternoon of 12/1/15, the nursing notes indicate the facility called the physician and discussed the risks and benefits of Resident #6 taking her MDIs in that manner. It was after this discussion that a plan of care was written. Example #2: Resident #11 has also been identified as being able to take her medications. Her plan of care does not address this transfer of responsibility until questioned by the surveyor. On 12/2/15 at 1:35 p.m., Surveyor # interviewed RN-C (Registered Nurse) regarding Resident #6's self-administration of medications. RN-C stated she stays with Resident #6 while she takes both her MDIs and oral medications. RN-C stated the only resident that she can leave is Resident #11 when she self-administers her nebulizer treatment. On 12/2/15 at 3:45 p.m., Surveyor # interviewed LPN-F regarding the self-administration of medications by Resident #6. LPN-F stated staff can leave her oral medications for her to take on her own and that she will take her own MDIs. LPN-F stated staff can leave Resident #11's oral medications also. LPN-F stated staff prepare Resident #11's nebulizer treatment and she can have her own pills. LPN-F stated she found out who can self-administer medications when she was first oriented and that would be how subsequent employees would also learn.

Based on observation, interview and record review, the facility did not ensure that staff followed accepted standards of practice related to infection control for 1 of 10 sampled residents. RN-C (Registered Nurse) did not implement hand hygiene at appropriate intervals during Resident #4's dressing change. This is evidenced by: On 12/1/15 at 10:03 a.m., Surveyor # observed RN-C apply a moisturizing cream and change the wound dressing to Resident #4's venous stasis ulcer on her right lower shin. Prior to the procedure RN-C was noted to wash her hands at the sink, take off the resident's sock, and don a pair of gloves. RN-C cleaned a scissors and cut off the old dressing. RN-C did not remove her gloves or wash her hands after removing the old dressing. The old dressing was noted to be moist with body fluids. RN-C then applied a moisturizing cream to both Resident #4's legs but not over the open wound. RN-C removed her gloves and donned a new pair of gloves without decontaminating or washing her hands. RN-C applied [MEDICATION NAME] to the open areas with an applicator and applied a petroleum-based dressing over the wound with her gloved hands. RN-C then wiped off the now soiled scissors with an alcohol infused wipe and covered the wound with a 4 inch by 4 inch square piece of gauze. RN-C removed her gloves but still did not decontaminate or wash her hands. RN-C proceeded to wrap Resident #4's wound area with a roll of clinging gauze and tape it. RN-C then wrapped both of Resident #4's legs with four elastic bandages. It was only after the procedure was done that RN-C went to the sink to wash her hands. Surveyor # observed a bottle of alcohol based hand sanitizer clipped to RN-C's uniform. On 12/2/15 Surveyor # interviewed RN-C about the expectations of staff when changing a dressing or bandage. RN-C stated nurses are to wash whenever they take off a pair of gloves and after removing an old dressing. When asked why this step was missed in the previous observation, RN-C stated, It was just human error.

Based on random observations and interviews, the facility did not ensure safe practices were implemented regarding sanitary practices with food service. This has the potential to affect all residents in the facility. 1. Scoops were left in the dry bulk containers with the handles in full contact with the food. 2. CNA staff entered the kitchen/preparation area without a hair restraint. 3. Bare hand food contact by two CNAs was observed. 4. Bare hand food contact by the cook was observed. This is evidenced by: Example #1: During the initial tour of the facility on 11/2/14 at 9:30 a.m., conducted by Surveyor # , and throughout kitchen observations, two stand-up Rubbermaid containers were stored in the dry storage area of the kitchen. These were labeled sugar and flour. In each of the bulk dry good bins was a clear plastic 1 cup pouring scoop. Surveyor # observed the handles of the scoops in contact with the foods on: ~ 11/2/14 at 3:30 p.m. ~ 11/3/14 at 9:00 a.m. ~ 11/4/14 at 10:00 a.m. On 11/4/14 at 10:30 a.m., Surveyor # approached the Dietary Manager (DM) regarding the observations made. The DM stated, "That's a no-no..." Example #2: During preparation observations made by Surveyor # on 11/3/14 at 9:00 a.m., CNA-J (Certified Nursing Assistant) entered the kitchen preparation area while toast was being made and buttered. She walked to the coffee machine and poured a cup of coffee for a resident, then left. There was no hair restraining device on CNA-J. Example #3: During meal service of 11/3/14 at 10:40 a.m., Surveyor # observed CNA-F (Certified Nursing Assistant) pick up Resident #1's toast with bare hands and then put jelly on the toast. CNA-F then continued to serve other residents their meals, including Resident #12. She then picked up Resident #12's toast with bare hands and put butter on each piece. Example #4: During meal service of 11/3/14 at 10:40 a.m., Surveyor # observed CNA-A pick up Resident #13's toast with bare hands and put jelly on each piece. On 11/4/14 at 7:15 a.m., Surveyor # asked CNA-A about bare hand food contact. CNA-A stated she wasn't aware of any training and did not know about not touching resident's food with her bare hands. She stated she knows she is to wash her hands before serving residents and if she touches resident food, she sanitizes or washes afterwards. Example #5: During meal preparation observation conducted by Surveyor # on 11/3/14 at 9:00 a.m., Cook-H was preparing a tossed salad for a single resident serving. She sliced the boiled eggs with an egg slicer and placed the egg onto the salad and with bare hands, separated the egg slices. On 11/4/14 at 10:30 a.m., Surveyor # met with the Dietary Manager (DM) and explained the observations made above. The DM stated bare hand food contact is not allowed either with nursing staff or dietary staff. The DM stated good handwashing and gloves are to be worn whenever staff need to touch food items. The DM stated staff education will be conducted.

Based on interview and record review, the facility did not complete thorough investigations into allegations of abuse and injuries of unknown origin, did not protect residents from further potential abuse, and/or did not immediately report allegations for 5 of 10 sampled and supplemental sampled residents. Resident #6 reported an allegation of abuse and identified the staff person. The facility did not immediately remove the suspected staff or report the allegation as required. Resident #13 had suspicious bruising on both wrists. When the facility identified the staff person involved, the staff person was not removed from duty during the facility's investigation, the investigation was not thorough and the injury was not reported as required. Resident #5 had an injury of unknown origin which was not thoroughly investigated. Resident #10 developed bruising to her inner forearm on 8/6/14. The bruising was not investigated to determine a root cause. Resident #7 was noted to have: ~Bruising/abrasions on his right lateral abdominal/side on 02/16/14; ~Bruising on both arms and left abdomen was noted on 02/17/14; and, ~Bruising to the right side of the head on 3/9/14. Although the nurse's notes surmised what may have happened, there was no investigation into bruising to determine possible environmental factors and/or to rule out abuse. This is evidenced by: On 11/2/14 and 11/3/14, Surveyor # requested information regarding the facility's investigations into abuse, neglect, mistreatment, and injuries of unknown origin. DON-C (Director of Nursing) indicated there were no investigations. Example #1: On 11/13/14 at 2:50 p.m., Surveyor # spoke with the SW (Social Worker). Surveyor # asked the SW how she was involved in the facility's investigations into abuse, neglect, mistreatment, and injuries of unknown origin. The SW indicated she would initiate an investigation if a resident specifically spoke with her about a concern. The SW indicated otherwise she was involved in investigations as directed by the nursing department. Surveyor # asked the SW what investigations she had been involved with over the past year. SW indicated she was currently working on an allegation of mistreatment from Resident #6. The SW indicated Resident #6 approached her on 11/2/14 and indicated a staff person had mistreated her. The SW indicated Resident #6 also relayed this information to the DM (Dietary Manager) and had identified the staff person to the DM. The SW indicated Resident #6 had made an allegation of mistreatment in the past, however the allegation was greater than 1 year ago. Resident #6 had current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 9/15/14. The MDS indicated Resident #6: ~ Had a BIMS (Brief Interview for Mental Status) score of 9 indicating a moderate cognitive impairment; ~ Required the assistance of 1 staff person for all aspects of care; ~ Did not walk; and ~ Had no behaviors, hallucinations, or delusions. Surveyor # requested and reviewed the facility's investigation of Resident #6's allegation of mistreatment. The investigation was noted to have started on 11/2/14 when Resident #6 expressed to the SW she had been mistreated by a staff person on the evening of 10/31/14. The information indicated Resident #6 had also relayed the information to the DM (Dietary Manager) on 11/2/14, at which point Resident #6 visually identified and pointed to the staff person. The facility had knowledge of the staff person in question on 11/2/14. This staff person was not removed from resident care after being identified by Resident #6 and while the facility conducted an investigation. The facility's investigation included interviews with 6 staff persons. No residents were interviewed. The facility concluded that due to Resident #6's cognition, no evidence of injury, history of like allegation, and Resident #6's description of the person, they could not determine that the allegation took place. The facility's investigation indicated the allegation was not reported as employee misconduct was ruled out during the investigation. There was no evidence that the facility immediately reported the allegation as required. On 11/4/14 at 8:00 a.m., Surveyor # spoke with Resident #6 about the incident. Resident #6 recalled the incident. Resident #6 stated she didn't know the staff person's name but indicated she was "very rough." Resident #6 also stated, "The girl was in here again last night but I had no problems with her." On 11/4/14 at 8:10 a.m., Surveyor # and DON-D (Director of Nursing) observed Resident #6's feet. Surveyor # observed a bruise on Resident #6's left foot which included the base of the left great toe extending medially up the side of the great toe approximately 3 inches. The bruising also extended to the first toe. Resident #6 was unsure of how the bruise occurred but indicated she had recently been seen by podiatry services. On 11/4/14 at 8:20 a.m., DON-D indicated to Surveyor # Resident #6 was last seen by podiatry services on 10/21/14. On 11/4/14 at 11:45 a.m., DON-C and DON-D approached Surveyor # and indicated the bruise as noted on Resident #6's left foot had been identified by LPN-G (Licensed Practical Nurse) on 11/3/14. Example #2: Resident #13's current [DIAGNOSES REDACTED]. Resident #13 was also legally blind. Resident #13's most current MDS (Minimum Data Set) was dated 8/18/14. The MDS indicated Resident #13 was cognitively intact, was able to transfer independently, required the assistance of 1 staff person for all other aspects of care, had no aggressive behaviors directed toward staff or other residents and had not rejected any care. Surveyor # completed a review of Resident #13's comprehensive care plan. The comprehensive care plan was not dated. The care plan did not contain a behavior problem indicating Resident #13 was aggressive, rejected care, or combative. Surveyor # completed a review of Resident #13's physician orders [REDACTED]. Surveyor # completed a review of Resident #13's nursing notes and noted the following: ~ 6/1/14, "10:36 (10:36 a.m.)...noted to have bilateral wrist bruise...left inner wrist to top...7.8 cm (centimeters) x (by) 8.0 cm...right wrist...5.2 cm x 7.4 cm...Bruises appear to be caused from resident bumping on commode...noted yesterday to be incontinent of stool...and was attempting to clean self bruising appears to be caused from this..." Staff surmised Resident #13's bruising was self inflicted. An investigation was not started. Nursing notes continue: ~ 6/1/14, "...14:21 (2:21 p.m.)...After shift to shift report was reported that resident was combative last evening hitting out at staff, (staff) did grab residents wrists to keep resident from hitting out at CNA (Certified Nursing Assistant)...appears this is where bruising is from..." Surveyor # requested the facility's investigation into Resident #13's bruises. Surveyor # received from DON-C (Director of Nursing) a word document titled "Follow up investigation...wrists/forearms found 6/1/14." DON-C indicated the word document was all she could find. The document was neither signed nor dated. Surveyor # completed a review of the word document. The document indicated the incident occurred on 5/31/14. The document indicated when a CNA attempted to clear Resident #13's call light without indicating to Resident #13 the CNA's intention, Resident #13 began to swing out at the CNA. The CNA called out for assistance and another staff member entered Resident #13's room and intervened by grabbing Resident #13's wrist from behind to prevent Resident #13 from hitting the CNA. The document indicated Resident #13 had "...two purple bruises to the top of her wrists/forearm and continue toward the underside as well..." The size of the bruising was not documented. The document indicated Resident #13 was questioned about the bruising on both wrists and Resident #13 was uncertain how they occurred. The document did not include the date or time when this interview with Resident #13 occurred. The document did not indicate any further questions posed to Resident #13 regarding the occurrence on 5/31/14. The document indicated "...No abuse intended..." According to Resident #13's care plan and MDS, Resident #13 was cognitively intact and not combative. On 11/13/14 at 2:50 p.m., Surveyor # spoke with the SW (Social Worker). The SW indicated she was aware an investigation regarding an injury of unknown origin regarding Resident #13. The SW indicated Resident #13 had very suspicious bruising on both wrists indicative of finger print bruising. The SW indicated staff had come to her with concerns about the appearance of the bruising. The SW indicated she looked at the bruising and concurred the bruising was suspicious in nature. The SW indicated the nursing department conducted the investigation. On 11/4/14 at 11:15 a.m., Surveyor # again spoke with the SW about Resident #13's bruises. The SW indicated the bruising went around the wrists to the underside. The SW indicated the bruising was linear indicative of finger marks. There was no evidence that the facility thoroughly investigated the incident, or spoke with Resident #13 regarding the treatment Resident #13 received from the 2 staff members involved in the occurrence. There was no indication the facility spoke with other staff or residents to gather as much information as possible in order to make the determination of caregiver misconduct. The facility did not take all necessary steps to prevent future potential abuse from occurring as the staff in question continued to work. The incident was not reported to the State Agency as required. Nursing notes continue: ~ 10/1/14, "...noted to have a large bruise to the top of right foot. bruise...15.5 cm x 9.0 cm appears to be caused from resident continuously bumping on commode after toileting and getting back into bed...moved commode to foot of bed and informed resident that commode should be left at foot of bed if resident continues to move will take out of room..." Surveyor # requested the investigation into bruise as noted above. None was received. Surveyor # received handwritten information from DON-D which indicated, "...no investigation needed 'not an injury of unknown origin'..." A bruise measuring 15.5 cm x 9.0 cm is significant. There was no indication staff were spoken with regarding the circumstances surrounding the development of Resident #13's bruise. Staff surmised the cause without completing an investigation to determine actual cause. Example #3 Resident #5 had current [DIAGNOSES REDACTED]. Resident #5's most current MDS (Minimum Data Set) was dated 9/7/14. The MDS indicated Resident #5: ~ Had a BIMS (Brief Interview for Mental Status) score of 11 indicating a moderate cognitive impairment; and ~ Required the assistance of 1 staff person for all aspects of care. Surveyor # completed a review of Resident #5's nursing notes and noted the following: ~ 6/2/14, "...Small bruise, dark purple in color, observed to front of resident's neck. Resident reports a small amount of soreness. Area measure approximately 2.0 cm (centimeters) in width and approximately 2.7 cm in length. Resident says that bruise was caused from call light pressing into it..." Surveyor # requested the investigation of Resident #5's bruise as noted above. None was received. A bruise on the front of the neck is considered highly unusual. Nursing notes continue: ~ 6/22/14, "...Bruise, dark purple in color observed to resident's left wrist...Resident...reports not knowing how it occurred...measure approximately 4.2 cm in length and approximately 2.5 cm in width..." Surveyor # requested the investigation into the bruise as noted above. None was received. On 11/3/14 at 3:45 p.m., Surveyor # spoke with DON-D and DON-I about the facility's practice for investigating all incidents of abuse, neglect, mistreatment and injuries of unknown origin. DON-I indicated any incidents of mistreatment to residents would be reported to administration, staff would be suspended immediately, and the incident would be investigated. DON-D indicated if significant bruising was found an investigation would be started by the floor nurses which would include talking with staff and residents unless the resident was cognitively intact and could identify the cause of the bruise. DON-D indicated this was an informal process and did not include the use of the facility forms for investigation of actual allegations of abuse. DON-D indicated if the floor nurses could determine the cause of a bruise, no further investigation would be done. DON-D stated if the floor nurse could not determine by talking with staff what the cause of the bruise was, they would begin a more formal investigation. DON-D stated the administration team would be updated with the findings and determine what action needed to be taken, including if the incident was reportable. DON-D stated if a formal investigation was required it would be completed by herself, DON-I, DON-C and possible the SW. DON-D indicated the facility looks at the investigation, including if the occurrence had willful intent to do harm to a resident, in determining employee misconduct. DON-D indicated she considered highly suspicious bruising to include finger print marks, a pattern of bruising, especially on wrists. DON-D stated bruising of the inner thigh may not be suspicious in nature if the cause could be identified. On 11/4/14 at 10:30 a.m., Surveyor # spoke with DON-C. DON-C indicated their systems could be better, however, felt the facility as a whole was identifying and investigating allegations of abuse including injuries of unknown origin appropriately. Example #4: Resident #10 has medical [DIAGNOSES REDACTED]. The facility currently monitors Resident #10 for behaviors of hitting or scratching herself, pacing/rummaging, and walking aimlessly/wandering into other resident rooms. On 8/6/14, staff reported a new bruise to Resident #10's inner right forearm that measured 2.0 cm (centimeters) by 2.0 cm. Surveyor # requested the investigation of this injury from DON-C on 11/3/14. There was no documentation indicating the potential cause of the bruising. The facility was unaware if she bumped her arm or had contact with another peer. This prevented the facility from developing interventions to protect Resident #10 from further harm. On 11/4/14, Surveyor # received a "Rule Reminder" directed at the nurse responsible to investigate. This document indicated that on 11/3/14, the facility educated the nurse on inappropriate documentation and investigation of the bruise. Example #5: Surveyor # review of Resident #7's closed medical record revealed that Resident #7's most recent Minimum Data Set Assessment ((MDS) dated [DATE], indicated: ~Totally dependent on two persons for bed mobility and transfers; ~Totally dependent on one person for locomotion on the unit, toilet use and personal hygiene; ~ Range of motion lower extremity impairment both sides and upper extremity impairment on one side; ~No speech and rarely understands others; ~Unable to complete a brief interview of mental status; ~No physical, verbal or other behavioral symptoms directed towards others; ~Rejection of care occurred 4-6 days; ~Left sided weakness; ~Uses wheelchair for mobility; ~No falls; and ~Non Alzheimer's Dementia. Surveyor # 's review of Resident #7's nurse's notes reveal the following entries: ~ "02/16/14 07:19:29 Skin Problems: Bruises Abrasions noted on the residents right lateral abdominal/side area. This is believed to be caused by the sling lift. Resident does not state where it came from. Length: cm 6.5 cm approximately Width: 9 cm approximately Blanchable: yes Drainage: none Pain no preventative Measures other more are when using sling lift." ~"02/17/14 07:24:51 Skin Problems: Bruises Resident has bruises going up and down both arms. We are assuming that this is from his side rails being left up on his bed and him pushing into or bumping them and so we will be trying some long sleeves and sleeve protectors on his arms. Resident also has a bruise on the left abdominal lateral side of his body measuring approximately 3 cm length x 8.2 cm width deep purple in color when being palpated a bump is noted. This bruise may be caused by resident banging on the table in the dining rom. This is something he has done in the past. Resident is already a full assist to eat so his care plan will be updated to move him away from the table when done eating and not being monitored. There is also a red spot the residents left upper chest just below the clavicle. This mark appears more red in color and measures approximately 7.5 cm length and 2 cm width. When palpated it also has a bump. This may have been from him being rolled on his side to be changed. Resident does have an INR lab today." ~"03/09/14 07:53:52 Skin Problems: Bruises undefined bruising observed to right side of head, located directly behind right ear. Two areas measure approximately 3 cm x 2 cm and 2 cm x 2.5 cm. Primary MD observed and aware, when making rounds. Nursing will continue to monitor." No possible cause of the head bruises was noted in the nurse's notes. On 11/04/14 at 6:40 a.m., Surveyor # spoke with DON-C who said if the causes of the injuries are noted in the nursing notes, they are known injuries and they would not do an investigation. DON-C said the floor nurse does an internal investigation when the injury is discovered by talking with staff. Surveyor # asked for the information that the nurse obtained and how they determined a possible cause of the bruises related to Resident #7's bruises noted on 02/16/14, 02/17/14 and 03/09/14. No additional information was received.

Based on interview and record review, the facility did not develop and/or operationalize their policies and procedures related to abuse prohibition/investigation for 5 of 10 sampled and supplemental sampled residents. Resident #6 made an allegation of abuse. Residents #13, #5, #10, and #7 had suspicious injuries. The facility's policies and procedures outlined the steps all staff should take when injuries of unknown origin and allegations of abuse are made, however, there was no evidence that this occurred for the 5 residents listed above. This is evidenced by: Resident #6 had an allegation of abuse in which Resident #6 identified the staff person. The facility did not immediately remove the suspected staff, complete a thorough investigation, or report the allegation as required. Resident #13 had highly suspicious bruising on both wrists. When the facility identified the staff person, the staff person was not removed from duty during the facility's investigation, the investigation was not thorough and the injury was not reported as required. Resident #5 had a bruise on the front of the neck and, in a separate incident, bruising to the wrist. These suspicious injuries were not thoroughly investigated. Resident #10 developed bruising to her inner forearm on 8/6/14. The bruising was not investigated to determine a root cause. Resident #7 was noted to have bruising to the right abdomen on 02/16/14, bruising to both arms and left abdomen on 02/17/14, and bruising to the right side of the head on 3/9/14. Although the nurse's notes surmised what may have happened, there was no investigation into bruising to determine possible environmental factors and/or to rule out abuse. Surveyor # completed a review of the facility's abuse policies. The policies themselves were not inclusive of all 7 components required in abuse prohibition policies. The components of the prevention of abuse, the identification of abuse, and reporting/response obligation by the facility was noted on the facility's tool titled "Abuse/Neglect Investigation Record." This tool was utilized only for facility substantiated allegations of abuse and mistreatment. On 11/2/14 and 11/3/14, Surveyor # requested information regarding the facility's investigations into abuse, neglect, mistreatment, and injuries of unknown origin since the last recertification survey in December 2013. DON-C (Director of Nursing) indicated there were no investigations. On 11/13/14 at 2:50 p.m., Surveyor # spoke with the SW (Social Worker). Surveyor # asked the SW how she was involved in the facility's investigations into abuse, neglect, mistreatment, and injuries of unknown origin. The SW indicated she would initiate an investigation if a resident specifically spoke with her about a concern. The SW indicated otherwise she was involved in investigations as directed by the nursing department. (Refer to F225.) On 11/3/14 at 3:45 p.m., Surveyor # spoke with DON-D and DON-I about the facility's practice for investigating all incidents of abuse, neglect, mistreatment, and injuries of unknown origin. DON-I indicated any incidents of mistreatment to residents would be reported to administration, staff would be suspended immediately, and the incident would be investigated. DON-D indicated if significant bruising was found, an investigation would be started by the floor nurses, which would include talking with staff and residents unless the resident was cognitively intact and could identify the cause of the bruise. DON-D indicated this was an informal process and did not include the use of the facility forms for investigation of actual allegations of abuse. DON-D indicated if the floor nurses could determine the cause of a bruise, no further investigation would be done. DON-D stated if the floor nurse could not determine by talking with staff what the cause of the bruise was, they would begin a more formal investigation. DON-D stated the administration team would be updated with the findings and determine what action needed to be taken, including if the incident was reportable. DON-D stated if a formal investigation was required it would be completed by herself, DON-I, DON-C and possibly the SW. DON-D indicated the facility looks at the investigation, including if the occurrence had willful intent to do harm to a resident, in determining employee misconduct. DON-D indicated she considered highly suspicious bruising to include finger print marks, a pattern of bruising, especially on wrists. DON-D stated bruising of the inner thigh may not be suspicious in nature if the cause could be identified. On 11/4/14 at 10:30 a.m., Surveyor # spoke with DON-C. DON-C indicated their systems could be better, however, felt the facility as a whole was identifying and investigating allegations of abuse, including injuries of unknown origin, appropriately.

Based on random observations, interview, and record review, the facility did not ensure it maintained an Infection Prevention Program designed to prevent the spread of disease and infection for 11 residents. Multi-use glucometers were cleansed with peroxide wipes instead of the manufacturer's specified instructions of a 1-to-10 dilution of bleach. The facility has 9 residents who receive insulin and would require blood glucose monitoring. CNA-M did not wash her hands after exiting Resident #5's room and removing gloves. Resident #5 is on contact precautions. CNA-M was about to serve another resident their meal with contaminated hands when the surveyor intervened. On 11/03/14, CNA-A (Certified Nursing Assistant) completed frontal pericare care for Resident #1 with gloved hands and then proceeded to touch presumed clean items in Resident #1's room (closet door, clean shirt and pants, etc.) with the same dirty gloves. This is evidenced by: Example #1: On 11/2/14 at 3:36 p.m., Surveyor # observed RN-K (Registered Nurse) obtain an Assure Platinum glucometer from her cart and complete an accucheck for Resident #4. RN-K indicated to Surveyor # that glucometers were shared as residents did not have their own. RN-K returned to her medication cart and obtained a peroxide wipe and cleansed the glucometer. Surveyor # obtained the manufacturer's instructions for the Assure Platinum glucometer. The instructions directed staff to disinfect the glucometer with a 1-to-10 dilution of bleach. According to the facility's medication reports, 9 residents receive insulin and would require blood glucose monitoring. Using bleach according to manufacturer's specification is essential to prevent the spread of blood borne disease and infection. On 11/4/14 at 10:25 a.m., Surveyor # spoke with DON-C (Director of Nursing). DON-C stated the staff should be cleaning the glucometers according to the manufacturer's recommendations. Example #2: On 11/4/14 at 7:40 a.m., Surveyor # observed CNA-M (Certified Nursing Assistant) passing a continental breakfast via a cart to residents who chose to eat in their rooms. CNA-M entered Resident #5's room carrying a plate of food with gloved hands. Surveyor # noted Resident #5 was special precautions for an infection. While CNA-M was in Resident #5's room CNA-M handled papers on Resident #5's bed side table as well as returned Resident #5's phone to its cradle. CNA-M exited Resident #5's room without removing her gloves and washing her hands. CNA-M proceeded to obtain another plate with food for another resident. Surveyor # intervened and requested CNA-M throw away the plate she had obtained, remove her gloves, and wash her hands. Surveyor # completed a review of Resident #5's clinical record and noted Resident #5 had been placed on contact precautions for a MRSA infection to an ulcer within the ear. On 11/4/14 at 8:30 a.m., Surveyor # spoke with DON-I (Director of Nursing). DON-I indicated CNA-M should have taken off her gloves and washed her hands when CNA-M exited Resident #5's room. Example #3: On 11/03/14 beginning at 6:20 a.m., CNA-A completed frontal pericare on Resident #1 with gloved hands. CNA-A then proceeded to the closet with same dirty gloved hands, opened the closet door, and took out a clean shirt and pants for Resident #1. CNA-A proceeded to put the pants on Resident #1 with the same dirty gloved hands. CNA-A proceeded to cleanse and lotion Resident #1's back and put a new brief partially on, put the sling underneath Resident #1, lowered the bed and elevated Resident #1's head before taking the dirty gloves off and leaving the room to assist another certified nursing assistant. On 11/4/14 at 7:15 a.m., Surveyor # asked CNA-A when she is to wash her hands. CNA-A stated she is to wash her hands before and after cares with residents and if her gloves become soiled, she is to remove her gloves, wash, and apply new gloves. CNA-A was asked if she would practice handwashing following pericare. CNA-A stated that after pericare provided to a resident, she would remove her gloves, wash or sanitize her hands, and apply a new pair of gloves On 11/04/14 at 7:35 a.m., Surveyor # spoke with LPN-B (Licensed Practical Nurse). LPN-B indicated she does the staff training for the facility and also does the Certified Nursing Assistant training program at the local technical college. LPN-B indicated that after doing pericare with gloved hands, staff should remove the dirty gloves and wash their hands before proceeding on to other activities of daily living tasks.

Based on observations, interviews, and record reviews, the facility did not revise 1 of 10 sampled residents' care plans. 1. Resident #2 has a stage III pressure ulcer on his right heel that began as a Deep Tissue Injury (DTI). The approaches for the wound healing are not consistent throughout the care plan. 2. Resident #2's care plan does not consistently identify transfer and ambulation status. 3. Resident #2's care plan does not include isolation precautions after being diagnosed with [REDACTED]. This is evidenced by: Resident #2 has medical [DIAGNOSES REDACTED]. According to his most recent Minimum Data Set (MDS), dated [DATE], which was a Significant Change Assessment, Resident #2 requires extensive assistance with his personal hygiene, dressing, and bed mobility, and is dependent on staff for his bathing tasks. This MDS also indicates Resident #2 requires limited assistance of one staff for ambulation and transfers with the use of a walker. Pressure Ulcer: Resident #2's care plan includes a problem dated 7/23/14 for High Risk Pressure Ulcers. An approach dated 11/2/14 indicates staff are to place heel lift boot to right foot and wear special slippers during the day. Resident #2's care plan includes a problem dated 10/17/14 of Self Care Deficit. An approach for this problem includes apply heel boots when in bed and in recliner. Resident #2's care plan dated 10/17/14 for Potential for Falls, lists an approach dated 7/23/14 that indicates Resident #2 is to wear nonskid footwear. Ambulation/Transfer: Resident #2's Self Care Deficit includes an approach dated 9/18/14 indicating staff are to assist Resident #2 with ambulation and also to place nonskid footwear on Resident #2. Resident #2's care plan dated 10/17/14 for Mental Status/Gait/Balance includes an approach dated 7/23/14 to use nonskid footwear, is to rise slowly, dangle feet and dorsiflex his feet before standing, and staff are to assist with ambulation. Resident #2's care plan for Cognitive Impairment, dated 10/22/14, includes staff to transfer Resident #2 with two assist with a walker and gaitbelt. Isolation: There is no care plan and/or approach addressing [MEDICAL CONDITION] infection and the need for isolation precautions. Resident #2's CNA care card, indicates Resident #2 is to wear nonskid footwear, ensure heels are not on the bed, heel boots on when in bed and recliner, ambulate with walker and gaitbelt as resident allows. Isolation precautions are not addressed on the CNA care card. Surveyor # observed Resident #2's cares from 11/2/14 through 11/4/14. There were occasions where the Prevalon boots were on. There were also observations of the boots not on when they may have been required. Resident #2 was also noted to be under Isolation Precautions. Staff were observed to use a mechanical lift for transfers. On 11/4/14 at 8:45 a.m., Surveyor # asked RN-D (Registered Nurse), DON-I (Director of Nursing), and LPN-G (Licensed Practical Nurse) about what interventions were to be in place for Resident #2 in regards to pressure ulcer prevention and healing. All three staff stated Resident #2 was to wear special slippers that were purchased for the resident. They also stated the resident was to use heel boots in the bed and the chair. The care plan did not reflect the correct care Resident #2 required.

Based on observations, interviews, and record reviews, the facility did not consistently implement approaches for pressure ulcer prevention and healing for 1 of 5 residents reviewed for pressure ulcers. Resident #2 has a stage III pressure ulcer on his right heel. Staff did not apply heel lift boots to relieve pressure from the heals and promote the healing of the existing wound. This is evidenced by: Resident #2 has a [DIAGNOSES REDACTED]. Resident #2 has an extensive history of vascular ulcerations on his toes. On 9/26/14, documentation in the wound notes indicated the resident developed a fluid filled blister to the right heel that measured 4.0 cm (centimeters) by 5.0 cm. Approaches in the wound notes indicated the resident was to wear heel lift boots in bed and in the recliner chair. According to the wound notes and nursing notes, the pressure ulcer is infected and on 10/29/14 measured 3.8 cm x 4.8 cm. The comprehensive care plan dated 7/23/14 for the problem of pressure, high risk, has an approach dated 11/2/14, which indicates staff are to place heel lift boot to right foot for protection as well as heal the wound. An approach in the self care deficit care plan indicates the heel boots are to be on Resident #2 when in bed and in recliner. The CNA care card indicates staff are to ensure the heels are not on the bed, and that they place heel boots on when in bed and in the recliner chair. On the following dates, Surveyor # observed Resident #2 not wearing the heel boots: ~ 11/2/14 at 12:15 p.m., 12:45 p.m., and 2:00 p.m., resident was in his reclining geri-chair in his room. The boots were on the over-the-bed table. ~ 11/3/14 at 8:45 a.m., following morning cares which were observed by Surveyor # , staff placed a slip-grip sock over the bandaged heel rather than the heel boot. The boot remained off until 12:55 p.m. ~11/3/14 at 12:55 p.m., Surveyor # observed DON-D (Director of Nursing) and LPN-G (Licensed Practical Nurse) conduct the treatment to the wound. Following the treatment, neither DON-D nor LPN-G put the heel boot on Resident #2's right foot. The slip-grip sock was replaced. On 11/4/14 at 8:30 a.m., Surveyor # spoke with Resident #2's primary physician regarding the resident's comorbidities and the pressure ulcer. The physician stated Resident #2 is in a terminal state related to the extensive medical conditions he has, including severe [MEDICAL CONDITION] and that the resident is not a candidate for surgical debridement as a result. He stated the resident also has severe protein-calorie malnutrition and often refuses interventions in place for dietary enhancement. The doctor stated he had a culture of the wound, which isn't always reliable, but that the culture was positive [MEDICAL CONDITIONS]. When asked what practices the facility needs to incorporate into the resident's care, knowing his comorbidities, the doctor stated, "...to keep pressure off the heel as much as possible, protect it from further damage..." On 11/4/14 at 8:45 a.m., Surveyor # asked DON-D, DON-I, and LPN-G about the interventions for Resident #2 in regards to pressure ulcer prevention and healing. All three staff stated Resident #2 was to use heel boots in the bed and recliner. The Surveyor requested the three staff accompany her to the resident's room and showed them that the resident had on nonskid footwear, not the Prevalon floating boots in place. The three staff did not know why the heel floating boots were not in place.

Based on observation, interview, and record review, the facility did not ensure that 1 of 1 sampled resident with pressure ulcers received the necessary care and services to promote healing and prevent the occurrence of new pressure ulcers. On 11/18/12, Resident #6 had a significant decline in condition. While the facility was aware of the decline in condition, there was no skin risk assessment completed and no changes made to Resident #6's care plan to promote skin integrity. On 12/3/12, Resident #6 developed suspected DTI (Deep Tissue Injury) to both heels. The DTIs were noted as healed on 5/5/13. On 5/20/13, Resident #6 developed a blister on the right heel. The facility indicated it was from shoes. A physicians note indicated it was pressure related from rubbing the right heel on the mattress. The blister was noted as healed on 7/9/13. On 11/8/13, Resident #6 developed suspected DTI to a toe on each foot. These were noted during survey. Observations revealed the facility had no measures in place to remove pressure on Resident #6's toes. All documentation of Resident #6's DTI's were not consistent with current standards of practice including weekly assessment and documentation by a RN (Registered Nurse). Resident #6 was noted to have a wedge cushion in place to off-load or float both heels. Observations revealed Resident #6's right heel was not consistently off-loaded. This resulted in an observation of redness to Resident #6's right posterior heel. This redness as noted 6 hours later had subsided. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP), a suspected deep tissues injury (DTI) is a "...Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or sheer..." The NPUAP also indicates, "...Ensure that the heels are free of the surface of the bed...Heel-Protection devices should elevate the heel completely..." According to the National Pressure Ulcer Advisory Panel (NPUAP) skin care and treatment of [REDACTED]. ~ Development and implementation of individualized programs of skin care; ~ Built-in mechanisms to evaluate programs to ensure they are effective; ~ Proper positioning, transfer, and turning techniques to minimize skin injury due to friction and sheer; ~ Accurately document skin risk assessment, prevention strategies as well as resident response. According to the EPUAP (European Pressure Ulcer Advisory Panel) and NPUAP (National Pressure Ulcer Advisory Panel), "Pressure Ulcer Prevention Quick Reference Guide," indicates to monitor a pressure ulcer daily and assess any pressure ulcer at least weekly identifying the stage, location, wound characteristic including the wound bed and periwound and any exudate. Surveyor # completed a review of Resident #6's clinical record and noted the following. Resident #6 had current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 11/21/13. It indicated Resident #6, ~ Had both long and short-term memory problems; ~ Cognition was severely impaired; ~ Required extensive assistance of 2 staff members for all aspects of care including walking and bed mobility; ~ Was at risk for developing a pressure ulcer; ~ Had 2 unstageable pressure ulcers with suspected deep tissue evolution; and ~ Had pressure ulcers present on the prior MDS. Resident #6's care plan did not have a specific problem identifying Resident #6's current suspected DTIs. The care plan had interventions intermixed within multiple identified problems which included: ~ 9/14/12, to inspect skin daily during cares. ~ 11/28/12, encourage to reposition. ~ 3/14/13, a wedge to float bilateral heels, and consult the wound care nurse as indicated. Surveyor # requested all skin risk assessments completed since Resident #6's admission to the facility. Surveyor # received assessments dated 12/16/12, 3/11/13, 5/27/13, and 11/15/13. A skin risk assessment dated [DATE] indicated Resident #6 was at high risk for developing a pressure ulcer. All other skin risk assessments indicated Resident #6 was at moderate risk for the development of a pressure including the most current assessment dated [DATE]. On 11/18/12, Resident #6 had a fall. Post fall, Resident #6 had a decline in overall functioning. During the time frame from 11/18/12 to 12/3/12 when Resident #6 was noted to have a DTI on both heels, no assessment had been completed. No changes were made to Resident #6's plan of care to promote skin integrity. HEELS Surveyor # completed a review of Resident #6's nursing notes and noted the following: ~ 11/25/12, "...No skin problems...no foot problems...no pressure ulcers..." ~ 12/3/12, "...L & R (left and right) heel noted to be Red with black area noted to center of heel approx (approximately) 0.5cm (0.5 centimeters) in circumference...Heels floating off mattress at this time and RN charge nurse...notified...Regarding possible air mattress and/or heel type boots...dark colored intact, fluid-filled blister...Heel lift boats (sic) applied. Air mattress request..." ~ 12/5/12, "...Continue to have bilateral redness with dark in color, w/ (with) fluid filled blister...bilaterally. Air mattress on..." From 12/3/12 through 2/24/13 there was weekly documentation. Most of the weekly documentation was completed by an LPN (Licensed Practical Nurse). A description of the wound characteristics was not consistently completed. None of the documentation included the stage of the pressure ulcer. Nursing notes continue: ~ 2/24/13, "...continues to have darkened areas to bilateral heels...L (left) heel measures 0.3 cm x 0.6 cm ( 0.3 centimeters by 0.6 centimeters) Right heel measures 0.4 cm x 0.6 cm..." There was no stage documented. There was no weekly documentation including size, and wound characteristics until 3/13/13. Nursing notes continue: ~ 3/13/13, "...continues to have darkened areas to heels...L (left) heel measures 0.2 cm x 0.3 cm (0.2 centimeters by 0.3 centimeters)...right heel measures 0.6 cm x 0.5 cm..." There was again no stage documented. There was no weekly documentation including size and wound characteristics until 3/24/13. On 3/24/13 the stage was again not documented. There was no further weekly documentation including size, stage and wound characteristics until 5/2/13 when Resident #6's right heel was noted as resolved. On 5/5/13, both of Resident #6's heels were noted as healed. Nursing notes continue: ~ 5/20/13, "...Clear fluid-filled blister to right heel. Left lateral edge of blister light purple/bruised...4.4 cm x 2.4 cm...resident stated...foot was 'sore'..." ~ 5/21/13, "...Both heels floating on wedge pillow..." This indicated Resident #6 had developed another suspected DTI to the right heel. Nursing notes continue: ~ 5/23/13, "...blister remains fluid filled...pressure ulcer: partial thickness loose of skin layers that presents as an abrasion or blister Pressure Stg. (stage) 2...R posterior calcaeus (heel)...3.5 cm x 4.5 cm...clear fluid filled blister...Appears that blister caused from increased [MEDICAL CONDITION] and increased tightness of shoe. Shoes removed..." Surveyor # completed a review of Resident #6's physician progress notes [REDACTED]. From 5/20/13 through 7/9/13, when Resident #6's suspected DTI was noted as healed, there was weekly documentation. All weekly documentation with the exception of 1 nursing note did not include the stage of the wound. TOES Surveyor # completed a review of Resident #6's nursing notes and noted the following: ~ 3/15/13, "...Noted a 0.5 cm x 0.5 cm dry area on left foot second digit, possible from rubbing again shoe...Skin prep applied..." ~ 3/17/13, "...left foot 2nd digit is dark colored scab...slight redness surrounding scab..." ~ 3/24/13, "...left 2nd digit has scab present that measures 0.5 cm x 0.5 cm..." ~ 4/7/13, "...left second digit continues to have scab present. area measures 0.6 cm x 0.8 cm..." There was no further documentation of Resident #6's left second toe until 11/8/13. Nursing notes continue: ~ 11/8/13, "...Blood blister on the right foot 3rd diget (sic) 0.7 cm x 0.6 cm and blood blister on left 2nd diget (sic) 1.7 x 1.1 (1.7 cm x 1.1 cm)...appears blisters caused from over bedside table..." Resident #6's left second toe as described in the nursing note of 3/17/13 was increased in size and now noted as a blood blister indicative of a suspected DTI. Resident #6 also is noted to have a suspected DTI on the right third toe. From 11/8/13 to the time of survey, there was no further documentation including measurements, stage, and wound characteristics of Resident #6's toes. On 12/10/13 at 1:05 p.m., Surveyor # observed Resident #6 lying in bed under the covers. Surveyor # noted Resident #6's feet were on a cushion which elevated Resident #6's feet off the mattress approximately 8 inches. This position created increased pressure from the bed linens to Resident #6's toes. There was no device on Resident #6's bed to relieve the pressure caused by the linens. On 12/10/13 at 5:00 p.m., Surveyor # observed Resident #6 in bed lying on his back. Resident #6's right foot was off the wedge cushion and resting directly on the surface of the mattress. On 12/11/13 at 8:05 a.m., Surveyor # observed CNA-I (Certified Nursing Assistant) and CNA-J assist Resident #6 with care. Upon entry into Resident #6's room, Surveyor # noted Resident #6's right heel was again not on the wedge cushion but resting directly on the surface of the mattress. Surveyor # requested CNA-I and CNA-J remove Resident #6's gripper socks. Surveyor # observed: ~an area of redness on Resident #6's right heel which measured approximately 4.0 cm x 2.0 cm. ~a dark red-brown irregular shaped scab Resident #6 left second toe which measured approximately 1.0 cm in diameter ~a dark red-brown irregular shaped scab on Resident #6's right third toe which also measured approximately 1.0 cm in diameter. ~a purple-blue area on the tip of Resident #6's left great toe which measured approximately 2.0 mm (millimeters) in diameter. This area had not been identified by the facility. On 12/11/13 at 2:00 p.m., Surveyor # again viewed Resident #6's heels with RN-B (Registered Nurse). Surveyor # noted Resident #6's right heel was no longer red. RN-B indicated both Resident #6's left second toe and right third toe were initially noted as blood blisters. Surveyor # asked RN-B what caused the suspected DTI to Resident #6's toes. RN-B indicated he was not sure. On 12/12/13 at 9:30 a.m., Surveyor # spoke with LPN-M (Licensed Practical Nurse). LPN-M indicated she was the full time day nurse responsible for all residents who resided in the facility. Surveyor # asked LPN-M what the facility practice was for monitoring and charting pressure ulcers. LPN-M stated pressure ulcers were documented on a weekly basis. LPN-M indicated whatever nurse noted a pressure ulcer was responsible to document the pressure ulcer and obtain orders for treatment if indicated. LPN-M indicated weekly documentation was then done. LPN-M indicated if she needed any assistance with wound management, she would contact either the Director of Nursing (DON) or RN-N who was the wound nurse in a sister facility. Surveyor # reviewed Resident #6's wound documentation and noted most weekly entries were completed by LPN-M. Surveyor # asked LPN-M why none of the wound documentation had an identified stage. LPN-M stated she did not stage wounds as she was an LPN. Surveyor # asked LPN-M why Resident #6 developed suspected DTIs on both heel. LPN-M indicated Resident #6 suspected DTIs on both heels were caused by pressure. LPN-M stated Resident #6 had a fall in November after which he was in a lot of pain. LPN-M stated Resident #6 wasn't moving much due to the pain. Surveyor # asked LPN-M about the suspected DTI which later occurred on Resident #6's right heel. LPN-M stated she felt this was not pressure related but due to new shoes. Surveyor # asked LPN-M about Resident #6's current suspected DTIs on the toes. LPN-M indicated she did not think these were pressure related but due to an over-the-bed table. Surveyor # asked LPN-M about the purple-blue area Surveyor # noted on Resident #6's left great toe. LPN-M indicated she had not observed this. Surveyor # asked LPN-M if she had ever consulted with RN-N. LPN-M indicated she thought she had but could not find evidence of this in the documentation. On 12/12/13 at 11:00 a.m., Surveyor # spoke with the DON. The DON indicated she was responsible for the all residents who resided in the facility. Surveyor # asked the DON about Resident #6's suspected DTIs on both heels and toes. The DON stated she was not certain as she had never viewed the suspected DTIs. The DON indicated it was the responsibility of the nurses on the floor to complete weekly wound rounds. Surveyor # spoke with RN-N. RN-N indicated she was the DON of a sister facility housed in the same building. RN-N indicated she was wound certified. RN-N stated she consulted with the facility when they called her with any concern. RN-N stated she only viewed pressure ulcers when requested to do so by the facility. RN-N indicated the facility requested her to look at Resident #6's heels after the development of a blister due to Resident #6's shoes. RN-N indicated this was the only time she observed Resident #6's heels and toes. There had been no RN managing the care including documentation of Resident #6's suspected DTIs.

Based on observation, interview, and record review, the facility did not ensure that 4 of 8 sampled residents with incontinence received the necessary care and treatment to restore and/or maintain bladder function. Resident #5 had a decline in bladder function. There was no comprehensive bladder assessment completed to determine an individualized toileting program. Resident #5 had subsequently remained frequently incontinent of urine. Resident's #6 and #7 were frequently incontinent of bladder. There was no comprehensive bladder assessment completed to determine an individualized toileting program for either resident. Resident #6 and Resident #7 were not afforded the opportunity to improve continence. Resident #4 has a toileting program in which she is lifted with a Hoyer above the bed or wheelchair when she needs to void or defecate, and staff manually stimulate her genital region with a warm washcloth wiping from front to back. Voiding is completed while the resident is suspended in the Hoyer. Review of Resident #4's most recent bladder assessment, dated 09/28/13, indicated a history of urinary incontinence which is greater than 90 days. The corresponding 3-day continence monitoring completed on 09/24/13, 09/25/13 and 09/26/13 was not completely filled out, with multiple gaps in the data collection. A previous assessment dated [DATE], indicated a check and change program. In addition, the facility has not determined if Resident #4 is retaining urine as a possible cause for the need for manual stimulation. This is evidenced by: Example #1: Resident #5 had current [DIAGNOSES REDACTED]. Resident #5's admission MDS, dated [DATE], indicated Resident #5 was frequently incontinent of urine. Resident #5's most current MDS (Minimum Data Set), dated 10/24/13, indicated Resident #5: ~ Had a severe cognitive impairment; ~ Required extensive to total assistance with all aspects of care; ~ Did not walk; and ~ Was always incontinent of bladder. Since admission, Resident #5 has had a decline in bladder function. Surveyor # completed a review of Resident #5's care plan. Under the problem dated 2/5/13 and identified as "...ADL (Activities of Daily Living) Defect..." it indicated, "...Toileting: Total dependence. Needs staff to place urinal, does voice need to urinate..." The toileting plan as noted in Resident #5's care plan is not an individualized toileting program designed to promote continence. Surveyor # reviewed Resident #5's "Bladder Data Collection" dated 10/18/13. The form was incomplete. The form indicated Resident #5 had functional incontinence related to mobility and medications. The toileting program was noted as "check and change." Surveyor # reviewed Resident #5's "3 Day Continency Monitoring" dated 2/5/13 through 2/7/13. The form indicated Resident #5 had blocks of time in which he was noted as "dry." The form also indicated specific times when Resident #5 was noted as "wet." These times correlated during the 3 day assessment period. Despite identified and correlated times in which Resident #5 was noted as "wet" there was no individualized toileting program put into place. Surveyor # completed a review of a "3 Day Continency Monitoring" dated 10/15/13 through 10/17/13. All 3 days had incomplete documentation. This would make it impossible to determine an individualized toileting program. On 12/12/13 at 7:40 a.m., Surveyor # spoke with CNA-L (Certified Nursing Assistant) what the facility practice was for filling out "3 Day Continency Monitoring" form. CNA-L stated it was filled out according to a resident's current toileting plan. On 12/12/13 at 11:00 a.m., Surveyor # spoke with the facility Director of Nursing (DON). The DON stated the nurses on the floor were responsible to complete all bladder assessments. The DON stated she then develops a toileting plan based off the bladder assessment. Example #2: Resident #6 had current [DIAGNOSES REDACTED]. Resident #6's most current MDS (Minimum Data Set) was dated 11/21/13. It indicated Resident #6: ~ Had both long and short-term memory problems; ~ Cognition was severely impaired; ~ Required extensive assistance of 2 staff members for all aspects of care including walking and bed mobility; ~ Was currently on a toileting program; and ~ Was frequently incontinent of urine. Surveyor # completed a review of Resident #6's care plan. Under the problem identified as "ADL (Activities of Daily Living) Defect" it indicated, "...Toileting Program: does have a [DIAGNOSES REDACTED]. This does not constitute an individualized toileting schedule designed to promote continence. Surveyor # reviewed Resident #6's "Bladder Data Collection" dated 10/10/13 through 10/13/13. The form was incomplete. It identified Resident #6 has having functional incontinence. It also indicated Resident #6 should be placed on a scheduled toileting plan based on Resident #6's voiding patterns. Resident #6's "3 Day Continency Monitoring" dated 10/10/13 through 10/12/13, was incomplete. This would make it impossible for the assessor to develop a toileting program. On 12/12/13 at 7:40 a.m., Surveyor # spoke with CNA-L (Certified Nursing Assistant) about what the facility practice was for filling out the "3 Day Continency Monitoring" form. CNA-L stated it was filled out according to a resident's current toileting plan. On 12/12/13 at 11:00 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON stated the nurses on the floor were responsible to complete all bladder assessments. The DON stated she then develops a toileting plan based off the bladder assessment. Example #3: Resident #7 had current [DIAGNOSES REDACTED]. Resident #7's most current MDS (Minimum Data Set) was dated 10/17/13. It indicated Resident #7: ~ Cognition was moderately impaired; ~ Required the assistance of 1 staff person for all aspects of care including walking; and ~ Was frequently incontinent of urine. Surveyor # completed a review of Resident #7's care plan. Under the problem dated 9/14/12 and titled, "ADL (Activities of Daily Living) deficit" it indicated, "...Toileting Program: AM (days) PM (evenings) Encourage...to notify staff as soon as she has the urge to urinate. Offer praise after each bladder...continent episode..." This does not constitute an individualized toileting program designed to promote continence. Surveyor # completed a review of Resident #7's "Bladder Data Collection" dated 10/10/13 through 10/13/13. The form was incomplete. It indicated Resident #7 should be on a scheduled toileting program based on Resident #7's voiding patterns. Surveyor # completed a review of Resident #7's "3 Day Continency Monitoring" dated 10/10/13 through 10/12/13. The form was incomplete. This would make it impossible for the assessor to determine an individualized toileting program. On 12/12/13 at 7:40 a.m., Surveyor # spoke with CNA-L (Certified Nursing Assistant) about what the facility practice was for filling out the "3 Day Continency Monitoring" form. CNA-L stated it was filled out according to a resident's current toileting plan. On 12/12/13 at 11:00 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON stated the nurses on the floor were responsible to complete all bladder assessments. The DON stated she then develops a toileting plan based off the bladder assessment. Example #4: Surveyor # 's review of Resident #4's most recent Minimum Data Set assessment (MDS), dated [DATE], indicated Resident #4 is frequently incontinent of urine and is on a bladder toileting program. Review of Resident #4's most recent bladder assessment dated [DATE], indicated a history of urinary incontinence which is greater than 90 days. The corresponding "3 Day Continency Monitoring" form completed on 09/24/13, 09/25/13 and 09/26/13 was not completely filled out, with multiple gaps in the data collection. A previous assessment, dated 07/06/13, indicated a check and change program. Review of Resident #4's most recent comprehensive care plan with a print date of 12/10/13, revealed the following Approach on page 1: "Toileting Program AM PM ...prefers to be lifted with Hoyer above bed or wheelchair when needing to void/defecate as needed. She will nod or shake head for yes or no. This process takes approximately 30 minutes with each episode. Staff will need to provide manual stimulation to genital region (using a warm washcloth wiping it against the peri area from front to back)." On 12/11/13 at 10:05 a.m., Surveyor # observed CNA-K and CNA-L assist Resident #4 with toileting. Both CNAs assisted Resident #4 into a Hoyer sling. Both CNAs lifted Resident #4 via the Hoyer lift and suspended Resident #4 approximately 1 1/2 feet above the bed. CNA-K indicated Resident #4 required manual stimulation to void. CNA-K stated this involved utilizing warm wet wipes and swiping Resident #4's perineum from front to back until Resident #4 voided. This process was viewed by Surveyor # . CNA-K indicated the process could take up to 30 minutes. CNA-K also stated Resident #4 was incontinent at times, usually when she coughed. On 12/12/13 at 8:35 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON and Surveyor # reviewed Resident #4's bladder assessment dated [DATE] and the corresponding "3 Day Continency Monitoring" form. The DON indicated the 3 day monitoring form was incomplete. The DON said Resident #4 has a toileting program to suspend in the air with a Hoyer and to provide manual stimulation. The DON said Resident #4 has a history of urinary tract infections but has not had one recently. The DON said Resident #4 has not had a bladder scan to determine if Resident #4 is retaining urine. The DON also indicated they do not have a bladder scanner in the building. On 12/12/13 at 9:25 a.m., Surveyor # spoke with MD-E (Physician). MD-E indicated Resident #4 has a history of a [MEDICAL CONDITION] (Stroke/[MEDICAL CONDITION]). MD-E indicated Resident #4 had a Foley catheter in the past and could have [MEDICAL CONDITION].