Every finding on record at Cedarburg Health Services

Based on staff and resident interview and record review, the facility did not ensure the right to smoke for 1 resident (R) (R9) of 14 sampled residents.R9 expressed a desire to smoke. Staff stated R9 was not allowed to smoke and removed smoking materials from R9's room. The facility did not complete a smoking assessment for R9 following the removal of smoking materials or offer R9 smoking cessation assistance. Findings include:The facility's Smoking Policy, revised 9/10/24, indicates: .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. This center shall establish and maintain a safe resident environment; while maintaining resident rights, smoking or nicotine use will be limited to designated areas and safety plans .nicotine or smoking use includes the use of smokeless tobacco, cigarettes, e-cigarettes, cigars, vaping, whether such products contain nicotine or not .residents who wish to engage in these practices will be educated, assessed, and provided with appropriate supervision to safely do so. This center shall try to accommodate residents who wish to use nicotine products, but safety is also our primary obligation. Residents or visitors who do not comply with procedure may be asked to restrict or relinquish smoking privileges .Usage may be temporarily suspended due to inclement weather or other reasons that may jeopardize the safety of our residents or visitors per the Executive Director or designee .Those residents who wish to participate in a cessation program will be assisted and encouraged to do so .4. All residents will be asked about tobacco/nicotine use during the admission process, and during each quarterly or comprehensive .assessment process. 5. Residents who smoke or use nicotine or e-cigarettes will be further assessed .to determine whether supervision is required for smoking, or if resident is safe to smoke at all .6. Electronic cigarettes (e-cigarettes/vape/vapor pen) can catch fire and/or explode if not handled and stored safely. Safety measures for the use of electronic cigarettes by residents will include but are not limited to: a. Use of e-cigarettes in designated smoking areas only. b. A nicotine assessment will be completed on all residents using e-cigarettes. C. Staff supervision of resident use if indicated .12. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Residents who do not require supervision will be offered the opportunity to have their smoking materials maintained by nursing staff .if they decline such offer, the residents shall maintain their materials in a secure fashion .failure to maintain security of their smoking materials will require interventions .13. The Interdisciplinary Team, with guidance from the physician, will help to support the resident's right to make an informed decision regarding smoking by: a. Including the resident, family, and/or resident representative in discussions regarding the risks associated with smoking. B. offering pharmacological and/or behavioral interventions to assist with smoking cessation . On 4/27/26, Surveyor reviewed R9's medical record. R9 had diagnoses including atherosclerotic heart disease of coronary artery without angina pectoris (the accumulation of plaque in heart arteries that restricts blood flow without causing chest pain), transient ischemic attack (TIA) and cerebral infarction (mini stroke or stroke with no lasting physical or neurological impairments), and major depressive disorder. R9's Minimum Data Set (MDS) assessment, dated 4/2/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R9 had intact cogntion. A progress note, dated 7/4/25, indicated R9 was notified there is no smoking or vaping in the building. R9's vape pen was obtained and placed in the nurses' station. R9's medical record contained a smoking assessment, dated 7/17/25, that indicated R9 did not smoke/vape. A progress note, dated 8/1/25, indicated a Certified Nursing Assistant (CNA) found a bag with a vape while completing personal cares for R9. The note indicated R9 was not allowed to maintain possession of the vape due to a fire hazard per the facility's policy. Staff discussed the policy with R9. A care plan, dated 9/12/25, indicated R9 had a history of smoking in community/inappropriate smoking related to non-compliance with policy - vape removed. The care plan contained the following interventions: Instruct (R9) to ask staff to provide/light smoking material; Secure smoking materials at nurses' station or other designated area for storage. On 4/27/26, Surveyor requested R9's most recent smoking assessment from Nursing Home Administrator (NHA)-A. On 4/28/26, NHA-A provided Surveyor with the smoking assessment from 7/17/25 that indicated R9 did not smoke/vape. On 4/28/26 at 11:09 AM, Surveyor interviewed R9 who stated R9 was told R9 was not allowed to smoke/vape after admission to the facility. R9 stated, I would smoke in a heartbeat if I could. R9 stated R9's smoking materials were taken to the nurses' station and R9 was told R9 could not smoke. R9 stated R9 had dreams of being able to smoke again. R9 stated no one spoke to R9 about smoking or offered assistance with smoking cessation since R9's smoking materials were removed. On 4/28/26 at 1:28 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R9 was observed with a vape in R9's room and the vape was brought to the nurses' station. DON-B stated the smoking policy was explained to R9 at that time. DON-B verified a smoking assessment was not completed at that time to determine if R9 was capable of handling smoking materials and could smoke independently or with assistance. DON-B also verified a conversation regarding R9's desire to smoke or potentially stop smoking was not offered following the removal of R9's smoking materials.

Based on staff interview and record review, the facility did not offer a PCV20 vaccine for 1 resident (R) (R25) of 5 sampled residents.R25 was not offered the recommended PCV20 vaccine.The Facility's Pneumococcal Vaccine policy, dated 3/25/25, indicates: It is our policy to offer residents and staff immunization against pneumococcal disease in accordance with current Centers for Disease Control and Prevention (CDC) guidelines and recommendations .1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders .6. The type of pneumococcal vaccination (PCV15, PCV20, PCV21, or PPSV23) offered will depend upon the recipient's age, having certain risk conditions, and previously received pneumococcal vaccines, in accordance with CDC guidelines and recommendations. On 4/29/26, Surveyor reviewed R25's medical record. R25 was admitted to facility on 10/14/22 and had diagnoses including diabetes, coronary artery disease, and vitamin D deficiency. R25's Minimum Data Set (MDS) assessment, dated 4/7/26, indicated R25 was dependent for transfers and toileting and required substantial/maximal assistance with dressing. R25 did not have an activated Power of Attorney for Healthcare (POAHC). R25's medical record indicated R25 received a PPSV23 vaccine on 10/17/05 and a PCV13 vaccine on 8/26/15. R25's medical record did not indicate R25 was offered, declined, or received the PCV20 vaccine per CDC recommendations. On 4/29/26 at 12:53 PM, Surveyor interviewed Infection Preventionist (IP)-D who verified R25 was not previously offered a PCV20 vaccine. IP-D indicated IP-D had just offered the PCV20 vaccine to R25 who wished to receive the vaccine.

Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of care and treatment to prevent pressure injuries from developing and/or promote healing for 3 residents (R) (R4, R11, and R25) of 3 sampled residents.R4 had an order (dated 3/11/26) that indicated R4's air mattress should be set at 150 pounds (lbs). The order indicated to check the setting and function every shift. R4's air mattress was set at 50 lbs during multiple observations. R11 had an order (dated 4/1/26) that indicated R11's air mattress should be set at 200 lbs. The order indicated to check the setting and function every shift. R11's air mattress was set at 50 lbs during multiple observations and the low pressure light was on.R25 had an order (dated 2/4/26) that indicated R25's air mattress should be set at 200 lbs. The order indicated to check the setting and function every shift. R25's air mattress was set at 50 lbs during multiple observations.Findings include: The Drive brand manual, copyright 2016, indicates: Drive support surfaces are high quality and affordable air replacement mattress systems. Specifically designed to redistribute pressure, these systems offer a solution for the prevention and treatment of pressure ulcers and offer an optimal solution for pressure redistribution and microclimate control .the pressure of the mattress can be adjusted by choosing the patient's corresponding weight setting using the weight setting buttons. Use the weight setting buttons to select the desired level .This product is designed to provide maximum comfort and therapeutic levels of pressure redistribution. Please be sure to review this manual for appropriate use and optimal benefit .do not change any component by yourself .When the normal pressure indicator lights up (green), the pressure in the mattress has reached the pre-define level and the patient can then be placed on the mattress .the red light low pressure indicator flickers when the pressure is below the pre-defined level indicating a system malfunction. The facility's Pressure Injuries and Non-Pressure Injuries policy, revised 7/20/22, indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .Complete the Braden Scale to assess risk of developing a pressure injury .When determining skin risk status and appropriate interventions, consider the following: i. Braden Scale score. ii. Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus .presence of a previously healed pressure injury. The history of any healed pressure injury, its origin, treatment, its stages (if known) is important assessment information .Communicate identified risk factors and interventions to direct care staff .1. Develop interventions based on subsets of Braden Scale that may include .As mobility scores decrease, concern about the adequacy of the support surface should increase - evaluate need for specialty wheelchair cushion and specialty mattress . 1. On 4/27/26, Surveyor reviewed R4's medical record. R4 had diagnoses including Parkinson's disease with dyskinesia, type 2 diabetes, and non-pressure chronic ulcer of lower left extremity. R4's Minimum Data Set (MDS) assessment, dated 4/23/26, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R4 had moderately impaired cognition. A care plan, dated 6/13/23, indicated R4 had an unstageable deep tissue injury (DTI) on the right heel left heel and sacrum were resolved on 6/16/23. A care plan, dated 6/13/23 and revised 1/21/26, indicated R4 was at risk for alteration in skin integrity related to impaired mobility, Parkinson's disease, diabetes, incontinence, pain, protein calorie malnutrition, history of contact dermatitis, refusals to get out of bed, and preference to lay on back. The care plan contained a goal to decrease/minimize skin breakdown risks. The care plan contained interventions for an air mattress (initiated 11/13/25) and to check function and setting every shift. The mattress should be set a 150 lbs. On 4/27/26 at 11:16 AM, Surveyor observed R4 in bed on a Drive brand air mattress. The air mattress contained a sticker indicating to set to 150 lbs. Surveyor noted the air mattress was set to 50 lbs. A Braden Scale (for predicting pressure score risk) assessment, dated 4/1/26, had a score of 14 which indicated R4 was at moderate risk for pressure injuries due to R4's bed bound status. R4's skin was occasionally moist. R4 required an extra linen change approximately once daily and had limited ability to reposition independently. A progress note, dated 4/8/26, indicated R4 had a popped blister on the left medial thigh that measured 1.5 centimeters (cm) x 2.0 cm with a light amount of serosanguineous drainage and no signs or symptoms of infection. R4 did not have a stat lock (to hold R4's catheter tubing in place) on at the time of the assessment. The stat lock was replaced. A progress note, dated 4/20/26, indicated R4 had new blister on the left medial leg. A nurse observed the blister and notified the wound Registered Nurse (RN) and physician. A new order for skin prep was implented. R4 will be seen during weekly wound rounds. R4 chooses and prefers to stay in bed. R4 had an indwelling urinary catheter, was incontinent of bowel, an dhad bilateral contractures in the upper and lower extremities. R4 made R4's needs know and could use a call light. R4 had moist skin intermittently from shaking and sweating due to Parkinson's disease. R4 wears bilateral heel boots in bed. Encourage a pillow in-between heel boots to prevent R4's legs from touching/rubbing against each other. Air mattress is present and functioning appropriately. On 4/27/26 at 11:16 AM, 1:10 PM, and 3:45 PM, Surveyor observed R4 in bed on a Drive brand air mattress. The air mattress contained a sticker that indicated to set the mattress to 150 lbs. Surveyor noted the air mattress was set at 50 lbs. On 4/28/26 at 7:40 AM and 10:03 AM, Surveyor observed R4 in bed with the air mattress set at 50 lbs. On 4/28/26 at 11:06 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated R4's mattress should be set at 150 lbs per R4's weight. Surveyor and LPN-E observed R4's mattress and noted it was set to 50 lbs. LPN-E indicated the setting was not correct. 2. On 4/27/26, Surveyor reviewed R11's medical record. R11 had diagnoses including non-pressure chronic ulcer of buttock with unspecified severity and metabolic encephalopathy. R11's MDS assessment, dated 2/12/26, had a BIMS score of 8 out of 15 which indicated R11 had severely impaired cognition. A care plan, dated 2/13/26, indicated R11 had a stage 2 pressure injury on the right buttock related to immobility A Pressure Injury Weekly Tracker, dated 3/3/26, indicated R11 had a stage 2 pressure injury on the right buttock that was present upon admission and was currently healed. R11's Braden Scale risk assessment, dated 3/5/26, had a score of 15 which indicated R11 was at risk for pressure injuries. R11 was prominently bed bound with occasionally moist skin and required an extra linen change approximately once daily. R11 had limited ability to reposition independently. A care plan, dated 4/5/26, indicated R11 had the potential for pressure ulcer development related to immobility and refusals to get out of bed. The care plan conained a goal that indicated R11 would have intact skin, free of redness, blisters or discoloration. The care plan contained an intervention to follow the facility's policy/protocol for the prevention/treatment of skin breakdown. On 4/27/26 at 9:43 AM, Surveyor heard an audible alarm on the 100 wing. Surveyor interviewed LPN-F who indicated the alarm was from R11's bed. LPN-F did not attend to the alarm and continued with medication administration on the opposite end of the wing. On 4/27/26 at 9:46 AM, Surveyor interviewed R11 who stated the alarm was loud and has sounded once before. R11 did not know what the alarm was for. Surveyor noted R11 had a Drive brand air pressure mattress that indicated it should be set at 200 lbs. Surveyor noted the air mattress was set at 50 lbs and a blinking red light indicated the mattress had low pressure. On 4/27/26 at 1:15 PM and 3:47 PM, Surveyor observed R11 in bed with the air mattress set at 50 lbs. A blinking red light indicated the mattress had low pressure. The alarm was not sounding. On 4/28/26 at 7:42 AM and 10:05 AM, Surveyor observed R11 in bed with the air mattress set at 50 lbs. A blinking red light indicated the mattress had low pressure. On 4/28/26 at 11:06 AM, Surveyor interviewed LPN-E who indicated R11's pressure relieving mattress should be set at 200 lbs. Surveyor and LPN-E observed R11's mattress and noted it was set at 50 lbs. A red light indicated the mattress had low pressure. LPN-E verified the setting was incorrect and the mattress was malfunctioning. LPN-E stated LPN-E would inform a maintenance staff since LPN-E did not know how to work the control unit when the mattress malfunctioned. On 4/29/26 at 7:38 AM, Surveyor observed R11 in bed and noted R11's air mattress was set at 200 lbs. Surveyor observed a Drive brand control unit on the floor. R11 stated the control unit was new. R11 stated the previous control unit did not provide comfort like the new one. R11 stated staff replaced the control unit on the afternoon of 4/28/26. On 4/29/26 at 8:56 AM, [NAME] President of Success (VPS)-C gave Surveyor a work order (dated 4/28/26) for a control unit replacement for R11's mattress. VPS-C stated the pump was not working properly and also needed to be replaced. On 4/29/26 at 11:57 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was informed R4, R11, and R25's mattresses were not set correctly. DON-B stated R4, R11, and R25 had mattress setting orders according to their weights and nursing staff were required to ensure the settings were correct each shift. VPS-C was present during the interview and stated a check setting task was on the Kardex (an abbreviated care plan used by nursing staff) so Certified Nursing Asistants (CNAs) were aware of the settings and as a double check for residents with pressure relieving mattresses. DON-B indicated CNAs should alert nurses of errors. DON-B confirmed despite nursing staff initialing orders that the settings for the mattresses were correct, the settings were not correct. VPS-C indicated the facility would work on education for how to use the control units to prevent future issues. 3. From 4/27/26 to 4/29/26, Surveyor reviewed R25's medical record. R25 was admitted to facility on 10/14/22 and had diagnoses including diabetes, difficulty walking, bone density disorder, and vitamin D deficiency. R25's MDS assessment, dated 4/7/26, indicated R25 was dependent with transfers and toileting. R25's medical record indicated R25 had a history of pressure injuries on the left and right buttocks. Surveyor reviewed R25's skin assessments and pressure injury history and noted the following: ~ On 10/21/25, R25 acquired an in-house fluid-filled blister that measured 1.0 centimeters (cm) x 2.0 cm x 0.0 cm. The wound was healed on 10/28/25. ~ On 1/20/26, R25 acquired an in-house unstageable pressure injury that measured 3.0 cm x 3.0 cm x 0.1 cm. The pressure injury was healed on 2/17/26. R25's Braden Scale assessment, dated 1/20/26, had a score of 15 which indicated R25 was at risk for pressure injuries. R25 had an order (dated 2/4/26) for an air mattress and to check the function and setting every shift. The mattress should be set at 200 lbs. On 4/27/26 at 12:20 PM, Surveyor noted R25's air mattress was set at 50 lbs. On 4/28/26 at 11:21 AM, Surveyor noted R25's air mattress was set at 50 lbs. On 4/29/26 at 11:57 AM, Surveyor interviewed DON-B who indicated an air mattress setting is determined by a resident's weight. DON-B indicated there is an order for the setting and nursing staff should check to ensure the mattress is correctly set. DON-B stated CNAs also check mattress settings, however, nurses document the checks. DON-B verified R25's order indicated the mattress should be set at 200 lbs.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R7) of 4 sampled residents was not free of a physical restraint.R7 had a motorized wheelchair with a seatbelt that R7 could not independently remove. R7 did not have a physician order for use of the seatbelt which was considered a restraint.Findings include:The facility's Restraint Free Environment policy, revised 2/5/25, indicates: The resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical or chemical restraints for discipline or convenience and limits restraint use .a physical restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints include .applying leg or arm restraints, hand mitts, soft ties, or vests that the resident cannot remove .physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner .On 4/27/26, Surveyor reviewed R7's medical record. R7 had diagnoses including Multiple Sclerosis (MS) and epilepsy. R7's Minimum Data Set (MDS) assessment, dated 2/13/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 had intact cognition.R7's comprehensive care plan, initiated 5/2/23, indicated R7 used a seat belt in an electric wheelchair for safe positioning related to MS with a goal of exhibiting no adverse reaction to use of restraints, including no physical decline in function, pressure ulcer development, or decline in behavior/mood, etc. The care plan contained the following interventions: assist R7 to reposition; physical restraint/device (seat belt in wheelchair) per physician order.R7's physical restraint assessments, dated 6/5/25, 6/18/25, 7/18/25, 8/18/25, 9/18/25, 10/30/25, 11/30/25, 12/30/25, 2/6/26, 3/6/26, and 4/6/26 indicated the following: Physical restraint: type - electric wheelchair seat belt for medical reasons and safe positioning due to MS. R7 is unable to release. Each assessment also indicated the seat belt was physician ordered. (Of note: R7's medical record did not contain an order for use of the seat belt.)On 4/27/26 at 9:48 AM, Surveyor interviewed R7 who indicated the motorized wheelchair R7 used for mobility inside and outside the facility had a seat belt that R7 could not unbuckle independently because the release button was on the left-hand side. R7 agreed with the use of the seat belt because it allowed R7 to be independent in mobility and provided safety for R7. On 4/27/26 at 2:52 PM, Surveyor requested the physician order for R7's seat belt restraint from Nursing Home Administrator (NHA)-A and [NAME] President of Success (VPS)-C.On 4/28/26 at 11:27 AM, VPS-C provided Surveyor with a physician order for R7's seat belt restraint. Surveyor noted the order was discontinued on 4/21/25 with a revision date that indicated the order was reinstituted on 4/27/26.On 4/28/26 at 1:28 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B spoke with VPS-C and did not understand how the order for the seat belt was not in R7's medical record. DON-B stated all residents who have a physical restraint are required to have a physician order. DON-B confirmed the seat belt order was obtained after Surveyor requested the order on 4/27/26. DON-B indicated R7 was transferred to the hospital and the order was discontinued on 4/21/25 when R7 was transferred to the hospital and not reinstituted upon R7's return.

Based on observation, staff interview, and record review, the facility did not ensure adequate supervision during meals for 2 residents (R) (R24 and R10) of 8 sampled residents observed during mealtime. R24 had a diagnosis of dysphagia (difficulty swallowing). R24's care plan indicated R24 required full assistance with eating and should be cued to take one sip at a time and slow down. On 1/21/25, R24 was observed eating lunch in the dining room without staff assistance. In addition, staff removed R24 from the dining room after R24 coughed, drooled, and appeared to be in distress during the meal. R10's care plan indicated R10 had difficulty swallowing and contained interventions to remind R10 to swallow after each bite and take a drink after every 2-3 bites. On 1/21/25, R10 was observed eating lunch in the dining room without staff assistance. Findings include: During the survey, the facility indicated they do not have a policy related to dining assistance. 1. From 1/21/25 to 1/23/25, Surveyor reviewed R24's medical record. R24 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, dementia, dysphagia, traumatic subdural hemorrhage, traumatic brain injury, and impaired vision. R24's most recent Minimum Data Set (MDS) assessment, dated 12/29/24, indicated R24 had moderate cognitive impairment. R24 had an activities of daily living (ADL) self-care deficit related to Parkinson's disease, weakness, unsteady gait, and impaired vision care plan. The care plan contained the following interventions: One assist with feeding for all meals; Feed slowly; Double swallow; Drinks in-between bites; Make sure R24 is sitting upright in wheelchair. R24's nutrition care plan indicated R24 was at risk for nutritional status changes related to Parkinson's disease, dementia, diabetes, inconsistent intake, and texture modified diet. The care plan contained the following interventions: Full assist with eating; Have R24 in the dining room and feed R24; Cue to take 1 sip at a time and to slow down; Cut up meats; Use handled cup. R24's medical record indicated R24 was discharged from speech therapy on 9/11/24 because R24 reached the maximum potential with skilled services. Speech therapy discharge recommendations included supervision and assistance at meal time for swallow safety. On 1/21/25 at 12:18 PM, Surveyor observed Licensed Practical Nurse (LPN)-H enter the dining room and sit alone at a table apart from the residents. Surveyor observed LPN-H work on a laptop during lunch service. On 1/21/25 at 12:22 PM, Surveyor observed R24 eat lunch in the dining room and noted there were no staff seated at the table with R24. Surveyor observed R24 feed R24's self and drink liquids without staff at the table to assist. Surveyor observed R24 cough after eating a bite of food and then cough and drool after taking a drink. LPN-H checked on R24 and then sat back down at a table alone and continued to work on R24's laptop. On 1/21/25 at 12:24 PM, Surveyor observed R24 continue to eat and drink without staff assistance. Surveyor observed R24 take a drink and then cough, drool, and lean forward in R24's wheelchair. R24 appeared to be in distress. LPN-H continued to work on LPN-H's laptop and did not react to R24. Nursing Home Administrator (NHA)-A (who was assisting with meal trays in the dining room) checked on R24 and removed R24 from the dining room. On 1/21/25 at 12:27 PM, Surveyor interviewed LPN-H who confirmed LPN-H supervised residents during the lunch meal. LPN-H confirmed R24 was at risk for aspiration and required monitoring during meals. LPN-H indicated it was not required for staff to sit at the table with R24. LPN-H indicated if LPN-H was in the same room as R24 it was considered adequate supervision. 2. From 1/21/25 to 1/23/25, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had diagnoses including dementia, dysphagia following unspecified cerebrovascular disease, aphasia following cerebral infarction, and cerebral vascular accident with residual right sided hemiplegia. R10's most recent MDS assessment, dated 12/24/24, indicated R10 had moderate cognitive impairment. R10's care plan (dated 12/16/24) indicated R10 required assistance/potential to restore function for eating related to difficulty swallowing. The care plan contained the following interventions: Cue/remind R10 to swallow after each bite; Take small bites; Take a drink after every 2-3 bites; Tell R10 to cough loud when clearing throat. On 1/21/25 at 12:22 PM, Surveyor observed R10 eat lunch in the dining room and noted there were no staff seated at the table with R10. Surveyor observed R10 feed R10's self and drink liquids without a staff seated at the table to assist. On 1/21/25 at 12:38 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects two staff to circulate in the dining room to monitor residents during meals. DON-B indicated staff are not expected to sit at the table with residents who require assistance during meals. On 1/21/25 at 12:50 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated CNA-F is sometimes assigned to monitor residents during meal time in the dining room. CNA-F indicated staff circulate around to assist all residents during meal time. CNA-F confirmed staff do not sit at a table with residents to assist with meals. On 1/21/25 at 1:03 PM, Surveyor interviewed NHA-A who indicated NHA-A expects staff to sit next to residents who require assistance with meals. NHA-A indicated the seated staff should monitor residents for aspiration and provide feeding assistance. On 1/22/25 at 1:43 PM, Surveyor interviewed Speech Therapist (ST)-G who reviewed R24 and R10's care plans. ST-G indicated a staff should be seated next to R24 and R10 during meals to supervise, set up, and cue R24 and R10.

Based on staff interview and record review, the facility did not ensure a physician was notified of blood sugar levels that were outside the ordered parameters for 1 resident (R) (R20) of 15 sampled residents. R20 had a diagnosis of diabetes and a physician's order that instructed staff to notify the physician if R20's blood sugar level was over 400 (milligrams/deciliter (mg/dL)). On 12/19/24, 12/23/24, and 1/3/25, R20's blood sugar level was over 400 mg/dL. R20's physician was not notified. Findings include: The facility's Change in Condition of the Resident policy, dated 9/20/22, indicates: Notifications that do not require immediate consultation with a physician may be made via phone, fax, or method preferred by the physician being contacted. The Center shall develop a method to track faxes sent to ensure timely response. On 1/22/25, Surveyor reviewed R20's medical record. R20 was admitted to the facility on [DATE] and had a diagnosis of diabetes. R20's Minimum Data Set (MDS) assessment, dated 11/8/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R20 had intact cognition. R20's care plan indicated R20 had insulin-dependent diabetes. R20 had a physician order that indicated: Accucheck two times a day for diabetes. Call (physician) if (blood glucose) less than 60 or greater than 400. Before breakfast and before dinner checks. R20's medical record indicated the following: ~ On 12/19/24, R20 had a blood sugar level of 410. ~ On 12/23/24, R20 had a blood sugar level of 422. ~ On 1/3/25, R20 had a blood sugar level of 421. R20's medical record did not indicate the physician was notified in accordance with R20's order. On 1/22/25 at 2:10 PM, Surveyor interviewed [NAME] President of Success (VPS)-E who indicated the facility could not locate physician notifications for R20's blood sugar levels. VPS-E confirmed staff should have notified R20's physician and documented that R20's physician was notified.

Based on observation, staff interview, and record review, the facility did not ensure it was free a medication error rate of 5% or greater. During medication administration observations, 3 errors occurred during 30 opportunities which resulted in a 10% medication error rate that affected 1 resident (R) (R19) of 5 residents observed during medication administration. During medication administration observations for R19 on 1/22/25, staff did not administer Biofreeze menthol topical analgesic (a pain relieving treatment), cholecalciferol (a vitamin supplement), or levetiracetam (a seizure medication) as ordered. Findings include: 1. From 1/21/25 to 1/23/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including stroke with hemiplegia, hypertension, and seizure disorder. R19's most recent Minimum Data Set (MDS) assessment, dated 12/30/24, indicated R19 had moderate cognitive impairment. On 1/22/25 at 9:02 AM, Surveyor observed Registered Nurse (RN)-D prepare and administer 13 medications to R19. RN-D stated RN-D was administering Biofreeze but applied Diclofenac 1% topical cream to R19's legs. Surveyor reviewed R19's medication administration record (MAR) and noted R19 did not have an order for Diclofenac 1% topical cream. R19 had an order for Biofreeze 4% menthol external gel to be applied three times a day to the left hip. RN-D documented on R19's MAR that Biofreeze was administered during the medication pass. Surveyor also noted that RN-D documented that cholecalciferol 25 micrograms (mcg) 1 tablet was administered, however, Surveyor did not observe RN-D administer cholecalciferol. In addition, Surveyor noted R19 had an order for levetiracetam twice daily but did not observe RN-D administer levetiracetam during the medication pass. On 1/22/25 at 11:25 AM, Surveyor interviewed RN-D who confirmed RN-D did not administer levetiracetam at the scheduled time of 7:30 AM because the medication was not available. RN-D could not recall if cholecalciferol was administered. On 1/22/25 at 3:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should document a medication as administered when the medication is administered.

Based on observation, staff interview, and record review, the facility did not ensure the accurate administration of medication for 3 residents (R) (R13, R18, and R19) of 15 sampled residents. R13's physician order for fluticasone (a nasal spray) indicated not to keep fluticasone at the bedside. On 1/21/25, fluticasone was observed at R13's bedside. R18's medication administration record (MAR) did not accurately reflect the time polyethylene glycol (an osmotic laxative) was administered on 1/22/25. Staff administered hydralazine (a vasodilator medication used to lower blood pressure) to R19 on 1/22/25 prior to obtaining R19's blood pressure in accordance with the physician's order. In addition, R19's MAR did not accurately reflect the time polyethylene glycol was administered on 1/22/25. Findings include: The facility's Medication Administration Self-Administration by Resident policy, dated 1/2023, indicates: Residents who desire to self-administer medication are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. The facility's Medication Administration General Guidelines policy, dated 1/23, indicates: The individual who administered the medication records the administration on the resident's medication administration record (MAR) immediately following the medication being given .Obtain and record any vital signs as necessary prior to medication administration . 1. From 1/21/25 to 1/23/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had a diagnosis of allergic rhinitis. R13's Minimum Data Set (MDS) assessment, 1/21/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R13 had intact cognition. On 1/21/25 at 11:01 AM, Surveyor interviewed R13 in R13's room and observed a bottle of fluticasone nasal spray on R13's bedside table. R13's medical record contained the following: ~ R13 was prescribed Flonase Allergy Relief Nasal Suspension 50 micrograms/actuation (mcg/act) (Fluticasone Propionate); 1 spray in both nostrils every morning and at bedtime for allergic rhinitis. The order indicated: May not keep at bedside, nursing to store in med cart. ~ A self-administration of medication assessment, dated 12/18/23, indicated R13 was aware of the use and administration times for fluticasone but had over-used nasal sprays in the past. The assessment indicated R13 was not safe to self-administer fluticasone and fluticasone should not be kept at the bedside. ~ A self-administration of medication assessment, dated 12/4/24, indicated R13 preferred that staff administer medications. On 1/22/25 at 10:21 AM, Surveyor interviewed Registered Nurse (RN)-D who worked regularly with R13. When Surveyor informed RN-D that R13 had fluticasone at the bedside, RN-D indicated R13 was able to keep fluticasone at the bedside. When RN-D reviewed R13's order for fluticasone, RN-D confirmed the order indicated fluticasone should not be kept at R13's bedside. RN-D indicated RN-D would remove fluticasone from R13's room. On 1/22/25 at 10:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed if R13's order states not to leave fluticasone at the bedside, staff should not leave fluticasone at R13's bedside. DON-B indicated if staff set medications at R13's bedside, R13 sometimes takes the medications and staff have difficulty getting the medications back. 50479 2. From 1/21/25 to 1/23/25, Surveyor reviewed R18's medical record. R18 was admitted to the facility on [DATE] and had diagnoses including dementia, cancer, and diabetes mellitus. R18's most recent MDS assessment, dated 1/23/25, indicated R18 had moderate cognitive impairment. On 1/22/25 at 8:54 AM, Surveyor observed RN-D prepare and administer medication to R18. Surveyor did not observe RN-D administer polyethylene glycol. Following the observation, Surveyor reviewed R18's MAR and noted RN-D documented that RN-D administered polyethylene glycol to R18 at 9:24 AM. On 1/22/25 at 11:24 AM, Surveyor Interviewed RN-D who confirmed RN-D did not administer polyethylene glycol to R18 at the time it was documented in the MAR. RN-D indicated R18 preferred to take polyethylene glycol early in the day, therefore, RN-D had administered polyethylene glycol earlier. On 1/22/25 at 3:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should document medication administration at the time the medication is administered. 3. From 1/21/25 to 1/23/25, Surveyor reviewed R19's medical record. R19 was admitted to the facility on [DATE] and had diagnoses including stroke with hemiplegia and seizure disorder. R19's most recent MDS assessment, dated 12/30/24, indicated R19 had moderate cognitive impairment. On 1/22/25 at 9:02 AM, Surveyor observed RN-D prepare and administer medication to R19, including one hydralazine HCL 10 mg tablet. Surveyor did not observe RN-D obtain R19's blood pressure prior to administering hydralazine. In addition, Surveyor did not observe RN-D administer polyethylene glycol to R19. Following the observation, Surveyor reviewed R19's MAR and noted R19's hydralazine HCL order contained instructions to hold the medication if R19's systolic blood pressure was less than 110. Surveyor also noted R19's MAR indicated RN-D administered polyethylene glycol at the same time R19's other AM medications were administered (9:23 AM). On 1/22/25 at 11:25 AM, Surveyor interviewed RN-D who verified RN-D did not obtain R19's blood pressure prior to administering hydralazine. RN-D also verified RN-D documented that RN-D administered polyethylene glycol to R19 at 9:23 AM, but had not yet administered the medication. RN-D indicated R19 preferred to take polyethylene glycol later in the day. On 1/22/25 at 3:29 PM, RN-D informed Surveyor that RN-D had just administered R19's polyethylene glycol. Surveyor noted R19's MAR still indicated R19 was administered polyethylene glycol at 9:23 AM. On 1/22/25 at 3:46 PM, Surveyor interviewed NHA-A who indicated staff should document medication administration at the time the medication is administered.

Based on observation, staff interview, and record review, the facility did not ensure all drugs or biologicals were discarded when expired in 1 of 2 medication rooms in the facility. On 1/21/25, expired stock medications were observed in a cabinet and refrigerator in the 400 unit medication room. Findings include: The facility's Disposal of Medications, Syringes and Needles policy, dated 2007, indicates: .5. Dispose of discontinued medications within 90 days of the date the medication was discontinued .7. Outdated medications .shall be destroyed according to the above policy . On 1/21/25 at 11:06 AM, Surveyor and Director of Nursing (DON)-B observed medications stored in the medication room on the 400 unit and noted the following expired medications in the floor stock medication cabinet: ~ An unopened bottle of diphenhydramine HCL 25 milligram (mg) tablets with an expiration date of 10/2024 ~ An open bottle of diphenhydramine HCL 25 mg tablets with an expiration date of 6/2024 ~ An unopened bottle of loratadine 10 mg tablets with an expiration date of 10/2024 Surveyor and DON-B observed the following expired medications in the medication refrigerator: ~ An open box of acetaminophen 650 mg suppositories with an expiration date of 12/2024 ~ A COVID-19 vaccine with an expiration date of 5/4/24 Following the observations, DON-B confirmed the above medications were expired and should have been discarded.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R9 and R15) of 4 sampled residents. R9 and R15 had symptoms of an upper respiratory infection and were not placed on precautions in a timely manner. Findings include: The facility's Transmission Based (Isolation) Precautions policy, revised 9/24/24, indicates: 1. Facility staff will apply transmission based precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The facility will use standard approaches, as defined by the Centers for Disease Control and Prevention (CDC) for transmission based precautions; airborne, contact, and droplet precautions. 9. Initiation of Transmission Based Precautions (Isolation Precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on transmission based precautions/isolation empirically while awaiting confirmation .11. Droplet Precautions: a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e., respiratory droplets that are generated by a resident who is coughing, sneezing, or talking.) The CDC indicates at https://www.cdc.gov/long-term-care-facilities/hcp/respiratory-virus-toolkit/index.html Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 1/8/25: Healthcare personnel (HCP) who enter the room of a resident with signs or symptoms of an unknown respiratory viral infection that is consistent with SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved(R) particulate respirator with N95(R) filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This personal protective equipment (PPE) can be adjusted once the cause of the infection is identified. Test anyone with respiratory illness signs or symptoms. Selection of diagnostic tests will depend on the suspected cause of the infection (e.g., which respiratory viruses are circulating in the community or the facility, recent contact with someone confirmed to have a specific respiratory infection) and if the results will inform clinical management (e.g., treatment, duration of isolation). At a minimum, testing should include SARS-CoV-2 and influenza viruses with consideration for other causes (e.g., RSV). 1. From 1/21/25 to 1/23/25, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis and depression. R9's Minimum Data Set (MDS) assessment, dated 12/16/24, had a Brief Interview for Mental status (BIMS) score of 15 out of 15 which indicated R9 had intact cognition. R9's medical record indicated R9 had an Activated Power of Attorney for Healthcare (POAHC). A progress note, dated 1/19/25 at 7:09 PM, indicated R9 complained of a headache, nasal congestion, and sore throat. R9's temperature was 99.7 degrees. Tylenol was administered. R9's COVID-19 test was negative. A progress note, dated 1/20/25 at 11:58 AM, indicated R9 complained of a sore throat and headache over the weekend and tested negative for COVID-19 on 1/18/25. R9 was tested again for COVID-19 on 1/20/25 and was negative. R9 did not have a sore throat, fatigue, or headache. Tylenol was administered for pain. A progress note, dated 1/21/25 at 3:35 AM, indicated R9 was weak, febrile, and congested. Tylenol was administered. On 1/21/25 at 10:28 AM, Surveyor interviewed R9 and noted there was not a contact or droplet precaution sign on R9's door or a personal protective equipment (PPE) cart inside or outside R9's room. A progress note, dated 1/21/25 at 7:23 PM, indicated R9's face was flushed and R9 complained of achy muscles and chills. R9's lungs contained crackles. R9 was sent to the emergency room (ER). A progress note, dated 1/21/25 at 11:17 PM, indicated R9 was diagnosed with influenza A and returned from the ER with a precaution sign and PPE in place. A progress note, dated 1/22/25 at 2:38 AM, indicated R9 had chills, body aches, wheezing, and complained of weakness. R9 returned from the ER and indicated R9 wanted to sleep. Droplet isolation precautions were initiated. A progress note, dated 1/22/25 at 1:21 PM, indicated R9 was tired and slept most of the AM shift. R9 denied a headache, cough, or congestion. Tamiflu was ordered. On 1/23/25 at 9:58 AM. Surveyor interviewed Infection Preventionist (IP)-C who indicated R9 was tested for COVID-19 twice due to complaints of nasal congestion, sore throat, fever, and headache and both tests were negative. IP-C indicated R9 was assessed on 1/20/25 and did not have any respiratory symptoms. IP-C indicated IP-C was notified by nursing staff on 1/21/25 that R9 complained of a sore throat, congestion, fever, and a headache and was placed on droplet precautions. The physician was updated on 1/21/25 at 8:09 AM and ordered R9 be evaluated in the ER where R9 was diagnosed with influenza A. IP-C verified R9 was symptomatic of upper respiratory symptoms starting on 1/19/25 and was not put on droplet precautions until 1/21/25 at 11:37 PM. 43361 2. From 1/21/25 to 1/23/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE], received Hospice services, and had diagnoses including malignant neoplasm of endometrium and encounter for palliative care. R15's MDS assessment, dated 12/20/24, had a BIMS score of 13 out of 15 which indicated R15 had intact cognition. On 1/21/25 at 9:37 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated one resident was on isolation precautions for COVID-19. NHA-A indicated the resident had just tested negative but would remain on isolation precautions for the full 10 days. On 1/21/25 at 11:20 AM, Surveyor interviewed R15 who was in bed. R15 indicated R15 did not feel well, had a sore throat and cough, and was congested. R15 indicated R15's symptoms started a couple of days prior. Surveyor did not observe a precautions sign or PPE cart near R15's door. R15's medical record indicated R15 was administered guaifenesin (Robitussen) oral tablet 200 milligrams (mg) for allergies, cough and congestion on 1/17/25 at 2:02 PM and 1/20/25 at 3:05 PM. On 1/22/25 at 10:20 AM, Surveyor interviewed Registered Nurse (RN)-D who confirmed R15 was congested and RN-D placed oxygen on R15 that morning. RN-D indicated RN-D thought Director of Nursing (DON)-B contacted the physician that morning regarding R15. RN-D confirmed R15 was not on precautions. On 1/22/25 at 10:36 AM, Surveyor interviewed IP-C who was not aware that R15 had illness symptoms. IP-C indicated if R15 had illness symptoms, R15 should be on precautions. On 1/22/25 at 10:44 AM, Surveyor interviewed DON-B who confirmed nurses can put a resident on precautions if they have illness symptoms. DON-B indicated DON-B did not contact R15's physician and was not aware that R15 had illness symptoms. DON-B indicated DON-B would expect R15 to be on precautions, however, R15 was on Hospice and Hospice directed R15's care. DON-B confirmed staff should put precautions in place for residents at symptom onset while figuring out what testing should be completed. On 1/23/25, Surveyor noted R9 (in the previous example) had tested positive for Influenza A.

Based on observation and staff and resident interview, the facility did not ensure 2 residents (R) (R13 and R9) of 14 sampled residents had hot water in their bathrooms. During observations on 10/4/24, R13 and R9's bathroom sinks did not have hot water. Findings include: 1. On 10/4/24, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and diabetes mellitus. R13's Minimum Data Set (MDS) assessment, dated 8/24/24, stated R13's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R13 had intact cognition. R13's MDS assessment also indicated R13 required staff set up/supervision for oral hygiene and toileting and moderate assistance for bathing. R13's medical record indicated R13 was responsible for R13's healthcare decisions. On 10/4/24 at 9:21 AM, Surveyor entered R13's bathroom and tested the hot water. Surveyor noted there was no hot water in the sink. R13 was not in R13's room at the time. On 10/4/24 at 2:44 PM, Surveyor interviewed R13 who indicated R13 had not had hot water since June. R13 indicated it would be nice to have hot water and stated staff brought a basin of hot water from down the hall. R13 indicated the lack of hot water made R13 feel [NAME] and made R13 not like R13's room. R13 also indicated R13 was frustrated and wanted to wash R13's hands with soap and warm water and brush R13's teeth without waiting so long. 2. On 10/4/24, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, and depression. R9's MDS assessment, dated 9/29/24, stated R9's BIMS score was 11 out of 15 which indicated R9 had moderate cognitive impairment. R9's MDS assessment also indicated R9 was dependent on staff for personal hygiene, toileting, and bathing. R9's medical record indicated R9's Power of Attorney for Healthcare (POAHC) was responsible for R9's healthcare decisions. On 10/4/24 at 9:25 AM, Surveyor entered R9's bathroom and tested the hot water. Surveyor noted there was no hot water in the sink. R9 was not in R9's room at the time. On 10/4/24 at 1:44 PM, Surveyor interviewed R9 who indicated R9 was upset because there was no hot water in R9's bathroom sink. On 10/4/24 at 2:39 PM, Surveyor again interviewed R9 regarding the lack of hot water. R9 indicated staff brought hot water in a basin from another room which slowed down R9's activities of daily living (ADL) cares. R9 also indicated R9 would like hot water in R9's sink. On 10/4/24 at 10:08 AM, Surveyor interviewed Maintenance Manager (MM)-C who confirmed the facility had an underground leak in February and excavated multiple times to fix the water pipes which were ultimately unredeemable. Per MM-C, the facility completed a project to install hot water. The facility recently discovered issues with water pipes under the therapy gym and there was no way to bypass the pipes which led to a whole building water shut down in August. Per MM-C, temporary water lines were installed overhead in order to run water to units. MM-C confirmed 3 rooms did not have hot water, including R13 and R9's rooms and one unoccupied room. MM-C indicated the first project approval took a month and the facility needed another approval to fix the pipes and ensure all rooms had hot water. On 10/4/24 at 3:37 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed R13 and R9's rooms did not have hot water. NHA-A indicated the facility tried to transition residents out of the rooms and were working on fixing the water pipes.

Based on staff and resident representative interview and record review, the facility did not ensure a grievance was thoroughly resolved for 1 resident (R) (R3) of 14 sampled residents. Resident Representative (RR)-H filed a grievance on behalf of R3 on 8/8/24 that indicated R3 experienced a delayed call light response time and was not attended to in a timely manner. The facility did not resolve the grievance in a timely manner. Findings include: The facility's Grievance Policy, with a revision date of 7/2022, indicates: When a complaint/grievance report is initiated: .The Department Head that is assigned the concern form is responsible for investigating the issue and following up to provide a resolution to the issue within 72 hours of being assigned the grievance. The facility's Call lights: Accessibility and Timely Response policy, with a revision date of 8/8/24, indicates: .10. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. 11. Process for responding to call lights: a. Turn off the signal light in the resident's room. b. Identify yourself and call the resident by name. c. Listen to the resident's request and respond accordingly. Inform the resident if you cannot meet the need and assure him/her that you will notify the appropriate personnel. d. Inform the appropriate personnel of the resident's need. e. Do not promise something you cannot deliver. f. If assistance is needed with a procedure, summons help by using the call light. Stay with the resident until help arrives. On 10/4/24, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including dementia and overactive bladder. R3 received Hospice services and had an activated Power of Attorney for Healthcare (POAHC) who was noted as the first contact in R3's medical record. RR-H was noted as the second contact. R3's care plan contained the following interventions: Toileting assistance with 2 staff; Transfer with sit-to-stand lift; Provide assistance with toileting; Remind and assist as needed with toileting at routine times such as upon arising in AM, before/after meals, activities, therapy and at bedtime. On 10/4/24, Surveyor reviewed a grievance, dated 8/8/24, that contained a concern from RR-H that R3's call light was on for a period of time and was not answered in a timely manner. Nursing Home Administrator (NHA)-A was the individual designated to take action on the concern. The date to be resolved was 8/10/24. Actions to be taken included: NHA-A to do call light audits for three weeks; Continuous education for nursing staff on the call light policy. The grievance contained call light response time education that indicated the following: Objective: 1) Answer call lights in a timely manner. 2) Call lights are to be accessible to residents at all times. 3) All staff members can assist with call lights. A document titled Call Light Response Times was included with the education and indicated: Ensuring the imperativeness of answering call lights in a timely manner is paramount in any healthcare setting to guarantee patient safety, satisfaction, and overall well-being. Prompt response to call lights is a critical component of patient care, reflecting the attentiveness and responsiveness of the healthcare staff. It helps in addressing immediate needs, reducing anxiety, and preventing potential complications, such as falls or unmanaged pain. Staff signatures accompanied the document. Surveyor reviewed another grievance form, dated 9/9/24, that was initiated by a former resident's family member and contained multiple concerns, including call light response time. The resolution portion of the grievance indicated NHA-A conducted audits for 3 weeks. Staff education was not part of the grievance. On 10/4/24 at 9:05 AM, Surveyor interviewed R3's POAHC (POAHC-I) who indicated on the evening of 9/25/24 and 9/26/24, nursing staff responded to R3's call light and said R3 had to wait to use the bathroom because supper was on the way. POAHC-I indicated staff turned off R3's call light and did not return to assist R3 to the bathroom. Surveyor reviewed the staff signatures of those who were educated on answering call lights for R3's 8/8/24 grievance. Surveyor compared the signatures to the staff who worked on 9/25/24 and 9/26/24. Surveyor noted Certified Nursing Assistant (CNA)-D, CNA-E, CNA-F, and CNA-G were assigned to R3's wing on 9/25/24 or 9/26/24; however, only CNA-D was listed on the staff signatures sheets as having received call light response time education. On 10/4/24 at 10:30 AM, Surveyor interviewed RR-H who was visiting R3 in R3's room. RR-H indicated RR-H visited daily in the morning through lunch except for Sundays and POAHC-I visited in the afternoon through supper. RR-H indicated R3 sometimes went 5 hours without being assisted to the bathroom by staff. RR-H indicated in the morning when R3 has to use the bathroom, staff say Hospice will take R3. RR-H indicated Hospice staff come to the facility some mornings. RR-H indicated when RR-H lets staff know that R3 has to use the bathroom, staff don't assist R3 and say Hospice will be there soon. RR-H indicated nursing staff enter R3's room when R3's call light is on, turn off the call light, say they will be back when they find another person to assist, but then don't come back. RR-H indicated some staff use the sit-to-stand lift with two staff and some say they do not need two staff and use the lift alone. RR-H also said some staff come in and turn off the call light, do not say anything at all, and leave the room. RR-H indicated R3's skin has been raw due to R3 being left in urine and stool. RR-H indicated staff do not typically assist R3 before meals to the bathroom and some say they will help R3 after lunch but lunch varies and can last from 12:30 PM to 2:00 PM. RR-H verified CNAs pass room trays. RR-H indicated Hospice staff assisted R3 to the bathroom that morning at 10:00 AM. On 10/4/24 at 11:00 AM, Surveyor interviewed CNA-D who confirmed the majority of residents eat in their rooms and CNAs deliver room trays. CNA-D indicated call lights are answered unless staff are in the middle of passing trays because CNAs need to be careful to not cross-contaminate. On 10/4/24 at 12:08 PM, Surveyor noted staff had not started to pass meal trays. Surveyor interviewed RR-H who was still visiting R3 in R3's room. RR-H indicated R3 had not been toileted before the lunch meal as of that time. On 10/4/24 at 12:20 PM, Surveyor noted meal trays were being served on R3's wing. On 10/4/24 at 12:53 PM, Surveyor interviewed NHA-A who confirmed of the 4 CNAs assigned to R3's wing on 9/25/24 and 9/26/24, only one CNA was listed on the staff signature sheet as having received call light education. NHA-A indicated the training format was a read and sign related to call light accessibility and timely response. On 10/4/24 at 2:05 PM, Surveyor interviewed POAHC-I who was visiting R3 in R3's room. POAHC-I indicated on 9/25/24, R3's call light was activated at 4:30 PM. Staff entered R3's room, turned off the call light, and said they would help R3 after supper. Supper arrived at 6:00 PM and POAHC-I asked staff if they could assist R3 to the bathroom but was told R3 had to wait. POAHC-I indicated staff assisted R3 at 7:45 PM. On 10/4/24 at 3:04 PM, Surveyor interviewed Hospice Staff (HS)-J who indicated HS-J visited R3 on Monday, Wednesday, and Friday mornings at 9:30 AM. HS-J indicated sometimes R3 had not been assisted up or to the bathroom yet when HS-J arrived .

Based on observation, staff and resident interview, and record review, the facility did not ensure fluids were provided on a consistent basis for 4 residents (R) (R3, R4, R5, and R6) of 4 sampled residents. R3, R4, R5 and R6 did not receive fresh drinking water on a consistent basis or in accordance with their nutritional assessment. Findings include: The facility's Hydration policy, with a review date of 7/26/22, indicates each resident should be offered sufficient fluids, to include water and other liquids, based on resident preferences and needs, to maintain proper hydration and health. This includes ensuring fluids are available and within reach. 1. R3 was admitted to the facility on [DATE] with diagnoses including morbid obesity with alveolar hypoventilation, type 2 diabetes mellitus with diabetic neuropathy, chronic diastolic (congestive) heart failure, irritable bowel syndrome without diarrhea, and gastroesophageal reflux disease without esophagitis. R3's Minimum Data Set (MDS) assessment, dated 1/30/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. R3's care plan contained an intervention for staff to encourage and assist R3 as needed to consume foods and/or supplements and fluids offered. On 4/4/24 at 11:53 AM, Surveyor interviewed R3 who stated at times staff are either too busy to fill R3's water cup or take R3's water cup and don't bring it back. Surveyor observed and touched the outside of R3's water cup and noted the water was at what appeared to be room temperature. R3 was unsure when the cup was provided. On 4/4/24, Surveyor reviewed R3's medical record including a Nutritional Assessment, dated 1/24/24, that indicated R3 received a controlled carbohydrate (CCHO) cardiac diet with thin liquids. The Nutritional Assessment indicated R3 had a recommended estimated total daily fluid intake between 1960-2287 ccs (cubic centimeters). Documentation for March of 2024 indicated R3 received [PHONE NUMBER] ccs of fluid per day. The documentation contained 40 incomplete entries and 26 entries that indicated R3 refused fluids. 2. R4 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness, depression, and anxiety. R4's MDS assessment, dated 3/7/24, contained a BIMS score of 11 out of 15 which indicated R4 had moderate cognitive impairment. On 4/4/24 at 10:44 AM, Surveyor interviewed R4 who stated R4 wanted water every night but ice and water were rare. Surveyor observed an empty water cup on R4's bedside table. On 4/4/24, Surveyor reviewed R4's medical record including a Nutritional Assessment, dated 3/6/24, that indicated R4 received a regular diet and had a recommended estimated total daily fluid intake between 2695-3144 ccs. Documentation for March of 2024 indicated R4 received [PHONE NUMBER] ccs of fluid per day and contained 45 incomplete entries. 3. R5 was readmitted to the facility on [DATE] with diagnoses including chronic diastolic (congestive) heart failure, and a history of urinary (tract) infections. R5's MDS assessment, dated 3/29/24, contained a BIMS score of 10 out of 15 which indicated R5 had moderate cognitive impairment. On 4/4/24 at 12:00 PM, Surveyor interview R5 who stated staff do not always have time to pass water. R5 indicated several residents expressed water concerns to administration and stated there are some evenings when R5 is dying of thirst. On 4/4/24, Surveyor reviewed R5's medical record including a Nutritional Assessment, dated 3/27/24, that indicated R5 received a regular diet and had a recommended estimated total daily fluid intake between 1886-2113 ccs. Documentation for March of 2024 indicated R5 received between [PHONE NUMBER] ccs of fluid per day and contained 26 incomplete entries. 4. R6 was admitted to the facility on [DATE] with diagnoses including cerebral palsy, unspecified. R6's MDS assessment, dated 3/10/24, contained a BIMS score of 14 out of 15 which indicated R6 had intact cognition. On 4/4/24 at 12:10 PM, Surveyor interviewed R6 who indicated R6's ability to receive water on a regular basis depended on the staff and how busy they were. Surveyor observed an almost empty water cup next to R6 who indicated the water was from the previous evening. On 4/4/24, Surveyor reviewed R6's medical record which included a Nutritional Assessment, dated 3/6/24, that indicated R6 received a regular diet and had a recommended estimated total daily fluid intake between 2045-2250 ccs. Documentation for March of 2024 indicated R6 received between 0-1200 ccs of fluid per day and contained 29 incomplete entries. On 4/4/24 at 11:47 AM, Surveyor interviewed Medication Technician (MT)-H who stated staff should pass water every few hours and during medication pass. MT-H stated MT-H felt there were times when water was not passed as it should be. On 4/4/24 at 12:57 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B expects Certified Nursing Assistants (CNAs) to pass water every shift and as requested by residents. DON-B stated DON-B was not aware residents had concerns with receiving water.

Based on staff interview and record review, the facility did not ensure thorough background checks were completed for 2 of 8 sampled staff. The facility did not ensure a Department of Justice (DOJ) letter and State of Wisconsin Department of Health Services (DHS) Governmental Findings Report (GFR) (formerly known as the Integrated Background Information System (IBIS) letter) were obtained for Certified Nursing Assistant (CNA)-C and CNA-E prior to hire. Findings include: The Wisconsin Background Check and Misconduct Investigation Program Manual by the Department of Health Services, revised January 2024, indicates: An entity is required to complete caregiver background checks on caregivers. At a minimum, a complete caregiver background check completed for a caregiver consists of the following three documents: 1. A completed DHS F-82064 (Background Information Disclosure) form. 2. A response from the DOJ, either ~A 'no record found' response or ~A criminal record transcript; and 3. A GFR from DHS that reports the person's status, including administrative finding or licensing restrictions. The facility's Abuse, Neglect, and Exploitation policy, reviewed/revised on 7/15/22, indicates: The components of the facility's abuse prohibition plan are discussed herein: I. A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials checks shall be conducted on potential employees .Background checks .will be completed consistent with applicable state laws and regulation. On 4/4/24, Surveyor selected a sample of eight staff to review for background checks, including CNA-C and CNA-E. Surveyor noted CNA-C was hired on 10/24/23, however, CNA-C's DOJ letter and GFR were not obtained until 11/20/23. Surveyor noted CNA-E was hired on 10/2/23, however, CNA-E's DOJ letter and GFR were not obtained until 1/17/24. On 4/4/24 at 2:03 PM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated an audit was done on 11/20/23 by the Human Resources (HR) Support Center that indicated CNA-C did not have a background check and CNA-C's DOJ letter and GFR (IBIS letter) were obtained on 11/20/23. VPS-D provided Surveyor with a copy of the facility's Performance Improvement Plan (PIP) to implement audits of background checks starting on 11/21/23. The action item: Ensure each new employee has a background check completed prior to first day on the job was reviewed by HR Support Center staff to ensure the facility was in compliance as of 12/20/23. VPS-D verified CNA-E was hired on 10/2/23 and did not have a DOJ letter or GFR completed until 1/17/24. VPS-D confirmed background screening should have been completed prior to hire. On 4/4/24 at 2:45 PM, Surveyor interviewed Scheduler (SC)-E who indicated SC-E was unsure why CNA-E's background check was not completed prior to hire because SC-E did not start as the Scheduler/HR assistant until 2/24/24. SC-E was also unsure if a new PIP was completed after CNA-E's background check was not completed timely.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 resident (R) (R2) of 1 sampled resident. R2 reported care and treatment concerns. The facility did not thoroughly investigate the allegation of abuse. Findings include: The facility's Abuse Neglect and Exploitation policy, reviewed/revised on 7/15/22, indicates: V. Investigation of Alleged Abuse, Neglect and Exploitation .B. Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations(s) .6. Providing complete and thorough documentation of the investigation .VII. Reporting/Response .B. The Administrator will follow up with government agencies to report the results of the investigation when final within 5 working days of the incident, as required by State Agencies. On 4/4/24, Surveyor reviewed R2's medical record. R2's diagnoses included paroxysmal atrial fibrillation (irregular heartbeat), malignant neoplasm of ampulla of [NAME] (cancerous tumor of the duct formed by the union of the common bile duct and pancreatic duct within the wall of the small intestine), status post decompression and fusion of cervical vertebras 1 and 2, and polyneuropathies. R2's Minimum Data Set (MDS) assessment, dated 12/14/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R2 had intact cognition. R2 was responsible for R2's health care decisions. On 4/4/24, Surveyor reviewed a facility-reported incident (FRI) that involved an allegation of abuse related to R2. The investigation indicated on 12/10/23 at approximately 9:30 AM, CNA-C provided morning care for R2. R2 reported to R2's daughter that CNA-C was too rough and stated the incident was painful, uncomfortable, and caused R2 to cry. R2's daughter reported the allegation of abuse to a nurse on the PM shift. CNA-C was suspended pending the results of the investigation. The police were notified and conducted an onsite visit which included an interview with R2. The police investigation indicated a crime was not committed. Surveyor noted the investigation did not include a 5-day report submitted to the State Agency (SA), an interview with R2 and other residents cared for by CNA-C, an interview with CNA-C and other staff, and documentation that R2's physician was notified. Surveyor also noted R2's activities of daily living (ADLs) and pain care plans were not reviewed or revised following the incident. On 4/4/24 at 11:48 AM, Surveyor interviewed [NAME] President of Success (VPS)-D who indicated VPS-D spoke with Nursing Home Administrator (NHA)-A and verified NHA-A did not know where the interviews with R2, other residents, and staff were located. VPS-D did not provide the above-mentioned interviews and agreed the interviews should have been included in the investigation. On 4/4/24 at 1:30 PM, Surveyor interviewed VPS-D who verified that although the investigation summary indicated R2's provider was notified, VPS-D could not provide documentation that R2's provider was notified. On 4/4/24 at 1:34 PM, Surveyor interviewed VPS-D and Director of Nursing (DON)-B who verified they could not locate the 5-day investigation in the Misconduct Incident Reporting (MIR) system (used by facilities to report incidents to the SA). VPS-D also verified R2's ADL and pain care plans were not updated following the incident and did not contain an intervention(s) that informed staff how to move R2 during toileting to prevent or decrease pain. VPS-D stated R2's plan of care should have been updated.

Based on observation, staff and resident interview, and record review, the facility did not ensure a safe environment that was free of accident hazards for 1 Resident (R) (R17) of 17 sampled residents. R17 had a space heater in R17's room which was not in accordance with the facility's policy. Findings include: The facility's Space Heater Policy, with a review date of 5/25/23, included the following: .Portable space heating devices are prohibited in this facility . On 11/27/23, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including history of diabetes, coronary artery disease, and hypertension. R17's Minimum Data Set (MDS) assessment, dated 10/21/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was not cognitively impaired. R17 did not have an activated Power of Attorney for Healthcare (POAHC). On 11/27/23 at 11:40 AM, Surveyor interviewed R17 who indicated R17's room was cold. R17 stated R17 was unsure if the facility was going to do anything about it because R17 reported the concern a few weeks ago. R17 could not recall who R17 reported the concern to. R17 stated staff gave R17 extra blankets and pointed to a stack of blankets on R17's chair. R17 stated R17's room wasn't currently cold, though, and pointed to a white, approximately three foot long and one foot high, space heater. On 11/28/23 at 10:00 AM, Surveyor observed the same space heater in R17's room. On 11/28/23 at 10:20 AM, Surveyor notified Director of Nursing (DON)-B of R17's space heater and room temperature concern. On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who stated the space heater was removed from R17's room. DON-B stated R17's family was notified and asked to pick up the space heater. On 11/29/23 at 8:33 AM, Surveyor interviewed Maintenance Staff (MS)-G who stated MS-G wasn't aware R17's room was cold. MS-G stated during the first few months of cold weather, an increase in work orders are submitted and MS-G works with each resident on the specific concerns. MS-G verified the space heater was removed form R17's room and stated the facility's policy does not allow the use of space heaters. On 11/29/23 at 11:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified space heaters are not allowed in the facility.

Based on staff and resident interview, and record review, the facility did not ensure the medical record contained advanced directives for 1 Resident (R) (R25) of 17 sampled residents. R25 was admitted to the facility on [DATE]. R25's medical record did not contain advanced directives, including a Power of Attorney for Healthcare (POAHC) document. Findings include: On 11/27/23, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease with dyskinesia (uncontrolled, involuntary muscle movement), dementia, encounter for palliative care, and senile degeneration of the brain. R25's Minimum Data Set (MDS) assessment, dated 9/1/23, contained a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 was not cognitively impaired. Surveyor noted R25's medical record did not contain advanced directives, including a POAHC document. On 11/28/23 at 12:40 PM, Surveyor interviewed R25 who verified R25 did not currently have a POAHC document. When Surveyor asked if the facility asked if R25 would like to complete advanced directive documents, R25 stated R25 was asked a lot of questions on admission and could not remember. When Surveyor asked if R25 was recently asked about advanced directive documents, R25 stated R25 was not recently asked, but would like to complete them. On 11/28/23 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R25 did not have advanced directive documents, including a POAHC document, on file and directed Surveyor to speak with Social Worker (SW)-F. On 11/28/23 at 1:20 PM, Surveyor interviewed SW-F who stated SW-F was not sure who speaks to residents about advanced directives. SW-F stated if SW-F was aware R25 wanted to complete an advanced directive, SW-F would assist R25. On 11/28/23 at 1:24 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A expects advanced directive documents to be addressed by the first care conference. NHA-A verified R25's advanced directive documents were missed and stated SW-F did not realize advanced directives were within SW-F's scope of duty.

Based on observation, staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R17 and R36) of 2 sampled residents had a self-administration of medication assessment, or a physician's order to self-administer medication and keep medication at the bedside. R17 kept a nasal spray and multivitamins on R17's bedside table and stated R17 self-administered both medications. R17 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R17 could safely and accurately self-administer medication. R36 kept a bottle of iron on R36's bedside table and stated R36 self-administered the medication. R36 did not have a physician's order to self-administer medication or a self-administration of medication assessment that indicated R36 could safely and accurately self-administer medication. Findings include: The facility's Medication Administration Self-Administration by Resident policy, revised January 2023, indicated: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. 1. R17 was admitted to the facility on [DATE] with diagnosis including history of diabetes, coronary artery disease, and hypertension. R17's Minimum Data Set (MDS) assessment, dated 10/21/23, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R17 was not cognitively impaired. R17 did not have an activated Power of Attorney for Healthcare (POAHC). On 11/27/23 at 11:40 AM, Surveyor observed a bottle of multivitamins and fluticasone nasal spray on R17's bedside table. R17 stated R17 used the nasal spray independently twice daily and took one multivitamin daily. On 11/27/23, Surveyor reviewed R17's medical record which did not contain a physician's order to self-administer medication or a self-administration of medication assessment. R17's Treatment Administration Record (TAR) indicated R17's nasal spray was administered twice daily by staff. On 11/28/23 at 10:20 AM, Surveyor notified Director of Nursing (DON)-B that R17 had medication at the bedside. On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who verified R17 did not have a physician's order to self-administer medication and stated the facility will implement a process improvement for better tracking. 2. R36 was admitted to the facility on [DATE] with diagnosis including history of care following a joint replacement, hypertension, and asthma. R36's MDS assessment, dated 10/30/23, contained a BIMS score of 12 out of 15 which indicated R36 had moderate cognitive impairment. R36 did not have an activated POAHC. On 11/27/23 at 11:43 AM, Surveyor observed a bottle of iron on R36's bedside table. R36 stated R36 took 2 iron tablets daily. On 11/27/23, Surveyor reviewed R36's medical record which did not contain a physician's order to self-administer medication or a self-administration of medication assessment for iron. On 11/28/23 at 10:20 AM, Surveyor notified DON-B that R36 had medication at the bedside. On 11/28/23 at 11:51 AM, Surveyor interviewed DON-B who verified R36 did not have a physician's order to self-administer medication and stated the facility will implement a process improvement for better tracking.

Based on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R3) of 1 sampled resident received catheter care in accordance with their prescribed plan of care. R3 had physician's orders to irrigate R3's Foley catheter with 60 mL (milliliters) of sterile saline 3 times per week (Monday, Wednesday, and Friday) at HS (bedtime) and PRN (as needed), and for catheter care every shift. The orders were not consistently followed. Findings include: From 11/27/23 through 11/29/23, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease stage 3, schizoaffective disorder bipolar type, unspecified dementia, cognitive communication deficit, and neuromuscular dysfunction of bladder. R3's Minimum Data Set (MDS) assessment, dated 10/9/23, contained a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R3 had moderate cognitive impairment. The MDS also indicated R3 was dependent on staff for toileting. R3 had a physician's order, dated 7/3/23, to irrigate R3's Foley catheter with 60 mL of sterile saline 3 times per week (Monday, Wednesday, and Friday) at HS and PRN, and a physician's order, dated 7/2/23, for catheter care every shift. R3's care plan contained the following interventions: Indwelling catheter care every shift and as needed; Ensure peri area and tubing is cleaned every shift; Irrigate catheter as ordered. On 11/28/23, Surveyor reviewed R3's Treatment Administration Record (TAR) from 9/1/23 through 11/29/23. R3's TAR contained missing documentation for 7 of 38 opportunities to irrigate R3's catheter and 14 of 114 opportunities to provide catheter care. On 11/29/23 at 11:41 AM, Surveyor interviewed R3 who stated R3 thought staff provided catheter care once per day, but was unsure how often staff irrigated R3's catheter. On 11/29/23 at 12:20 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expects all documentation to be completed regarding catheter care and irrigation. DON-B stated DON-B was unsure if the missed documentation meant the care wasn't provided or if staff provided the care but did not document the care was provided.

Based on staff interview and record review, the facility did not ensure ongoing communication with a dialysis facility for 1 Resident (R) (R193) of 1 resident who received dialysis care and services. R193 received dialysis three times per week. The facility did not ensure ongoing communication occurred between the nursing facility and the dialysis facility prior to and following R193's dialysis appointments. Findings include: The facility's Care of Hemodialysis policy, with a revision date of 9/10/23, contained the following information: Purpose: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. That will include: Ongoing communication and collaboration with dialysis facility regarding care and services. Compliance Guidelines: 2. The facility will coordinate and collaborate with the dialysis facility to ensure that: d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4. The licensed nurse will communicate to the dialysis facility by utilizing the Pre-dialysis communication UDA, that will include, but not limit itself to: Timely medication administration by the nursing home and/or dialysis facility; Physician/treatment orders, laboratory values, and vital signs; . From 11/27/23 through 11/29/23, Surveyor reviewed R193's medical record. R193 was admitted to the facility on [DATE] with diagnoses including end stage renal disease, dependence on renal dialysis, and Alzheimer's disease. R193's medical record indicated R193 attended dialysis on Mondays, Wednesdays, and Fridays. On 11/28/23, Surveyor reviewed R193's dialysis communication sheets from 9/11/23 through 11/27/23 (with the exception of 10/20/23 through 10/23/23 and 11/8/23 through 11/21/23 when R193 was hospitalized ). Surveyor noted 7 communications sheets were dated, but not completed by the facility or dialysis center, and 6 communication sheets were missing for a total of 13 incomplete or missing communication sheets for 26 dialysis sessions. On 11/28/23 at 2:26 PM, Surveyor interviewed Director of Nursing (DON)-B regarding R193's dialysis communication sheets. DON-B stated DON-B expects staff to complete the dialysis communications sheets. DON-B stated if the communication sheets are not returned to the facility, staff should call the dialysis center to get their documentation.

Based on observation, record review, and interview, the facility did not thoroughly assess, document, and provide services consistent with professional standards of practice to prevent development or worsening of pressure injuries for 1 (R31) of 1 residents reviewed for pressure injuries. R31 developed a moisture associated skin damage area to the coccyx that progressed into a Stage 2 pressure injury. No documentation was found from 2/19/2020 until 7/15/2020 when it was assessed as a Stage 3 pressure injury with slough. The wound was not comprehensively assessed weekly and the care plan was not revised as needed with interventions to prevent further breakdown. Findings: The facility guidelines and education provided to staff titled, How to prevent and address pressure injuries undated states: 2. b. Weekly Skin Check must be completed as ordered i. Assessment must be thorough and complete ii. Any skin issue must be documented, whether old or new iii. If new skin condition is noted, it must be measured. Risk Management must be completed iv. MD must be notified and treatment initiated v. Wound Tracker UDA must be initiated for skin condition vi. If a new skin condition exists, a RN must assess within 24 hours vii. Weekly Skin Review UDA must be completed for the weekly skin check 3. All skin impairments must be assessed every 7 days or more frequently if needed. Weekly assessment cannot be completed after the 7th day. 4. If there is no improvement in the skin condition in 2 weeks or a decline is noted, the MD must be updated and new treatment initiated. 5. If skin condition resolves, update the MD and get order to discontinue treatment 6. Treatments must be completed per MD order. All dressing changes, prescription powders and ointments must be applied by the nurse to allow for nurse observation of the skin condition with every treatment. R31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31 needed extensive assistance with bed mobility and was incontinent of bowel and bladder as coded on the significant change Minimum Data Set (MDS) assessment dated [DATE]. R31's At Risk for Skin Integrity Care Plan was initiated on 2/3/2019 with the following interventions: -Assess skin for redness or pressure related changes with each care encounter; report any changes immediately. -Avoid friction/shearing while repositioning; if R31 is unable to assist, use at least two staff members and lift sheet; bed should be as flat as possible with lifting. -Frequent repositioning when in bed and chair. -Keep clean and dry; use barrier cream after good peri-care; apply proper incontinent products as indicated. R31's Actual Skin Integrity Pressure Sore Care Plan was initiated on 9/4/2019. The Care Plan did not indicate the site of the skin breakdown. Interventions implemented with the Care Plan on 9/4/2019 were not available to Surveyor. On 2/4/2020 on the Wound Evaluation Tracker, nursing documented R31 had a pressure injury to the gluteal cleft that was caused by moisture. The wound was not Staged. The wound measured 1.0 cm x 0.5 cm x 0.1 cm with 100% granulation tissue. The form indicated a treatment was initiated on 2/4/2020 but review of the Treatment Administration Record did not show any treatment was in place on that date. On 2/11/2020 on the Wound Evaluation Tracker, nursing documented R31 had a Stage 2 pressure injury to the gluteal cleft that measured 1.0 cm x 0.4 cm x 0.1 cm with 100% granulation tissue. The form indicated the area was not resolving with barrier cream and a new order was obtained for calcium alginate. On 2/12/2020, a treatment was ordered to cleanse coccyx wound with normal saline, apply calcium alginate to wound bed, and cover with a foam dressing daily. Surveyor noted the PI is identified to be located on the coccyx wound and is no longer referred to as being on the gluteal cleft; however, according to the facility this is the same pressure injury. On 2/19/2020 on the Wound Evaluation Tracker, nursing documented R31 had a Stage 2 pressure injury to the coccyx that measured 0 cm x 0 cm x 0 cm with 100% granulation tissue. The form indicated the wound had healed on 2/19/2020. Surveyor noted 100% granulation tissue is not considered a healed pressure injury and would still be considered an open wound. Surveyor noted a wound described as 100% epithelial would be considered healed. DON-B was not assured by the description of 100% granulation that the wound was actually healed on 2/19/20. On 3/14/2020, the treatment to the coccyx wound was changed to cleanse wound with soap and water, apply skin prep to peri wound, and apply foam dressing every three days until healed. On 4/6/2020, the treatment to the coccyx wound was changed to cleanse wound with soap and water, apply skin prep to peri wound, apply cellatrix (Cellalinix 10) to the wound bed and cover with foam dressing Monday, Wednesday, and Friday. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 4/9/2020 with the following interventions: -Apply alternating pressure air mattress to bed if indicated; assure and maintain proper inflation controls. -Assess and measure all skin integrity areas per policy. -Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications. -Initiate skin monitoring forms per facility policy. -Monitor and report any new open areas, drainage, increased drainage or pain to nurse immediately. -Monitor for pain; medicate as needed and offer pain medication prior to treatment. -Provide treatment to wounds per current treatment order; assess wounds for infection with each dressing change; report findings of infection to physician immediately. -Report changes in skin integrity found during daily care. -Report wound progress or decline to physician with any changes or lack of response to treatment. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 5/6/2020 to include a Stage 3 pressure injury to the coccyx and moisture-associated skin damage to the left buttock and the following intervention: apply Roho cushion to wheelchair and recliner; check inflation weekly R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 5/14/2020 with the following intervention: position side to side, keep pressure off back; use pillow to position. On 6/27/2020, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/1/2020, an order was entered onto the Treatment Administration Record (TAR) to monitor inflation of the Roho cushion every Wednesday. No documentation was found in R31's medical record of a weekly comprehensive assessment of the coccyx pressure injury from 2/19/2020 until 7/15/2020. On 7/15/2020 on the Wound Evaluation Tracker, nursing documented R31 had a Stage 3 pressure injury to the coccyx that was first identified on 2/4/2020. The wound measured 2.4 cm x 0.5 cm x 0.5 cm with 95% granulation tissue and 5% slough. The form indicated the current treatment was Cellutrix and will consult with the physician for a treatment change. On 7/17/2020 on the Wound Evaluation Tracker, nursing documented the treatment to the wound will be changed to [MEDICATION(S)]. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 7/17/2020 with the following intervention: culture wound or other diagnostic tests as needed per physician order. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 7/18/2020 with the following intervention: consult with the dietician. On 7/18/2020, an order was entered onto the TAR to check the function of the air mattress every shift. The treatment order was changed to cleanse coccyx wound with wound cleanser, apply [MEDICATION(S)] wound/burn dressing to the wound bed, and cover with gauze daily. On 7/24/2020 on the Wound Evaluation Tracker, the form was left blank. The wound was not comprehensively assessed from 7/15/2020 until 8/21/2020, 37 days later. On 8/21/2020 on the Wound Evaluation Tracker, nursing documented the Stage 3 pressure injury measured 2.0 cm x 1.0 cm with no depth documented. The wound had 95% granulation tissue and 5% slough. The form indicated the current treatment to the wound was Silvakollogen and recommended R31 be seen by the wound physician, but R31 refused at that time. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 9/29/2020 to include a Stage 3 pressure injury to the coccyx, a Stage 3 pressure injury to the left buttock, a Stage 3 pressure injury to the right buttock, and moisture-associated skin damage to the left buttock and the following intervention: reposition every two hours while in bed and when up in the wheelchair. Surveyor noted there was no other documentation in the medical record, other than this reference in the care plan, pertaining to these new identified areas. The new identified areas included a Stage 3 pressure injury to the right buttock, a Stage 3 to the left buttock, and moisture-associated skin damage to the left buttock. The following coccyx wound assessments were noted; 09/24/2020 - The Stage 3 PI measured 2.0 cm x 0.5 cm x 1.0 cm with 100% pink tissue. 10/15/2020 - The Stage 3 PI measured 2.4 cm x 0.8 cm x 0.7 cm with pink tissue. 11/03/2020 - The Stage 3 PI measured 1.7 cm x 0.8 cm x 0.4 cm with pale red tissue. Weekly assessments were completed after 11/3/2020 until 11/20/2020. 11/20/2020 - The Stage 3 PI measured 2.0 cm x 1.4 cm x 0.3 cm with red tissue. 12/8/2020 - The Stage 3 PI measured 2.0 cm x 1.4 cm x 0.2 cm with red tissue. DON-B stated if one color was documented on the Skin Grid form for the type of tissue in the wound bed, the wound was 100% that tissue type; if there were two or more colors documented, a percentage would be written for each tissue type. Surveyor noted the coccyx wound was not comprehensively assessed from 9/24/2020 until 10/15/2020, 21 days; from 10/15/2020 until 11/3/2020, 21 days; and from 11/20/2020 until 12/8/2020, 18 days. On 12/17/2020 at 2:59 PM in the progress notes, nursing charted R31's buttocks was assessed and noted to have multiple areas of breakdown to bilateral buttock where the dressing used on the coccyx adheres to the skin. A new treatment order was obtained. R31 was educated on pressure offloading and R31 agreed to stay off the buttocks as much as possible. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 12/17/2020 to include a Stage 3 pressure injury to the coccyx, resolution of a Stage 3 pressure injury to the left buttock, resolution of a Stage 3 pressure injury to the right buttock, resolution of moisture-associated skin damage to the left buttock, and multiple open areas to bilateral buttocks. R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 1/17/2021 to include a Stage 3 pressure injury to the coccyx, resolution of a Stage 3 pressure injury to the left buttock, resolution of a Stage 3 pressure injury to the right buttock, resolution of moisture-associated skin damage to the left buttock, and multiple open areas to bilateral buttocks due to bandage adhesive. On 1/19/2021 on the Skin Grid form, the Stage 3 coccyx PI measured 1.0 cm x 0.3 cm that was superficial with pink tissue. On 1/20/2021, a new order was obtained to cleanse coccyx pressure injury with normal saline, apply [MEDICATION(S)] barrier cream to surrounding skin, and cover with sacral foam dressing every Monday, Wednesday, and Friday. Surveyor noted other than cleansing the coccyx wound with normal saline, there was no treatment being applied to the wound base. The coccyx wound assessments were noted on the following: 01/29/2021 - The Stage 3 PI measured 1.0 cm x 0.3 cm that was superficial with red tissue. 02/26/2021- The Stage 3 PI measured 1.0 cm x 0.3 cm x 0 cm with red tissue. 03/12/2021 - The Stage 3 PI measured 1.0 cm x 0.3 cm x 0 cm with red tissue. 04/02/2021 - The Stage 3 PI measured 0.5 cm x 0.3 cm x 0.3 cm with red tissue. 04/15/2021 - The Stage 3 PI measured 0.5 cm x 0.4 cm x 0.3 cm with red tissue. The coccyx wound was not comprehensively assessed from 1/19/2021 until 1/29/2021, 10 days; from 2/26/2021 until 3/12/2021, 14 days; and from 4/2/2021 until 4/15/2021, 13 days. The facility conducted weekly wound assessments after 4/15/2021 R31's Actual Skin Integrity Pressure Sore Care Plan was revised on 4/20/2021 to include a Stage 3 pressure injury to the coccyx, resolution of a Stage 3 pressure injury to the left buttock, resolution of a Stage 3 pressure injury to the right buttock, resolution of moisture-associated skin damage to the left buttock, and resolution of multiple open areas to bilateral buttocks due to bandage adhesive. On 5/6/2021 on the Skin Grid form, the Stage 3 coccyx PI measured 0.5 cm x 0.3 cm x 0.2 cm with red tissue. On 5/14/2021 on the Skin Grid form, the Stage 3 coccyx PI measured 2.0 cm x 1.0 cm x 2.0 cm with red tissue. The wound had deteriorated and the physician was called to obtain a new treatment. On 5/14/2021, a treatment was obtained to cleanse the coccyx pressure injury with normal saline, add Collagen (Alginate) to the wound base, and cover with a sacral foam dressing every Monday, Wednesday, and Friday. In an interview on 5/18/2021 at 3:15 PM, Director of Nursing (DON)-B stated R31 has missing documentation for R31's pressure injury and provided all the documentation that could be found. DON-B stated the facility had recognized documentation is lacking in regards to wound assessments and they have started a Performance Improvement Plan (PIP) with education provided to all the nurses and a facility-wide skin sweep. On 5/19/2021 at 7:39 AM, Surveyor observed Assistant Director of Nursing (ADON)-J provide wound care to R31's coccyx. R31 was in bed with a low air loss mattress in place. R31 had excoriation to the rectal area with active bleeding when cleansed. The left lower buttock had an open area with active bleeding from where the adhesive dressing had been in place to the coccyx. The coccyx wound on 5/19/2021 measured approximately 2.0 cm x 1.0 cm x 0.5 cm with dark red wound base and bloody drainage. ADON-J stated when ADON-J first saw the wound two weeks ago, the order did not have any packing or anything being applied to the wound base. ADON-J stated the physician was contacted and ADON-J got an order on 5/14/2021 to put Collagen (Alginate) on the wound base. In an interview on 5/19/2021 at 10:45 AM, Surveyor asked Certified Nursing Assistant (CNA)-K if there had been any recent training on pressure injuries or the care provided to prevent pressure injuries. CNA-K stated there had not been any training in the last month on pressure injuries. In an interview on 5/19/2021 at 10:47 AM, Surveyor asked Registered Nurse (RN)-L if there had been any recent training on pressure injuries. RN-L stated there was some training at the nurses' station, but had not gotten a chance to look at it. In an interview on 5/19/2021 at 10:55 AM, Surveyor asked RN-N if there had been any recent training on pressure injuries. RN-N stated there was an in-service last week where about seven different topics were discussed and pressure injuries were one of them. RN-N stated ADON-J was responsible for all wound assessments and RN-N would do any treatment that was in the TAR to complete. In an interview on 5/19/2021 at 12:38 PM, Surveyor reviewed all the wound documentation with DON-B and shared the concerns of missing documentation for months as well as missing weekly comprehensive assessments with documentation that was provided. DON-B agreed with all the concerns shared by Surveyor. DON-B provided paper TARs from 2/2020 through 6/2020 which the facility used prior to having the TARs on the electronic charting system. DON-B questioned the charting on 2/19/2020 where it was documented the wound had healed because the treatments to the coccyx were never discontinued and were changed periodically. DON-B stated they weren't able to complete the PIP prior to the recertification survey. Surveyor shared the interviews with CNA-K, RN-L, and RN-N. No further information was provided at that time.

Based on observation, record review and interview, the facility did not ensure that 3 (R51, R13 & R50) of 4 residents reviewed and at risk for developing pressure injuries, and or with pressure injuries, received consistent measures to prevent the development of pressure injuries. *R50 did not have RN (Registered Nurse) assessments, treatments and or pressure injury interventions in place for the treatment of [REDACTED]. * R51 did not have RN (Registered Nurse) assessments, treatments and or pressure injury interventions in place for the treatment of [REDACTED]. * R13 developed 2 unstageable and 2 deep tissue injuries after being observed to not have pressure injury interventions in place. Examples 1 and 2 are being cited at actual harm. Findings include: 1.) R50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The actual skin integrity break and/or pressure sore(s) See wound assessment Pressure Sore Stage UST (unstageable) Rt (right) hip. Coccyx, stage 2 initiated 7/16/19 and revised on 8/19/19 documents interventions all dated 7/16/19 of: Assess and measure all skin integrity areas per policy. Follow pressure ulcer prevention guidelines to prevent additional skin problems, promote healing and prevent complications. Initiate skin monitoring forms per facility policy. Initiate treatment per Physician order. Monitor and report any new open areas, drainage, increased drainage or pan to nurse immediately. Monitor for c/o (complaint of) pain. Medicate PRN (as needed) and offer pain medication prior to treatment. Update physician regarding effectiveness and increased need for pain medications. Provide treatment to wound(s) per current treatment order. Assess wound(s) for s/s (signs/symptoms) of infection with each dressing change/treatment. Report findings of redness, warmth, swelling, increased drainage or increased pain to physician immediately. Report wound progress or decline to MD (medical doctor) with any changes or lack of response to treatment per facility guidelines. The admission MDS (minimum data set) with an assessment reference date of 7/18/19 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R50 requires extensive assistance with two plus person physical assist for bed mobility & transfer, does not ambulate and is coded as frequently incontinent of bowel and bladder. R50 is at risk for developing pressure injuries and is coded has having one unstageable slough and/or eschar pressure injury. The pressure ulcer/injury CAA (care area assessment) dated 7/25/19 under care plan considerations documents . [MEDICAL CONDITION] rt (right) side. pt (patient) has unstageable eschar to Rt hip. impaired mobility/transfers. at risk for pressure ulcers/impaired skin integrity d/t (due to) impaired mobility, incontinence. at risk for MASD (moisture associated skin damage) d/t incontinence. proceed to care plan for interventions to minimize risks. The Braden Assessments dated 7/23/19, 7/30/19, & 8/6/19 all have a score of 15 which indicates at risk. The at risk for skin integrity care plan initiated 8/7/19 has interventions all dated 8/7/19 of : Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. Avoid friction/shearing while repositioning: if Resident is unable to assist, use at least two staff members, use lift sheet, bed should be as flat as possible with lifting. Conduct pressure injury skin assessments (i.e. Braden Scale) as indicated. Frequent repositioning in bed and chair. Keep Resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. RIGHT HIP The admission skin assessment dated [DATE] documents Right hip OA (open area) = 4.5 cm (centimeter) x (times) 2 cm. There is no assessment of the wound bed and this skin assessment was completed by LPN (Licensed Practical Nurse)-[NAME] There are no measurements or assessment of R50's right hip pressure injury during the week of (MONTH) 14th to (MONTH) 20th. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under initial identification dated 7/24/19 documents for site Rt (right) hip. Pressure is checked. Stage is documented as UST (unstageable). Length is 3.8, width 1.8 and depth 0. Color is documented as Eschar. This assessment is not signed. Surveyor is unable to determine if this assessment was completed by a RN (Registered Nurse) or LPN. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 7/31, under stage documents ust (unstageable), length 3.8, Width 1.8 color B (black (eschar)). This was completed by LPN-K. There is no RN assessment of R50's right hip pressure injury. The physician orders [REDACTED]. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/7, under stage documents ust (unstageable), length 3.8, Width 1.8 color B. This was completed by LPN-K. There is no RN assessment of R50's right hip pressure injury. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/14/19, under stage documents 0 with a line, length 3.6, Width 1.8 color Dark. Under comments documents Area remains with minimal change (triangle). This was completed by LPN-H. There is no RN assessment of R50's right hip pressure injury. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/19/19, under stage documents 0 with a line, length 3.6, Width 1.8 color Dark B (black). Under comments documents Area scabbed open to air. This was completed by LPN-H. There is no RN assessment of R50's right hip pressure injury. On 8/19/19 Surveyor reviewed R50's (MONTH) TAR (treatment administration record) and noted the treatment for [REDACTED]. C[NAME]CYX The admission skin assessment dated [DATE] documents Gluteal clear no O/A's (open areas). This skin assessment was completed by LPN (Licensed Practical Nurse)-[NAME] The nurses note dated 7/15/19 documents 24 hrs (hours) report: Resident is alert and oriented. Open area to buttocks is being monitored. Resident was kept clean and dry. Barrier cream applied to buttocks. Complained of pain and pain management implemented. No new concerns. Staff will continue to monitor. This note was written by an LPN. Surveyor noted this is the first note regarding an open area on the buttocks. There is no assessment or measurements documented on 7/15/19. The nurses note dated 7/25/19 documents Resident has open area on coccyx. Measuring 2.5L (length) and 1.0W (width). NOR (new order received) for clean with NS (normal saline), pat dry and apply allevyn. change Q3 (every three) days until healed. Resident c/o (complained of) pain and discomfort in area. PRN (as needed) given with relief. Resident clean and dry. Dressing CDI (clean dry intact). Will continue to monitor until end of shift. This note was written by a LPN. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under initial identification dated 7/25/19 documents for site coccyx. Pressure is checked. Stage is documented as 2. Length is 2.5, width 1.0 and depth 0 with a line. Color is documented as R (red). This assessment was completed by LPN-L. There is no RN assessment of R50's coccyx. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 7/31/19. There are no measurements or assessments documented. Under comments documents Pt (patient) (R) (right) to have nurse assess OA (open area). The physician orders [REDACTED]. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/7/19. There are no measurements or assessments documented. Under comments documents Pt (patient) (R) (right) to have ____ assess d/t (due to) dressing being changed (triangle 'd) yesterday. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/12/19, under stage documents Stage 2, length 0.2, Width 0.2, depth 0.1 color Pink. Under comments documents Area remain dressing dry & intact. This was completed by LPN-H. There is no RN assessment of R50's coccyx pressure injury. Review of R50's (MONTH) TAR (treatment administration record) for wash coccyx area with normal saline, pat dry, cover with foam adhesive dressing, change 3 days until healed, reveals the treatment was initialed as being completed on 8/15/19. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/19/19, under stage documents Stage 2, length 0.2, Width 0.2, depth 0.1 color Red. Under comments documents Area con' t (continue) to heal. This was completed by LPN-H. There is no RN assessment of R50's coccyx pressure injury. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/20/19, under stage documents Superior unstageable), length 0.5, Width 1.8, depth 0 color Y (yellow). Under comments documents. MD (medical doctor) notified tx (treatment) change: Wound cleanse: to coccyx apply antifungal house cream to periowound skin. Apply Iodosorb to wound bed f/b (followed by) ABD (abdominal) pad secure with hypofix tape change (triangle) QD (every day). Hip tx (treatment) remains the same. Wound is yellow slough without viability to wound base. This assessment was completed by RN (Registered Nurse)/Staff Development Director-E. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under initial identification dated 8/20/19 documents for site Coccyx/Inferior. Pressure is checked. Stage is documented as Unstageable. Length is 0.3, width 1.0 and depth 0 with a line. Color is documented as Y (yellow). Under comments documents Wound has yellow slough without visibility to wound base. Peri-wound is yeasty. MD notified new orders obtained: Wound cleanse to coccyx apply antifungal house cream to peri-wound skin. Apply Iodosorb to wound bed f/b ABD pad secure with hypofix tape change (triangle) QD (every day). Hip tx remains the same. LEFT ELBOW The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under initial identification dated 8/19/19 documents for site (L) (left) elbow. Pressure is checked. Stage is blank. Length is 0.1, width 0.1 and depth n/a (non applicable). Color is documented as P (pink). This assessment was completed by LPN (Licensed Practical Nurse)-H. The nurses note dated 8/19/19 documents Resident has a new area on left elbow that is 0.1 in diameter. The area is from resident leaning to her left side while in w/c (wheelchair). New tx (treatment) in order in place also an order [REDACTED].O. (new order) to d/c skin prep to bilateral heels resident c/o nausea during lunch but refused to eat was given ginger ale and saltine crackers. Resident is to be offered alternatives during meal time if she does not like section d/t (due to) her being a brittle diabetic. Continue to monitor. This note was written by a LPN. The skin grid- pressure/[MEDICAL CONDITION] ulcer/other sheet under date documents 8/20/19, under stage documents 2, length 0.2, Width 0.2, Depth 0.1, drainage S (serosanqineous), and Color R (red). Under comments documents Shallow open area with a pink/red wound bed. No slough. Peri wound color is WNL (within normal limits). No pain expressed facially or verbally. This assessment was completed by RN (Registered Nurse)/Staff Development Director-E. The nurses note dated 8/20/19 documents Patient being monitored for new pressure ulcer on left elbow. No complaints of pain or discomfort. Will continue to monitor. OBSERVATIONS & INTERVIEWS On 8/19/19 at 11:15 a.m. Surveyor spoke with R50. Surveyor inquired if she had any open areas such as pressure ulcers. R50 informed Surveyor she thinks a pressure ulcer developed on her elbow. R50 then showed Surveyor her left elbow. Surveyor observed a round pressure injury the approximate size of Surveyor's pen top with the wound bed pink. R50 informed Surveyor she was unsure of any other areas. Surveyor asked R50 if Surveyor could look at R50's heels. After receiving permission, Surveyor observed R50's heels are resting directly on the mattress and are not being offloaded. On 8/19/19 at 11:52 a.m. Surveyor observed R50 in bed on her back. Surveyor observed R50's heels are not being offloaded. On 8/19/19 at 12:12 p.m. Surveyor observed CNA (Certified Nursing Assistant)-I and COTA (Certified Occupational Therapy Aide)-M in the bathroom with R50. CNA-I & COTA-M placed gloves on, asked R50 if she was ready, and raised R50 off the toilet with a sit to stand lift. CNA-I washed R50's buttocks and rectal area, removed her gloves, washed her hands and placed new gloves on. COTA-M informed R50 they were going to pull her out and then pull up her pants. Surveyor observed the dressing on R50's coccyx area is dated 8/15/19. CNA-I pulled up R50's incontinence product and pants & R50 was lowered into the wheelchair. On 8/19/19 at 1:35 p.m. Surveyor observed CNA-I in R50's room. CNA-I washed her hands, placed gloves on, placed a sling around R50 and informed R50 she was waiting for LPN (Licensed Practical Nurse)-H. CNA-I closed the blinds and informed R50 LPN-H is getting supplies for her bottom. R50 stated LPN-H may need one for her elbow. CNA-I looked at R50's left elbow and informed R50 she would let LPN-H know. At 1:39 p.m. LPN-H entered R50's room with treatment supplies. CNA-I informed LPN-H R50 may need something for her elbow. LPN-H looked at R50's left elbow and stated looks like pressure from wheelchair. LPN-H & CNA-I hooked the sling to the sit to stand lift, R50 was raised off the wheelchair and wheeled into the bathroom. On 8/18/19 at 2:17 p.m. Surveyor observed LPN-H inform R50 who was in bed she was going to do the treatment for [REDACTED]. LPN-H opened a foam dressing and placed gloves on. LPN-H pulled on the drawsheet to move R50 towards the left side of the bed and rolled R50 on her side. Surveyor observed the same dressing on R50's coccyx as during the observation at 12:12 p.m. which is dated 8/15/19. Surveyor asked LPN-H the date of the dressing. LPN-H informed Surveyor 8/15/19. LPN-H removed the dressing. Surveyor noted serosanguious (bloody) drainage on the dressing. LPN-H threw the dressing in the garbage, and placed sterile water on gauze. LPN-H cleansed R50's pressure injury and stated it's getting better. LPN-H did not removed her gloves and wash or cleanse her hands. Surveyor observed there was multiple areas of slough on R50's coccyx . LPN-H placed a [MEDICATION NAME] dressing over the pressure injury, placed an incontinence product under R50 and stated she was going to look at the right hip. LPN-H looked at R50's right hip pressure injury informing Surveyor the area was open to air but she had put a foam dressing on it as it the wheelchair was putting pressure on the area. Surveyor observed the right hip pressure injury has eschar. LPN-H did not apply [MEDICATION NAME] on R50's right hip pressure injury. LPN-H fastened the incontinence product, pulled up R50's pants and placed a pillow under R50's left upper side. Surveyor observed R50's heels are resting directly on the mattress and are not being offloaded. LPN-H covered R50 with a blanket, raised the head of the bed, placed the call light in reach, removed her gloves and washed her hands. On 8/19/19 at 2:32 p.m. Surveyor asked LPN-H if she knew why R50's treatments were not done on 8/18/19. LPN-H informed Surveyor she wasn't sure. LPN-H explained she and another nurse were working and they were short. LPN-H informed Surveyor she had a pretty busy day and there was some stuff she couldn't get to. LPN-H stated she passed on to the 2nd shift that she didn't get the treatments done. Surveyor asked if LPN-H if she remembered who she passed this information onto. LPN-H informed Surveyor she gave it in report. LPN-H informed Surveyor she couldn't remember the 2nd shift nurses name and stated I'm just drained. On 8/19/19 at 3:07 p.m. Surveyor asked LPN-H if there is any treatment that should be done for R50's feet. LPN-H informed Surveyor R50's heels felt mushy so they were putting skin prep on them. LPN-H informed Surveyor she's going to get an order to get the skin prep discontinued. Surveyor asked if the order has been discontinued as Surveyor didn't observe her putting skin prep on R50's heels. LPN-H informed Surveyor she wasn't sure if the order was discontinued. Surveyor asked if skin prep should be placed on R50's heels. LPN-H replied not right now and explained R50's heels were tender which came from R50 laying in bed and R50 hasn't complained. LPN-H informed Surveyor R50's heels should be floated and they put a pillow until therapy orders a heels up pad as they don't have any more. LPN-H informed Surveyor she needs clarification from the doctor about R50's heels and also about the area on R50's elbow. Surveyor asked LPN-H if the open area on R50's left elbow is from pressure. LPN-H informed Surveyor R50 leans on the side and thinks its a pressure area from the wheelchair. LPN-H informed Surveyor she is going to speak to therapy about positioning while R50 is sitting in the wheelchair. Surveyor asked LPN-H if they are still applying [MEDICATION NAME] to R50's right hip. LPN-H informed Surveyor in her opinion [MEDICATION NAME] doesn't have to be applied to the right hip pressure injury. LPN-H informed Surveyor she is going to speak to the doctor. Surveyor asked if are applying [MEDICATION NAME] to the right hip. LPN-H informed Surveyor they are suppose to continue during the treatment until the orders are clarified. Surveyor noted LPN-H did not apply [MEDICATION NAME] to R50's right hip pressure injury during today's observation nor did LPN-H apply skin prep to R50's heels. On 8/19/19 at 3:37 p.m. Surveyor observed R50 continues to be on her right side. R50's heels are resting directly on the mattress and are not being offloaded. On 8/20/19 at 7:38 a.m. Surveyor observed R50 awake in bed on her back. Surveyor observed R50's heels are resting directly on the mattress and are not being offloaded. On 8/20/19 at 9:00 a.m. Surveyor observed R50 in bed on her back with the head of her bed elevated. Surveyor observed there are two pillows under R50's feet and R50's heels are resting on the pillow. Surveyor noted the pillows were not under R50's feet during the previous observation. On 8/20/19 at 9:28 a.m. Surveyor observed R50 in bed on her back. Surveyor observed there are pillows under R50's feet but R50's heels are resting directly on the mattress. R50 informed Surveyor her feet are sliding down. Surveyor asked R50 if her heels hurt. R50 replied yes. On 8/20/19 at 3:05 p.m. Surveyor met with DON (Director of Nursing)-B to inquire what the system at the Facility is regarding pressure injuries and non pressure areas. DON-B explained the nurses on the units have been doing the weekly assessments and documenting on them. DON-B informed Surveyor she is going to be changing this next week to make it a more formalized wound round process. DON-B informed Surveyor she identified this needs some tweaking. Surveyor informed DON-B R50 was admitted to the Facility with a pressure injury on 7/11/19. This area was measured on admission by an LPN but there was no RN assessment. 7/24/19 is the next time this area was assessed & measured but Surveyor is unable to determine who did this assessment as the assessment is not signed. Surveyor informed DON-B the right hip area hasn't been assessed by an RN and the treatment hasn't been initialed as completed since 8/16/19. Surveyor informed DON-B R50's coccyx dressing should have been changed on 8/18/18 and wasn't as Surveyor observed the dressing to be dated 8/15/19 on 8/19/19. Surveyor informed DON-B there has been no RN assessment of R50's coccyx and no change in the care plan. Surveyor also informed DON-B Surveyor observed R50's coccyx treatment on 8/19/19 with LPN-H. Surveyor informed DON-B LPN-H cleansed the pressure injury with sterile water instead of normal saline and did not have appropriate hand hygiene. Surveyor informed DON-B Surveyor isn't sure when LPN-H measured R50's coccyx as LPN-H did not measure the area before applying the [MEDICATION NAME] dressing. Surveyor also informed DON-B during this observation Surveyor observed multiple areas of slough and asked DON-B if DON-B wanted to go with Surveyor to look at R50's coccyx. DON-B explained to Surveyor they were doing a skin sweep and may have already measured and assessed R50's coccyx. Surveyor informed DON-B of the new pressure injury on R50's left elbow. On 8/20/19 at 3:18 p.m. Surveyor asked DON-B if R50's heels should be offloaded. DON-B informed Surveyor she will get back to Surveyor. On 8/21/19 at 7:45 a.m. DON-B informed Surveyor they did measure and assess R50's pressure injuries. DON-B informed Surveyor the area around R50's coccyx looked fungal and there is a new treatment. Surveyor asked DON-B if there are areas of slough on R50's coccyx. DON-B verified there are areas of slough on R50's coccyx. DON-B informed Surveyor they revised R50's care plan and provided Surveyor a copy of R50's revised care plans. Surveyor noted on the actual skin integrity care plan initiated 7/16/19 & revised on 8/20/19 the interventions added initiated & revised on 8/20/19 documents right hip- unstageable, Coccyx - Inferior-unstageable, and PT/OT (physical therapy/occupational therapy) as indicated. An additional intervention of Dietitian review' is initiated 8/21/19. On 8/21/19 at 10:44 a.m. Surveyor asked DON-B if R50's heels should be offloaded. DON-B replied yes and informed Surveyor when she went into R50's room, R50's heels were appropriately offloaded with a pillow. Surveyor informed DON-B of Surveyor's observations of R50's heels not being offloaded. The nurses note dated 8/20/19 at 5:00 p.m. documents Writer assessed the following areas: (1) left elbow which measures 0.2 cm (centimeter) x (times) 0.2 cm x 0.1 cm. Area is shallow with pinkish red bed. No signs of slough. Peri wound color is in WNL (within normal limits). No pain expressed facially or verbally. Treatment orders remain the same. (2) Writer also assessed coccyx. Area has a superior open area with minimal drainage of serosanqineous, the wound bed is not visible r/t (related to) yellow slough. (3) The coccyx also has an inferior area that measures 0.3 cm x 1.0cm, wound bed is not visible r/t yellow slough, minimal serosanqineous drainage. New orders obtain: Wound cleanser to coccyx, apply antifungal house cream to peri-wound skin f/b (followed by) application of Iodosorb to wound bed f/b abd (abdominal) pad and secure with hypofix tape to superior and inferior pressure injuries. (4) Assessed right hip a 1.0 cm x 3.0 cm unstageable pressure injury. Area has loose black eschar (eschar). Peri area is clean and dry. Current treatment involves [MEDICATION NAME] to hip daily. R50 (first name) has been updated to treatment change. Braden scale score and care plan updated. This note was written by RN (Registered Nurse)/Staff Development Director-E. 2.) R51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R51's Quarterly MDS (Minimum Data Set) dated 6/3/19 documents a BIMS (Brief Interview for Mental Status) score of 14, indicating that R51 is cognitively intact. Section G (Functional Status) documents that R51 requires extensive assistance and two person physical assist for his bed mobility needs. Section G also documents that R51 has total dependence on staff and requires a two person physical assist for his transfer needs. Section M (Skin Conditions) documents that R51 is at risk for the development of pressure ulcers/injuries and at the time of the assessment had 1 deep tissue injury and 3 Venous/Arterial ulcers. R51's Discharge Summary dated 3/5/19 documents that R51 had a left heel pressure injury prior to R51's admission to the facility on [DATE]. R51's Pressure Ulcers CAA (Care Area Assessment) dated 3/21/19 documents under the Care Plan Considerations section, Alert and oriented x3, clear speech, able to make needs known. Extensive assist with ADL's (activities of daily living) .At risk for pressure injuries due to decreased mobility, [MEDICAL CONDITION] [MEDICAL CONDITION] (end stage [MEDICAL CONDITION]), diabetes. R51's Braden Scale for Predicting Pressure Sore/Injury Risk assessment dated [DATE] documents a score of 15, indicating that R51 is at risk for the development of pressure ulcers/injuries. R51's Skin Integrity care plan documents under the Interventions section, Prevalon boots to BLE (Bilateral Lower Extremities); Revised on 4/26/19. Interventions Not In Place R51's Wound Report of Consultation dated 7/8/19 documents under the Report section, Left Heel Ulcer 2.2 x 1.5 cm (centimeters) necrotic base; Diagnosis: [REDACTED].may wear shoes for therapy only. Needs offloading of left heel especially at night with prevalon boot or equivalent. Surveyor reviewed R51's Skin Integrity care plan and noted that the above Wound Consultation recommendations were not integrated or incorporated into R51's plan of care. On 8/19/19 at 11:36 a.m., Surveyor observed R51 sitting in his wheelchair in his room wearing shoes on both feet. Surveyor noted that R51 did not have any offloading interventions in place to his left heel and was wearing shoes while not in therapy. On 8/19/19 at 3:25 p.m., Surveyor observed R51 sitting in his wheelchair in his room wearing shoes on both feet. Surveyor noted that R51 did not have any offloading interventions in place to his left heel and was wearing shoes while not in therapy. On 8/21/19 at 8:03 a.m., Surveyor observed R51 sleeping supine in bed with both heels resting directly on the mattress and not offloaded per R51's Wound Care recommendations and plan of care. On 8/21/19 at 8:05 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings and Surveyor and DON-B walked to R51's room and confirmed R51's did not have his heels offloaded to prevent pressure injuries. On 8/21/19 at 8:20 a.m., Surveyor asked DON-B if R51 should be wearing shoes while not in therapy. DON-B informed Surveyor that R51 should not be wearing shoes while not in therapy and informed Surveyor that she had ordered a pressure relieving boot for R51 to wear on his left foot. Surveyor asked R51 should have his heels floated to prevent pressure injury development per R51's Wound Care recommendations and plan of care. DON-B informed Surveyor that R51 should have his heels floated to prevent pressure injury development per R51's Wound Care recommendations and plan of care. No additional information was provided as to why R51 did not have his heels offloaded to prevent pressure injury development per his plan of care and Wound Care recommendations. Treatment Not Completed R51's Wound Report of Consultation dated 8/14/19 documents under the Report section, Findings: Bilateral heel ulcers; Recommendations: Dressing change M (Monday), W (Wednesday), F (Friday) apply [MEDICATION NAME] and foam border dressing for left heel, continue offloading. R51's (MONTH) 2019 TAR (Treatment Administration Record) documents that the above treatment was not completed on 8/16/19 as ordered. On 8/19/19 at 3:35 p.m., Surveyor observed the dressing on R51's left heel with LPN (Licensed Practical Nurse)-H. Surveyor observed the dressing on R51's left heel not to be dated. Surveyor asked LPN-H if R51's pressure injury dressing should be dated when changed. LPN-H informed Surveyor that she changed R51's left heel wound dressing on 8/15/19 and that the dressing Surveyor and her (LPN-H) observed on R51's left heel was not the dressing she had applied on 8/15/19, as that wound dressing was signed by LPN-H. On 8/21/19 at 8:07 a.m., Surveyor informed DON (Director of Nursing)-B of the above findings. Surveyor asked DON-B if R51 had his left pressure injury wound dressing changed on 8/16/19 as ordered. DON-B informed Surveyor that she could not provide any evidence that R51 had his left pressure injury wound dressing changed on 8/16/19 as ordered. No additional information was provided. RN (Registered Nurse) Assessments Not Completed R51's Skin Grid dated 7/17/19 and signed by an unknown LPN (Licensed Practical Nurse) documents, Left Heel Pressure Injury: 2.0 cm in length; 1.5 cm in width; no depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN (Registered Nurse) for the week of 7/17/19. R51's Skin Grid dated 7/24/19 and signed by an unknown LPN documents, SDT (suspected deep tissue injury) Left Heel; 1.5 cm in length; 1.0 cm in width; no depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN for the week of 7/24/19. R51's Skin Grid dated 7/31/19 and signed by an unknown LPN documents, SDT Left Heel; 1.5 cm in length; 1.0 cm in width; no depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN for the week of 7/31/19. R51's Skin Grid dated 8/7/19 and signed by LPN-K documents, Eschar- Left Heel; 1.0 cm in length; 0.9 cm in width; no depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN for the week of 8/7/19. R51's Skin Grid dated 8/15/19 and signed by LPN-H documents, Stage 2- Left Heel; N/A (not applicable) length; N/A width; no depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN for the week of 8/15/19. R51's Skin Grid dated 8/19/19 and signed by RN-E documents, Unstageable- Left Heel; 2.1 cm in length; 2.8 cm in width; 0.1 cm in depth. Surveyor was unable to locate any documentation in R51's medical record that R51's left heel pressure injury was assessed by an RN from7/17/19 to 8/19/19. On 8/21/19 at 8:20 a.m., Surveyor informed DON (Director of Nursing)- B of the above findings. Surveyor asked DON-B if R51's left heel pressure injury was assessed by an RN during anytime from 7/17/19 to 8/19/19, as Surveyor was unable to locate any documentation in R51's that documented R51's left heel pressure injury was assessed by an RN during that time period. DON-B informed that she could not provide any documentation or evidence that R51's left heel pressure injury was assessed by an RN during any time from 7/17/19 to 8/19/19. No additional information was provided as to why R51 did not have interventions and or care provided to treat and prevent the development of pressure injuries. 3.) R13 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R13's Quarterly MDS (Minimum Da

Based on observation, interview and record review, the facility did not provide services and assistance to 2 (R13 and R146) of 2 residents who were incontinent of bladder received appropriate treatment and services to restore continence to the extent possible. * R13 complained that she often had to wait for long periods of time to get assistance with the bedpan resulting in urinary incontinence. Staff members confirmed R13 was only incontinent if they did not answer her call light in time. This prevented the resident from reaching her highest practicable level of physical, mental, and psychosocial well-being and resulted in psychosocial harm (embarrassment, humiliation, degradation) and pain for R13. The facility did not follow bladder policies, did not develop and implement a care plan related to incontinence prevention, did not assess bladder continence timely and did not provide toileting program or patterning for R13 resulting in continued incontinence. * The facility did not follow bladder policies, did not develop and implement a care plan related to incontinence prevention, did not assess bladder continence timely and did not provide toileting program or patterning for R146 resulting in continued incontinence. Finding Include: 1. On 6/18/19 at 9:09 AM, Surveyor interviewed R13. R13 stated she gets upset when she has to use the bedpan. She presses her call light but the aides take too long to answer making her incontinent of bladder. R13 reports she is embarrassed by this and feels humiliated that I am [AGE] years old and should not have to go in my britches. R13 reports incontinence is making her depressed. On 6/20/19 at 10:10 AM, Surveyor interviewed R13. R13 stated she does have overactive bladder and is humiliated when she is incontinent. R13 states, I barely go anywhere anymore, it is embarrassing. On 6/18/19 at 9:53 AM, Surveyor observed R13 press call light for assistance stating she needed to use the bedpan. At 10:01 AM, Surveyor observed R13 with facial expressions of pain. R13 stated that she was trying to hold her urine in but it hurts my bladder. At 10:03 AM, Certified Nursing Assistant (CNA)-LL entered room and assisted R13 onto bedpan. Surveyor observed R13 remained continent of urine for the 10 minute wait time. Surveyor reviewed R13's medical record. R13 was admitted to the facility 7/27/17 with [DIAGNOSES REDACTED]. Surveyor reviewed R13's Care Area Assessment (CAA) Worksheet with an assessment reference date of 10/2/18. Under Urinary Incontinence and Indwelling Catheter is documented, Triggering Conditions: 1. Activities of Daily Living (ADL) assistance for toileting was needed as indicated by: Toilet use: self performance = extensive assistance. 5. Urinary incontinence has a value of 1 through 3 as indicated by: Urinary continence - Occasionally incontinent. Surveyor reviewed R13's PPS Unscheduled Assessment Minimum Data Set (MDS) with an assessment reference date of 4/11/19 which indicates; Under C0500 Summary Score for Cognitive Patterns documented R13 had a Brief Interview Mental Status (BIMS) score of 14 which indicated cognitively intact. Under G I Toilet Use is documented patient is 3/3 or Extensive Assistance- resident involved in activity, staff provide weight bearing support, two+ person physical assist. Under H0200 Urinary Toileting Program is documented, Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? No. Under H0300 Urinary Continence is documented, Occasionally incontinent: less than 7 episodes of incontinence. Under H0400 Bowel Continence is documented, Always continent. Surveyor reviewed the 10/2/18 Significant Change MDS which indicated R13 is occasionally incontinent of urine and always continent of bowel. Surveyor reviewed R13's Kardex report for Certified Nursing Assistants (CNAs) with a date of 4/1/19. Documented under Resident Care was Bedpan as requested and Toileting: Continent: Bowel and Bladder. Surveyor reviewed R13's Bowel and Bladder Elimination charting from 3/1/19 to 6/20/19. 80% of entries were documented as Urinary continence - continent and 20% documented as Urinary continence - incontinent. Surveyor reviewed R13's Comprehensive Plan of Care with an initiation date of 2/6/18. Documented under Focus: Resident is incontinent of urine, diuretic use, frequently dribbling, immobility. Interventions: Bladder and bowel status evaluation and pattern review as indicated. Surveyor reviewed R13's Electronic Medical Record. Found under Assessments was Bladder/Incontinence Evaluation with an effective date of 10/5/18. No other incontinence assessment or pattern reviews were found. On 6/20/19 at 1:15 PM, Surveyor interviewed CNA-NN. Surveyor asked if R13 was ever incontinent. CNA-NN stated, Sometimes she asks for the bedpan and she is incontinent if (CNAs) don't get to her right away. On 6/25/19 at 9:05 AM, Surveyor interviewed CNA-MM. Surveyor asked if R13 is continent or incontinent. CNA-MM stated R13 is continent. Surveyor asked if R13 had ever been incontinent. CNA-MM stated R13 knows when she has to go but sometimes she is incontinent when the (CNAs) do not get to her in time. That is the only time. On 6/25/19 at 9:13 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-O. Surveyor asked when bladder assessments are completed. ADON-O stated at admission to the facility and at change in condition. Surveyor asked what change of condition would constitute a new assessment. ADON-O stated if they have a change in continence we would reevaluate as needed. Surveyor asked if they would do an assessment if someone is occasionally incontinent. ADON-O stated Yes, then we would do a bladder training program after a reassessment. Surveyor asked if R13 is occasionally incontinent, should she have been reassessed and put on a toilet program and/or patterning. ADON-O stated, Yes, I am going to start one for her right away. On 6/25/19 at 9:29 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked when bladder assessments are completed for residents. DON-B stated when a resident is first admitted and as needed assessment to determine what their pattern is. Surveyor showed DON-B R13's Bowel and Bladder Elimination charting and asked what R13's continence status was. DON-B stated It looks like she is occasionally incontinent, we use the bedpan for her. Surveyor showed DON-B R13's Plan of Care intervention of bladder evaluation and pattern review and asked what that meant. DON-B stated if she has a change in status or needs an assessment we will complete one as needed. Surveyor asked by looking at her urinary continence patterns should she have had an assessment, toileting program and/or patterning completed. DON-B stated, She should have had a new assessment and yes to all. Surveyor shared concerns of R13 feeling humiliated and depressed in relation to her incontinence episodes. Surveyor asked what should have been done for R13. DON-B stated if R13 is having issues we need to do full assessments including psychosocial. Surveyor stated there has been no bladder assessment completed since 10/5/18 and no assessments in relation to the psychosocial aspects related to incontinence. DON-B stated there should have been a bladder and psychosocial assessment related to this. 2. The state agency received a complaint related to a resident being left in in urine and feces. The facility's Bladder Management (Retraining) Program policy, dated 4/2017, states; .10. Develop toileting schedule with the resident's participation. Toileting schedule should be as close to the resident's customary routine as possible . 14. Observe and record the resident's voiding pattern and revise toileting schedule to meet resident's needs. This should be done until a routine is established . 20. When a voiding pattern has been established, arrange for the resident to toilet one half-hour prior to the established time. The time between voiding may be increased as the resident gains control .CARE PLAN D[NAME]UMENTATION GUIDELINES Identify the plan for management of urinary incontinence as an approach under the appropriate underlying problem on the resident's care plan. Identify the underlying problem will assist the nursing staff in developing an individualized management program. The facility's Bowel Management (Retraining)Program policy, dated 4/2017, states, Asses and observe the resident's bowel habits and document date, time, place of evacuation, color, consistency and amount of feces until a pattern is established. The Minimum Data Set observation period is 7 days. A resident's bowel elimination pattern may be established within five to seven days .CARE PLAN D[NAME]UMENTATION GUIDELINES Care plan documentation is determined by the reason for the resident's bowel incontinence and complicating conditions. If the resident is able to participle in a bowel-retraining program, document the reason for the bowel incontinence as the problem. The plan for management may be listed as approached under the appropriate problem related to the cause of bowel incontinence on the resident's care plan. If the resident is incapable of participating in a bowel-retraining program, develop a care plan for a scheduled toileting plan to meet the resident's needs. R146 has [DIAGNOSES REDACTED]. R146's admission MDS (Minimum Data Set)Assessment, with an assessment reference date of 4/5/19, documents; R146 required extensive assistant of 1 person's physical assistance for toileting, and was frequently incontinent of bowel and bladder. The assessment documents a toileting program was not in place for bowel or urinary. R146's Care Area Analysis for urinary incontinence, signed as completed on 4/9/19 by MDS Coordinator-UU states impaired mobility, transfers, toileting, left side [MEDICAL CONDITION], weakness, Rt ICA occlusion s/p (status [REDACTED]. Social isolation is at risk d/t odor associated w/ incontinence, at risk for pressure ulcers r/t DX DM, [MEDICAL CONDITION] and incontinence. Proceed to care plan for interventions to minimize risks. On 4/15/19, a Bladder/Incontinence Evaluation documents R146 as being currently incontinent of bladder. The evaluation documents conditions that include impaired mobility/ambulation and decreased manual dextetiry. The evaluation documents R146 as likely experiencing functional incontinence. Under Treatment Program schedule toileting/habit training and not appropriate for toileting or retraining program Rationale: SEE SUMMARY is checked. The summary section of the evaluation is blank. The evaluation did not include an assessment related to determine a pattern of R146's incontinence. The surveyor reviewed R146's care plan in place during his admission and noted no care plan and interventions in place related to assisting R146 with his incontinence. On 4/25/19, the date R146 was discharge from the facility, R146 is documented as having declined to always incontinent of bowel and bladder. On 06/20/19 at 12:42 PM the surveyor interviewed CNA (certified nursing assistant)-Y. The surveyor asked how CNA-Y would know how to care for someone with bowel and bladder incontinence. CNA-Y stated she would look on the care plan. On 06/20/19 at 12:43 PM the surveyor interviewed CNA-NN. CNA-NN recalled R146. CNA-NN recalled R146 being incontinent of urine, and toileting him for a bowel movement, that he woud call out that he needed to have a bowel movement. On 06/20/19 at 12:31 PM the surveyor interviewed MDS Coordinator-WW. MDS Coordinator informed the surveyor the current process is the ADON (assistant director of nursing) would do a bowel and bladder assessment and would review for a toileting care plan if appropriate. MDS Coordinator-WW stated at the time R146 was here she would do the MDS and another person would do the care plan. Regional Director of Clinical Reimbursement-XX, who was present during the interview stated, If the CAA (care area analysis) triggered it is ultimately the MDS nurse's job to make sure the care plan is completed. The surveyor informed MDS Coordinator-WW and Regional Director of Clinical Reimbursement-XX of being unable to find a care plan related to R146's urinary and bowel incontinence. Regional Director of Clinical Reimbursement-XX confirmed she did not see it on R146's care plan. On 06/20/19 at 02:35 PM the surveyor informed Administrator-A, Consultant-P, and Consultant-Q of R146 not having a care plan related to bowel and bladder incontinence. The surveyor asked how interventions for bowel and bladder incontinence are determined. Consultant-Q stated by their patterns. The surveyor informed the facility of R146 not having any documented evaluation of his incontinence pattern.

Based on record review and staff interview, the facility did not ensure 1 resident (Resident (R)13) of 14 residents reviewed for pressure injuries and pressure injury risk received appropriate treatment and services to promote healing and/or prevent pressure injuries from developing. R13 developed a pressure injury under a medical device on the left achilles. The facility failed to assess, care plan and monitor for skin breakdown under the compression wrap, leading to the pressure injury worsening. Additionally, the facility assessed the pressure injury to be a Stage 2, when NPUAP (National Pressure Ulcer Advisory Panel) standards would have classified it otherwise (Stage 3). Findings include: On 2/27/17 at 1:45 p.m., DON (Director of Nursing)-G informed Surveyor the facility follows NPUAP standards for pressure injuries and other wounds. The NPUAP publication The Prevention and treatment of [REDACTED]. ~ 1. Inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue. ~ 1.1. Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface in individuals vulnerable to fluid shifts and/or exhibiting signs of localized or generalized [MEDICAL CONDITION]. ~ The health professional should apply any type of medical device cognizant of the potential for tissue expansion and worsening [MEDICAL CONDITION]. Depending on the type/purpose of the device, loosening, replacement or removal (i.e., compression stockings) may be advised. On 2/27/17, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R13's MDS (Minimum Data Set) assessment dated [DATE], documents R13 is at risk for pressure injury, with no pressure injuries present. R13 was seeing an orthopaedic doctor regarding the bimalleolar fracture to the left ankle. On 11/1/16, the orthopaedic doctor placed a hard fiberglass cast on the left ankle with orders for no weight bearing for four weeks. R13 returned to the orthopaedic doctor on 11/29/16. On 2/28/17, Surveyor requested the facility obtain orthopaedic doctor's documentation from R13's visit on 11/29/16. On 11/29/16 the orthopaedic doctor noted the following: R13 had a partial thickness ulcer anterial medial ankle and along the Achilles region with no exposed tendon, no surrounding redness, warmth noted around the ulcers. Orthopaedic doctor cleansed wounds and then applied [MEDICATION NAME] dressing over the pressure injuries. A short leg total contact cast was applied to the left ankle and cast precautions were given. Orthopaedic doctor requested R13 to come back in 4 weeks. Orthopaedic doctor wrote orders to the facility that stated to leave splint on, patient has total contact cast on. Continue non-weight bearing to left leg. Pillow under calf, not heel or achilles. Only wear cast shoe when up, should be removed in bed. According to the American Orthopaedic Foot and Ankle Society, a total contact cast is a casting technique that is used to heal [MEDICAL CONDITION] and to protect the foot during the early phases of Charcot fracture dislocations. The cast is used to heal [MEDICAL CONDITION] by distributing weight along the entire plantar aspect (sole) of the foot. It is applied in such a way to intimately contact the exact contour of the foot; hence, the designation total contact cast. R13 returned to the orthopaedic doctor on 12/27/16. On 2/28/17 Surveyor requested the facility obtain orthopaedic doctor's note from R13's visit on 12/27/16. On 12/27/16 the orthopaedic doctor noted the following: R13's posterior wound has healed with no purulence or redness or warmth. The orthopaedic doctor removed the total contact cast and recommended compressive Ace wrap and diabetic boot to left leg. Orthopaedic notes indicated measurements were obtained for 3 wounds at this visit. The first wound located on the left posterior ankle measures 3.5 cm (centimeters) in length by 1.2 cm in width. The second wound located on the left medial ankle measures 1.2 cm in length by 0.9 cm in width. The third wound located on the left dorsal foot measures 1.0 cm in length by 0.5 cm in width. Orthopaedic doctor wrote orders to facility that stated, Ace wraps for swelling, progressive weight-bearing starting with 30 pounds weight, boot may be removed for sleeping and showering. R13 to return to orthopaedic in 4 weeks. R13 returned to orthopaedic doctor on 1/24/17. On 2/28/17 Surveyor requested the facility obtain orthopaedic doctor's note from R13's visit on 1/24/17. On 1/24/17 the orthopaedic doctor noted the following: R13's ankle fracture continues to heal. Orthopaedic doctor recommended ongoing use of the diabetic boot and then transfer the patient into a CROW (Charcot Restraint Orthotic Walker). The orthopaedic notes also indicate one wound was measured at this visit. The left achilles wound was 5.5 cm in length by 1.4 cm in width. R13 to return to orthopaedic in 2 months. Orthopaedic doctor wrote orders that included, progress with weight bearing in boot on left leg, advance with progress provided no redness or swelling in left ankle. May remove boot to shower, sleep, sit. On 2/27/17 at 3:20 p.m., Surveyor interviewed RN (Registered Nurse)-M from the orthopaedic doctor's office. RN-M stated when the Ace wraps were ordered on [DATE], the doctor would expect the facility staff to remove the wraps daily to check for looseness and tightness and to check the skin underneath. On 2/28/17, Surveyor reviewed therapy notes for R13. On 1/31/17 during R13's therapy session, PT (Physical Therapist)-L made the following notes: removed wrap to assess response/condition of foot, wound on back of foot with increased drainage/scab, notified nursing. A nurse and PA assessed wound, reports increased size and adjusting tx (treatment) plan to trial [MEDICATION NAME] vs ACE wrap. On 2/28/17 at 12:50 p.m., Surveyor interviewed PT-L regarding R13. PT-L indicated once R13's cast was off in late December, orthopaedic doctor's order was to check for swelling or redness and if not showing those signs, R13 could progress with advancing with weight-bearing on left leg. PT-L indicated R13 was seen about 5 times a week for therapy and during those initial sessions after the cast was off, she would take the wraps off to check for redness and swelling. Once R13 was not showing signs of swelling or redness, PT-L didn't remove the wraps every time. PT-L stated from day one of therapy, PT-L had noticed 2 areas on R13's left foot, one on the top of the foot and one on the achilles. PT-L indicated they initially appeared to be scabs and she thought it was just part of the healing process. PT-L stated she notified nursing on 1/31/17 when she noticed the achilles wound had some drainage. On 2/27/17 at 1:45 p.m., Surveyor interviewed DON-G regarding R13. DON-G stated she became aware of the left achilles wound on 1/31/17 and the nurse practitioner was notified and she found orthopaedic notes indicating the wounds were present at the last orthopaedic visit on 1/24/17. DON-G stated the orthopaedic doctor never mentioned the wounds to the facility. DON-G indicated the facility did not have an order to remove the Ace wraps and in the past, the orthopaedic doctor stated not to touch the left leg. DON-G verified facility staff did not contact the orthopaedic doctor's office to find out how often the Ace wraps should be removed after the 12/27/16 appointment. DON-G stated she would have expected nursing staff to remove the Ace wraps daily and complete a skin check. DON-G was unable to provide any documentation indicating nursing staff was removing the Ace wraps and completing skin checks at least twice a day on the left foot/leg from 12/27/16-1/31/17. On 2/27/17, Surveyor reviewed R13's care plan. On 11/11/16, a care plan was initiated for the potential for a pressure ulcer related to the use of a boot. The interventions under this focus area state to provide assistance with placing brace and check skin under every shift. There was no mention of removing Ace wraps in the care plan. STAGING OF PRESSURE INJURY NPUAP states a Stage 2 pressure injury is: partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. NPUAP states a Stage 3 pressure injury is: full thickness loss of skin in which fat is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible. On 2/27/17, Surveyor requested wound assessments for R13 since admission. Surveyor was provided a Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document for the left achilles. The first assessment date on the document was 1/31/17 and the wound is identified as not present on admission. Additionally, the wound was classified as a pressure wound and assessed to be 9 cm in length (L) by 2 cm in width (W) by less than 0.1 in depth (D). A small amount of blood was noted to be draining and the color of the wound was noted to be yellow, pink. On 1/31/17 the wound is classified as a stage 2. No additional notes were available. The next assessment was dated 2/7/17. The left achilles wound measured 4.2 cm (L) by 2.2 cm (W) by less than 0.1 cm (D). The color is identified as yellow slough/pink and the wound was classified as a Stage 2. RN-K's notes regarding the wound documented wound base pink with yellow slough covering 80%. Medium amount of purulent drainage. Periwound red in color . On 2/14/17, another assessment was completed. The wound measured 2.3 cm (L) by 1.3 (W) unable to assess the depth. The color is identified as yellow slough and the wound was classified as a Stage 2. RN-K's notes about the wound state, wound base covered in yellow slough, UTA (unable to assess) depth. Scant amount of purulent drainage . The next assessment completed was dated 2/20/17. The wound measured 2.6 cm (L) by 1.8 cm (W) unable to assess the depth. The wound is classified as unstageable. DON-G's notes about the wound state, wound base 95% slough with some pink tissue noted, periwound bed pink scant amount of purulent drainage noted . On 2/27/17 at 2:00 p.m., Surveyor interviewed RN-K regarding the left achilles wound assessments. RN-K stated they classified it as a Stage 2 on 2/7/17 and 2/14/17 because they could still see the wound bed and it was pink. RN-K stated now it is fully covered with slough so it is classified as unstageable. On 2/28/17 at 8:50 a.m., Surveyor interviewed DON-G regarding the wound assessments. DON-G acknowledged there was slough present on 2/7/17 and 2/14/17, but since they could still see the wound bed and it was pink, they classified the wound as a Stage 2.

Based on record review and staff interview, the facility did not ensure 1 (Resident (R)13) of 15 sampled residents received the necessary care and services for wound management to attain or maintain the highest practicable physical well-being. R13 was ordered to wear a compression wrap and boot to the lower left extremity. R13 developed a wound to the top of the left foot, under the compression wrap. The facility did not ensure skin checks were being completed on a daily basis, resulting in the wound worsening. Findings include: The NPUAP publication The Prevention and treatment of [REDACTED]. 1. Inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue. 1.1. Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface in individuals vulnerable to fluid shifts and/or exhibiting signs of localized or generalized [MEDICAL CONDITION]. The health professional should apply any type of medical device cognizant of the potential for tissue expansion and worsening [MEDICAL CONDITION]. Depending on the type/purpose of the device, loosening, replacement or removal (i.e., compression stockings) may be advised. Additionally, the facility policy entitled, Treatment Protocol Diabetic Neuropathic Ulcers effective July 2015, states, .8. Identify and/or revise interventions to address contributing factors, including, but not limited to: a. Assess and treat pain. b. Assess pulses-dorsalis pedis and posterior tibial. c. Debride callouses as appropriate. d. Monitor diabetes. e. Monitor feet daily . On 2/27/17, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R13 was followed by an orthopaedic doctor relating to the lower left leg fracture. R13 had a non-removable cast on the lower left leg until 12/27/16. On 12/27/16, the orthopaedic doctor removed the cast and at that time R13 was ordered to wear a compression wrap along with a diabetic boot on the lower left leg. Documentation from the orthopaedic doctor's office, indicated the orthopaedic doctor treated wounds on R13's top of left foot and left achilles on 11/29/16, 12/27/16 and 1/24/17. R13's medical record did not include documentation from the orthopaedic doctor's office indicating he was treating wounds to R13's top of left foot and left achilles. R13's MDS (Minimum Data Set) assessment dated [DATE], documents R13 is at risk for pressure injury, and the MDS did not identify any open areas. R13's TAR (Treatment Administration Record) dated November 2016, December 2016, January 2017 and February 2017, instructed staff to completed diabetic foot checks every day. ~ November 2016 diabetic foot checks were not completed on 11/3/16, 11/14/16, 11/21/16, 11/24/16, and 11/29/16. ~ December 2016 diabetic foot checks were not completed on 12/2/16, 12/6/16, 12/10-12/12/16, 12/15/16, 12/20-12/21/16, and 12/26/16. ~ January 2017 diabetic foot checks were not completed for the entire month. ~ February 2017 diabetic foot checks were not completed on 2/18/17 and 2/20/17. On 2/27/17, Surveyor requested to review wound assessments from admission for R13 and was provided a Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other document related to the top of R13's left foot. The document shows the initial identification of the wound on 1/31/17. The box was checked that this wound had not been present on admission and the nurse classified the area as a scab. The wound measured 1 cm (centimeter) in length (L) by 0.5 cm in width (W), depth is UTA (unable to assess). The wound is not draining and was yellow in color. No additional documentation was provided regarding the wound for 1/31/17. The next documented assessment was dated 2/7/17 and included the wound measured 1.0 cm (L) by 0.5 cm (W) and depth was UTA. No drainage was noted and the wound color was marked as yellow slough. RN (Registered Nurse)-K's wound note stated, wound bed covered in yellow slough with no drainage, unable to assess depth d/t (due to) slough .periwound without redness. The next documented assessment was on 2/14/17 and included the wound measured 1.8 cm (L) by 0.4 cm (W) and depth was UTA. No drainage and the wound color is yellow slough. RN-K's note stated wound bed covered in yellow slough with no drainage UTA depth . The next documented assessment was on 2/20/17 and included the wound measured 0.9 cm (L) by 0.3 cm (W), depth is UTA. No drainage and the wound color is marked as Y. DON (Director of Nursing)-G's documented note relating to the wound stated, wound based covered with slough periwound pink, no drainage . On 2/27/17, Surveyor reviewed R13's care plan and on 11/11/16, a focus area was initiated to care for R13's Diabetes Mellitus. The interventions for this focus area, did not include inspecting the resident's feet on a daily basis and reporting any changes. On 2/27/17 at 2:00 p.m., Surveyor interviewed RN-K regarding R13's wound on the top left foot. RN-K stated they are not considering this wound to be a pressure wound and do not believe it came from the cast or the ace wrap. RN-K stated the area was a scab and when the nurse found the wound on the left achilles, R13 was picking at the top of the left foot and then the nurse noticed the scab. On 2/27/17 at 1:45 p.m., Surveyor interviewed DON-G regarding R13. DON-G stated they became aware of the top of the left foot wound on 1/31/17 when they saw the achilles wound. DON-G stated they do not consider it a pressure wound because it was blanchable, pedal pulse was good and it was not in an area where the cast was or the edge of the Ace wrap. DON-G stated the orthopaedic doctor never mentioned any wounds to the facility. DON-G indicated they did not have an order to remove the Ace wraps and in the past, the orthopaedic doctor stated not to touch the left leg. DON-G verified, facility staff did not contact orthopaedic doctor's office to find out how often the Ace wraps should be removed and stated she would have expected nursing staff to remove the Ace wraps daily and complete a skin check. DON-G verified diabetic foot care was not completed for 5 days in November, 9 days in December and for the entire month of January. DON-G provided information to show the facility identified a problem with diabetic foot checks on 2/1/7 and trained nursing staff on the importance of completing diabetic foot care on 2/6/17.

Based on interviews, observations and record review the Facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This is evidenced by the number and seriousness of the citations issued at this survey. F309 was cited at an IJ (immediate jeopardy) when the Facility failed to assess a Resident (#15) with a change of condition & did not provide CPR (cardiopulmonary resuscitation) to a Resident who wished to have CPR and did not use a [MEDICAL CONDITION] machine on a Resident #40 during the first night of admission & did not get an order for [REDACTED]. F327 was cited at an IJ when the Facility failed to monitor Resident 14's fluid intake according to their individual calculated requirements to maintain proper hydration. The Resident was admitted to the hospital with [REDACTED]. F441 was cited at an IJ when the Facility did not have an effective infection control program to prevent the spread of a[DIAGNOSES REDACTED] ([MEDICAL CONDITIONS]) outbreak. F490 was cited at an IJ as the Facility has not been administered in a manner that enables it to use its resources effectively and efficiently to maintain the highest practicable physical, mental & psychosocial well-being of each Resident. *Twenty seven (27) Federal deficiencies are issued during this recertification and complaint survey. This deficiency at F490 has the potential to affect all 57 residents of the facility. The failure to ensure that the Facility was administered in a manner that enabled to use its resources in a manner that promoted the health, safety, and well being of residents created a finding of immediate jeopardy, which began on [DATE]. The facility administration was notified of the immediate jeopardy on [DATE] at 3:58 p.m. The immediate jeopardy was not removed at the conclusion of the survey on [DATE]. Findings include: The facility's administrative staff, which includes the administrator, department managers and nurse managers, are responsible for ensuring that facility policies and procedures are being operationalized and implemented in each department and that all systems are in place to safeguard residents and to ensure each resident is attaining or maintaining his or her highest practicable physical, mental and psychosocial well-being. This oversight and management was not effectively being done, as evidenced by the following deficiencies: 1.) The Facility did not ensure there is consistent code status in Resident's medical records (Cross reference F155, scope & severity D; potential for harm/isolated). 2.) The Facility did not ensure that written notice for payment change was provided to a Resident and/or their legal representative. (Cross reference F156, scope & severity D; potential for harm/isolated). 3.) The Facility did not ensure that Resident's personal and clinical records were kept confidential. (Cross reference F164, scope & severity E; potential for harm/pattern). 4.) The Facility did not ensure that grievances were resolved. (Cross reference F166, scope & severity E; potential for harm/pattern). 5.) The Facility did not thoroughly investigate and report to the State agency allegations of abuse, mistreatment, neglect and misappropriation of resident property. (Cross reference F225, scope & severity F; potential for harm/widespread.) 6.) The Facility did not ensure operationalize their abuse policy & procedure, the Facility's Elder Justice policy did not indicate which police department should be notified, and a CNA (Certified Nursing Assistant) did not know who to report an allegation of mistreatment to if the alleged staff member was the Administrator. (Cross reference F226, scope & severity F; potential for harm/widespread). 7.) The Facility did not ensure that a Resident was cared for in a dignified manner. (Cross reference F241, scope & severity D; potential for harm/isolated). 8.) Three Residents were observed with their call lights not in reach. (Cross reference F246, scope & severity D; potential for harm/isolated). 9.) A Resident's cognition, mood and behavior assessment was not completed. (Cross reference F272, scope & severity D; potential for harm/isolated). 10.) A Resident's toileting, catheter and infection care plan was not updated. (Cross reference F280, scope & severity D; potential for harm/isolated). 11.) A Resident's plan of care was not being followed regarding his communication board. (Cross reference F282, scope & severity D; potential for harm/isolated). 12.) The Facility failed to assess a Resident with a change of condition and did not provide CPR (cardiopulmonary resuscitation) to a Resident who wished to have CPR, did not ensure that a Resident who required the use of a wound vac had the wound vac working properly, and did not comprehensively assess a Resident for pain. (Cross reference F309, scope & severity J; immediate jeopardy/isolated). 13.) The Facility did not implement interventions to prevent pressure ulcers for a Resident. (Cross reference F314, scope & severity D; potential for harm/isolated). 14.) The Facility did not ensure that Residents with indwelling catheters had a medical justification for their continued use. (Cross reference F315, scope & severity D; potential for harm/isolated). 15.) The Facility did not follow interventions to prevent accidents. (Cross reference F323, scope & severity D, potential for harm/isolated). 16.) The Facility did not monitor Resident's fluid intake according to their individual calculated requirements to maintain proper hydration. (Cross reference F327, scope & severity J, immediate jeopardy/isolated). 17.) The Facility did not ensure that Resident's were not receiving unnecessary medication and did not adequately monitor a Resident's medication. (Cross reference F329, scope & severity D, potential for harm/isolated). 18.) The Facility did not ensure that there were sufficient nursing staff on duty to meet the needs of the Residents. (Cross reference F353, scope & severity F; potential for harm/wide spread). 19.) The Facility did not ensure that the nurse staff posting data was posted as required. (Cross reference F356, scope & severity C; no actual harm with potential for minimal harm/widespread). 20.) The Facility did not ensure that pureed food was prepared using a recipe and that there was a recipe for the food item. (Cross reference F364, scope & severity D; potential for harm/isolated). 21.) The Facility did not ensure that it provided pharmaceutical services to meet the needs of the Residents. (Cross reference F425, scope & severity E; potential for harm/pattern). 22.) The Facility did not have an effective infection control program to prevent the spread of a[DIAGNOSES REDACTED] ([MEDICAL CONDITION]) outbreak and staff did not perform proper hand hygiene. (Cross reference F441, scope & severity L; immediate jeopardy/widespread). 23.) The Facility did not ensure that a sanitary environment was provided in the Resident rooms, bathrooms, hand rails, and for Resident's wheelchairs. (Cross reference F465, scope & severity E; potential for harm/pattern). 24.) The Facility is not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This is cited at F490, Immediate Jeopardy, scope & severity level L: immediate jeopardy/widespread. 25.) The Facility did not ensure that four out of five CNA's (Certified Nursing Assistants) had yearly performance evaluations. (Cross reference F497, scope & severity F; potential for harm/widespread). 26.) The Facility did not ensure that Resident's medical records were accurately documented. (Cross reference F514, scope & severity D; potential for harm/isolated). 27.) The Facility did not ensure that the medical records were stored in a manner that would protect the records in the event of a fire and the sprinklers were activated. (Cross reference F516, scope & severity C, no actual harm with potential for minimal harm/widespread). The failure to ensure that the facility is administered in a manner that enabled it to use its resources in a manner that promoted the health, safety, and well-being of residents created a finding of immediate jeopardy.

Based on observation, interview and record review, multiple facility staff did not adhere to accepted current infection control standards of practice while providing care for 3 of 15 sampled residents (#5, #7, and #4), plus one supplemental Resident (#34). * Staff did not follow standards of practice regarding infection prevention while providing care to Resident #34 on the 100 unit, or for Residents #5 and #7, who reside on the 400 unit a few rooms apart; all three residents reportedly were infected with clostridium difficile (c. diff.) * The Infection Preventionist, DON (Director of Nursing)-B, had Resident #5 on the unit line listing as having [DIAGNOSES REDACTED], but did not list Resident #7 on the November log. DON-B stated she needed to carry over Resident #7's information from October because his infection started in October. A review of the October logs shows Resident #7 was only identified as having a UTI (urinary tract infection), not [DIAGNOSES REDACTED]. * Further review of the unit surveillance logs shows Resident #45 on the 300 unit also tested positive for [DIAGNOSES REDACTED]. on [DATE]. The surveillance log indicated a resolved date 3 days into the future. On [DATE], on Initial Tour, Resident #45 was not marked on the Roster Matrix as having any infection, nor was their signage on the outside of Resident's door alerting staff and visitors to see the nurse for further instruction. * Resident #34 had signage on the outside of his door alerting staff/visitors to see nurse for further instruction. Staff did not know whether Resident #34 had c.diff upon his return from the hospital. * On [DATE], RN-C was going to remove Residents #5 and #7 from contact isolation since RN-C was under the impression that Resident #5 and #7 had not had diarrhea for 48 hours. Surveyor # shared with RN-C that nurses notes indicate Resident #5 and #7 were still experiencing loose stool. * Staff did not follow accepted standards of practice regarding washing hands when hand-washing is indicated. * CNAs utilized a stained gait belt used for other residents with Resident #7 who had[DIAGNOSES REDACTED]. Visitors for Resident #7 were not wearing PPE for contact precautions and cross contaiminated the environment by disposing of Resident #7's soiled bedding into common use laundry carts and obtained clean bedding from the clean laundry storage closet. * Staff are not confined to just one unit, but float to multiple units to provide coverage, creating the opportunity to spread infections from one unit to another. The facility's failure to maintain an accurate survailance line listing of residents with infections, which identified the type of infection, correct on-set dates and resolved dates, to identify and know which residents were experiencing loose stool/C-diff and which residents needed to be in contact isolation, to know when a resident may be removed from contact isolation, to know when to wear and to actually wear personal protective equipment (PPD), to follow standards of practice with handwashing, to ensure communication to all staff regarding residents who have infections, (door signage, care cards, housekeeping/maintenance services), to ensure family/visitors are aware of infection control measures, in order to avoid cross contaimination created a finding of of Immediate Jeopardy beginning [DATE]. This deficient practice has the potential to affect all 57 Residents currently residing in the facility. On [DATE] at 4:19 p.m., Surveyor # informed NHA (Nursing Home Administrator)-A, RN Manager-G, Corporate RN-C and Executive Director-HH that a finding of Immediate Jeopardy was identified regarding Infection Control, beginning [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility implemented an action plan related to infection control. The deficient practice continues at a scope/severity level of F (potential for harm/pattern) as the facility continues to implement and monitor their action plan and infection control program under which it investigates, controls and prevents infections in the facility. Findings include: Centers for Disease Control (CDC) guidelines indicate that doctors, nurses, and healthcare personnel should clean their hands with soap and water or an alcohol-based hand rub before and after caring for individuals with[DIAGNOSES REDACTED]; should use contact precautions (gown and gloves) when in the room, and remove gown and gloves and wash hands when leaving the room. According to this source, The elderly and people with certain medical problems have the greatest chance of getting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] spores can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. (www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf <http://www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf>) Surveyor # reviewed the facility's Infection Control policies and procedures; all are effective July, 2015. The Infection Control Manual, Infection Prevention Chapter 7.3.12 states: Procedure: Subject-Criteria for Identification of Signs and Symptoms of Infection- Gastrointestinal (GI) Tract Infections: Clostridium Difficile Infection (both criteria 1 and 2 must be present): 1. One of the following GI subcriteria: a. Diarrhea: 3 or more liquid or watery stools above what is normal for the resident with a 24-hour period. b. Presence of toxic megacolon (abnormal dilation of the large bowel, documented radiologically). 2. One of the following diagnostic subcriteria: a. A stool specimen yields a positive laboratory test result for [DIAGNOSES REDACTED]icile toxin A or B, or a toxin-producing [DIAGNOSES REDACTED]icile organism is identified from a stool sample culture or by a molecular diagnostic test such as PCR; b. Pseudomembranous colitis identified during endoscopic examination or surgery or in histopathologic examination of a biopsy specimen. The facility's Infection Prevention and Control Program 1.1.1 Procedure states the facility uses a two-tier Transmission-Based Precautions: Standard Precautions plus Transmission-Based Precautions: Contact, Droplet, and Airborne. The facility's Infection Prevention policy 7.14.1 Two-Tier Transmission-Based Precautions: Contact Precautions states: The center will utilize Contact Precautions in addition to Standard Precautions, or the equivalent, for specified residents known or suspected to be infected with, epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin-to-skin contact that occurs when performing resident-care activities that require touching the resident's dry skin) or indirect contact (touching) with environmental surfaces or resident-care items in the resident environment. Procedure: Gloves and Handwashing: 1. Wear gloves when entering the room. 2. Change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). 3. Remove gloves before leaving the room and use appropriate hand hygiene immediately. Ensure hands do no touch potentially contaminated environmental surface or items in the room after glove removal. Gown (7.14.2) 1. Wear a gown (clean, nonsterile gown) when entering the room. 2. Remove the gown before leaving the resident environment and discard in appropriate container. Ensure clothing does not contact potentially contaminated environmental surfaces after gown removal. The facility's Policy Clostridium -difficile: Preventing Spread (9.2.1) states: Clostridium-difficile organism causes gastrointestinal infections that range in severity from asymptomatic colonization to server diarrhea, colitis, toxic megacolon and possible death Residents diagnosed with [REDACTED].Advise families, visitors, and residents about the importance of hand hygiene to minimize spread of fecal contamination to surfaces . 2. Utilize Contact precautions with every resident with an active [DIAGNOSES REDACTED]icile infection. Use contact precautions until 48 hours after diarrhea has ceased. 3. Wear clean, non-sterile gloves when entering the room or cubicle of a [DIAGNOSES REDACTED]icile infected resident. 4. Wear clean, non-sterile gowns when entering the room of a resident with an active C.difficile infection due to the environmental significance of the organism spores 5. Cleanse resident's hands thoroughly before leaving their room. 6. Remove gloves and gowns before leaving the resident's room and wash hands immediately with soap and water. 7. Ensure hands do not come in contact with environmental surfaces potentially contaminated with [DIAGNOSES REDACTED]icile (e.g. door knob) after removal of gloves and gown. 8. Dedicate the use of the following non-critical items such as stethoscope, sphygmomanometer, and gait belt, to a single resident or cohort of residents infected with c.diff. Use 10:0 diluted bleach or an EPA registered disinfectant with kill data against [DIAGNOSES REDACTED]icile spores daily to disinfect highly touched areas of residents room. Highly touched areas may include, but are not limited to: bed rails, drawer handles, toilet seat, toilet flush handle, sink, sink handles, bedside table, overbed table, electronic equipment e.g. television, bed controls 12. Do not order Post-Treatment Toxin Assay. (Surveyor Note: repeat (post-treatment) stool cultures for c.diff were ordered for Residents #7, 45, 46). Linens: 14. Collect linen in a manner that minimizes agitation to prevent contamination of the environment and personnel . 15. Place soiled linen in a plastic leak-proof bag at the site of use and place bag in a covered hamper in the area of use The facility's Hand Hygiene- Plain Soap and Water Handwash (7.6.1) states: Hand hygiene is the most important procedure for preventing Healthcare Associated Infections (Refer to CDC, 2002 Hand Hygiene Guideline) . A plain soap and water handwash will be used: -if hands are visibly soiled; -Before eating and after using a restroom; -If exposure to spores is suspect or proven, e.g. [DIAGNOSES REDACTED]icile . A plain soap and water handwash or an alcohol hand rub may also be used: -If hands are not visibly soiled. -Before having direct contact with residents. -Before inserting indwelling catheters, peripheral vascular catheters, other invasive devices that do not require a surgical procedure. -After contact with a resident's intact skin (e.g. when taking a pulse or blood pressure or lifting a resident). -After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressing if the hands are not visibly soiled. -During resident care if moving from a contaminated-body site to a clean-body site. -After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident. -After removing gloves. 1. On [DATE] at 12:35 p.m., Surveyor # observed LPN (Licensed Practical Nurse)-JJ pass noon medications on the 400 unit after she finished passing medications on the 200 unit (LPN-JJ was the nurse assigned/ covering both units.) Surveyor # had previously informed Surveyor # that LPN-JJ had stated on the initial tour of the facility that Resident #5 had the bowel infection, clostridium difficile (c. diff). Surveyor # observed a small sign on the door frame to Resident #5's room that said, See Nurse. At 12:35 p.m. LPN-JJ responded to Resident #5's room (on the 400 unit) because Resident #5 had her call light on. LPN-JJ entered Resident #5's room without donning a gown or gloves, turned the call light off, and went over to where Resident #5 was sitting in her recliner. Resident #5 ([AGE] years old) requested Tylenol for neck pain. Besides touching Resident #5's call light with her bare hands, LPN-JJ touched and moved Resident #5's over-the-bed table (OBT) that was directly in front of Resident #5, touched/held Resident #5's hand, touched the recliner and other items. Resident #5 had most likely previously touched (paper and box of tissues on OBT, remote control, etc.). Resident #5 had a visitor sitting on her bed at that time. LPN -JJ left Resident #5's room to get the Tylenol without washing her hands. LPN-JJ opened the MAR (Medication Administration Record) binder that was sitting on top of the medication cart, paged through multiple pages to get to Resident #5's page of PRN's (as needed medications), then after reviewing the order, opened the drawer and retrieved a stock bottle of Tylenol ([MEDICATION NAME]). LPN-JJ removed the cap, shook two tablets out of the bottle into a medication cup, put the cap back on the bottle, and put the bottle back in the drawer on the medication cart. LPN-JJ then re-entered Resident #5's room again without donning a gown or gloves, and took the Tylenol over to Resident #5 who was sitting in the recliner. LPN-JJ handed Resident #5 the cup of medication and Resident #5 tried to toss her head back to take the pills but her neck hurt her so she was unable to take the pills that way. Resident #5 said she can usually take her medications that way but her neck hurt that day- she thought she may have slept on it funny. LPN-JJ then took the Tylenol out of the cup with her bare hands (that have touched many contaminated items) and placed them in Resident #5's mouth. LPN-JJ then picked up Resident #5's Styrofoam cup of water with a straw in it and Resident #5 took a drink of water to help swallow the pills. LPN-JJ set the cup of water back on the OBT, moved the OBT closer to Resident #5, and touched other items on the OBT. Resident #5 mentioned she was cold. LPN-JJ first helped her put a sweater on, then took one afghan off Resident #5's bed and placed it on Resident #5. Resident #5 said she would like the other blanket, too, so LPN-JJ took a second blanket off the end of the bed and put it over Resident #5 also. LPN-JJ offered Resident #5 her neck pillow, which Resident #5 agreed to use so LPN-JJ put the neck pillow in place for Resident #5. Resident #5's visitor left at that time. LPN-JJ did not suggest the visitor wash his hands even though he had handled numerous items in Resident #5's room and was not wearing gloves. Surveyor # asked LPN-JJ if Resident #5's call light would reach from the wall all the way over to where her recliner is positioned, (Cross reference F246). LPN-JJ went to the wall where the call light was hanging, draped the call light over the bed, looped in over the foot of the bed to get it as close to Resident #5 as possible, but it still was not within reach of Resident #5. LPN-JJ touched Resident #5's call light, bedding, bed enabler bar/ grab bar, and the foot of the bed while moving the call light. LPN-JJ then left Resident #5's room without washing her hands. LPN-JJ went to the medication cart, used a pump-type bottle of hand antiseptic hand gel to clean her hands, picked up her pen, paged through the MAR, and initialed that she administered Tylenol to Resident #5. In addition to the small See Nurse sign, Surveyor # observed a plastic cart immediately inside Resident #5's room containing PPE (personal protective equipment) including disposable, yellow gowns, masks, and gloves. Surveyor # asked what the sign was for. LPN-JJ said Resident #5 has c.diff. (clostridium difficile- a bowel infection). LPN-JJ stated she was not doing cares so she didn't think she needed to wear gloves. LPN-JJ then asked Surveyor # if she should have worn gloves. Surveyor # referred LPN-JJ to her facility policies and procedures, her supervisor, the DON (Director of Nursing), Education Nurse or Infection Control Preventionist. Surveyor # reviewed an undated CNA (Certified Nursing Assistant) care card for Resident #5. The Care Card does not mention anything about Resident #5 having [DIAGNOSES REDACTED] or any precautions the CNAs should use. LPN-JJ stated that this was the current CNA care card in use for the 400 unit. A short time later, CNA-FF entered Resident #5's room to pick up her lunch tray. From the hall, Surveyor # could see CNA-FF did not don a gown or gloves, nor did she wash her hands before leaving Resident #5's room or after she set the tray on the cart with other room trays. CNA-FF touched several items on Resident #5's OBT, arranging them closer to Resident #5. CNA-FF then went in another Resident's room to retrieve another lunch tray. CNA-FF did not wash her hands before going in to the next Resident's room. Centers for Disease Control (CDC) guidelines indicate that doctors, nurses, and healthcare personnel should clean their hands with soap and water or an alcohol-based hand rub before and after caring for individuals with[DIAGNOSES REDACTED]; should use contact precautions (gown and gloves) when in the room, and remove gown and gloves and wash hands when leaving the room. According to this source, The elderly and people with certain medical problems have the greatest chance of getting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] spores can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. (www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf <http://www.cdc.gov/HAI/pdfs/cdiff/Cdiff_tagged.pdf>) On [DATE] at 1:06 p.m., LPN-JJ entered another Resident's room, (Resident #7) to administer several medications to him. LPN-JJ donned a gown and gloves prior to starting medication administration. Surveyor # observed an orange sign on Resident #7's door stating the Resident has an infection and you must wash your hands with soap and water and not use hand sanitizer. Surveyor # asked what infection Resident #7 had. LPN-JJ stated, c.diff. When asked why she was wearing a gown and gloves in Resident #7's room and not Resident #5's room, LPN-JJ did not reply. When asked, LPN-JJ stated she would not be doing cares. LPN-JJ had previously said she did not wear a gown or gloves in Resident #5's room because she was not going to perform cares with the Resident. LPN-JJ disposed of her gown and gloves in the open waste basket in the room. A large Rubbermaid-type covered garbage can was in the room near the PPE cart. Surveyor # asked what that container is for. LPN-JJ was not sure. On [DATE], Surveyor # observed CNA-GG enter Resident #5's room to pick up her breakfast tray without donning a gown or gloves. CNA-GG did not wash her hands before going in to the next Resident room to pick up a tray. On [DATE], Surveyor # reviewed Resident #5's medical record, which indicates Resident #5 has lived at the facility for several years. Resident #5 has multiple [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #5's Care Tracker Bowel and Bladder Chart Detail Report from [DATE] to [DATE]. This report indicates Resident #5 had 5 episodes of diarrhea between [DATE] to [DATE]. Diarrheal episodes are documented on: [DATE] 3:49 p.m., [DATE] at 6:31 p.m., [DATE] at 9:12 p.m., [DATE] at 10:05 p.m., and [DATE] at 9:23 a.m. Surveyor # reviewed Resident #5's Nurses' Notes and noted the following: On [DATE], Resident #5 had a temperature (T) of 100.9, given Tylenol, later T 99.9 axilary. Resident #5's physician ordered a urinalysis and chest x-ray. The chest x-ray identified probable aspiration pneumonia. On [DATE], Resident #5 was started on the antibiotic [MEDICATION NAME], 500 mg. (milligrams) once a day for 10 days, and the [MEDICATION NAME], twice a day for 14 days. The Mayo Clinic report on Antibiotic Associated Diarrhea (http://www.mayoclinic.org/diseases-conditions/antibiotic-associated-diarrhea/basics/causes/con- 556) states: Antibiotic-associated diarrhea occurs when antibacterial medications (antibiotics) upset the balance of good and bad bacteria in your gastrointestinal tract. The antibiotics most likely to cause diarrhea: Nearly all antibiotics can cause antibiotic-associated diarrhea, colitis or pseudomembranous colitis. The antibiotics most commonly linked to antibiotic-associated diarrhea include: · Cephalosporins, such as cefixime (Suprax) and [MEDICATION NAME] · [MEDICATION NAME] ([MEDICATION NAME]) · [MEDICATION NAME], such as [MEDICATION NAME] ([MEDICATION NAME], Larotid, others) and [MEDICATION NAME] · Fluoroquinolones, such as [MEDICATION NAME] (Cipro) and [MEDICATION NAME] ([MEDICATION NAME]) Clostridium difficile causes most serious antibiotic-associated diarrhea. The bacterium responsible for almost all cases of pseudomembranous colitis and many instances of severe antibiotic-associated diarrhea is [DIAGNOSES REDACTED]icile. Most people acquire a [DIAGNOSES REDACTED]icile infection during a stay in a hospital or nursing home after they've received antibiotics. Resident #5's Nurses' Notes on [DATE] at 8:00 a.m. and 12:00 p.m. state Resident #5 has no adverse reaction to the antibiotics. Notes at 9:30 p.m. state Resident #5 complained of stomach pain and received Tylenol, writer noted Resident had gas, last bowel movement yesterday, denies constipation . Resident #5's CareTracker Bowel record documents Resident #5 had watery diarrhea on [DATE], documented at 9:32 a.m., yet none of the nurses notes reflect this. Again on [DATE] at 10:05 p.m., CareTracker documentation indicates Resident #5 had watery diarrhea, but the Nurses' Notes make no mention of it. The only note dated [DATE] is documented at 2200 (10:00 p.m.) noting no adverse reaction status [REDACTED]. CareTracker notes diarrhea on [DATE] at 9:12 p.m. Nurses' Notes ,[DATE]-,[DATE] note Resident #5 prefers to stay in bed, little appetite, accepting fluids. The Nurses' Note on [DATE] at 9:30 p.m. states Resident #5 was incontinent of urine and stool, unable to obtain stool specimen this shift .bowel sounds present x 4 . Nurses' Notes dated [DATE] at 8:00 p.m. indicate a stool specimen for [DIAGNOSES REDACTED] was obtained. Notes dated [DATE] at 6:30 a.m. indicate the stool specimen tested positive for [DIAGNOSES REDACTED]icile and Resident #5 was placed in contact isolation. Notes on ,[DATE] at noon indicate Resident #5 started on [MEDICATION NAME] 250 mg. (milligrams)/ 5 mL (milliliters) four times a day for 14 days, plus [MEDICATION NAME] for GI (gastrointestinal) health. Resident #5 did not want to get out of bed, continued having loose stools, incontinent of stool x 3 . Notes dated [DATE] at 9:15 p.m. state Large watery stool x 2, refused supper . Surveyor noted the CareTracker Bowel record does not indicate Resident #5 had watery stool between [DATE] at 9:12 p.m. until [DATE] at 6:31 p.m., then the last watery/diarrhea entry was [DATE] at 3:49 p.m. A note dated [DATE] at 9:25 a.m. from DON (Director of Nursing)-B states IDT (interdisciplinary team) aware of Resident isolation due to [DIAGNOSES REDACTED]. Nurses' Notes on [DATE] at 5:00 a.m. and 2200 (10:00 p.m.) state Resident #5 had loose stools. Notes on [DATE] at 11:05 a.m. state loose stool x's 1 noted this shift. Notes during this time indicate Resident #5 was spending most of her time in bed, did not feel well and was eating little. Nurses' Notes on [DATE] at 7:00 a.m. state No adverse effects to antibiotics noted. One XLG (extra large) loose stool during the night. On [DATE] at 10:40 a.m., Surveyor # interviewed DON-B, who serves as the Infection Preventionist at the facility. DON-B showed Surveyor # a UTI (urinary tract infection)/GI Infection Surveillance Worksheet for Resident #5 completed by RN Manager-G on [DATE]. The form notes: Onset of Symptoms: [DATE]; Resolution of Symptoms: [DATE]. Surveyor # asked how they knew Resident #5's symptoms would resolve by [DATE]- one week in the future. DON-B stated that is the day the antibiotics will be completed, not the date the symptoms resolved. The Worksheet indicates Resident #5 has c.diff (clostridium difficile). DON-B provided Surveyor # with the Monthly Line Listing/Monthly Healthcare Associated Infection Incidence Rate document for [DATE] on the 400 Wing. The only name listed is Resident #5. It documents Resident #5 had start of symptoms on [DATE], culture taken [DATE], positive for [DIAGNOSES REDACTED]., antibiotics/[MEDICATION NAME] started [DATE], the infection met CDC (Centers of Disease Control) definition, contact precautions in place, and the infection is classified as a healthcare associated infection. Surveyor # asked if LPN-JJ should have worn PPE when administering medications and performing other tasks for Resident #5. DON-B stated LPN-JJ should have at least had gloves on, and wash her hands before leaving the room. DON-B stated the CNAs should wear gloves to pick up room trays for Residents in contact precautions, and wash their hands when they remove the gloves. Surveyor # asked DON-B why Resident #7 is not on the Line Listing. DON-B stated she needed to bring Resident #7's information forward from her October log because his infection started in October. Surveyor # reviewed the October Line Listing and noted for Resident #7, it only notes he had a UTI (urinary tract infection); Onset [DATE], urinalysis [DATE] was negative and Resident #7 was sent to the hospital. The listing indicates Resident #7's admitted is several years earlier, and he has a healthcare associated infection. There is no indication in DON-B's Infection Control records (Line Listing, Infection Surveillance Worksheets, lab reports, etc.) that Resident #7 has c.diff. (See below for further details regarding Resident #7). Surveyor # stated surveyors have been informed by nursing staff on tour that Resident #7 had c.diff. There are only two rooms between Resident #7's room and Resident #5's room. The line listing for the 300 unit shows Resident #45 tested positive for [DIAGNOSES REDACTED] on [DATE], with symptoms starting [DATE]. Surveyor # noted she conducted the Initial Tour of the 300 unit and Resident #45 is not identified on the Roster Sample Matrix as having an infection, nor was there a sign outside Resident #45s door alerting staff and residents of the need to see the nurse for further instructions. DON-B's 300 Unit line listing has a hand-written column stating resolved. Here ,[DATE] is entered. Surveyor # asked how they knew Resident #45's [DIAGNOSES REDACTED] would be resolved three days into the future. DON-B stated she uses resolved to mean the last date of the antibiotics are administered. Surveyor # reviewed the lab results for Resident #45 with DON-B, which indicate a stool sample was obtained on [DATE]. On [DATE], with the results positive for [DIAGNOSES REDACTED]., staff obtained new orders for [MEDICATION NAME] ([MEDICATION NAME]) 500 mg. (milligrams) TID (three times a day) x 2 weeks. Recheck stool on day 15. [MEDICATION NAME] x 2 weeks. The information printed on the lab results sheet states, This test should not be used as a test of cure. Cure is clinical. Do not submit additional specimens within one week . The UTI/GI Surveillance Worksheet completed for Resident #45 states the [MEDICATION NAME] was started on [DATE] for [DIAGNOSES REDACTED]. and will be stopped on [DATE]. DON-B did not know why she entered ,[DATE] as the resolved date. Surveyor noted on [DATE], Surveyors were provided with updated information regarding current infection control status in the facility at that time. A facility map provided to Surveyor # has Resident #45's room highlighted, noting + (positive for [DIAGNOSES REDACTED].) on [DATE], resolved [DATE]. A review of Resident #45's MAR shows she completed the [MEDICATION NAME] on [DATE]. It is unknown why there are multiple resolved dates, and DON-B was not present at the facility on [DATE] for further questions. Surveyor # asked DON-B what constitutes an outbreak of c.diff. DON-B stated if two or more residents on the same unit had the same type of infection, they would be on alert, they would consider that an outbreak. Surveyor # asked if she was aware Resident #7 had c.diff. DON-B stated she thinks she may have been informed, but could not remember when (October or November). Surveyor # asked if she considered Resident #5 and Resident #7 a few rooms apart on the same unit an outbreak. DON-B stated she would look into it. Surveyor # noted it has been a week since Resident #5 was diagnosed with [REDACTED]. DON-B stated she would review the records. Surveyor # noted that during the two days on site thus far, it is noted that staff float from one unit to another, nurses and CNAs, and may work one shift on one unit and work on another unit for the next shift or part of the next shift. With staff floating, and if they are not following standards of practice regarding wearing gowns and gloves while caring for a Resident with c.diff, could they not spread the infection to another unit? DON-B stated that would be possible. Surveyor # reviewed monthly summaries titled, Monthly Healthcare Associated Infection Incidence Rate for July, August, September and October and noted no residents had any healthcare associated GI illness during those months. Surveyor # requested facility policies regarding infection control, including identifying and management of an outbreak. DON-B stated the normal process for reviewing who has what infections in the facility is that she takes the information to the morning meeting and they review any new information, residents with signs and symptoms of infection, new antibiotics orders, etc. On weekends, the nursing supervisor calls twice a shift to keep updated on new information, and staff can also call the on call supervisor with questions. When Surveyor # first approached DON-B, she was looking in a resident's chart. DON-B said a dietary staff member had just come to her asking if she could go into a Resident's room because there was a sign on a room on the 100 unit saying: Isolation-See Nurse Before Entering, and there is a cart with PPE inside the room. DON-B did not know why that sign was on the door, and needed to research it before we could meet. Then DON-B stated after reading through dozens of pages of hospital records, the resident tested positive for c.diff in the hospital on [DATE], and returned to the facility on [DATE], and that is why the See Nurse sign is on the door. DON-B then added Resident #34 to the [DATE] unit Line Listing; Resident #34 was then the only Resident documented of the 100 unit infection control line listing. Surveyor # asked why DON-B did not add the Resident (#34) to the line listing when he returned on [DATE]. DON-B stated they have been very busy. A short time later, RN Manger-G informed Surveyor # that they further researched the See Nurse sign on Resident #34's door and learned Resident #34's c.diff had cleared before he was readmitted to the facility and he did not require the sign. Resident #34 did not have the [DIAGNOSES REDACTED]. However, in October, the Resident's roommate had a UTI and was treated with antibiotics for 5 days, and an isolation cart with PPE was placed in the room and the sign was put on the door. RN-G stated they must have forgotten to remove the sign and cart from the room. Surveyor # asked how staff are supposed to function if they can ignore some of the signs because they are expired, but others are current. RN-G stated they give report to CNAs, but acknowledge the signs should reflect a Resident's current status. On [DATE] at 12:44 p.m., RN Corporate Consultant-C provided Surveyor # with several Infection Control Policies and Procedures, but none that addressed outbreak identification and management. RN-C stated they are still looking for that policy. On [DATE] at 4:19 p.m., Surveyor # informed NHA (Nursing Home Administrator)-A, RN Manager-G, Corporate RN-C that a finding of Immediate Jeopardy was identified regarding F441, Infection Control. On [DATE], RN-C stated that they had reviewed the records for Residents #5 and #7, and since they have not have diarrhea for 48 hours, they were removing them from contact isolation, and deep cleanin

Based on record reviews and staff interviews, the facility did not ensure residents received sufficient fluid intake based upon assessment to maintain proper hydration and health for 2 (Resident #14 and #2) of 4 sampled residents and 2 (Resident #32 and #33) supplemental residents. Resident #14's assessed fluid needs were not sufficiently monitored by the facility. The facility Dietitian was only alerting nursing staff when fluid intake was 1 liter or less in a 24 hour period for all residents in the facility and not accounting for individual fluid needs. Resident #14 was assessed for fluid needs between 1375 - 1650 ml (milliliter) a day. Resident #14 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Resident #14's estimated free water deficit was 5.1 liters. The facility's failure to ensure that Resident #14 received sufficient fluids to ensure proper hydration created a finding of immediate jeopardy. The immediate jeopardy began on 10/18/15. Administrator-A and Corporate Consultant-C were informed of the immediate jeopardy on 11/16/15 at 1:35 p.m. The immediate jeopardy was removed on 11/20/15. The deficient practice continues at a scope and severity (s/s) of an E - potential for harm pattern as the facility continues to implement their action plan for the individuals at risk for dehydration in the facility and as evidenced by the following: The facility did not have evidence that Resident #2, #32 and #33's fluid intake was adequately monitored according to their assessed daily fluid needs. Findings include: On 11/16/15 at 8:45 a.m. Surveyor # reviewed the facility's Hydration policy and procedure, dated July 2015, with RD-H (Registered Dietitian). The policy and procedure indicates The center strives to outline Nutrition Services responsibilities and management of a resident with a history, a diagnosis, symptoms, and/or risk of dehydration. The procedures include the following: 1. Calculate fluid requirements for all residents upon admission, changes in condition and as deemed necessary. 2. Identify causes and risk factors-fluid loss and increased fluid needs, functional impairments, Dementia, refusal of fluids and thickened liquids. 3. Monitor for physical signs of dehydration 4. Monitor and evaluate biochemical data to assess hydration status. 9. Provide a minimum of 1500 cc/a day with meals unless contraindicated. 10. Provide thickened liquids as needed. 13. Develop individualized interventions to reduce/ prevent risk of dehydration. 14. Review interventions as needed for effectiveness and revise as applicable. According to a study published by the National Institute of Health (<http://www.ncbi.nlm.gov/pubmed/ 084>), an overall mortality rate of 29.8% was found in elderly persons who were hospitalized with dehydration. This increased to 33.3% for those whose sodium levels were 151-153 and to 71.4% whose sodium levels exceeded 154. 1.) Resident #14's medical record was reviewed due to a complaint intake that included dehydration concerns. Resident #14 resided in the facility from [DATE] - 10/18/15 and has a [DIAGNOSES REDACTED]. The nurse's notes indicate that on 10/18/15 Resident #14's family visited, Resident #14 appeared lethargic and they requested Resident #14 be sent to the hospital. Resident #14 was admitted into the hospital on [DATE]. The emergency department notes for 10/18/15 were reviewed and include the following: lethargy, leukocytosis of 17.8, glucose of 313, sodium of 160, chloride of 121 and BUN (blood urea nitrogen) of 81. An estimated free water deficit of 5.1 liters. Resident #14 was admitted and treated for [REDACTED]. Resident #14's most recent MDS (minimum data set) assessment was a Significant Change in Status MDS completed 8/17/15. The BIMS (brief interview for mental status) score is 7 of 15 indicating Resident #14 is moderately cognitively impaired. Resident #14 is non-ambulatory and requires total staff assist for all activities of daily living, including eating. Resident #14 requires extensive assistance of 1 staff person to assist with eating/oral intakes. Resident #14 also receives a pureed diet with thickened liquids. Resident #14's weight is entered as 139 pounds. The CAA (care area assessment) for Nutritional Status completed 8/21/15 by RD-H indicates Resident #14 has great oral intake, staff assist with eating in the dining room, their food and fluid intake is monitored daily, with fluid intake around 1400 cc a day. Resident #14 receives a pureed diet with honey thick liquids. The Nutrition Risk Data Collection and assessment dated [DATE], assessed Resident #14's estimated fluid needs to be 1375 - 1650 a day. The last nutritional note was dated 9/10/15, and indicates a 9 pound weight loss in a month, and also indicates Resident #14 has adequate fluids. The plan of care for Nutrition Risk, revised 9/10/15, indicates risk factors of [MEDICAL CONDITION], potential for dehydration, diabetes, mechanical altered diet and weight loss. The interventions indicate to provide prescribed pureed diet with honey thick liquids, monitor for signs of dehydration, encourage fluids, monitor fluid intake daily, monitor weights monthly, and assist with meals. On 11/12/15 at 2:45 p.m. Surveyor # spoke with RD-H regarding fluid monitoring. RD-H indicated they run a fluid report the days she works. RD-H works Monday, Tuesday, Thursday and Friday. RD-H does not know who runs a fluid report when she is not in the facility. RD-H explained that the fluid report is for any resident whose intake is 1 liter (1 liter is equal to 1000 ml) or less in the past 24 hours. For the residents that are on the report as receiving 1 liter or less, they are mentioned in morning report. Then the Nurse Mangers pass on the information to the staff. The nursing staff would also perform a hydration assessment and encourage more fluids. RD-H indicated that a resident would not trigger a dehydration assessment unless they had 1 liter or less. Resident #14's fluid intake reports were requested for the 2 weeks up to hospital admission on 10/18/15. RD-H indicated she does not keep the documents for residents that triggered for 1 liter of fluid or less. RD-H did not know if Resident #14 had triggered for fluid deficit. Surveyor # reviewed Resident #14's daily fluid intakes from 10/5/15 - 10/18/15. These daily intakes were tallied and compared to Resident #14's nurses notes. 10/5/15 fluid total was 780 cc and a nurses note indicates fluids were encouraged; 10/6/15 fluid intake was 970 cc and no nurses note regarding fluids; 10/9/15 fluid intake was 630 cc and no nurses note regarding fluids; 10/15/15 fluid intake was 660 cc and no nurses note regarding fluids; 10/17/15 fluid intake was 990 cc and no nurses note regarding fluids; 10/18/15 fluid intake was 940 cc and no nurses note until Resident #14 was sent out to the hospital. On 11/12/15 at 2:53 p.m. Surveyor # spoke with CC-C (Corporate Consultant) and requested any documentation or monitoring, related to dehydration for Resident #14 leading up to the hospital admission on 10/18/15. On 11/16/15 at 8:00 a.m. CC-C provided a nurse's note dated 10/12/15 that mentions mucous membranes. There was no any additional information to show Resident #14's hydration status/intake was being monitored despite her fluid intake amounts being significantly less than she was assessed as needing. On 11/16/15 at 8:05 a.m. Surveyor # spoke with Resident #14's Nurse Manager RN-G (Registered Nurse). RN-G indicated that the Dietitian will pull a list off of Caretracker for residents at risk for dehydration. RN-G does not recall Resident #14 being triggered for dehydration. RN-G indicated that the Dietitian will let them know who was on the fluid list. They would then do a physical assessment and make a note in the nurse's note section of the chart. RN-G indicated there is not a separate form for a dehydration assessment. RN-G indicated when a resident is flagged for dehydration they would follow-up in another 24 hours to make sure it was addressed. RN-G did not recall any fluid concerns with Resident #14. Because Resident #14 did not trigger for 1 liter or less no additional documentation was performed. Surveyor # noted that Resident #14 did have fluid intake that was less than one liter and still did not trigger for further review or monitoring. On 11/16/15 at 8:45 a.m. Surveyor # spoke with RD-H regarding daily fluid reports and the standard of practice the facility follows. RD-H indicated they run the 1 liter or less report because that was what the previous Dietitian did for fluid monitoring. RD-H did not have a standard of practice for using the 1 liter or less criteria for daily fluid intake. RD-H did not indicate why an individual's fluid needs were not part of the fluid reports. RD-H did provide the facility's policy and procedures for Hydration. This policy and procedure did not include a reference to 1 liter a day being a benchmark for further assessment or monitoring. On 11/16/15 at 11:15 a.m. Surveyor # spoke with RD-H regarding the facility fluid monitoring process. RD-H indicates the 1 liter or less fluid reports are run from the Caretracker system on the days they work. Those reports are reviewed for any related factors related to fluid deficit for example, new admissions or [DEVICE]s. RD-H indicated then residents on the report are brought to morning meetings. They also are identified on the plan of care. RD-H indicated no specific staff is assigned to complete/calculate daily fluid totals that a resident is actually assessed for. The only fluid monitoring report is the 1 liter or less, which would not capture dehydration if a resident is assessed for over 1 liter a day but is not meeting assessed need. There is not a system that monitors resident daily fluid totals, regardless of the 1 liter or less reports. The facility did not have a sufficient system in place to monitor a resident's actual fluid needs on a daily basis. The facility did not have a sufficient assessment process to capture and monitor residents at risk for dehydration. This created a finding of immediate jeopardy. This was removed on 11/20/14 by which time the facility had: The facility completed a Quality Assurance review of Resident #14's medical record. All licensed nursing staff, CNAs and other staff were trained on policies and procedures related to fluid intake monitoring and hydration status specific to ensuring accurate recording of resident's fluids, assessment to determine those who are clinically at risk for dehydration, and ongoing monitoring for residents determined to be at risk for dehydration. All residents were reviewed for nutritional risk data collection and assessments to ensure fluid needs are calculated. Physical assessments were completed on all residents to ensure no physical signs of dehydration. Any resident with signs and symptoms was referred to the MD for further review. The facility initiated 72 hour intake monitoring of all residents to establish baseline pattern The registered dietitian is to calculate fluid requirements for all residents. The facility will ensure 1500 ml of fluids on meal trays per physician order. The facility established a system to monitor the intake of all residents. If < (less than) 1500 ml with meals is notes, the nurse will document and place the resident on the 24 hour report for further monitoring. Care tracker fluid intake monitoring has been established. Care plans have been revised based upon assessment. The facility will review residents at the daily clinical meeting. The deficient practice continues at a scope/severity of E (potential for harm that is not immediate jeopardy/isolated) as evidenced by: 2.) Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11-10-15 at 9:15a.m. Surveyor # reviewed the medical record of Resident #2. Resident #2 was placed onto Hospice on 9-4-15. Review of the Nutrition Risk Data Collection and Assessment form for Resident #2, with a last entry dated 9-18-15, notes the estimated fluids to meet Resident #2's needs are 1600 cc to 1920 cc per day. This form was not reviewed or updated when Resident #2 was placed onto Hospice. The Nutrition Risk Care Plan dated 9-2015 notes under interventions to monitor for dehydration, encourage fluids unless contraindicated, monitor fluid intake daily. Under Other it notes: Transitioned to hospice. On 11-16-15 at 2:10p.m. Surveyor # received the Fluid Intake Detail Report for Resident #2 from Dietitian-H with the following intake amounts: 11-10-15 intake 1460 cc. No nurses notes on this day. Intake for dates 11-11-15 and 11-12-15 not provided. No nurses notes for either day 11-13-15 intake 360 cc. Nurses notes state that 100ml (milliliters) of output for am shift. Resident requested milk. No food eaten. 11-14-15 intake 520 cc. No nurses notes for this day. 11-15-15 intake 920 cc. No nurses notes for this day. On 11-16-15 at 11:30a.m. Surveyor # interviewed the Dietitian-H regarding the intake not being adequately monitored for Resident #2 according to the Nutrition Risk Care Plan form for 1600 cc to 1920 cc per day. Dietitian-H stated that they do not follow that close once a resident is on hospice. Dietitian-H stated they put intake on Caretracker but she does not share this at the daily meeting due to a resident being on hospice and due to comfort measures. 3.) Surveyor # reviewed Resident #32's medical record on 11/16/15. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The nutrition risk care plan dated 10/15 includes interventions of provide diet as ordered: Reg (regular) nectar thick, honor food preferences, monitor intake of meals and offer alternate, monitor weights: as ordered, monitor for signs of dehydration, and encourage fluids unless contraindicated. The nutrition risk data collection and assessment dated [DATE] documents diet order as Reg/Nectar Thick. Under typical intake for fluid (with meals) is documented as 1000 ml (milliliters). Under estimated fluid to meet needs is documented 1650-1950. Assessment summary documents Res. (Resident) admitted after hosp. (hospitalization ) for aspiration pna (pneumonia). Nutritional assessment Res. on regular diet with thickened liq. (liquids). Has good po (by mouth) intake. Cannot st. (state) needs d/t (due to) nursing not obtaining weight. Nutrition dx (diagnosis) none at this time. Intervention Reviewed basic nutrition for wellness. Encourage fluids. The nurse's note dated 10/18/15 documents Res. (Resident) A&OX3 (alert and orientated times three) O2 (oxygen) at 2 L (liters) via nc (nasal canula). Nectar thick fluids offered and accepted. Without s/s (signs symptoms) of dehydration. Resident on general diet and family informed writer that res. does not eat fish or chicken. Res. able to make needs known. The nurse's note dated 10/21/15 documents A&OX1 self. LCTA (lungs clear to auscultation). BS (bowel sounds) x 4 (+) (plus). without c/o (complaint of) pain. Without sob (short of breath). Up with 1 assist. 2 L O2 via n.c. (I) (independent) with meals. Nectar thick liquid offered and accepted. VSS (vital signs stable). The nurse's note dated 10/24/15 documents A&OX0 self, LCTA, without SOB, VSWNL (vital signs within normal limits), eats in his room, without s/s of dehydration, mucus membranes moist, nectar thick liquids tolerated, without SOB, on 2L of O2, makes needs known, will continue to monitor. The nurse's note dated 11/3/15 documents Skin turgor adequate. fluids taken as per offered. The nurse's note dated 11/6/15 documents Resident comfortable appears sleeping when assessed. VSS (vital signs stable) without fever fluids @ (at) bedside and encouraged dislikes thickened fluids. Skin turgor WNL (within normal limits). Oral mucosa is pink continue to monitor. The nurse's note dated 11/11/15 documents Without s/s of hydration, mucus membranes moist, skin turgor < (less) 3 sec. (seconds), fluids offered & accepted with med pass & meals. On 11/16/15 Surveyor # reviewed the I/O (intake/output) chart detail report for Resident #32 and noted the fluid intake is as follows: 10/17/15 Resident #32 consumed 1070 cc (cubic centimeter) which is 580 cc less than the low end of the estimated fluid need. The estimated fluid need is 1650 cc to 1950 cc per nutrition assessment dated [DATE]. 10/18/15 Resident #32 consumed 920 cc which is 730 cc less than the low end of the estimated fluid need. 10/19/15 Resident #32 consumed 680 cc which is 970 cc less than the low end of the estimated fluid need. 10/20/15 Resident #32 consumed 790 cc which is 860 cc less than the low end of the estimated fluid need. 10/21/15 Resident #32 consumed 960 cc which is 690 cc less than the low end of the estimated fluid need. 10/22/15 Resident #32 consumed 1080 cc which is 570 cc less than the low end of the estimated fluid need. 10/23/15 Resident #32 consumed 730 cc which is 920 cc less than the low end of the estimated fluid need. 10/24/15 Resident #32 consumed 720 cc which is 930 cc less than the low end of the estimated fluid need. 10/25/15 Resident #32 consumed 1200 cc which is 450 cc less than the low end of the estimated fluid need. 10/26/15 Resident #32 consumed 1200 cc which is 450 cc less than the low end of the estimated fluid need. 10/27/15 Resident #32 consumed 570 cc which is 1080 cc less than the low end of the estimated fluid need. 10/28/15 Resident #32 consumed 940 cc which is 710 cc less than the low end of the estimated fluid need. 10/29/15 Resident #32 consumed 960 cc which is 690 cc less than the low end of the estimated fluid need. 10/30/15 Resident #32 consumed 960 cc which is 690 cc less than the low end of the estimated fluid need. 10/31/15 Resident #32 consumed 780 cc which is 870 cc less than the low end of the estimated fluid need. 11/01/15 Resident #32 consumed 770 cc which is 880 cc less than the low end of the estimated fluid need. 11/02/15 Resident #32 consumed 960 cc which is 690 cc less than the low end of the estimated fluid need. 11/03/15 Resident #32 consumed 830 cc which is 820 cc less than the low end of the estimated fluid need. 11/04/15 Resident #32 consumed 700 cc which is 950 cc less than the low end of the estimated fluid need. 11/05/15 Resident #32 consumed 900 cc which is 750 cc less than the low end of the estimated fluid need. 11/06/15 Resident #32 consumed 720 cc which is 930 cc less than the low end of the estimated fluid need. 11/07/15 Resident #32 consumed 640 cc which is 1010 cc less than the low end of the estimated fluid need. 11/08/15 Resident #32 consumed 640 cc which is 1010 cc less than the low end of the estimated fluid need. 11/09/15 Resident #32 consumed 696 cc which is 954 cc less than the low end of the estimated fluid need. 11/10/15 Resident #32 consumed 640 cc which is 1010 cc less than the low end of the estimated fluid need. 11/11/15 Resident #32 consumed 400 cc which is 1250 cc less than the low end of the estimated fluid need. 11/13/15 Resident #32 consumed 600 cc which is 1050 cc less than the low end of the estimated fluid need. 11/14/15 Resident #32 consumed 440 cc which is 1210 cc less than the low end of the estimated fluid need. 11/15/15 Resident #32 consumed 740 cc which is 910 cc less than the low end of the estimated fluid need. Surveyor # noted there is not one day when Resident #32 met his estimated fluid need. On 11/16/15 at 12:07 p.m. Surveyor # spoke with RD (Registered Dietitian)-H to inquire how the Facility monitors to ensure that Resident #32 consumes his estimated fluid needs daily. RD-H explained that they print out a report every day which shows Residents who have taken less than 1000 cc per day. Surveyor # informed RD-H that Resident #32's estimated fluid needs are between 1650 and 1950. Surveyor # informed RD-H that if they are only monitoring Residents with less than 1000 cc then Resident #32 could have a deficit of 650 to 950 cc a day without the Facility doing anything. Surveyor # asked RD-H about hydration assessments. RD-H informed Surveyor # that nursing would be responsible for them. Surveyor # informed RD-H that the I/O (intake/output) chart detail report for Resident #32 only shows fluids taken during the meals and asked if there was another report. RD-H informed Surveyor # that she would have to check. On 11/16/15 at 12:11 p.m. Surveyor # asked RN (Registered Nurse) Manager-G where Surveyor # would locate hydration assessments. RN Manager-G indicated that when the nurses do an assessment a note is written. Surveyor # asked what a hydration assessment consists of. RN Manager-G replied mucus membranes, skin turgor then make a note. On 11/16/15 at 12:16 p.m. RD-H informed Surveyor # that the I/O chart detail report is the only report there is and that the section for staff to input fluids between meals was not highlighted so staff could not chart this. RD-H stated that he may have gotten fluids between meals but they don't know. On 11/16/15 at 1:43 p.m. during the daily exit conference Administrator-A and RN (Registered Nurse) Corporate Consultant-C were informed of the above. 4.) Surveyor # reviewed Resident #33's medical record. Resident #33 was admitted to the facility on [DATE], sent to the hospital on [DATE] to 10/20/15 for recurring hypoglycemic episodes. Resident #33 has diabetes and hypertension, among other diagnoses. Surveyor # reviewed a Food Preference Record dated 10/13/15 that states Resident #33 has a regular, no added salt, consistent carbohydrate diet. Nothing is checked in the sections Check Beverage Likes/Dislikes. Surveyor # reviewed an Admission Nutrition Risk Data Collection and Assessment document completed by RD (Registered Dietician)-H for Resident #33 on 10/16/15. The form states Food /Preference/Issues- see preferences but, as stated above, that is blank. This Assessment indicates Resident #33's typical intake is <1000 mL (milliliters) of fluid with meals, 80% of meals, and 50% of snacks. The Estimated Fluid Needs is left blank. (Estimated Caloric and estimated protein needs were also left blank). The Summary states Resident #33 is admitted for long term care and specifies his insulin orders. RD-H updated the Summary on 10/22/15 after Resident #33 returned from the hospital. The Summary discusses Resident #33's diabetes, diet, recent unintended weight loss, a foot ulcer, and states Encourage Fluids, but the Estimated Fluid Needs was still left blank. Resident #33's Nutrition Risk Care Plan dated 10/15 notes Resident #33 is at risk for dehydration. A Goal is Resident #33 will be free of dehydration as evidenced by good skin turgor, labs, etc. Interventions include Monitor for signs of dehydration, encourage fluids unless contraindicated, monitor fluid intake as ordered. On 11/16/15, Surveyor # reviewed Resident #33's Food and Fluid Intake reports from Care Tracker from 10/17/15- 11/16/15. The CareTracker report indicates total fluid intake during that timeframe was 27,783 cc's (cubic centimeters), and average fluid intake (total intake divided by 29 days) of 958 cc's. Surveyor # began totaling daily fluid intakes and most of the totals were between 700-850 cc's, so it was surprising the average daily total was 958 cc's. Surveyor # noted on 11/3/15, staff documented Resident #33's dinner fluid intake was 3603 cc's. This is almost one gallon of fluid (one gallon = 3785 cc's). It is most likely supposed to be 360 cc's, as that is more in line with Resident #33's documented fluid intake at dinner. If the total fluid intake reflected 360 cc's for dinner on 11/3, instead of 3603 cc's., the average daily intake would be 846 cc's. Similarly, on 11/13/15 staff documented Resident #33 drank 2400 cc's of fluid at lunch; most of the lunch fluid intakes were 200-300 cc's. This is over 80 ounces of fluid. Subtracting another 2000 cc's from the total would bring Resident #33's average daily total to about 772 cc's. Resident #33's daily documented fluid intakes are: 10/17/15 840 cc's; 10/18/15 710 cc's; 10/19/15 - 10/20/15 in hospital; 10/21/15 720 cc's; 10/22/15 710 cc's; 10/23/15 820 cc's; 10/24/15 900 cc's; 10/25/15 640 cc's; 10/26/15 700 cc's; 10/27/15 840 cc's; 10/28/15 960 cc's; 10/29/15 680 cc's; 10/30/15 1240 cc's; 10/31/15 590 or 740 cc's (there is one duplicate 150 cc entry at exactly the same time- 9:48 a.m.); 11/1/15 710 cc's; 11/2/15 730 cc's; 11/3/15 840 cc's or 4083 cc's if entry of 3603 cc's at dinner is accurate; 11/4/15 700 cc's; 11/5/15 700 cc's; 11/6/15 840 cc's; 11/7/15 1060 cc's; 11/8/15 850 cc's; 11/9/15 770 cc's; 11/10/15 920 cc's; 11/11/15 640 cc's; 11/12/15 780 cc's; 11/13/15 720 cc's or 2880 cc's including the 2400 cc lunch intake; 11/14/15 720 cc's; 11/15/15 700 cc's. Resident #33's Nurses' Notes include multiple notes throughout October regarding [DIAGNOSES REDACTED], urinary tract infection, critically high potassium levels 10/26/15-10/28/15, and a fall on 10/25/15. The first mention of fluid intake in the Nurses' Notes is on 10/26/15 stating .taking fluid well, and 10/27/15 noting the NP (nurse practitioner) ordering to push fluids. Notes starting 10/27/15 to 11/10/15 15 state taking fluids well and no signs of dehydration. On 11/16/15 at 12:05 p.m. Surveyor # interviewed RN (Registered Nurse) Manager-G how staff conduct hydration assessments. RN Manager-G stated there is no specific form used for a hydration assessment, nurses should monitor mucus membranes, skin turgor, fluid intake, and document in the Nurses' Notes. RN Manager-G stated if anything is abnormal, the nurses should also contact the doctor. Surveyor # asked RN-G if nurses should be monitoring the CareTracker fluid intakes. RN-G stated only if the resident flags - then they are monitored in IDT (Interdisciplinary Team) meetings. A Resident flags when intake is under 1000 cc's. The Resident is put on the 24 hour board and staff push fluids, communicate closely with CNAs (certified nursing assistants). Surveyor # asked if the IDT has reviewed Resident #33 since even with two probable erroneous fluid consumption entries of about 5,000 cc total, Resident #33 still averaged under 1,000 cc's a day. RN-G stated Resident #33 is more alert and staff can talk with him, encourage him to drink more. RN-G stated they do watch Residents Care Tracker reports. Surveyor # asked how they evaluate Resident #33's intake since RD-H has not calculated his estimated fluid intake. RN-G referred Surveyor # to RD-H. On 11/16/15 at approximately 12:20 p.m. Surveyor # spoke with RD (Registered Dietitian)-H to inquire what Resident #33's estimated fluid needs are. RD-H returned a short time later with a copy of the Resident #33's Nutrition Risk Data Collection and Assessment with the Estimated Fluid Needs calculated as 1750-2100 cc's. Surveyor # noted it appears even with 5,000 cc's in potentially inaccurate entries, Resident #33 still averages under 1000 cc's a day, the flag level, but no specific efforts seem to be have been taken to ensure increase fluid intake and monitoring. The facility's data shows he averages about half of his now-estimated needs. Later on 11/16/15, RD-H informed Surveyor # that staff neglected to activate or highlight the between-meals section in CareTracker so staff could not chart any between-meal fluid intake. RD-H stated Resident #33 may have gotten fluids between meals but they don't know. On 11/16/15 at 1:45 p.m. during the daily exit conference Administrator-A and RN (Registered Nurse) Corporate Consultant-C were informed of the above.

Based on observation, interview and record review the facility did not ensure that 4 (Resident #15, #7, #14 and #1) of 15 residents reviewed and 1 (Resident #40) of 32 supplemental residents reviewed received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. ~ Resident #15 was admitted to the facility on [DATE] and signed a CPR (Cardiopulmonary Rescuscitation) form indicating he wanted CPR to be performed in the event of a [MEDICAL CONDITION]. The facility documentation indicates on [DATE] Resident #15 stopped breathing and CPR was not performed because Resident #15's son requested staff not to perform CPR on Resident #15. The facility had Resident #15's son sign a DNR (Do Not Rescuscitate) form on [DATE]; however, this was not valid because there was no documentation Resident #15 had been deemed incapacitated by 2 physicians or 1 physician and 1 psychologist. Resident #15 should have been considered his own decision maker up to his death and facility staff should have followed his advanced directives rather than the wishes of his son. The facility also had no documentation of any assessments having been completed during Resident #15's change of condition prior to his death. These failures created an immediate jeopardy beginning on [DATE]; Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on [DATE] at 1:30 p.m This immediate jeopardy was not removed at the time of exit from the survey due to the second example of immediate jeopardy regarding Resident #40. ~ Resident #40 was admitted to the facility on [DATE] from an acute long-term care hospital after being weaned from a ventilator in the days just prior to discharge from the hospital. Resident #40's [DIAGNOSES REDACTED]. Resident #40's admission papers identified that Resident #40 required oxygen via a nasal cannula and the use of a [MEDICAL CONDITION] machine at night. The facility did not ensure that they reviewed the pertinent discharge papers accompanying Resident #40 to ensure the admission orders [REDACTED]. Resident #40 was not provided with oxygen via a [MEDICAL CONDITION] at bed time on [DATE] through the night and into the morning of [DATE]. During the night Resident #40 experienced a change in condition that was not addressed properly by facility nursing staff. On [DATE] Resident #40 went into [MEDICAL CONDITION] and required CPR. Resident #40 was transferred to the community hospital where Resident #40 subsequently passed away related to the [MEDICAL CONDITION]. The facility's failure to ensure that Resident #40's medical needs were met upon admission created a situation of immediate jeopardy that started on [DATE]. NHA-A was informed of the immediate jeopardy on [DATE] at approximately 4:00 pm. This immediate jeopardy was not removed at the time of exit from the survey on [DATE]. In addition to the two examples at the scope/severity (s/s) of J - immediate jeopardy/isolated the facility has the following 3 additional examples of deficient practice. ~ Resident #1 has a [DIAGNOSES REDACTED].#1 distress. ~ Resident #14 had an order for [REDACTED]. ~ Resident #7 did not have a comprehensive pain assessment. Findings include: 1.) On [DATE] Surveyor # reviewed Resident #15's medical record. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital record indicates Resident #15 was living with his son and on [DATE] went to the hospital emergency room complaining of severe abdominal pain. The documentation indicates while at the hospital, it was discovered Resident #15 had a STEMI (ST elevation [MEDICAL CONDITION] infarction), which is a complete blockage of the heart artery and causes a full blown [MEDICAL CONDITION]. The hospital documentation indicates Resident #15 refused cardiac catherization to treat the STEMI but did allow IV (intravenous) [MEDICATION NAME] to be used. The documentation indicates the hospital physician discussed with Resident #15 his code status. The documentation indicates Resident #15 wanted to remain a full code. The hospital records indicate Resident #15 is alert and oriented and able to make his own decisions. Resident #15 was Russian speaking but the family interpreted for Resident #15 when necessary. Upon admission to the facility on [DATE], Resident #15 signed the facility's CPR (cardiopulmonary resuscitation) form indicating he wanted CPR to be done in the event of a [MEDICAL CONDITION]. The current signed physician orders [REDACTED]. The nursing comprehensive admission data collection and assessment form dated [DATE] indicates Resident #15 was a full code, was alert and oriented to person, place and time. The admission MDS (minimum data set) dated [DATE] indicates Resident #15's BIMS (brief interview for mental status) score was 9, which indicates moderate cognitive impairment. Resident #15 also needed extensive assistance of two staff for transfers, dressing and hygiene. Resident #15's advance care planning care plan dated [DATE] indicates Resident #15's POA (power of attorney) is not activated. The physician note dated [DATE] indicates Resident #15 is alert and oriented X3 through interpretation by his son. It also indicates Resident #15 has anasarca, generalized [MEDICAL CONDITION] throughout the body, and the note indicates this is likely secondary to his poor cardiac function. At this point they are refusing ER visit. They want to try oral [MEDICATION NAME] to see if we can bring some fluid off. They do know that the likelihood is a little low that we will be able to make much headway orally. In any case, we want to try this first. The social service note dated [DATE] indicates Resident #15 had a power of attorney document for healthcare, not activated at this time. It also indicates resident's plan is tentative based on how well he progresses but resident and son would like for resident to return home. The nursing note dated [DATE] at 5:00 p.m. indicates Resident #15 is alert and oriented X3. It also indicates Resident #15 complained of pain and received as-needed [MEDICATION NAME] that was effective and accepted all meds except for [MEDICATION NAME]; fluids offered and accepted. The next nursing note is dated [DATE] at 8:00 p.m. and indicates BP (blood pressure) med held due to low bp and no complaint of pain. The next nursing note documented in the medical record is dated [DATE] at 8:30 p.m., which indicates upon assessing resident noted that his respirations was ex (absent), crash cart and defibrillator brought to room, family at bedside stated they did not want CPR to be performed, sign DNR statement, 911 was called, paramedic at bedside no CPR performed patient expired, family stated that funeral home was called and MD notified. Son stated that the funeral home will not be here in the morning, family remains at bedside. There was no further documentation in the medical record as to Resident #15's health status prior to expiring. On [DATE] there was no nursing assessment documented. The medical record had a CPR form that was signed on [DATE] by Resident #15's son indicating No CPR. However, there is no documentation indicating Resident #15 had been found to be incapacitated or that POA had been activated. Activation of the health care power of attorney in Wisconsin requires 2 physician signatures or the signature of 1 physician and 1 psychologist attesting to the fact that the individual is incapacitated and no longer able to make medical decisions. The state agency received a complaint from the local police agency regarding the situation involving Resident #15 and provided the police report dated [DATE] which indicates: Officer P was asked to respond to the facility due to a 911 hang up call. Officer P's report indicates upon responding to Resident #15's room he was met by Resident #15's son who indicated he (the son) was Resident #15's power of attorney and that Resident #15 had passed away and didn't want resuscitation. Officer P indicates he spoke with staff (does not name the staff) that indicated Resident #15 was a terminal patient and Resident #15's son became his power of attorney. It indicates the staff had originally called 911 because the family had not made a decision if they wanted Resident #15 to be a DNR or not and while Resident #15 was in a full code, the family made a decision to sign the DNR order and not have his father resuscitated. The report continues with Resident #15's son telling Officer P, he was given power of attorney one or two months earlier. Officer P asked the staff the order of events that had taken place regarding having a DNR signed and was informed by staff that DNRs work slightly differently at their facility; she indicated that as a patient there, it can be discussed previously if they want to be resuscitated or not and assured me that what was done was okay. The facility's CPR policy dated [DATE] indicates the CPR consent form will be presented to each resident/or legal representative upon admission. Be presented to the resident/or legal representative if they change their original CPR choice. Allow the resident/legal representative to make an informed consent regarding their decision to have or not have CPR initiated. Describe the process of what occurs relative to CPR in a language understandable to the non-medical person. There is no documentation as to changing the CPR status with Resident #15, prior to or during the event resulting in Resident #15's death. RN L was working the unit on which Resident #15 resided on the day he died . On [DATE] at 12:00 p.m. Surveyor # spoke with RN L regarding Resident #15's death on [DATE]. RN L stated she worked the morning shift and Resident #15 looked the same. RN L stated she did not notice any change with Resident #15 on [DATE] day shift. RN L could not remember who worked 2nd shift on [DATE]. On [DATE] at 3:45 p.m. Surveyor # spoke with former NHA K. Former NHA K stated she just happened to be at the facility on [DATE] when she overheard a CNA tell a nurse (she doesn't know who the nurse or CNA was) Resident #15 had a low blood pressure. Former NHA K stated at that time she spoke with Nurse Manager G. Nurse Manager G told former NHA K Resident #15 is a full code but that the son didn't want Resident #15 sent to the hospital. Former NHA K stated she called 911 but then the son came to talk with her and told her he didn't want Resident #15 to go to the hospital. Former NHA K stated she did not assess the resident (even though former NHA K is an RN) but stated when she was discussing with Resident #15's son about sending Resident #15 to the hospital, Resident #15 expired. Surveyor # asked former NHA K if CPR was performed and she said no because Resident #15's son said not to do CPR. Surveyor # asked if Resident #15 had an activated POA at that time and former NHA K stated Nurse Manager G told her the POA was activated but after Resident #15 died she realized the POA was not activated. Former NHA K stated Nurse Manager G had Resident #15's son sign the DNR form. Former NHA K states the physician was informed the next day of Resident #15's death. Former NHA K does not know who the responsible RN was caring for Resident #15 prior to his death. On [DATE] at 7:50 a.m. Surveyor # spoke with Nurse Manager G regarding Resident #15's death. Nurse Manager G stated she was not working the unit Resident #15 resided on, the day he died . Nurse Manager G stated former NHA K told her Resident #15's family told her (former NHA K) that Resident #15 stopped breathing. Nurse Manager G stated former NHA K attempted to initiate a code but the family refused. Nurse Manager G stated she was not involved with having Resident #15's son signing the DNR form. Nurse Manager G stated she did not assess Resident #15 because she was working a different unit. Nurse Manager G stated she was unsure if there was a nurse assigned to care for Resident #15 the evening he died . Nurse Manager G stated former NHA K was working Resident #15's unit the evening he died . Nurse Manager G stated she didn't think the POA was activated. Nurse Manager G stated she had no other information to provide. On [DATE] at 8:10 a.m. Surveyor # interviewed RN J. RN J stated she was not in the building when Resident #15 died . RN J stated Resident #15 was already dead when she came on her shift. RN J doesn't remember who the nurse was that told her Resident #15 had died . RN J states she doesn't remember when she came on her shift but thinks it may have been 10:00 p.m. RN J doesn't remember anything else and had no other information to provide. On [DATE] at 1:30 p.m. during a meeting with NHA A and RN Consultant C, Surveyor # discussed the concern Resident #15 was his own decision maker and requested CPR to be performed but the facility allowed Resident #15's family to refuse CPR to be performed. The facility also did not follow their CPR policy because there is no documentation Resident #15 wanted to change his CPR status. The facility also has no documentation that Resident #15 was found to be incapacitated and POA was activated prior to his death. Surveyor # explained there is no documentation of an assessment prior to and/or during Resident #15's change in condition (Cross-reference F514) which led to his death. Surveyor # explained Resident #15 wanted CPR and the facility did not make any attempt to do CPR, which resulted in Resident #15's death. 2.) On [DATE] and [DATE] Surveyor # investigated a complaint alleging facility staff did not have the appropriate equipment ([MEDICAL CONDITION] machine) available to Resident #40 on the night of his admission, [DATE]. Resident #40 was admitted to the facility following a lengthy stay at a long-term acute care hospital. In August, Resident #40 suffered a preforated appendix, and had multiple infections, setbacks including [MEDICAL CONDITION] diagnosis, and surgeries in the months following. Resident #40 developed respiratory and [MEDICAL CONDITION] the morning of [DATE], was revivied, transported to the hospital where family made the decision to remove life support due to the brain damage that had occurred. Resident #40 died at the hospital on [DATE]. Surveyor # reviewed Resident #40's closed medical record. The first [DIAGNOSES REDACTED]. -Acute hypercapnic (high levels of carbon [MEDICATION NAME])/ hypoxic (low levels of oxygen) [MEDICAL CONDITIONS] ventilator at night. The [DIAGNOSES REDACTED].#40's Admission Record Face Sheet lists: [MEDICAL CONDITION] with alveolar hypoventilation (poor ventilation/ oxygen exchange in the lungs leading to low levels of oxygen and higher levels of carbon [MEDICATION NAME] in the blood), colon and [MEDICAL CONDITION], diabetes, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] present, Surveyor # reviewed a History and Physical dated [DATE] from the Long-term Acute Care Hospital (LTAC) indicating Resident #40 was admitted there on [DATE] from an Acute Care Hospital with Chief Complaint of [MEDICAL CONDITION]. Reason for Admission to the Acute (LTCH- long term care hospital) Level of Care: . for acute hypercarbic (high levels of carbon [MEDICATION NAME]- same as hypercapnic) and hypoxic [MEDICAL CONDITION] requiring mechanical ventilation. In addition, has ruptured appendicitis with intraabdominal abcess and gangrenous cecum, status [REDACTED]. HPI (History of Present Illness): . His hospital course is also complicated by the development of acute hypoxemic-hypercapnic [MEDICAL CONDITION] requiring prolonged intubation and [MEDICAL CONDITION] . Past Medical History: Obstructive sleep apnea, on [MEDICAL CONDITION] (Continuous Positive Airway Pressure machine) at home. A LTAC physician progress notes [REDACTED].currenly weaning [MEDICAL CONDITION]. Another note dated [DATE] states : A/P (Assessment /Plan: [MEDICAL CONDITION], trach, .cont (continue) NOC (night) ventilation. MD (Physician) Progress notes from the LTAC dated [DATE] state Problem 1. Acute hypercapnic and hypoxic [MEDICAL CONDITION], on [MEDICAL CONDITION] and ventilator at night. Notes later on [DATE] state .Discussed with patient and family, want to [MEDICAL CONDITION] with PAP (positive airway pressure). LTAC RT (respiratory therapy) notes dated [DATE] at 1550 (3:50 p.m.) state patient to go on [MEDICAL CONDITION] with cap tonight. RT notes on [DATE] at 1:00 a.m. and 4:30 a.m. indicate Resident #40 was on the [MEDICAL CONDITION] with setting of ,[DATE] (15 for inspiration/ 10 on expiration). RT notes from the LTAC dated [DATE] at 1609 (4:09 p.m.) state: [MEDICAL CONDITION] set up in pt's (patient's) room. Pt. to be placed on nasal mask ,[DATE] per (Pulmonologist). Pt. to keep cap on during [MEDICAL CONDITION] trial. LTAC RT notes dated [DATE] at 2150 (9:50 p.m.) state Pt. to go on [MEDICAL CONDITION] with nose mask tonight. RT notes on [DATE] at 2310 (11:10 p.m.) state the patient was tolerating [MEDICAL CONDITION] with no distress. LTAC RT documentation dated [DATE] at 3:15 a.m. indicates Resident #40 tolerating Vision 55 ([MEDICAL CONDITION] machine) with nasal mask- uneventful evening. Setting ,[DATE]. A LTAC Wound Care Consult dated [DATE], the day prior to admission, states: CC (Care Concern): Abd (Abdominal) Wound, surgical. S (Subjective): Off vent! Using [MEDICAL CONDITION] at night. Feels good. O (Objective): VSS (vital signs stable). afebrile. Abd wound 100% granular, faint odor with wound VAC (vacuum assisted closure) removal. No purulent drainage. [MEDICATION NAME] migration noted at margins. Obese A/P 1.) Abd wound, surgical. Improved appearance with Santyl and VAC. Continue with VAC change M-W-F. Santyl for ,[DATE] more weeks. (All of the LTAC documentation noted above was located in Resident #40's closed medical record at the nursing home. Some of the pages had a fax date stamp of [DATE] noted on the pages, but no time was printed. No [DATE] LTAC RT documentation was included in the nursing home record.) A [MEDICAL CONDITION] and [MEDICAL CONDITION] are similar. A [MEDICAL CONDITION] provides continuous positive pressure while the [MEDICAL CONDITION] has two different pressures, one for inspiration and one for expiration. A form titled CPR (Cardiopulmonary Resuscitation) dated [DATE] indicates Resident #40 did want CPR performed if needed. Surveyor # reviewed Resident #40's admission orders [REDACTED]. The admission orders [REDACTED] - ,[DATE] Lpm (liters per minute) 02 (oxygen via NC (nasal canula) to keep POx (pulse oximetry- measures oxygen saturation in blood) > (greater than) 90%. - [MEDICAL CONDITION] (as needed) QD (every day). - POx check QS (each shift) . -Trach care QD (each day) . -Apply wound vac to abdominal wound, change Q M/W/F (change every Monday, Wednesday and Friday). -WTD (wet to dry) dressing BID (twice a day) until wound vac placed. - Carbohydrate controlled diet with nectar thick liquids. Resident #40's Nursing Comprehensive Admission Data Collection and Assessment form dated [DATE] indicates: Resident #40's POx was 92% with 4 L oxygen via nasal canula; BP (blood pressure) ,[DATE]; T (temperature) 97.4, Pulse 60; Respirations 16. The [MEDICAL CONDITION] section of the Admission Assessment states: Respirations unlabored; diminished breath sounds right and left. Resident #40 verbalized having SOB (shortness of breath) with exertion, SOB or trouble breathing when sitting at rest, and SOB or trouble breathing when lying flat.[MEDICAL CONDITION] noted to [MEDICATION NAME] 7.0. Suction prn. Surveyor # reviewed Resident #40's Nurses' Notes. Notes dated [DATE] at 2300 (11:00 p.m.) written by RN (Registered Nurse)-LL state: Pt. (patient) admitted to facility from (name of hospital) after hospitalization with [MEDICAL CONDITION]. A & O (alert and oriented) x 3 (times three- to person, place and time). Lungs diminished. 4 L (liters) O2 (oxygen) via NC (nasal canula) continuous.[MEDICAL CONDITION] with Passy Muir valve x 1. PRN suction needed with thick clear mucus removed. Pt. has own [MEDICAL CONDITION], declined to use it this shift. Foley patent with clear yellow urine. WTD (wet to dry) dressing changed to abdominal wound. (Family member) at bedside and plans to stay in room with patient . Pt. has issues swallowing per hospital discharge summary .MD (Medical Doctor-UU), attending MD, verified meds/tx (treatments). The next Nurses' Note is dated [DATE] at 5:15 a.m. by RN-KK stating A/O x3. Pt. on 4 L O2 via NC. Pt. has trach. Nectar thick liquids. (Family member) at bedside. PRN given for pain effective. The next Nurses' Note is dated [DATE] at 10:12 a.m., documented by LPN (Licensed Practical Nurse)-JJ. It states VSWNL (vital signs within normal limits), [MEDICAL CONDITION] HR (heart rate): 117. Heart assessed, rhythm regular, no signs of respiratory distress noted, no SOB noted, on 4 L via NC, speech clear, c/o (complaint of) pain, PRN Tylenol given at 7:30 a.m. and effective, meds taken whole with applesauce without difficulty, lungs diminished, A/O (alert/oriented) x (times) 3, able to make needs known last spoke/visualized resident at 10:00 a.m. when meds were given, (family member) at bedside. POx 92% . The next Nurses' Note is documented by RN Corporate Consultant -C dated [DATE] at 11:05 a.m. stating: Writer alerted by therapist that resident's O2 concentrator was beeping and resident was looking off. Writer entered resident's room and immediately called for a potential code. Oxygen concentrator turned off and back on. Resident assessed for a pulse and breathing with both absent. Resident determined to be a full code. CPR initiated. AED (automatic external defibrilator) applied, 911 called, supplemental oxygen applied to ambu bag. CPR continued until EMT (emergency medical technician) on scene. A Nurses' Note dated [DATE] at 12:05 p.m. from RN Manger-G states Paramedics arrived around 11:15 a.m. and initiated advanced life support, CPR continued in facility until 11:55 a.m., when Resident was transferred via ambulance to (hospital) where patient was admitted due to [MEDICAL CONDITION]. Surveyor # reviewed Resident #40's Vital Signs- Individual Resident Flowsheet which shows on PM shift on [DATE], Resident #40's pulse was 60 beats per minute, respirations 16. On Night shift [DATE], his pulse was 62 and respirations 16. On day shift [DATE], Resident #40's pulse was 117 (it appears as 127 with a 1 heavily written over the 2 as if it was originally 127). On [DATE], Surveyor # asked RN-C if there was additional documentation regarding who was involved in the code; why there were no admission orders [REDACTED]#40; where Resident #40's pain was that two nurses gave PRN medication for; and if day shift LPN-JJ informed an RN when she obtained a heart rate of 117, almost twice that of the previous two shifts (evening shift ,[DATE] pulse 60, night shift ,[DATE] pulse was 62). Surveyor # also asked what information facility staff had regarding Resident #40's [DIAGNOSES REDACTED]. RN-C stated she would gather the information and stated she did recall seeing a [MEDICAL CONDITION] machine in Resident #40's room. RN-C was involved in the code. On [DATE], RN-C provided Surveyor # with documentation stating: Life Enrichment Coordinator (LEC)-TT wrote a statement indicating she had been in Resident #40's room at about 10:00 a.m. on [DATE] and with the family member's help, they completed the Life Enrichment assessment. LEC-TT's statement says she became aware there was no phone in the room, and Resident #40 requested some magazines, so she left to retrieve those items and had not returned prior to Resident #40 coding. LEC-TT stated no alarms were sounding while she was in the room. Admitting nurse (RN-LL) states Resident #40 was admitted between 6:45 p.m. and 7:00 p.m All paperwork from (name of) Hospital was there at the center except the medication list which was delivered with the patient . [MEDICAL CONDITION] came with the Resident from the hospital-resident did not want to use it on admit-preferred oxygen via nasal canula-resident was awake [MEDICAL CONDITION]. Dr. (MD-UU) was contacted and approved admitting orders. RN-LL completed skin check on Resident at approximately 1:00 a.m. RN-LL last saw Resident in bed at about 1:30 a.m., he was awake with (family member) at bedside, oxygen in place. Night shift nurse (RN-KK)'s statement indicates RN-KK received report on resident at about 3:00 a.m.; she could not recall discussion about a [MEDICAL CONDITION]. Oxygen via nasal canula was in place; no complaints. The statement from LPN-JJ day shift [DATE] states LPN-JJ assessed Resident early in shift. HR (heart rate) was tachy at 117. LPN-did not obtain RN assessment as it had been reported that resident was [MEDICAL CONDITION] at times as his baseline. OTR (Occupational Therapist-Registered)-VV's statement indicates she was in Resident #40's room to conduct her initial therapy evaluation at around 10:15 a.m. The oxygen concentrator started beeping and Resident #40 did not appear well. OTR-VV poked her head into the hallway and called for a nurse. RN-C came into the room, family member at bedside, asking Resident #40 if he was OK. Oxygen concentrator beeping. RN-C reset the concentrator (turned off and back on) and when she looked at Resident, exited to call a code. OTR-VV stayed at the bedside until RN-C returned with other staff and crash cart. RN-C's statement says: RN-II called 911 as RN-C and RN-RR initiated CPR and ambu-bag and chest compressions. AED (automatic external defibrillator) applied, no shock advised. CPR was continued until EMT /Paramedics arrived and took over the process. (Family member) in hallway with facility staff. RN-C later assisted (family member) call family. On [DATE] at 10:50 a.m., Surveyor # interviewed LPN-JJ who was the nurse caring for Resident #40 when he suffered respiratory and [MEDICAL CONDITION]. LPN-JJ stated she heard in report the morning of [DATE] that Resident #40 was to use a [MEDICAL CONDITION], but she did not think it had been delivered yet. Surveyor # noted RN-C stated there was one in the room but LPN-JJ did not think she saw one, but is not 100% sure. LPN-JJ stated she went to assess Resident #40 after receiving report. Resident #40's family member stated Resident #40 did not sleep well because he did not have the [MEDICAL CONDITION]. LPN-JJ stated she did not recall any further conversation regarding not having all the pieces or adaptors for the [MEDICAL CONDITION] because she did not think it was even in the facility. LPN-JJ stated around 7:30 or 8:00 a.m., she went in Resident #40's room, (family member) at bedside. (Family member) said Resident #40 was very tired, he didn't have the machine and the night nurse kept him up all night with assessments and paperwork and skin checks. LPN-JJ stated she asked if she could quickly listen to his heart and lungs and Resident #40 agreed. LPN-JJ told Surveyor # I didn't think 117 was that unusual if his parameters were ,[DATE] and they kept him up all night and he was tired. Surveyor # offered LPN-JJ Resident #40's record to locate the documentation stating Resident #40's normal heart rate was ,[DATE]. LPN-JJ stated she already looked, and on further chart review, I don't see that (heart rate ,[DATE]). Surveyor # had reviewed Resident #40's hospital record and noted many heart rates documented as 60's -90's with a few just over 100, but not a normal heart rate of ,[DATE] bpm (beats per minute). LPN-JJ confirmed Resident #40's heart rate was 117. Surveyor # asked why LPN-JJ wrote Resident #40's vital signs were within normal limits, then wrote [MEDICAL CONDITION] HR (heart rate): 117 indicating Resident #40's heart was beating fast. LPN-JJ stated she thought she was told in report that Resident #40's normal heart rate was between ,[DATE] bpm, so she felt it was within Resident #40's normal limits. LPN-JJ did not inform a Registered Nurse about Resident #40's [MEDICAL CONDITION] Surveyor # asked if LPN-JJ noticed when she documented Resident #40's pulse/heart rate as 117, that on the two shifts prior, Resident #40's heart rate was 60 and 62. LPN-JJ stated she does not remember if she noticed the previously documented pulse rates. LPN-JJ stated she returned to Resident #40's room at approximately 9:30 a.m. with morning medications. He was awake, had eaten breakfast. I had to give him Tylenol- he didn't have anything else. He was OK with that. Surveyor # asked where Resident #40's pain was, and what level of pain he reported, because LPN-JJ did not document either the location of Resident #40's pain or pain scale rating in the Nurses' Notes nor the MAR (Medication Administration Record). LPN-JJ stated she could not remember what pain Resident #40 complained of. On [DATE] at 11:57 Surveyor # spoke with the complainant by phone, who confirmed the above concerns, stating Resident #40 was expected to return home. On [DATE] at 12:39 Surveyor # spoke with the family member who was present in the facility with Resident #40 throughout his entire 17-hour stay. The family member stated they brought the Resident's [MEDICAL CONDITION] machine from home, but the nurse said they couldn't hook up both the [MEDICAL CONDITION] and oxygen- they didn't have the right oxygen connector so they couldn't use it. The nurse said they had orders for the oxygen and not the [MEDICAL CONDITION], so she thought they should just use the oxygen that night. The family member said the nurse on admission stated they only had the few pages of information sent with the Resident and they should have had more paperwork in advance to prepare for the Resident's arrival before he got there. The family member said that after Resident #40 spent the night without the [MEDICAL CONDITION]/[MEDICAL CONDITION], and numerous interruptions from nursing staff, the next morning his breathing was labored and louder. Then the oxygen machine started beeping. A staff member was in the room who walked around and looked at the machine (oxygen concentrator) and said she would get someone to look at it. The family member thought that staff member was Life Enrichment Coordinator (LEC) -TT. The family member said LEC-TT left the room and did not return. The family member said she went over to Resident #40 who did not look well and she noticed nothing was coming out of the oxygen nasal canula and he was not breathing. The family member stated she started blowing into Resident #40's mouth, then more people came into the room. The family member was asked to leave the room, and she did so. On [DATE] at 1:00 p.m. Surveyor # interviewed LTAC RT (Respiratory Therapist)-XX by phone. RT-XX stated it was very important, imperative (emphasized) for Resident #40 to use the [MEDICAL CONDITION] at night at the nursing home because he had only been off the vent for a few nights when he discharged to the facility. RT-XX explained using the [MEDICAL CONDITION] is similar to using the vent- only the vent is hooked up to [MEDICAL CONDITION] the [MEDICAL CONDITION] is connected by mask to his face. RT-XX stated Resident #40 needed the [MEDICAL CONDITION] at night, set at 15 on inspiration and 10 on expiration. RT-XX stated Resident #40 usually put the [MEDICAL CONDITION] on when he was ready to go to sleep for the night, maybe 9:00 or 10:00 p.m., adding he had only been on the [MEDICAL CONDITION] for a few nights while at their facility. RT-XX stressed using the [MEDICAL CONDITION] was a very important piece of Resident #40's care, stating it's a b

Based on observations, record review and staff interviews, the facility did not ensure that 3 (resident #1, #3 and #6) of 9 residents reviewed for pressure ulcers, from a sample of 14 residents, received necessary treatment and services to promote healing and prevent new ulcers from developing. Resident #1 was admitted to the facility status [REDACTED]. Resident #1 had recently developed 2 pressure ulcers (a stage II and an unstageable) related to pressure of the leg immobilizer against her skin. The facility did not address the immobilizer or make changes or adaptations to prevent the development of additional pressure ulcers. During an observation of wound care, surveyor # noted a new, unstageable, deep tissue injury, adjacent to the other 2 pressure ulcers. Resident #3 currently had a stage IV coccyx pressure ulcer and an unstageable pressure ulcer on the right calf. Resident #3 was assessed to be moderate risk for pressure ulcer development. The plan of care for skin integrity indicated resident #3 was to pressure reduction support surface and heels were to be floated. The plan of care was not implemented. Resident #6 was assessed to be at risk for pressure ulcer development. The plan of care for resident #6 was to position calves on pillows to elevate heels off the bed. During observations of resident #6 in bed, the resident's heels were not elevated off the bed. Findings include: In 2009, The (NPUAP) National Pressure Ulcer Advisory Panel defined (suspected) deep tissue injury as "Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear...Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment." 1. On 5/21/12, surveyor # reviewed the medical record of resident #1. The 4/2/12 facesheet, contained within the medical record, indicated resident #1 was admitted to the facility 3/30/12 with [DIAGNOSES REDACTED].#1 was moderately cognitively impaired and required extensive assistance with bed mobility and transfers. A hospital history and physical dated 3/29/12 indicated resident #1 had been living in a group home where she fell and suffered a [MEDICAL CONDITION] femur (upper bone of the leg). Resident #1 had a leg immobilizer brace applied to the left leg since discharge from the hospital. A Braden pressure ulcer risk assessment dated [DATE], indicated resident #1 was at risk for the development of pressure ulcers. The 4/10/12 CAA (Care Area Assessment) for pressure ulcers revealed the following summary, "(resident #1) has a deep tissue injury to her right buttock. Care plan goal is for pressure ulcer to heel and to prevent further skin damage. Staff will reposition resident #1 every 1 - 2 hours and as needed per patient request. Other interventions include to manage moisture, provide incontinent care as needed, dietary consult, and monitoring and to float heel while in bed." The written plan of care for resident #1, dated 4/2/12, included the following interventions related to the leg immobilizer: "provide padding for casts, braces, splints as needed." A "Skin Grid" document dated 4/6/12 revealed the development of a deep tissue injury on resident #1's right buttocks. A "Skin Grid" document dated 4/11/12 revealed the development of another deep tissue injury on resident #2's left buttocks. The TAR (Treatment Administration Record) dated 4/12/12 indicated the following: "Monitor skin left lower extremity immobilizer every shift, symptoms of breakdown." Initials on the TAR indicated staff performed the above intervention. "Place knee immobilizer over pants." This intervention was charted as an FYI, with no staff initials to indicate compliance. A "Skin Grid" document for resident #1, dated 5/1/12, revealed the development of 2 unstageable blisters on the left lower calf. The initial identification charting on the "Skin Grid," indicated resident #1's wounds had not been present on admission and were related to pressure "from the brace." Later documentation on the "Skin Grid," dated 5/23/12, revealed one of these blisters remained unstageable with eschar, the other opened to become a stage II pressure ulcer. The TAR (Treatment Administration Record) for resident #1, dated 5/1/12, indicated the following: "Monitor skin below brace every shift! Must have on over pants!" Initials on the TAR indicated staff complied with the directive every shift." physician's orders [REDACTED]." physician's orders [REDACTED]." On 5/22/12 at 1:00 p.m., surveyor # interviewed DON (Director of Nursing)-B about interventions related to the leg immobilizer for resident #1. It was confirmed, after the development of 2 pressure ulcers associated with the leg immobilizer, the interventions were the same as before the development of the pressure ulcers; to monitor the skin and to place the immobilizer on the resident over pants. The only addition to the plan of care was the treatment of [REDACTED]. On 5/23/12 at 7:55 a.m., surveyor # observed resident #1 in her room. Resident #1 was wearing a nightgown, the leg immobilizer in place in direct contact with her bare skin. On 5/23/12 at 8:12 a.m., surveyor # observed resident #1 assisted with transfer from bed to wheelchair then at 8:16 a.m., wheeled to dining room by staff. Resident #1 remained in her night gown, covered by her robe, with leg immobilizer still in direct contact with her skin. On 5/23/12 at approximately 8:13 a.m., surveyor # interviewed CNA (Certified Nursing Assistant)-I, who confirmed resident #1 always wears nightgowns to bed as her sister provides them regularly. On 5/23/12 at 8:40 a.m., surveyor # observed resident #1 in the dining room, eating breakfast, wearing her night gown and robe, leg immobilizer in direct contact with her skin. On 5/23/12 at 8:55 a.m., surveyor # observed resident #1 being wheeled to her room. On 5/23/12, at approximately 11:15 a.m., surveyor # asked resident #1 about her attire. Resident #1 stated she wore a night gown to bed every night with no protection under the leg brace. Additionally, resident #1 indicated that on 5/23/12, the brace remained in direct contact with her skin from bedtime the previous night, through breakfast, until it was time to go to therapy around 9:00 a.m. On 5/23/12 at 11:45 a.m., surveyor # observed wound care for resident #1 by LPN (Licensed Practical Nurse)-H. At this time the leg brace was noted over pants worn by resident #1. At 11:47 a.m., LPN-H removed the leg brace, pants and dressing from the lower left leg. The previously noted 2 open areas were observed. Additionally, an area of indentation in the shape of the lower edge of the brace was noted on the resident's left calf, surrounded by [MEDICAL CONDITION] from the knee to the toes of the left leg. Within the indented skin, a purple, suspected deep tissue injury was noted. The observations of surveyor # were confirmed verbally by LPN-H at that time. When the brace was opened fully and spread flat, an egg crate foam padding was noted in the center of the brace, approximately 6 inches by 3 inches. When placed on the resident, the foam padding would rest on the resident's calf and the brace continued beyond the margins of this cushion. LPN-H left the room to call the nurse manager, RN (Registered Nurse)-J, for an observation of the wounds. RN-J confirmed the deep tissue injury was new. On 5/23/12 at 12:30 p.m., surveyor # interviewed PT (Physical Therapist)-K who confirmed the foam padding had been attached inside the leg immobilizer of resident #1 since admission and that the nursing staff was responsible for making assessments related to the brace. PT-K stated resident #1 wore the brace for all therapy sessions. On 5/23/12 at 2:00 p.m., LPN-H approached surveyor # indicating the foam padding had been extended to include the length of the entire immobilizer for resident #1, the physician was made aware of the new pressure area, and treatment had been initiated. On 5/24/12 at 11:00 a.m., surveyor # interviewed resident #1's FM (Family Member)-L, who verified she often saw the leg immobilizer in direct contact with resident #1's skin, stating the understood plan of care was to include placement of the brace over resident #1's pants, to protect the skin. 2. On 5/21/12 surveyor # reviewed the medical record for resident #3. The current, undated, [DIAGNOSES REDACTED]. The 2/2/12 MDS indicated resident #3 was alert and oriented, required extensive staff assistance for ADLS, could feed himself, was incontinent of bowel, had an indwelling catheter. The 4/3/12 Braden Risk assessment indicated resident #3 was a moderate risk for pressure ulcer development. The 4/19/12 pressure ulcer history indicated resident #3 had a healed stage II right gluteal ulcer. The 5/23/12 skin grid indicated resident #3 had a 2.5 cm by 3.2 cm unstageable area on the right posterior leg. The 5/23/12 skin grid indicated resident #3 had a, 8.4 cm by 5.1 cm by 2.0 cm, stage IV, area on the sacrum with a [DEVICE] to the area. The 2/3/12 plan of care for skin integrity indicated staff were to protect heels. The current, undated, CNA plan of care indicated resident #3's heels were to be floated. On 5/21/12 at 12:45 p.m. surveyor # observed resident #3 sitting in a wheel chair watching television. Resident #3 had slipper socks on both feet and both heels were resting directly on the wheel chair foot rests. Resident #3 did not have a pressure reduction support surface and the heels were not floated. On 5/21/12 at 2:00 p.m. surveyor # interviewed resident #3. Resident #3 indicated he was concerned about the status of his skin breakdown and the slow healing of the pressure ulcer on his coccyx. He indicated the facility had provided an alternating pressure low air loss mattress and that staff ensured he changed position when in the bed. Resident #3 indicated a trapeze has been provided so he could change position himself. Resident #3 indicated staff applied a protective cream to his heel but did not free float the heels as was indicated on his plan of care. Surveyor # observed resident #3's legs resting on a pillow and both heels imbedded into another pillow that was under the heels. On 5/22/12 at 1:05 p.m. surveyor # observed resident #3 in his wheel chair. Resident #3 has slipper socks on both feet and both heels were resting directly on the wheel chair foot rests. On 5/23/12 at 7:20 a.m. surveyor # observed resident #3 in bed. Both legs rested on top of pillows and both heels were imbedded into the pillows. Resident #3's heels were not floated. On 5/23/12 at 11:25 a.m. surveyor # observed HH-G provide care for resident #3. When completed, resident #3 was sitting in the wheel chair with slipper socks on both feet and both feet resting directly on the wheel chair footrests. HH-G indicated Hospice staff provide daily morning care for resident #3. HH-G indicated Hospice staff follow the plan of care for resident #3. HH-G did not know about the plan of care to float resident #3's heels. On 5/23/12 at 2:45 p.m. surveyor # and NHA-A observed resident #3 watching television. Resident #3 was sitting in the wheel chair wearing slipper socks and his heels were directly against the foot rest. NHA-A indicated resident #3 was a high risk for breakdown and should have heel protection. On 5/24/12 at 8:45 a.m. surveyor # interviewed resident #3. Resident #3 indicated the facility had provided heel boots to protect his heels. Resident #3 expressed his appreciation for the heel boots. The Quick Reference Guide entitled "Pressure Ulcer Prevention" published by the National Pressure Ulcer Advisory Panel in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Using a pillow under the calves so the heels are elevated (i.e., "floating") will accomplish reduction of pressure on heels. 3. Resident #6's face sheet, contained within the medical record and dated 5/10/12, indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated resident #6's cognition was severely impaired. The MDS also indicated resident #6 had a right [MEDICAL CONDITION] and required extensive assistance from staff for ambulation, transfer, and bed mobility. Resident #6's current Skin Integrity Assessment: Prevention and Treatment Plan of Care, dated 5/15/12, indicated resident #6 was at risk for altered skin integrity due to the right hip replacement and the Braden Risk Assessment Score between 15 and 18. The Braden Risk Assessment Scale updated on 5/22/12 also indicated resident #6's ability to change and control body position was slightly limited with the resident able to make frequent though slight changes in body or extremity position independently. The plan of care indicated staff were to position calves on pillows to elevate heels off the bed. The triggered CAA worksheet, dated 5/22/12, indicated resident #6 was at risk for developing pressure ulcers related to risk factors of needing a special mattress or seat cushion to relieve pressure, requiring regular schedule of turning, cognitive loss, medications and [DIAGNOSES REDACTED]. A plan of care was developed to reflect risk/interventions related to skin integrity, which included positioning calves on pillows to elevate heels off the bed to prevent the development of pressure ulcers. On 5/22/12 at 10:02 a.m. surveyor # observed resident #6 laying on his back in bed with shoes on and heels of shoes placed directly on the mattress. Resident #6's calves were not positioned on pillows to elevate heels off the mattress. On 5/23/12 at 11:39 a.m. surveyor # observed resident #6 laying on his back in bed with both heels placed directly on the mattress. Surveyor # went in the hall and interviewed CNA-O related to resident #6's heels positioned directly on the mattress. CNA-O verified the resident's heels were placed directly on the mattress and stated "no extra pillow in room...will get one." CNA-O left resident #6's room to find a pillow to elevate the resident's heels. CNA-O returned with a blanket and placed the blanket under the resident's calves to elevate the heels off the mattress and stated "good thing (the resident) is in and out of bed all day...will get pillow later." On 5/24/12 at 11:20 a.m. surveyor # observed resident #6 laying on his back in bed with a flat pillow under the calves with both heels directly on the mattress. On 5/24/12 at 11:27 a.m. surveyor # interviewed NHA-A related to resident #6's heels placed directly on the mattress during three observations on three days. NHA-A verified CNA-O came to her to explain why resident #6 did not have a pillow under calves to elevate heels off the mattress on 5/23/12. On 5/24/12 during the final daily exit at approximately 3:20 p.m. NHA-A verified to surveyor # that resident #6 had a flat pillow under calves and the resident's heels were placed directly on the mattress on 5/24/12.