Every finding on record at Countryside Care & Rehabilitation

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to ensure staff wore beard nets in the kitchen and appropriately stored, distributed, and labeled foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The Idaho Food Code, revised February 2021, documented, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.The Idaho Food Code, revised February 2021, 2-402.11 listed under hair restraints documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.The facility Food and Nutrition Services Policy and Procedures undated documented, Minidoka Memorial Hospital Food and Nutrition Services will follow the current edition of the [NAME] Policy and Procedure Manual, Chapter 4 Handwashing procedures of when to wash hands; after touching bare human body parts except for clean hands; and Chapter 4 Personal Hygiene - when around exposed foods, beards must be restrained using beard covers. On 9/8/25 at 9:15 AM, observed a contractor male cook touch his face and hair with his gloved hands and then pick up an open container of food without removing gloves and washing his hands. Additionally, observed the contractor main cook who had a beard, was not wearing a beard cover or net as required. On 9/8/25 at 9:16 AM, the contractor food service manager stated she was not aware the male cook needed to wear a beard net or cover. On 9/8/25 at 9:20 AM, observed the following in the dry food storage room. - [NAME] cracker crumbs were in a new container that had not been labeled with an expired or use by date. - Chocolate chips were stored in a new container that had not been labeled with an expired or use by date.On 9/8/25 at 9:30 AM, observed in the walk-in freezer an opened package of egg rolls that had not been labeled with an opened date and not labeled with an expired or use by date.On 9/8/25 at 9:35 AM, the contractor food service manager stated the food items in the walk-in refrigerator and freezer should have been labeled and dated correctly and were not.

Based on observation, interview, Department of Health and Welfare - Idaho Administrative rules, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility. This placed residents and staff at risk of potential food contamination from bugs and rodents that may enter the kitchen due to the open garbage containers. Findings include:Department of Health and Welfare - Idaho Administrative Rules 16.03.02. Environmental Sanitation 108. Garbage and Refuse 03a. All containers used for storage of garbage and refuse shall be constructed of durable, nonabsorbent material and shall not leak or absorb liquids. Containers shall be provided with tight-fitting lids unless stored in vermin-proof rooms or enclosures, or in a waste refrigerator.U.S. Food and Drug Administration 2022 Food Code, 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled.On 9/8/25 at 9:23 AM, observed in the food prep area, a 55-gallon garbage can half full not being used at the time without a lid.On 9/8/25 at 9:30 AM, the contractor food service manager stated the lid was on the ground under the table if they needed to close it but she was not aware the lid needed to be on when the trash can was not being actively filled.On 9/10/25 at 8:20 AM, observed two 55-gallon garbage cans without lids in the kitchen food prep areas. The contractor food service worker stated she was not aware the lids were needed.

Based on record review, State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 12 Residents (Resident #3) whose records were reviewed for Advance Directive. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning. Findings include:According to Appendix PP: DEFINITIONS S483.10(c)(6), (c)(8), (g)(12) Physician Orders for Life -Sustaining Treatment (POLST).a POLST form is not an advance directive. S483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives), (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative If the resident does not have an advance directive, facility staff must inform the resident or resident representative of their right to establish one as set forth in the laws of the State and provide assistance if the resident wishes to execute one or more directive(s). Facility staff must document in the resident's medical record these discussions and any advance directive(s) that the resident executes. Resident #3 was admitted to the facility on [DATE], with diagnoses including anoxic brain damage (brain injury caused by lack of oxygen) and quadriplegia (inability to voluntarily move upper and lower body).On 9/9/25 at 10:02 AM, Resident #3's medical record contained a POST and a Letter of Guardianship document. Resident #3's medical record contained no documentation of Advance Directive and no documentation that the facility had offered to assist the resident guardian with formulating an Advance Directive.On 9/10/25 at 8:35 AM, the DON stated Resident #3 had not created an Advance Directive prior to admission, and Resident #3's guardian had not completed an Advance Directive document either. On 9/10/25 at 11:27 AM, the Administrator stated Resident #3's record did not have documentation the Advance Directive information had been offered to Resident #3's guardian.

Based on record review and staff interview, it was determined the facility failed to provide the Advance Beneficiary Notice (CMS-10055 form) for 1 of 3 residents (Resident #1) whose medical records were reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended. Findings include:Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including stroke and hypertension.The facility had not provided an Advance Beneficiary Notice document to Resident #1 when he was discharged from Medicare Part A Skilled Nursing on 6/9/25 and admitted to the facility long term care unit on 6/10/25.On 9/9/25 at 2:30 PM, the Administrator stated Resident #1 should have received an Advance Beneficiary Notice document upon discharge and readmitted to the long-term care unit and had not been.

Based on facility standing orders, record review and staff interview, it was determined the facility failed to follow facility bowel care standing order of delivering specific medications when residents do not have BM within 24, 48, and 72 hours for 4 of 7 Residents (#1, #18, #24, and #26) who records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include:The Countryside Care & Rehab Standing Orders for bowel protocol dated 1/14/25, documented: - (step 1) No BM X 24 hours: Prune Juice in AM. - (step 2) 48 hours no BM: Prune Juice in AM, no result, give Prune Juice in PM, - (step 3) No BM by day 3: Give Prune Juice in 30ml MOM. - (step 4) Day 4 no BM: Give Bisacodyl, supp or Fleets enema. - (step 5) Day 5 no BM: Complete assessment and notify PCP.a. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including stroke and hypertension.Resident #1's medical record for bowel care documented no bowel movement from 8/15/25 to 8/19/25 with step 1, step 2, step 4, and step 5 being missed.b. Resident #18 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including polyosteoarthritis (a condition where multiple joints in the body develop osteoarthritis, a form of degenerative joint disease) and respiratory failure with hypoxia (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide, leading to low levels of oxygen (hypoxia) in the blood).Resident #18's medical record for bowel care documented no bowel movement from 8/12/25 to 8/16/25 with step 1 being missed.Resident #18's medical record for bowel care documented no bowel movement from 8/27/25 to 9/6/25 with step 2 and step 5 being missed.c. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including epileptic seizures (brief episodes of abnormal brain activity that can cause involuntary movements, altered consciousness, and other symptoms) and hypertension.Resident #24's medical record for bowel care documented no bowel movement from 8/14/25 to 8/18/25 with step 4 being missed.d. Resident #26 was initially admitted to the facility on [DATE], and was readmitted on [DATE] with multiple diagnoses including chronic kidney disease and chronic obstructive pulmonary disease (a group of lung diseases that cause airflow obstruction and breathing problems).Resident #26's medical record for bowel care documented no bowel movement from 9/1/25 to 9/6/25 with step 1, step 2, and step 3 being missed or given a day late.On 9/9/25 at 3:15 PM, the DON stated the nursing staff had missed some of the bowel protocol steps with these four residents and should not have.

Based on observation, policy review, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 4 of 5 residents (#4, #13, #19, and #26) whose records were reviewed for respiratory services. This failure created the potential for residents to experience respiratory related infections, increased fatigue, and low oxygen levels. Findings include:The facility's Oxygen Administration policy undated documented change oxygen tubing and mask/cannula monthly and as needed if it becomes soiled or contaminated. a. Resident #4 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including dementia and anxiety disorder.The facility oxygen audit for the month of August dated 8/25/25, documented Resident #4's oxygen tubing was last changed 7/2/25 and it should also have been replaced on 8/3/25 but was not. b. Resident #13 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including hypertensive heart and chronic kidney disease.Resident #13's physician oxygen order dated 5/19/25, documented to change oxygen tubing first Sunday of each month.On 9/8/25 at 9:45 AM, observed Resident #13's oxygen tubing was last changed on 8/3/25 and should have been changed on 9/7/25 but was not.Resident #13's TAR documented the oxygen tubing was changed on 9/8/25 at 12:29 PM, after the surveyor brought this issue to the attention of the DON.c. Resident #19 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including paroxysmal atrial fibrillation (a type of heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly for a short period of time) and chronic kidney disease. Resident #19's physician order related to oxygen tubing change dated 4/2/25, documented night shift to change oxygen tubing on the 1st of each month.On 9/8/25 at 11:22 AM, observed Resident #19's oxygen tubing was last changed on 8/3/25 and should have been replaced on 9/1/25 but was not. d. Resident #26 was initially admitted to the facility on [DATE], and was readmitted on [DATE], with multiple diagnoses including chronic kidney disease and chronic obstructive pulmonary disease (a group of lung diseases that cause airflow obstruction and breathing problems).Resident #26's physician order related to oxygen tubing change dated 5/19/25, documented night shift to change oxygen tubing on the 1st of each month.On 9/8/25 at 9:50 AM, observed Resident #26's oxygen tubing had yellowed and was last changed on 8/3/25 and should have been replaced on 9/1/25 but was not.On 9/8/25 at 11:30 AM, the DON stated resident oxygen tubing should be changed on the first Sunday of each month and had not been.

Based on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and how the alternatives failed to meet the resident's assessed needs. This was true for 4 of 6 residents (#6, #7, #8, and #32) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death. Findings include: The facility's policy, Proper Use of Bed Rails, revised 2024, stated it was the policy of the facility that the resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs.if no appropriate alternatives are identified, the medical record should include evidence of the following; purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful.a. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including hemiparesis (weakness or inability to move on one side of the body) and diabetes.On 9/8/25 at 10:02 AM, Resident #6's bed was observed with bilateral upper side rails. Resident #6's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails.b. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (condition that causes brain dysfunction) and respiratory failure.On 9/8/25 at 11:02 AM, Resident #7's bed was observed with bilateral upper side rails. Resident #7's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails.c. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including heart failure and diabetes.On 9/8/25 at 10:32 AM, Resident #8's bed was observed with bilateral upper side rails. Resident #8's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails. d. Resident #32 was admitted to the facility on [DATE], with multiple diagnoses including osteomyelitis (infection in a bone) and atherosclerosis (thickening of the arteries).On 9/8/25 at 2:37 PM, Resident #32's bed was observed with bilateral upper side rails. Resident #32's medical record did not have documentation of the evaluation of the alternatives attempted or documentation of the purpose of the intended use of the side rails. On 9/9/25 at 2:52 PM, the DON stated documentation of the evaluation of alternatives attempted or the intended purpose of the use of side rails should be documented in the resident's medical record and had not been. On 9/9/25 at 2:53 PM, the Administrator stated bed rails are used primarily for mobility but there should be documentation of the evaluation of alternatives attempted or the intended purpose of the use of side rails in the resident's medical record and had not been.

Based on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 1 medication cart reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility. Findings include:On 9/9/25 at 11:16 AM, during the medication cart audit, observed the narcotic accountability sheets, dated 2/1/25 to 9/9/25, with 3 licensed nurse signatures not documented. On 9/9/25 at 11:20 AM, LPN #1 stated two nurses should have signed the narcotic accountability sheet when they accepted the medication cart or released the medication cart. On 9/9/25 at 12:07 PM, the Administrator stated two nurses should have signed the narcotic accountability record when they accepted the medication cart or released the medication cart.

Based on observations, interviews, and policy review, the facility failed to properly sanitize the thermometer used to take temperatures of the food. These failures had the potential to increase the risk of foodborne illnesses and infection for all residents receiving food from the facility kitchen. Findings include: Review of the facility's undated policy titled, Taking Accurate Temperatures, indicated that the probe should be cleaned, rinsed, sanitized, and air-dried before taking temperatures and immediately cleaned and re-sanitized after taking the temperature of each food. During an observation of the tray line on 09/18/24 at 11:30 AM, Cook1 was observed to take the thermometer out of her pocket and take the temperature of the food without sanitizing the thermometer before use. Cook1 was observed to use an alcohol swab to clean the thermometer after taking the temperature of the first item and re-use the same alcohol swab after taking the temperature of the next two food items. Cook1 then placed the thermometer back into her pocket. Cook1 then removed the thermometer and took the temperature of the next two food items without sanitizing the thermometer first and then using the same alcohol swab to sanitize the thermometer between taking the temperature of the next two food items. During an interview on 09/18/24 at 11:37 AM [NAME] 2 stated that they usually clean the thermometer before use and between testing each food item. During an interview on 09/18/24 at 11:40 AM Cook1 stated that she knew her pocket would contaminate the thermometer, and she should have cleaned the thermometer before using it. During an interview on 09/18/24 at 12:20 PM the Food Service Supervisor (FSS) stated that the thermometers need to be cleaned before and after each use. The FSS stated that she would expect the staff to follow the sanitizing requirements.

Based on record review, observations, interviews, and review of the National Institute of Health (NIH) guidance, the facility failed to ensure professional standards of care were met for one resident (Residents (R)14) of one resident observed receiving medication through a gastrostomy (G) tube out of a total sample of 14 residents. This failure created the potential for R14 to have unwanted complications related to administration of her medication. The findings include: The facility's policies and procedures related to the administration of medication via G-Tube were requested by the survey team on 09/18/24. During an interview with the Administrator in Training (AIT) on 09/18/24 at 1:04 PM, she stated the facility did not have a policy to address the administration of medication via G-Tube. Review of the National Institutes of Health (2021) guidance on how to administer enteral (G-Tube) medication revealed, Prepare each medication individually in its own cup. Crush pills, open capsules, and pour liquid medication into a medication cup. Dilute the medication in 5 to 10 mL of water; and Elevate the head of the bed at least 30-45 degrees to prevent aspiration. NIH.org Review of R14's Admission Record, dated 09/19/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including anoxic brain damage and quadriplegia. Review of R14's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/18/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be conducted due to the resident's poor cognition. The assessment indicated R14 had both short and long-term memory deficits and indicated the resident had a G-Tube in place through which she received all of her nutrition and medication. Review of R14's Order Summary Report, dated 09/19/24 and found in the EMR under the Orders tab, indicated orders for the resident to receive Baclofen (a muscle relaxant) 10 MG (milligrams) per her G-Tube four times daily, Famotidine (an acid reducing medication) 20 MG per her G-Tube twice daily, and Sertraline (an antidepressant medication) 25 MG per her G-Tube every morning. Further review of the Orders revealed no orders for checking placement, to have the head of bed (HOB) elevated while administering medications, administering medications separately, and/or water flushes before, between medications, and after medication administration. Licensed Practical Nurse (LPN1) was observed administering R14's medications on 09/18/24 at 9:53 AM. LPN1 crushed all three medications together and mixed them with water for administration. LPN1 then pushed water into the resident's stomach via her G-Tube prior to checking placement of the tube and administered the medications all at one time while the head of the resident's bed was elevated approximately 20 degrees. During an interview with LPN1 on 09/18/24 at 10:16 AM, she stated she thought she was supposed to push water into the resident's stomach with the plunger and then pull back to check residual to ensure proper placement of the tube. She stated she had never been told to crush medications separately and administer individually with a water flush between each medication. During an interview with the Administrator in Training (AIT), who was the former Director of Nursing (DON), on 09/18/24 at 1:04 PM, confirmed medications were to be crushed individually and given separately with a water flush in between each medication, placement of the G-Tube was expected to be done by checking residual without pushing water into the resident's stomach first, water and all medications were to be given through a G-Tube via gravity rather than using a plunger to push them into the stomach cavity, and the head of a resident's bed was to be elevated at least 30 degrees when administering medication through a G-Tube.

Based on record review, interviews, and review of facility policy, the facility failed to ensure one resident (Resident (R) 14) of seven residents reviewed for accidents had been assessed for the use of side rails, had risk and benefits discussed with her representative, and/or obtained informed consent for the use of side rails out of a total sample of 14 residents This failure created the potential for the resident to experience negative effects/risks associated with the use of the rails unnecessarily. Findings include: The facility's undated Proper Use of Bed Rails Policy, dated 2024 read, in pertinent part, It is the policy to utilize a person centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails; and The resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident (Bed Rail) assessment must also assess the resident's risk from using the bed rails; and Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of the bed rails; and Upon obtaining informed consent, the facility obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail. Review of R14's Admission Record, dated 09/19/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including anoxic brain damage and quadriplegia. Review of R14's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/18/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) assessment was not able to be conducted due to the resident's poor cognition. The assessment indicated R14 had both short and long-term memory deficits and indicated the resident was dependent upon staff to move in her bed as well as for transfers in and out of her bed. The assessment indicated R14 was not using side rails on her bed. Review of R14's Order Summary Report, dated 09/19/24 and found in the EMR under the Orders tab, indicated orders for May use side rails on bed based on admission/quarterly assessment. Review of R14's comprehensive care plan, dated 08/13/24 and found in the EMR under the Care Plan tab, indicated Side rails per side rail assessment. Bilateral upper rails. Review of R14's EMR revealed no Bed Rail Evaluation, risks and benefits, or signed informed consent for the use of the side rails. R14 was observed lying in her bed with bilateral half side rails in the raised position at the head of her bed on 09/16/24 at 11:02 AM, and on 09/17/24 at 9:37 AM, 12:02 PM, and 2:15 PM. During an interview with the Administrator in Training (AIT) on 09/17/24 at 12:05 PM, she confirmed R14 was not able to move in her bed independently and was not able to grasp her side rails due to her severely contracted upper extremities. During a follow-up interview with the AIT on 09/17/24 at 2:20 PM, she confirmed R14 should not have bed rails on her bed since there was no rationale for the use of the rails.

Based on record review, interviews, and policy review, the facility failed to thoroughly investigate an injury of unknown origin for one resident (Residents (R)20) out of two residents reviewed for abuse out of a total sample of 14 residents. This failure created the potential for residents to be, or to continue to be, abused/neglected. Findings include: The facility's Abuse, Neglect and Exploitation Policy dated 12/03/21 read, in pertinent part, It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property; and Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Review of R20's Admission Record, dated 09/19/24 and found in the electronic medical record (EMR) under the Admissions tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease. Review of R20's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/30/24 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of R20's Progress Notes, dated 08/29/24 and found in the EMR under the Notes tab, revealed [R20] with scattered bruising to the back of her right hand. [R20] does not know how she bruised her hand, un-witnessed injury. The facility's Incident/Accident Log, dated 01/01/24 through 09/17/24, was reviewed and indicated R20's 08/29/24 bruising was an injury of unknown origin. The facility's incident report related to R20's 08/29/24 injury of unknown origin indicated the injury was not witnessed and R20 was not able to tell staff how the bruising occurred. The form's Level of Pain, Mental Status, Predisposing Environmental Factors, Predisposing Physiological Factors, and Predisposing Situation Factors Sections were not complete. The facility was not able to provide an investigation into R20's 08/29/24 injury of unknown origin. During an interview with the Administrator in Training (AIT) on 09/17/24 at 2:24 PM, she confirmed no investigation had been done related to R20's injury of unknown origin. She stated her expectation was a thorough investigation should be done into any injury of unknown origin reported/experience by any resident in the facility.

Based on observation, policy review, review of resident and staff COVID-19 testing logs, review of manufacturers' instructions, and resident and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently and appropriately implemented to provide a safe and sanitary environment when: * Glucometers (devices used to check residents' blood sugar level) were not effectively cleaned and disinfected between residents and were not handled and transported appropriately. This placed 3 of 3 diabetic residents (#6, #12, and #13) in the facility, and any resident who received blood glucose testing in the facility, at risk of infection due to cross contamination. The facility's failure to implement and maintain infection control measures to prevent bloodborne infections placed all residents who received blood glucose testing in the facility in immediate jeopardy of serious harm, impairment, or death from bloodborne infections. * Staff did not perform hand hygiene according to policy and national standards. This had the potential to affect all 23 residents in the facility and place them at risk for infection due to cross contamination. Findings include: The facility's policy for Blood Glucose Monitoring, approved on 4/13/20, documented All testing shall be performed in accordance with Standard Precautions for the handling of blood and body fluids. This policy was not followed. 1. On 2/2/21 at 9:57 AM, RN #1 said she cleaned the glucometer after use by placing it in the Vioguard Cubby + machine (a device that disinfects items by ultraviolet light exposure), and then she removed it when it was done. She said the process did not take very long, and the Vioguard Cubby machine let her know when the cleaning was completed. On 2/2/21 at 5:17 PM, LPN #2 was observed obtaining a blood glucose reading for Resident #12 by using a glucometer. LPN #2 did not sanitize the glucometer after use and prior to placing it in her pocket. LPN #2 transported the glucometer in her pocket to the nurses' station and placed the glucometer in the Vioguard Cubby + machine. LPN #2 stated that using the Vioguard Cubby was a way to sanitize the glucometers, and the glucometers were used for multiple patients. The manufacturer's instructions for the Evencare G3 blood glucose monitoring system used by the facility, documented the meter should be cleaned and disinfected between each resident, and the following products were approved for cleaning and disinfecting the meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach; Medline Micro-Kill+Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; Clorox Healthcare Bleach Germicidal and Disinfectant Wipes; and Medline Micro-Kill Bleach Germicidal Bleach Wipes. The manufacturer's instructions did not identify ultraviolet light as an approved source of cleaning/disinfecting the blood glucose meter. The facility received an email from Medline (the manufacturer of the glucometer), dated 4/2/20, documented the disinfectant wipes named in the manufacturer's instructions were validated for routine disinfecting of the blood glucose meter. It did not mention any other approved methods of cleaning/disinfecting the glucometer. The manufacturer's instructions for the Vioguard Cubby/Cubby + did not document it was approved for use on glucometers or other medical equipment. On 2/2/21 at 6:05 PM, the DON stated the current procedure for sanitizing glucometers was to place them in the Vioguard Cubby machine. On 2/2/21 at 6:10 PM, the Administrator stated the glucometers could be sanitized using appropriate wipes or using the Vioguard Cubby machine. The facility did not clean and disinfect the glucometer in a manner that was approved by the manufacturer in order to remove potentially infectious material, which could expose other residents to bloodborne illnesses. This negative practice placed Residents #6, #12, #13, and any resident who received blood glucose testing in the facility at imminent risk from bloodborne illnesses resulting in serious harm, impairment, or death. On 2/3/21 at 1:32 PM, the facility Administrator and DON were verbally informed and provided written notification of the Immediate Jeopardy (IJ) determination at F880. On 2/4/21 at 4:36 PM, the facility provided a plan to remove the immediacy. The facility alleged the immediacy was removed on 2/4/21. The facility's plan to remove the IJ included: * The policy for glucometers was revised on 2-3-21 to reflect the changes in cleaning processes. The cleaning process included the glucometers were wiped and sanitized with an approved sanitizing cloth after each use. * The DON or her representative educated the licensed nursing staff prior to working to the appropriate way to disinfect the glucometers. On 2/4/21 at 4:55 PM, the facility's plan was accepted. On 2/5/21 at 11:00 AM, the surveyors were onsite to verify removal of the IJ and found the facilty remained out of compliance. 2. The facility's policy for Hand Hygiene/Hand Washing, approved on 2/27/20, stated, Hand Hygiene/hand washing should occur in the following situations .when entering and or exiting a patients (sic) room This policy was not followed. On 2/2/21 beginning at 9:10 AM, Maintenance Staff #1 was observed entering and exiting resident rooms to remove air filters from the wall heating/cooling units. Maintenance Staff #1 did not perform hand hygiene when entering or exiting rooms #334, #345, #342, #336, and #338. On 2/2/21 at 9:50 AM, Maintenance Staff #1 was observed entering and exiting patient rooms to install air filters in rooms #321 and #332. Maintenance Staff #1 did not perform hand hygiene when entering or exiting the resident rooms. On 2/2/21 at 9:55 AM, Maintenance Staff #1 was asked if the facility's policy allowed him to enter and exit resident rooms without performing hand hygiene, and he stated, I believe so. On 2/2/21, the IP was interviewed beginning at 11:12 AM. She stated that it was the facility's expectation for all staff to perform hand hygiene when entering and exiting resident rooms, even if they did not directly contact a resident. 3. On 2/2/21 at 5:17 PM, LPN #2 was observed obtaining a blood glucose reading from Resident #12 by using a glucometer. LPN #2 did not sanitize the glucometer after use and prior to placing it in her pocket. RN #2 transported the glucometer in her pocket to the nurses' station. On 2/3/21 at 1:15 PM, the DON stated that it was not appropriate for the nurse to put the glucometer in her pocket after use. She stated the acceptable procedure was to wrap the glucometer in a paper towel to transport it.

Based on staff interview, record review, and policy review, it was determined the facility failed to ensure residents received or were offered the Pneumococcal (pneumonia) vaccine as indicated. This was true for 3 of 5 residents (#3, #9, and #10) reviewed for immunizations. This deficient practice placed residents at increased risk of developing serious illness from pneumonia. Findings include: The CDC website, accessed on 2/9/21, included recommendations for Pneumococcal vaccination (PCV13 or Prevnar 13 and PPSV23 or [MEDICATION NAME]) for all adults [AGE] years or older without an immunocompromising condition, [DIAGNOSES REDACTED], or cochlear implant, as follows: * For adults [AGE] years or older can discuss and decide with their clinician to receive one dose of PCV13 if they have not previously received a dose. If the patient and clinician decide PCV13 is to be given a dose of PPSV23 should be given at least one year later. * For adults [AGE] years or older who have previously received one dose of PPSV23 and no doses of PCV13, may decide not to receive the PCV13 and the series is considered complete with no additional doses indicated. If, however, the patient and clinician decide the PCV13 is to be given then it should be given at least one year after the PPSV23. The facility's undated policy for Pneumonia Vaccination documented each resident admitted to the facility had the opportunity to receive a pneumonia vaccine unless medically contraindicated or refused, or the resident was already immunized. Any resident who refused the vaccine was re-offered annually. This policy was not followed. Examples include: a. Resident #3's Immunization Record documented on 10/6/15 a pneumonia vaccine was not given because she received the vaccine in October 2010. The record did not document which pneumonia vaccine was given, and there was no documentation she was offered any subsequent pneumonia vaccine after 10/6/15. On 2/2/21 at 3:32 PM, the IP said she had no answer regarding which pneumonia vaccine Resident #3 received or if she was offered another pneumonia vaccine. b. Resident #9's Immunization Record was blank in the areas for documenting the Prevnar 13 and Pneumococcal 23 vaccines. An Informed Consent Form documented she declined the Prevnar 13 vaccine on 9/24/19 because she already received it. There was no documentation she was offered or received the Pneumococcal 23 vaccine. On 2/2/21 at 3:25 PM, the IP said she did not know if Resident #9 received or was offered the Pneumococcal 23 vaccine. c. Resident #10's Immunization Record documented she received a pneumonia vaccine on 8/30/13. The record did not document which pneumonia vaccine was administered. An Informed Consent Form documented Resident #10's representative consented to a Prevnar 13 vaccine on 3/17/18, and it was given on 8/30/13. Another Informed Consent Form documented Resident #10's representative consented to a pneumonia vaccine on 8/29/13, and a previous Pneumococcal vaccine was given. The form did not document which pneumonia vaccine was consented to or which vaccine was previously given. There was no documentation Resident #10 received or was offered the Pneumococcal 23 vaccine. On 2/2/21 at 3:30 PM, the IP said she was not able to locate documentation of the Pneumococcal 23 vaccine for Resident #10. The facility did not ensure residents received or were offered the appropriate pneumonia vaccine according to the recommended schedule and their policy.

Based on resident and staff interview, policy review, and record review, it was determined the facility failed to ensure insulin was administered in a manner that was consistent with physician orders [REDACTED]. This was true for 2 of 2 residents (#6 and #12) reviewed for diabetic care. This failure created the potential for harm if residents experienced a decline in health related to low blood sugar after administration of insulin. Findings include: The facility's undated policy for Administration of Insulin stated, All insulin will be administered in accordance with physician's orders [REDACTED]. This policy was not followed. The Drugs.com website, accessed on 2/11/21, stated Insulin [MEDICATION NAME] is a fast-acting insulin that starts to work about 15 minutes after injection. Low blood sugar may happen with insulin [MEDICATION NAME]. Very low blood sugar can lead to [MEDICAL CONDITION], passing out, long-[MEDICATION NAME] brain damage, and sometimes death. The Drugs.com website also stated Humalog ([MEDICATION NAME]) is given within 15 minutes before a meal, or right after eating and [MEDICATION NAME] (insulin [MEDICATION NAME]) is a fast-acting insulin that starts to work about 15 minutes after injection. The website stated [MEDICATION NAME] is a fast-acting insulin that begins to work very quickly. After using it, you should eat a meal within 5 to 10 minutes. On 2/2/21 at 12:40 PM, the DON presented the menu board from the dining room that displayed mealtimes. Breakfast was scheduled at 8:30 AM, lunch at 12:30 PM and dinner at 6:30 PM. Residents were not administered their insulin as ordered by their physician. Examples include: 1. Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #6's physician orders [REDACTED]. When used as a meal-time insulin, inject 15 minutes before. The order started on 1/19/21. Resident #6's MAR indicated [REDACTED] - The Humalog-[MEDICATION NAME] was administered 20 to 45 minutes prior to his meal on 1/20/21 at 7:46 AM, 1/20/21 at 5:53 PM, 1/24/21 at 12:12 PM, 1/25/21 at 7:54 AM, 1/25/21 at 12:01 PM, 1/25/21 at 6:04 PM, 1/27/21 at 11:54 PM, 1/28/21 at 5:46 PM, 2/1/21 at 8:06 AM, and 2/1/21 at 6:07 PM. - The Humalog-[MEDICATION NAME]was administered 46 minutes to 90 minutes prior to his meal on 1/19/21 at 11:38 AM, 1/19/21 at 5:30 PM, 1/22/21 at 7:26 AM, 1/22/21 at 11:52 PM, 1/22/21 at 5:31 PM, 1/23/21 at 11:32 AM, 1/23/21 at 5:07 PM, 1/24/21 at 7:52 AM, 1/24/21 at 5:24 PM, 1/27/21 at 7:19 AM, 1/27/21 at 5:08 PM, 1/28/21 at 7:09 AM, 1/29/21 at 5:03 PM, 1/31/21 at 5:34 PM, and 2/2/21 at 7:00 AM. On 2/3/21 at 12:25 PM, Resident #6 stated he waited an average of at least 30 minutes for meals after his insulin was administered. The DON was interviewed on 2/3/21 at 1:00 PM, and Resident #6's record was reviewed in her presence. The DON confirmed Resident #6's fast-acting insulin was administered outside the parameters of the physician's orders [REDACTED]. 2. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #12's physician orders [REDACTED]. The order started on 1/19/21. Resident #12's MAR indicated [REDACTED] Resident #12's MAR indicated [REDACTED]. Resident #12's MAR indicated [REDACTED]. Resident #12's MAR indicated [REDACTED] On 2/2/21 at 5:30 PM, LPN #2 was observed administering [MEDICATION NAME]-[MEDICATION NAME] to Resident #12. A meal tray was then delivered to Resident #12 at 6:25 PM, which was 55 minutes after his fast-acting insulin was administered. Resident #12 was interviewed on 2/3/21 at 12:50 PM. Resident #12 stated he usually waited more than 15 minutes for meals after his short-term insulin was administered. The DON was interviewed on 2/3/21 at 1:00 PM, and Resident #12's record was reviewed in her presence. The DON confirmed Resident #12's fast-acting insulin was administered outside the parameters of the physician's orders [REDACTED].

Based on observation, staff interview, and record review, it was determined the facility failed to ensure bed rails were used only when required to treat the resident's medical symptoms. This was true for 1 of 7 residents (Resident #13) reviewed for restraints. This failure placed Resident #13 at increased risk for physical injuries, including entrapment in the bed rails, psychological decline due to restricted movement, and a diminished sense of dignity. Findings include: Resident #13 was re-admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's admission orders [REDACTED]. Resident #13's bed rail assessment, dated 1/20/21, documented half bed rails on the left side and half bed rails on the right side of her bed were determined to be appropriate for Resident #13. The assessment stated Resident #13 was slightly confused after COVID-19 diagnosis, and cognitive changes .might place Resident #13 at risk for entrapment. The assessment documented Resident #13 was using upper half bed rails bilaterally. There was no documentation lower half bed rails or full bed rails were approved or necessary. Resident #13's consent for assistive device, dated 1/20/21, documented Resident #13's representative provided verbal consent to place right ½ side rail - upper, and left ½ side rail - upper on Resident #13's bed. There was no documentation of consent for right or left ½ side rails - lower. Resident #13's annual MDS assessment for functional status, dated 1/25/21, documented she was severely cognitively impaired, required 2 staff to provide weight-bearing support for bed mobility, transfers, and toilet use. The assessment stated Resident #13 walked in her room with staff oversight, encouragement or cueing and with 2-person physical assistance. The assessment stated Resident #13 required staff assistance to stabilize herself and used a walker and wheelchair for mobility. Resident #13's care plan, dated 2/10/21, stated she was at risk for alteration in skin integrity related to left hip repair, history of pressure area to buttock, [DIAGNOSES REDACTED]. Interventions included a pressure reducing mattress on her bed - air bed. Resident #13's care plan, dated 2/10/21, stated she had an alteration in mobility due to [DIAGNOSES REDACTED]. Interventions included side rails per side rail assessment. Resident #13 was observed on 4/13/21 at 3:28 PM, lying in bed with all 4 bed rails up - a right half bed rail - upper and lower, and left half bed rail - upper and lower. When asked, LPN #4 stated on 4/15/21 at 2:05 PM, Resident #13 was on an air mattress and needed all 4 bed rails up. LPN #4 stated she did not believe a resident needed a consent for the 4 bed rails due to the air mattress policy. LPN #4 stated there was a concern Resident #13 would try to get out of bed on her own. When asked, the DON stated on 4/15/21 at 4:40 PM, Resident #13 was on an air mattress and the air mattress policy stated to have 4 bed rails up, and that was why Resident #13 she had 4 bed rails up. The DON said Resident #13's care plan included the use of 2 bed rails and the care plan was not updated to include 4 bed rails. The facility's air mattress policy, dated 10/4/17, stated: use all four side rails (full) when using an air mattress to prevent patient rolling out of bed. The facility's air mattress manufacturer's information, not dated, provided 4/15/21 by the DON, did not document the use of 4 side rails was required.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' were not placed inappropriately on isolation. This was true for 1 of 2 residents (Resident #9) who were reviewed for isolation precautions. This failure created the potential for psychosocial harm if residents experienced loneliness, isolation, and other negative emotional effects. Findings include: The facility's undated policy for the Infection Prevention and Control Program documented residents were placed on the least restrictive isolation precautions for the shortest duration possible. This policy was not followed. Resident #9 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #9's quarterly MDS assessment, dated 10/27/20, documented she was cognitively intact and she felt down, depressed, or hopeless. Resident #9's care plan documented she had the following identified problem areas: * Psychosocial well-being/mood due to COVID-19, initiated on 9/1/20: A goal was initiated for no decline in psychosocial well-being/mood through the next review period. An intervention was in place to provide reassurance to Resident #9 the facility is taking precautions for the health and safety of myself and my fell ow residents. * COVID-19, initiated on 9/17/20: She was on COVID-19 precautions and was unable to leave her room due to COVID-19. Interventions included offering in-room activities. A nurse's progress Note, dated 1/17/21 at 10:00 PM, documented Resident #9 expressed feeling lonely in her room all day, she was not allowed to have the door open, and she was alone most of the time. The facility's COVID-19 testing logs documented Resident #9's COVID-19 test results were negative on 1/11/21, 1/18/21, 1/25/21, and 1/31/21. A document provided by the facility, dated 2/2/21, documented the following: * Isolation was implemented on all residents on 1/1/21 due to an outbreak of COVID-19. * Residents who recovered from COVID-19 were allowed to come out of their rooms for meals and activities. Isolation was continued for the residents who did not have COVID-19, which included keeping their doors closed, and was implemented on 1/26/21. * The health district instructed the facility they were in outbreak status for 28 days after each staff or resident became COVID-19 positive, and to continue isolation of residents. The facility implemented this process with each COVID-19 positive case. * The Infection Control Consultant provided direction to the facility to keep the resident's door closed as a safety measure because COVID-19 was airborne. On 2/1/21 at 12:05 PM, the Administrator stated there were no active COVID-19 cases in the facility at that time, and the last resident who tested positive for COVID-19 was on 1/30/21 and they were subsequently moved to the hospital. On 2/1/21 at 12:12 PM, Resident #9's room had signs posted outside the door Droplet Precautions and Contact Precautions were in place, and the door was closed. During multiple observations throughout the survey, the same conditions were present and multiple staff were observed entering Resident #9's room after donning full PPE. On 2/1/21 at 12:25 PM, the Director of Social Services said Resident #9 was on isolation because staff were trying to protect her from being infected with COVID-19. On 2/1/21 at 3:15 PM, CNA #2 said Resident #9 was on precautions to protect her because she never had COVID-19. On 2/1/21 at 3:35 PM, Resident #9 said she had been in her room with the door closed because of COVID-19 for at least two weeks, she was tired of it, and she did not like her door closed. Resident #9 said she never had COVID-19, and she was not allowed out of her room since the isolation precautions were put in place. On 2/1/21 at 3:55 PM, the DON said Resident #9 was on precautions to try to prevent her from getting COVID-19, and she had been kept in her room since the precautions were initiated. The DON said the last COVID-19 positive case was a resident who tested positive approximately 2 days prior, and he was transferred out of the facility at that time. Resident #9 experienced loneliness and isolation when she was inappropriately placed on isolation precautions and restricted to her room by the facility.

Based on observation, record review, review of nurse schedules, staff interview, and policy review, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19 infections. The facility's failure to implement and maintain infection control measures to prevent transmission of COVID-19 placed all staff in the facility, and all residents on the non-COVID units in the facility, in immediate jeopardy of serious harm, impairment, or death related to COVID-19 infection. Findings include: 1.The facility's Coronavirus Surveillance Policy, dated 6/10/20, documented the facility monitored the status of the COVID-19 outbreak through the CDC website, and monitored the website for changes in prevention, treatment, isolation, or other recommendations. The CDC website, accessed on 8/27/20, included a section titled Responding to Coronavirus in Nursing Homes, which documented facilities were to assign dedicated healthcare professionals (HCP) to work only on the COVID-19 positive unit. The website also included Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, which documented dedicated means that HCP are assigned to care only for COVID-19 positive patients during their shift. The facility's policy and CDC guidelines were not followed. The facility included two halls, the East Hall and the West Hall. The East Hall included both a Southeast Hall and Northeast Hall. On the Southeast Hall two resident rooms, 336 and 341, which were across the hall from each other, had been turned into an anteroom (a small outer room that leads to a larger room or area), one room was a breakroom and the other used to store clean supplies. To ensure separation of the anteroom the hall between the two rooms was covered on each side with a plastic barrier that covered floor to ceiling and wall to wall. The 5 residents (#1 - #5) who had tested positive for COVID-19 resided in the 4 rooms located beyond the barrier at the end of the Southeast Hall, rooms 337. 338, 339, and 340. This was the facility's COVID-19 positive unit. Residents who tested negative for COVID-19, and newly admitted residents who were in quarantine, resided on the other side of the plastic barrier on the Southeast Hall in rooms 333-336 and 342-345, the Northeast Hall, and the West Hall. The facility's COVID-19 symptom and tracking form, dated 8/24/20, documented 5 residents (#1 - #5) tested positive for COVID-19 on 8/23/20. The Nurses' Schedule, dated 8/23/20 - 9/5/20, documented nurse staff assignments for the Southeast Hall. The schedule documented 3 licensed nurses were scheduled to work on the dayshift on 8/26/20. The schedule documented one licensed nurse was assigned to the Southeast Hall, to serve both the COVID-19 negative and COVID-19 positive residents. On 8/26/20 at 2:40 PM, LPN #1 stated she worked the dayshift on the Southeast Hall on 8/24/20, 8/25/20, and 8/26/20. LPN #1 stated on 8/26/20 at approximately 11:00 AM, she was told to stay in the COVID-19 positive unit and to not go back and forth between the COVID-19 negative and positive units of the Southeast Hall. LPN #1 stated prior to 11:00 AM on 8/26/20 she worked both the COVID-19 negative and COVID-19 positive units on the Southeast Hall. On 8/26/20 at 3:45 PM, the DON stated since 8/23/20, the licensed nurses scheduled to work the Southeast Hall for the 12 hour dayshift had been going through the COVID-19 barrier to pass medications and provide cares to the 5 residents on the COVID-19 positive unit and then came back through the plastic barrier to pass medications and provide cares to residents on the negative unit of the Southeast Hall. The DON stated licensed nurses scheduled to work the 12 hour nightshift worked on both sides of the Southeast Hall (COVID-19 positive and COVID-19 negative units), in addition to the Northwest Hall. On 8/26/20 at 6:15 PM, LPN #3 stated she was scheduled to work 12 hours on the Northeast Hall and Southeast Hall combined, including the COVID-19 positive unit. LPN #3 stated she had crossed the barrier from the negative unit into the COVID-19 positive unit to pass medications and provide cares on 8/24/20 and 8/25/20. LPN #3 stated she was scheduled to work a 12 hour nightshift on both the Northeast Hall and Southeast Hall, including the COVID-19 positive unit, that night (8/26/20). On 8/26/20 at 6:20 PM, the DON stated the nurses scheduled to work the Southeast Hall on the 12 hour dayshift and the nurses scheduled to work the 12 hour nightshift were crossing the plastic barrier and working both the COVID-19 negative unit and positive unit during their shift. 2. On 8/26/20 at 3:00 PM, CNA #1 stated at the end of her shift, she exited the COVID-19 positive unit on the Southeast Hall back into the COVID-19 negative unit of the Southeast Hall wearing a surgical mask and walked through the COVID-19 negative unit of the Southeast Hall. LPN #1, also present during the interview, and CNA #1, both stated they stopped and talked with other staff members at the East Hall nurse's station, which was located between the Northeast Hall and Southeast Hall, prior to walking through the dining room to exit the facility near the West Hall. The facility failed to ensure designated staff were assigned to work the COVID-19 positive unit each shift, and staff who worked on the COVID-19 positive unit had separate exit/entrance to the unit. These deficient practices placed staff and residents who had tested negative of COVID-19, at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death, related to the infection. On 8/26/20 at 6:30 PM, the facility Administrator and DON were informed verbally of a determination of Immediate Jeopardy for F880. The Immediate Jeopardy (IJ) template was provided to the facility via email on 8/27/20 at 1:15 PM, which provided written notification of the IJ. On 8/27/20 at 1:30 PM, the facility provided an acceptable plan to remove the immediacy. The facility alleged the plan to remove the immediacy was implemented August 27, 2020 at 6:30 AM. The facility's IJ removal plan included: *Staff had been placed into the COVID-19 positive unit, a nurse and a CNA, and they do not come out of the COVID-19 positive unit during their shift. *An anteroom was placed at the entrance into the COVID-19 positive unit, located at the end of the Southeast Hall, so staff could enter the unit from outside the facility. On 8/27/20 at 2:45 PM, the survey team was onsite at the facility to confirm implementation of the above IJ removal plan. However, changes initiated by the facility to correct the above IJ, resulted in a practice that continued to place residents' health and safety in IJ. This IJ is described below. The CDC website, accessed on 8/27/20, included a document dated 5/22/20, titled Responding to Coronavirus in Nursing Homes. The document stated healthcare providers must wear eye protection and an N95 or higher-level respirator at all times while on the COVID-19 positive unit. On 8/27/20 at 2:45 PM, the ICP stated the COVID-19 positive unit had its own entrance and exit area and staff were screened by the licensed nurse at the COVID-19 positive designated entrance. On 8/27/20 at 3:07 PM, LPN #5 was observed wearing a surgical mask, gown, booties, and gloves in the newly established anteroom located at the end of the Southeast Hall, at the outside entrance into the COVID-19 positive unit. LPN #5 was not wearing an N95 or higher-level respirator mask and a face shield. LPN #5 stated the COVID-19 positive unit hallway was the warm zone marked with 2 parallel strips of red tape in the center of the hallway. LPN #5 stated staff were instructed by the ICP to wear a surgical mask and face shield in the warm zone. LPN #5 stated the warm zone was identified with the 2 strips of red tape approximately 3 feet wide apart in the middle of the COVID-19 positive unit hallway. The strips of red tape were approximately 2 feet from rooms [ROOM NUMBERS] on the right side and rooms [ROOM NUMBERS] on the left side of the COVID-19 positive unit hallway. While walking through the COVID-19 positive unit hallway warm zone, the doors to rooms 338-340 were open. Resident #2 was observed reclined in a recliner and both Resident #3 and #5 were lying in bed. LPN #5 stated the residents' rooms were the hot zone and full PPE was required to be donned when in them. LPN #5 stated full PPE included a gown, booties, gloves, and an N95 mask and a face shield or a powered air purifying respirator (PAPR) and the PPE was to be worn while providing resident care. LPN #5 stated full PPE was located in the previously established anteroom utilizing rooms [ROOM NUMBERS] which were across the hall from each other. On 8/27/20 at 3:22 PM, LPN #5 walked through the positive unit hallway and entered the anteroom in rooms [ROOM NUMBERS]. The doors to the clean supply room and the staff breakroom/charting room were open. LPN #5 stated the doors remained closed unless used by a staff member. LPN #5 stated no one was in either room and the doors should have been closed. LPN #5 stated staff donned and doffed their PAPR or N95 mask and face shield in that anteroom. The facility failed to ensure staff assigned to work the COVID-19 positive unit wore an N95 or higher-level respirator and eye protection at all times, which placed staff and residents who had tested negative of COVID-19 at imminent risk of COVID-19 infection and subsequent serious harm, impairment, or death, related to the infection. On 8/28/20 at 3:00 PM, the facility Administrator, LSW, CNA Supervisor, Activities Director, Facility's Emergency Management Director, and DON, as well as, the Administrator of the attached critical access hospital, were notified via phone of the continued Immediate Jeopardy at F880. The IJ was not removed prior to the exit conference. 3. On 8/26/20 at 10:55 AM, the Administrator said the first COVID-19 positive resident was detected on 8/20/20 and was transferred to the hospital. The Administrator said five more residents tested positive on 8/23/20 and were moved and cohorted in the Southeast Hall. On 8/26/20 at 11:25 AM, the ICP said she was instructed by the ICP of the attached hospital to implement droplet precautions for all residents who were not COVID-19 positive residing in the facility. a. The CDC guidance Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated July 15, 2020, stated HCP should continue to adhere to standard and transmission-based precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. The facility's Novel Coronavirus Prevention and Response, dated 6/10/20, documented to promote easy and correct use of PPE by posting signs on the door or wall outside the resident room that clearly described the type of precautions needed and the required PPE. This policy and guidance was not followed. The West Hall and Northeast Hall only had four resident rooms with two signs on their door. These residents were identified as under quarantine because they were newly admitted to the facility. One sign instructed individuals to see the nurse before entering, and the second sign stated Droplet precautions (in addition to Standard Precautions) were in use with instructions for the required PPE. The sign for droplet precautions stated staff were to wear eye protection with respiratory symptoms and use eye protection, a gown, and gloves if contact with secretions was likely to occur. The instructions on the sign for droplet precautions for what PPE to wear, and under what circumstances, differed from what was observed and what staff stated they needed to wear when they entered a resident's room. There were no signs posted elsewhere in the facility or on resident doors to identify the type of precautions needed when entering resident rooms. On 8/26/20 at 11:40 AM, CNA #2 was wearing a surgical mask and a face shield on the West Hall when going into resident rooms. CNA #2 said the signs on the resident doors were used for newly admitted residents who were on quarantine for 14 days. She said she was to perform hand hygiene, put on a gown and gloves in addition to the face mask she was wearing, before assisting the residents who were on quarantine. CNA #2 said for rooms without signs, nursing staff were to put on all PPE only if they were going to touch the resident. On 8/26/20 at 12:30 PM, Housekeeper #1 was observed entering a resident's room to adjust the exterior window at the resident's request after putting on a surgical mask, face shield, gown and gloves. There were no signs on the resident's door stating they were on precautions. Housekeeper #1 said she was instructed yesterday morning to wear a surgical mask, face shield, a gown, and gloves into all the rooms on the Northeast Hall. On 8/26/20 at 12:35 PM, the CNA Supervisor stated all the residents residing on the East Hall were on droplet precautions. The CNA Supervisor stated the facility's droplet precautions instructed staff to wear a surgical mask, a face shield, a gown, and gloves. On 8/26/20 at 3:35 PM, CNA #3 said every resident was on airborne, standard, and droplet precautions. She said she was informed of what to wear by the RNs, the signs posted, and by what was in the PPE supply carts. CNA #3 said they did not have supplies or signs for every room and she did not know why, and she was doing what the CNA Supervisor instructed her to do. She said she came to work on Tuesday, 8/25/20, and the droplet precautions were in place. On 8/26/20 at 3:45 PM, CNA #4 said an RN informed them on Tuesday, 8/25/20, to start using the droplet precaution protocol, and they were to wear all the PPE, including a face mask, face shield, a gown, and gloves into all resident rooms. CNA #4 said those residents on quarantine had a PPE supply cart and signs at their door. CNA #4 said the newly admitted residents were placed on quarantine for two weeks and staff were required to wear full PPE in their rooms. On 8/26/20 at 4:00 PM, CNA #6 said the doors of the newly admitted resident rooms had signs indicating hand hygiene, a face mask, goggles, a gown, and gloves were required whenever staff went into those rooms. CNA #6 said since Monday or Tuesday the staff were to use droplet precautions in every resident room, as indicated on the signs. On 8/26/20 at 4:10 PM, CNA #5 said the Northeast Hall residents were all on droplet precautions since Tuesday, 8/25/20. On 8/26/20 at 4:25 PM, LPN #4 said the sign on the door meant a newly admitted resident was on quarantine for 14 days, and staff were to put on a gown, gloves, and a face shield; the staff already had on a face mask. LPN #4 said other residents without signs also required staff to wear gowns in their rooms. It was unclear what PPE was to be worn and when PPE was to be worn in resident rooms who were on quarantine or who had tested negative for COVID-19. b. The facility's COVID-19 Preparedness Plan, dated 4/22/20, stated the ICP will have the responsibility to educate staff on proper use of PPE, handwashing, and isolation precautions. This policy was not followed. On 8/26/20 at 3:10 PM, the ICP said the residents on the East and West Halls were on droplet precautions starting on 8/25/20. The ICP said the staff were trained one on one when they came in to start their shift. Facility staff were not consistently and appropriately trained and educated on the changes in required PPE once there was an outbreak of COVID-19 infection. Examples include: - On 8/26/20 at 3:35 PM, CNA #3 said every resident was on airborne, standard, and droplet precautions. She said she was informed of what to wear by the RNs, the signs posted, and by what was in the PPE supply carts. - On 8/26/20 at 3:45 PM, CNA #4 said an RN informed them on Tuesday, 8/25/20, to start using the droplet precaution protocol, and they were to wear all the PPE, including a face mask, face shield, a gown, and gloves into all resident rooms. - On 8/26/20 at 4:00 PM, CNA #6 said during report on Tuesday, 8/25/20, the charge nurse informed her the new PPE protocol, including surgical masks, were to be followed. CNA #6 said when the COVID-19 lock down started in March they received PPE use training from the ICP or the charge nurse. When the facility learned of the first COVID-19 positive resident CNA #6 said she was trained by another CNA on how to put on disposable booties and the Powered Air-Purifying Respirator (PAPR) hood for the COVID-19 positive unit. - On 8/26/20 at 4:25 PM, LPN #4 said when she came in to work on Monday morning, the night shift nurse informed her the droplet precautions were in place. 4. The facility's Coronavirus Surveillance Policy, dated 6/10/20, stated: * Heightened surveillance activities would be implemented to limit the transmission of COVID-19. These included, but were not limited to, screening residents. * Residents would be monitored for signs and symptoms of coronavirus illness: fever, cough, shortness of breath. Some older adults may exhibit subtle or atypical symptoms of COVID-19, such as new or worsening malaise, change in appetite, dizziness, diarrhea, or change in mental status or behavior. And, considerations for managing residents with suspected or confirmed COVID-19 infection include: * Increase monitoring of resident for development of more severe symptoms or other changes in condition. * Increase monitoring of all other residents when COVID-19 is suspected or confirmed. The CDC guidance for Responding to Coronavirus (COVID-19) in Nursing Homes, accessed 8/27/20, stated to increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. And, to consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms. The facility's COVID-19 Resident Symptom Tracking Log, dated 8/24/20, instructed to check vital signs and assess residents for symptoms of COVID-19 illness and to document them in the medical record. Vital signs included oxygen saturation, respiration, temperature, blood pressure, and pulse. Six residents tested positive for COVID-19 illness, the first on 8/20/20 and five on 8/23/20. Nurse Progress Notes which included COVID-19 symptom screening and a Vital Signs Roster from 8/22/20 through 8/26/20, documented for the five residents who tested positive on 8/23/20, the following: * Residnt #2 was not screened for symptoms on 8/22/20, 8/23/20 and 8/24/20, and was not screened for vital signs on 8/25/20. * Resident #5 was not screened for symptoms on 8/22/20 and 8/2320, and was not screened for vital signs on 8/25/20. * Resident #4 was not screened for symptoms on 8/23/20 and 8/24/20, and was not screened for vital signs on 8/25/20. * Resident #3 was not screened for symptoms on 8/22/20, and was not screened for vital signs on 8/25/20. * Resident #1 was not screened for symptoms on 8/23/20, and was not screened for vital signs on 8/25/20. On 8/26/20 at 3:10 PM, the IPC said they assessed the residents every shift, they took their temperatures, and documented symptoms by exception (meaning if they had symptoms then they were documented in the record, if no symptoms were exhibited then there was no documentation).

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure, consistent with professional nursing standards of practice, medications were dispensed and administered by one licensed nurse in the COVID-19 positive unit. The facility's failure placed all 5 residents (#1-#5) in the COVID-19 positive unit at imminent risk of significant medication errors and subsequent serious harm, impairment, or death. Findings include: The Potter & Perry Fundamentals of Nursing, Eighth Edition, textbook, copyright 2013, under Professional Standards in Nursing Practice states under the section Legal Guidelines for Recording, nurses should only chart for themselves, are accountable for information they enter into a patient's chart, and nurses were never to chart for someone else. The Nurse.com website, dated 12/16/15, documents, One of the first general principles in medication administration that a nurse must adhere to is to personally prepare any medications properly ordered for a patient and to personally administer those medications. Although there may be instances in which more than one healthcare provider may be required to administer a single medication, such as in a code, it is not generally acceptable practice to prepare any type of medication for another person to administer. Nor is it acceptable practice to administer a medication that another has prepared. The reasons for this strict rule are numerous. First and foremost, because preparation and administration are fraught with potential for error, relying on another nurse to prepare a medication that you administer is dangerous at best. According to the Agency for Healthcare Research and Quality article, Medication Administration Errors, updated on 9/7/19, errors in medication administration can occur through failures in any of the five rights: right patient, right medication, right time, right dose, and right route. The article states such errors may be the result at the individual-level but may also result from system-level failures such as understaffing and poor process. On 8/26/20 at 2:40 PM, LPN #1 was observed working in the COVID-19 positive unit. LPN #1 stated five residents (#1 - #5) were in the COVID-19 positive unit located beyond a floor to ceiling and wall to wall plastic barrier toward the end of the Southeast Hall. On 8/26/20 at 2:45 PM, LPN #1 stated when the residents received routine medications or requested as needed medications, she notified the DON or the nurse working on the Northeast Hall, located outside of the COVID-19 positive unit, and one of them prepared the medications and delivered them to her in the COVID-19 positive unit to administer to the residents. LPN #1 stated the medications were placed in medicine cups with the resident's first name handwritten on each medicine cup by either the DON or the licensed nurse from the other hall. LPN #1 stated she was unable to verify the medications were for the right resident and the resident received the correct medications. LPN #1 said she could not verify the medications were administered at the right dose, right time, and by the right route (e.g. oral, injection, rectal). LPN #1 stated she did not sign in the Electronic Medical Record (EMR) for the medications she administered. LPN #1 stated if a resident refused medications, she notified the DON or the licensed nurse working on the Northeast Hall of the resident's refusal and they documented the refusal in the resident's EMR. On 8/26/20 at 3:40 PM, LPN #2 stated the nurses that worked the Northeast Hall dispensed the medications of the 5 residents on the COVID-19 positive unit into medicine cups, wrote the resident's first name on the medicine cup, documented the medications as given in the EMR, and delivered the medication cups to the licensed nurse working the COVID-19 positive unit. On 8/26/20 at 3:45 PM, the DON stated she worked the COVID-19 negative side of the Southeast Hall at approximately 11:00 AM that day, and dispensed and pre-poured the medications for the 5 residents in the COVID-19 positive unit and documented in the EMR that she administered the medications to the 5 residents. The DON stated she delivered the medications to LPN #1 to administer to each of the 5 residents. The DON stated one licensed nurse should have been dispensing, administering, and documenting the medications as given to the 5 residents on the COVID-19 positive unit. The medications were not individually labeled and did not include sufficient information to identify which resident the medications were intended for. In addition, the licensed nurse who received the medications on the COVID-19 positive unit did not verify the medications or the resident they were intended for prior to administering them. These negative facility practices placed the 5 residents on the COVID-19 positive unit at imminent risk of significant medication errors resulting in serious harm, impairment, or death. On 8/26/20 at 6:20 PM, the facility Administrator and DON were verbally informed of the Immediate Jeopardy (IJ) determination at F684 and the IJ template was emailed on 8/27/20 at 1:15 PM, which provided written notification of the IJ. On 8/27/20 at 1:30 PM, the facility provided an acceptable plan to remove the immediacy. The facility had implemented the removal plan prior to submitting it for approval. In the removal the facility alleged the immediacy was removed as 8/27/20 at 6:30 AM. The facility's IJ removal plan included: - Medication Pass: A workstation on wheels (WOW) was to be placed in the COVID-19 positive unit so the licensed nurse in the unit may document medication administration. A licensed nurse would retrieve the medications from the Pyxis (medication storage and retrieval machine) and place them in a cup marked with the resident's name. The licensed nurse in the COVID-19 positive unit would then scan the resident barcode and scan the medication barcode for verification and administer the medications. Surveyors completed onsite verification of the removal of the IJ and confirmed the IJ removed as of 8/27/20 at 4:05 PM. On 8/27/20 at 4:57 PM, the facility Administrator, along with the DON from the attached critical access hospital, were verbally informed the immediacy was removed based on onsite verification the IJ removal plan was implemented.

Based on observation, policy review, review of staff schedules and screening logs, and staff interview, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination, including COVID-19. Findings include: 1. The facility's policy for Coronavirus Surveillance, undated, documented visitors and staff were screened for the following: a) signs and symptoms of a respiratory infection (fever, cough, shortness of breath, or sore throat) b) whether there was contact in the past 14 days with someone who had confirmed COVID-19, was under investigation for COVID-19, or was ill with a respiratory illness c) international travel to countries with sustained community transmission of COVID-19 d) residing in a community where community-based spread of COVID-19 was occurring. The policy stated staff who had signs and symptoms of a respiratory infection would not report to work. The facility's Staff Screening Tool included 3 screening questions which included: * Contact with someone in the past 14 days who had a confirmed [DIAGNOSES REDACTED]. * Current signs of respiratory infection (fever, cough, shortness of breath, sore throat, loss of taste of smell, myalgia (muscle aches), or nausea and vomiting. * Traveled internationally in the past 14 days or had contact with persons who had travelled internationally. The Staff Screening Tool also contained a column to document the staff member's temperature, a column for initials, and a signature/date line at the end of the page for a nurse to sign the form. The facility's as-worked schedule and Staff Screening Tools, dated 6/29/20 through 7/6/20, were reviewed for all employees of the facility. There were inconsistencies between the as-worked schedule and the Staff Screening Tool. Examples include: a. The following staff were not screened prior to working their shift: * The screening tool and schedule, dated 6/29/20, did not include screening for 3 CNAs, 1 LPN, and the Administrator. * The screening tool and schedule, dated 6/30/20, did not include screening for 6 CNAs, 2 LPNs, 1 RN, the Administrator, the DON, the IP, and the Social Worker. * The screening tool and schedule, dated 7/1/20, did not include screening for 7 CNAs, 2 LPNs, 1 RN, the Administrator, and the IP. * The screening tool and schedule, dated 7/2/20, did not include screening for 4 CNAs, 2 RNs, 1 LPN, the Administrator, and the IP. * The screening tool and schedule, dated 7/4/20, did not include screening for 1 RN and 1 CNA. * The screening tool and schedule, dated 7/5/20, did not include screening for 1 RN. * The screening tool and schedule, dated 7/6/20, did not include screening for 1 CNA. b. The Staff Screening Tool had an area for staff to write their name. The Staff Screening Tools were reviewed from 6/29/20 to 7/6/20 and there were entries without a staff name, as follows: * One entry missing a staff name on 6/30/20, 7/3/20, 7/5/20, and 7/6/20 * Four entries missing a staff name on 7/2/20 c. The facility's policy for COVID-19 reporting, undated, documented staff screening logs and resident symptom logs were reviewed daily by the IP, or designee. The policy stated the data was reviewed for items that required reporting such as new-onset of respiratory symptoms, suspected/confirmed COVID-19, or a severe respiratory infection that resulted in hospitalization or death. The Staff Screening Tool, at the bottom of the form, had a line for the nurse signature and date it was signed. The Staff Screening Tool was not signed by the IP or a designee for each shift on 6/30/20, 7/1/20, 7/2/20, 7/3/20, 7/5/20, and 7/6/20. On 7/6/20 at 2:34 PM, the Physician was observed in Resident #1's room. The Physician was wearing a face mask and was conversing with Resident #1. After several minutes, the Physician exited the room. The Physician said he performed hand hygiene and donned a mask when entering the facility. He said the facility used to do temperature checks and ask screening questions, but he did not think they were doing that anymore. The Physician said he snuck in without being screened on that day. On 7/6/20 at 3:55 PM, CNA #5 said when she came to work she checked her temperature, showed it to the nurse, and wrote it in the Staff Screening Tool, which was in the employee break room. CNA #5 said she wrote down her temperature and the nurse made sure the staff signed their temperature. On 7/6/20 at 4:00 PM, the Ward Clerk said when she came to work she took her temperature and the nurse witnessed her temperature and initialed it. On 7/6/20 at 4:02 PM, LPN #1 said when he arrived for work he went straight to the break room and checked his temperature, the temperature was verified by another nurse, and there was a binder where the Staff Screening Tool forms were kept. LPN #1 said he and the other nurse for that shift looked at the screening logs prior to getting shift report and going to the resident care area. On 7/6/20 at 4:03 PM, CNA #1 said when she started her shifts, she donned a mask, went to the break room and an RN took her temperature and asked questions related to COVID-19 risk factors and wrote down the answers. CNA #1 said if she had symptoms she would call the CNA Supervisor, or the LPN, and they would find coverage for her shift. On 7/6/20 at 4:15 PM, Activities Aide #1 said at the start of her shift she went into the building with her mask on, went to the breakroom and clocked in, then went to the East Unit RN station where an RN took her temperature. She said she then washed her hands and started her duties. On 7/6/20 at 4:28 PM, CNA #2 said at the start of her shift she went to the breakroom where the RN took her temperature and asked questions related to COVID-19 risk factors. CNA #2 said she signed her own name to the Staff Screening Tool, the RN showed her the temperature reading and she, CNA #2, wrote it down and the RN initialed it. CNA #2 said she then began her duties. On 7/7/20 at 8:38 AM, Housekeeping Staff #1 said she entered the facility door near the laundry room west of the West Unit. She said the Housekeeping Supervisor took her temperature and watched while Housekeeping Staff #1 filled out the Staff Screening Tool, and if she did not have a fever she started her work day. She said if she felt sick at work she would tell her supervisor who would take her temperature. On 7/7/20 at 9:15 AM, LPN #2 said when she came to work she checked her temperature and the charge nurse verified it. LPN #2 said after her temperature was checked she was asked the screening questions. LPN #2 said the screening was done in the break room. On 7/7/20 at 9:50 AM, the IP said staff were screened after they entered the building through the back door and went to the break room. The IP said the staff had their temperature checked, it was verified by a nurse, and they were asked screening questions. The IP said the nurse verified the staff's screening by initialing the log, and she looked at the employee screenings when she arrived in the morning. The IP said the DON also keeps on top of it. The IP said she did not sign the Staff Screening Tool, and she should be notified if an employee had a temperature of greater than 100 degrees or if they answered yes to any of the screening questions. The IP said the Physician should go through the same process when he entered the building. On 7/8/20 at 10:24 AM, Prep Cook #1 said he entered the facility door near the laundry room west of the West Unit with a mask on. He said he went into the kitchen office, the kitchen supervisor took his temperature, and the same was done with vendors. Prep Cook #1 provided the Employee Screening Criteria log which included dates, employee names and departments, the temperatures taken, and the initials of the person taking the temperatures. 50% of the initials were observed missing from the log. Prep Cook #1 said if no one was in the office they asked the staff to screen their own temperature. Prep Cook #1 said no questions were asked regarding symptoms, and if they were not feeling well they did not work. He said the Director of Kitchen Operations was responsible for overseeing the kitchen staff screening process. On 7/7/20 at 10:25 AM, the DON said when staff arrived, they were to check their temperature, and have it verified, and they were to answer the screening questions. The DON said if any of the screening questions were answered yes or if the temperature was 100.4 or greater, the staff was sent home. The DON said most staff entered the building by the break room and were screened in the break room. The DON said the charge nurse usually looked at the staff screening logs, and she had not personally reviewed them for quality assurance in a couple of weeks. The DON said it was up to the nurse working on the floor to ensure each staff had no symptoms of COVID-19 prior to entering the resident care area. The DON said some staff entered the building through the fireplace room, and sometimes the screening was done in the break room and sometimes it was done at the nurse's station. The DON said she realized the staff screening logs were missing signatures, and she did look at some of them, but it was usually the charge nurse who signed the logs. The DON also said she expected the Physician to follow the same precautions regarding COVID-19 and to be screened at the nurse's station. On 7/8/20 at 10:25 AM, when asked who was responsible to oversee the screening process of employees, the IP said either herself or the DON was helping her. The IP said the screening log book was close to the DON, so the DON checked on it. The IP said she was informed by the DON if there was missing information on the screening logs. On 7/8/20 at 10:38 AM, the Director of Kitchen Operations said she oversaw the kitchen screenings. She said the kitchen supervisor made a list of scheduled staff every morning before they started their shift. The Director of Kitchen Operations said she checked the temperatures every day and made sure they were not over the temperature limit. She said if their temperature was high, they contacted the IP in the (attached) hospital. She said she did not document that she looked at them. 2. The facility's policy Novel Coronavirus Prevention and Response, undated, stated to promote the easy and correct use of PPE by staff, signs were to be posted on the door or wall outside of the resident's room which clearly described the type of precautions needed and the required PPE. On 7/6/20 at 2:45 PM, carts or trays which contained PPE were placed outside the rooms of Resident #1, Resident #2, Resident #3, and Resident #4. There were no signs posted outside the residents' rooms which stated what precautions they were under or which PPE staff were required to wear prior to entering those rooms. On 7/6/20 at 3:06 PM, LPN #1 said Resident #1, Resident #2, Resident #3, and Resident #4 were on droplet precautions due to being on quarantine for 14 days per the facility's admission protocol. LPN #1 said prior to entering the room, staff should put on a new mask, a gown, gloves, and eye protection. On 7/6/20 at 4:30 PM, the IP said Resident #1, Resident #2, Resident #3, and Resident #4 were on droplet precautions, and staff were to wear the indicated PPE each time they entered the room. The IP said there were no signs posted near the residents' door which stated what kind of precautions or what PPE were required for staff to wear before entering the room. She stated there were no signs because she thought this was a potential dignity/privacy issue. 3. The facility's policy for Handling Clean Linen, undated, documented clean linens were transported by a method to ensure cleanliness and protection from dust and soil during intra-facility loading, transport and unloading. This included placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned textile material that could be secured to the cart. a. On 7/6/20 at 2:32 PM, CNA #2 was pushing a cart 48 inches tall, 18 inches wide, and 32 inches long with a blue vinyl cover from top to bottom. Linens were on shelves inside the covering and linens were placed on top of the cart with a sheet covering them. The cover had a 15-inch by 15-inch L-shaped cut or rip in the side on the front of the cart and the flap was hanging open exposing linens. CNA #2 said the linens must be covered. On 7/6/20 at 2:47 PM, CNA #2 was observed with a different linen cart that was the same size as the previous cart and had a different cover. This cover had a 6-inch rip along the seam on the upper side of the cart exposing linens down the side of the cart. On 7/7/20 at 10:20 AM, the DON said the linen cart was to be covered before walking it down the hall. b. On 7/6/20 at 3:04 PM, a laundry cart with residents' personal laundry was placed at the intersection of the East Unit and cross hallway near the East Unit nurses' station. The laundry was covered. CNA #8 unzipped the two side zippers of the cover and lifted the front of the cover and tossed it on top of the cart exposing residents' personal laundry, which was hanging and folded on the shelves below. CNA #1 removed clothing from the cart and delivered it to room [ROOM NUMBER] at the end of the East Unit hall. CNA #2 then removed clothing from the cart and walked it to room [ROOM NUMBER] at the other end of the East Unit hall. This was repeated until all the laundry was delivered. The laundry was exposed until the delivery was completed by CNA #1 and CNA #2. On 7/7/20 at 9:04 AM, the acting CNA Supervisor said staff were to take one set of clothing, close the cart cover, and then take the clothing to the resident's room. She said the CNAs should not take more than one or two sets of resident's personal laundry at a time to prevent cross-contamination by leaving it open. She said the CNAs could either take the cart down the hall to deliver laundry to each room or leave it in one place and the cover must always be closed.

Based on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers. This was true for 1 of 4 residents (Resident #23) reviewed for pressure ulcers. Resident #23 was harmed when she developed 2 unstageable pressure ulcers on her left foot. Findings include: The facility's undated Skin Assessment Policy and Procedure documented a licensed or registered nurse was to assess a resident's full body upon admission/readmission and weekly thereafter. The facility's undated Pressure Ulcer Policy and Procedure documented staff would screen for pressure ulcers during routine skin assessments. The policy documented if an area was discovered the nurse would implement interventions, notify the physician, family, and the wound nurse. The policy documented the wound would be measured and a description of the wound would be completed. The policy also documented the wound would be assessed and measured weekly and as needed. Resident #23 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #23's Braden Risk Assessment (a tool used to assess the risk for developing pressure ulcers), dated 3/26/18, documented no impairments and she was at mild risk for skin breakdown. A quarterly MDS assessment, dated 8/21/18, documented Resident #23 was cognitively intact and documented she required extensive assistance of one to two staff members with all cares except eating. The MDS documented Resident #23 had two unstageable pressure ulcers. A previous quarterly MDS assessment, dated 5/29/18, documented Resident #23 had one unstageable pressure ulcer, and a previous MDS assessment, dated 3/6/18, documented Resident #23's skin was intact, and she did not have a pressure ulcer. a. Resident #23 developed an unstageable pressure ulcer on the top of her left second toe and the facility failed to identify and implement interventions timely. Example includes: Resident #23's Skin Inspection Report, dated 3/30/18, documented Resident #23's skin was not intact with an existing injury. An assessment describing the injury was not completed on 3/30/18. A Nurse's Progress Note, dated 3/30/18, documented Resident #23's skin was intact with no new skin issues noted. The Skin Inspection Report and the nursing progress note contained conflicting data. A Skin Inspection Report, dated 4/6/18, documented Resident #23's skin was not intact with an existing injury. A Wound Assessment Report, dated 4/6/18, documented Resident #23 had a new wound on the top of her left second toe. The assessment documented the wound was an unstageable pressure ulcer with 100% eschar (black dead skin) in the wound bed and measured 0.7 cm by 0.6 cm. The assessment documented Resident #23 recently received new shoes and the staff thought the pressure ulcer was from the toe rubbing inside the shoe. A Nurse's Progress Note, dated 4/6/18, documented Resident #23's skin was warm and pink. The Skin Inspection Report and the nursing progress note contained conflicting data. The facility did not identify and document the presence of Resident #23's pressure ulcer on her second toe prior to it becoming unstageable. The care plan area addressing Resident #23's pressure ulcer, initiated 4/6/18, documented Resident #23's left foot, on the top of her second toe, had an unstageable pressure ulcer. The care plan documented staff would measure and assess her skin weekly and apply treatments as ordered. b. Resident #23's Weekly Skin Inspection Reports were not consistently completed. Examples include: Resident #23's Weekly Skin Inspection Reports were not completed between the dates of 4/28/18 and 6/15/18, 6/15/18 and 7/21/18, 7/21/18 and 8/24/18, and 8/24/18 and 9/07/18. Resident #23's Nurse's Progress Notes, dated 5/11/18, 5/18/18, 5/25/18, 6/1/18, 6/8/18, 6/22/18, 6/29/18, 7/6/18, 7/13/18, 7/20/18, 7/27/18, 8/3/18, 8/10/18, 8/17/18, 8/24/18, 9/7/18, and 9/14/18 documented she had not developed new skin issues. Resident #23's Nurse's Progress Notes did not include consistent skin assessments and staff did not assess her skin between the dates of 4/27/18 and 5/11/18 (12 days), and 8/24/18 and 9/7/18 (14 days). c. Resident #23's Wound Assessment Reports documented unstageable pressure ulcers to the top of her left second toe; to the pad of the left foot, under the fifth digit (toe); the pad of the foot, under the fourth digit; and an unspecified area to the left pad of her foot. The documentation included conflicting data as to size, location, and the number of pressure ulcers Resident #23 developed. Examples include: Resident #23's Wound Assessment Reports for the top of her second toe were not consistently completed between the dates of 4/6/18 and when it resolved on 8/24/18, to 0 cm by 0 cm. Resident #23's toe wound worsened to 0.8 cm by 0.8 cm on 5/14/18 and remained that size until 8/10/18. Resident #23's wound was not assessed for 12 days between 6/8/18 and 6/20/18. A Nurse's Progress Note, dated 5/31/18, documented Resident #23 had two dark black scabs on the ball of her left foot. The progress note documented the first one was located under her 5th digit, measuring 2 cm by 1.7 cm and the second was located under her 4th digit, measuring 1.4 cm by 1 cm. The facility did not identify Resident #23's pressure ulcers on the ball of her foot prior to them becoming unstageable. A Wound Assessment Report, dated 5/31/18, documented Resident #23 had a new wound on the ball of her left foot, under the 4th digit, measuring 1.4 cm by 1 cm. The assessment documented the wound was an unstageable pressure ulcer with 100% eschar (dry, dark dead tissue) in the wound bed. The assessment documented Resident #23 had [MEDICAL CONDITION] but not to the bottom of her foot. Resident #23's Wound Assessment Reports were dated 5/31/18, 6/4/18, 6/8/18, 6/12/18 and 6/22/18. On 6/22/18 the wound was documented as measuring 1.3 cm by 1 cm with 100% eschar in the wound bed. The report documented Resident #23's area remains stable with an intact superficial black scab. The 6/22/18 Wound Assessment Report documented the wound as resolved on that date, when the wound was still present. Resident #23's wound was not assessed for 10 days between 6/12/18 and 6/22/18. A Wound Assessment Report, dated 5/31/18, documented Resident #23 had a new wound on the ball of her left foot, under the 5th digit, measuring 2 cm by 1.7 cm. The assessment documented the wound was an unstageable pressure ulcer with 100% eschar in the wound bed. The assessment documented Resident #23 had [MEDICAL CONDITION] but not to the bottom of her foot. Resident #23's Wound Assessment Reports for this wound were dated 5/31/18, 6/4/18, 6/8/18, 6/12/18 and 6/20/18. On 6/20/18 the wound was documented as measuring 1.8 cm by 1.6 cm with 100% eschar in the wound bed. The report documented Resident #23's area remains stable with an intact superficial black scab. The 6/20/18 Wound Assessment Report documented the wound as resolved on 6/22/18 which was contradictory to the assessment of the wound. Resident #23's wound was not assessed for 8 days between 6/12/18 and 6/20/18. A Wound Assessment Report, dated 6/22/18, documented Resident #23 had a new wound on the ball of her left foot, under the 5th digit, measuring 1 cm by 1 cm. The assessment documented the wound was an unstageable pressure ulcer with 100% eschar in the wound bed. The report documented Resident #23's wound started as a black bruise in 5/31/18 and it turned into a black scab. Resident #23's previous Wound Assessment Reports did not describe the wound as a bruise but as 100% eschar. Resident #23's Wound Assessment Reports related to this described wound were dated 6/22/18, 6/25/18, 6/29/18, 7/2/18, 7/6/18, 7/13/18, and 7/20/18. On 7/20/18 the wound was documented as measuring 0.3 cm by 0.3 cm with 25% eschar in the wound bed. The Wound Assessment Reports documented Resident #23's wound was healing, and scar tissue was forming. Resident #23's clinical record did not include follow up wound assessments to the ball of her left foot, under the 5th digit after 7/20/18. A Wound Assessment Report, dated 7/27/18, documented Resident #23 had a wound on her left pad of her foot, measuring 0.3 cm by 0.3 cm. The assessment documented the wound was an unstageable pressure ulcer with 100% [MEDICATION NAME] tissue (a thin layer of skin) in the wound bed. The Wound Assessment Report documented Resident #23's scab had resolved and scar tissue remained. Resident #23's Wound Assessment Reports for this wound were dated 7/27/18, 8/1/18, 8/8/18, 8/10/18, 8/17/18, and 8/24/18. On 8/24/18 the wound was documented as measuring 0 cm by 0 cm and resolved. d. Resident #23's treatments were not consistent as follows: Resident #23's (MONTH) (YEAR) TAR documented she was to have a corn pad administered on her second left toe as needed. The TAR did not include documentation a corn pad was administered. Resident #23's (MONTH) (YEAR) TAR did not document treatments or the use of a corn pad for her second left toe after if worsened on 5/14/18. The TAR documented Resident #23 was to wear sandals or socks to her left foot until healing was evident, ordered 4/23/18. Resident #23's (MONTH) (YEAR) TAR documented staff was to monitor the ball of her left foot with the skin checks and were instructed to leave the foot brace off (undated). The (MONTH) TAR did not document Resident #23's second left toe treatments or the corn pad. The TAR documented Resident #23 was to wear sandals or socks on her left foot until healing was evident, ordered 4/23/18. Resident #23's (MONTH) (YEAR) TAR documented staff were to apply medi-honey (a wound gel) and [MEDICATION NAME] (a type of wound dressing made of foam) to her left second toe wound every day and as needed, ordered 7/30/18. The TAR documented administration was completed on 7/30/18. The TAR did not document it was completed on 7/31/18. Resident #23's wounds to the bottom of her left foot were not documented on the (MONTH) TAR. Resident #23's (MONTH) (YEAR) TAR was requested on 9/27/18 and was not provided for review. On 9/24/18 at 3:53 PM, Resident #23 stated she had areas of skin breakdown on her legs, however they were healed. Resident #23 stated she could reposition her bottom in the chair when she needed to, to prevent skin breakdown. Resident #23 was observed in her motorized wheelchair. The left foot pedal was covered with sheep skin and a pad, and the right foot pedal was not covered. On 9/26/18 at 7:03 AM, Resident #23 was observed assisted out of bed by CNA #1 and CNA #2. CNA #2 was observed applying lotion to Resident #23's legs and feet. Resident #23's feet did not have areas of skin impairment. CNA #1 assisted Resident #23 with placing stockings on her legs and applied braces on her legs. Resident #23 was observed as she was assisted into her wheelchair. Resident #23's wheelchair was observed with the left foot pedal covered with sheep skin and a pad and the right foot pedal was not covered. On 9/26/18 at 9:35 AM, Resident #23 stated she thought the pressure ulcers developed from the leg braces or the foot pedals. Resident #23 stated the foam and sheep skin was not on her wheelchair before the two wounds developed on the bottom of her foot. On 9/27/18 at 2:41 PM, the Wound RN stated nurses should complete skin assessments weekly during a resident's shower. The Wound Nurse stated the skin assessments were mostly documented in the nurses' progress notes. The Wound RN stated there were two wounds, one on the bottom of Resident #23's foot and one on the top of her second left toe. The Wound RN stated the wound documentation was inconsistent. The Wound RN could not explain the contradictory or conflicting data. The Wound RN stated the wound areas were small and the risk vs. benefits about wearing her shoes, was discussed with Resident #23 when the first pressure ulcer was discovered. The Wound RN stated the nurses should follow the physician's orders [REDACTED].

Based on observation, record review, and resident and staff interviews, it was determined the facility failed to ensure residents did not acquire pressure sores for 2 of 3 residents sampled for pressure sores (#1 & #3). Resident #3 was harmed when he acquired a deep tissue injury (DTI) to his right heel when the facility failed to care plan and assess an ankle foot orthosis (AFO) for skin breakdown. He also developed a Stage II pressure sore on his upper left thigh when the facility failed to assess catheter tubing for skin breakdown and then failed to monitor the pressure ulcer after it developed. Resident #1 was harmed when she acquired a Stage II pressure sore on her coccyx which became infected. The resident's bowel incontinence care plan did not direct staff on how often to check for bowel incontinence and during an observation of a dressing change it was determined to be inadequate and could have allowed BM to get into the wound and further infect the site. She also developed a Stage II pressure sore to her right thigh when the facility failed to asses catheter tubing for skin breakdown. Findings include: The facility's High Risk for Pressure Ulcers policy and procedures dated 3/9/09 documented, "Any resident who has a high risk for pressure ulcers will be referred to the wound care nurse for assessment, the wound nurse will make recommendations for interventions." 1. Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 7/24/14 significant change MDS, documented the resident was moderately cognitively impaired with a BIMS score of 10, required two person assist with bed mobility and transfers, was totally dependent on two person assist with dressing, had limited range of motion to both lower extremities and, had an indwelling catheter. a. The resident's Physical Therapy Evaluation and Plan of Treatment dated 3/2/13 documented, the resident, "...used an AFO and a hinged knee brace on the right lower extremity. The brace was for the knee...Functional with right ankle immobile with an AFO." The resident's 5/13/14 Mobility care plan, documented interventions of, "Brace to R(ight) leg & knee for ambulation. Remain set at 10-40 degrees" and "Assure hinge of brace is aligned with his knee joint to be effective." The resident's 8/12/14 Skin Integrity care plan, documented interventions of: -"Monitor skin for s/s (signs and symptoms) of infection, breakdown, rashes, hives, skin tears, etc and report to nurse. - Encourage shoe laces not be tight & shoes off when in recliner. - Float heels when in bed. - Skin checks per facility protocol." The care plan did not document the resident used a hard plastic AFO to his right lower leg and foot, when to use the AFO, and how to monitor for skin breakdown where the AFO and brace contacted the resident's body. The resident's Incident/Occurrence Report (I&A), Nursing Flow Sheet Notes (NFSN), Wound Assessment Worksheet (WAW), and Care Plan (CP) documented the following: -10/8/14 I&A, "...P(atien)t was noted to have a purplish/black area to R heel. Wound measures 2.4 x 2.1 cm wound." -10/8/14 NFSN, "CNA states pt had a dr(essin)g to his R heel. Asked pt why it was there. He states it was put there because it was hurting him last night. Upon assessment pt was noted to have a DTI to R heel..." -10/9/14 WAW, Newly Acquired Deep Tissue Injury measured 2.3 by 3.2 cm with 100 percent eschar. "Deep tissue injury just under skin layer." -10/9/14 CP, Interventions, "[MEDICATION NAME] to R heel QD (every day). Brace to R foot off when pt not in w/c (wheel chair) as pt allows. Float heels in recliner & bed...Keep heal (sic) floated. Leg brace off when in recliner. Shoes off when in recliner. Turn and reposition per schedule." The revised care plan still did not include information about the use of the AFO, even after the DTI was discovered. -11/6/14 WAW, DTI measured 2.2 by 2.8 cm with 100 percent eschar. "Remains intact under skin brownish black has not evolved into a scab." -11/14/14 WAW, DTI measured 1.9 by 2.7 cm with 100 percent eschar. "Starting to raise & form a scab." On 11/17/14 at 3:30 PM and at least four other times during the survey, the resident was in his recliner with both heels floated and without a leg brace or AFO attached to his right leg. On 11/18/14 at 10:00 AM, the resident was interviewed regarding the right heel DTI and he said it was healing fine and did not want a surveyor to look at it. On 11/19/14 at 11:40 AM, the Wound Care Nurse was interviewed regarding the DTI. When asked what caused the DTI, she said the AFO caused the DTI. She said the hard plastic AFO attached with a strap just below the right knee and extended the length of the leg. It curved at the heel and extended to the end of the residents toes. When asked why there was no care plan regarding skin integrity and the use of the AFO and leg brace, she stated, "I don't have it care planned to check for skin." When asked about the importance of skin integrity under a hard AFO or other device, she stated, "We missed looking under the skin." On 11/19/14 at 1:15 PM, CNA #2 was interviewed, while she showed the surveyor the resident's AFO and leg brace. When asked about the use of the leg brace and AFO prior to the skin breakdown, she said the resident only used the hinged leg brace when he walked, but the AFO was used all day long. b. The facility's Catheter Care policy dated 3/3/14, documented, "Be sure catheter is secured to inner thigh with tube holder, and that there are no kinks in catheter...or tubing." The resident's 8/12/14 Bowel and Bladder Supra Pubic Catheter care plan, documented an intervention of, "Care of supra pubic catheter per facility protocol." The care plan did not address potential skin issues associated with the catheter tubing and if the leg catheter strap was to be alternated between the legs to avoid skin breakdown. The resident's NFSN dated 10/20/14 at 10:00 PM, documented, "Fluid filled blister to L(ef)t (upper) thigh 1 cm x .5 cm. Appears to be caused from cath(eter) tubing. MD faxed." The resident's I&A dated 10/20/14, documented under the Recommendations/Corrective Action section to, "Keep cath tubing from rubbing." The resident's updated 10/20/14 care plan documented under the problem and intervention section, "Fluid filled blister...1. Monitor (with) w(ee)kly skin (check)s. 2. Keep tubing from rubbing. Place gauze on tubing." The resident's 2014 October TAR, weekly skin checks, and NFSN from 10/21/14 to 11/13/14 did not document weekly skin checks were completed for the Stage II pressure ulcer and did not document the size, color, description, or when the ulcer was resolved. The resident's 2014 November TAR documented, "Monitor fluid filled blister to Lt inner thigh with weekly skin checks until resolved." The area of the TAR to document the skin checks were blank. On 11/17/14 at 3:30 PM and throughout the survey, the resident was observed with catheter tubing coming from his left pant leg. On 11/18/14 at 10:00 AM, the resident was interviewed regarding the thigh pressure ulcer and he said it was already healed. On 11/19/14 at 1:40 PM, the DON was interviewed regarding the pressure ulcer. When asked what caused the ulcer, she said it was either from the catheter strap or the tubing itself and said it, "Looks like an area we need to improve." When asked about the lack of direction in the catheter care plan regarding skin breakdown, she said it lacked direction. When asked about the blank November TAR for weekly skin checks, she said, "I noticed that." She said she would follow up with staff. On 11/19/14 at 2:45 PM, the DON reported she checked with the nurse regarding the November skin checks and the nurse told her the ulcer had resolved before November. When asked why there was no documentation about the resolved ulcer, she said, "We missed it." When asked why the weekly skin check intervention was not added to the October 2014 TAR, she said, "We will do better." 2. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's admission MDS assessment, dated 6/26/14, documented the resident was cognitively intact with a BIMS of 15, required total assistance for bed mobility, transfers, toilet use and bathing, required extensive assistance for dressing and personal hygiene, had range of motion impairments to bilateral upper and lower extremities, was always incontinent of bowel, had an indwelling catheter and had no pressure ulcers. The most recent quarterly MDS assessment, dated 9/16/14, documented Resident #1 had a Stage 3 pressure ulcer. Resident #1's Skin Integrity Care Plan, dated 7/3/14, documented a risk for alteration in skin integrity. The interventions included to keep skin clean and dry, total assist of 2 for bed mobility, air mattress on the bed, egg crate and sheep skin to electric wheelchair, apply special lotions/creams to maintain skin integrity, barrier cream to moisture exposed skin, skin checks per facility protocol, monitoring skin for signs and symptoms of infection and breakdown, "She prefers not to be put on a schedule r/t (related to) the air bed is set up to turn her Q (every) 1 hour and she prefers staff not to disturb her when she is in bed," and, " Declined roho (a special cushion for a chair) use 7/7/14." Resident #1's Bowel and Bladder/Supra Pubic Care Plan, dated 7/3/14, documented a risk for alteration in elimination. Interventions included incontinence cares as needed, total assist of 2 for incontinence cares, bowel regimen per MD and per facility protocol, [MEDICATION NAME] as ordered to buttocks, suppository as ordered, care of supra pubic foley catheter per facility protocol and physician orders [REDACTED]. The Bowel and Bladder Care Plan did not document how often incontinence cares should be performed. a. An Incident/Occurrence Report for Resident #1, dated 8/13/14, documented an open area to coccyx which measured 3 cm x 1.4 cm. The following documentation was gathered from Resident #1's Physical Therapy Evaluation and Plan of Treatment and Physical Therapy Progress Notes (PT), Wound Nurse Consultation (WNC), Wound Assessment Worksheet (WAW), physician's orders [REDACTED]. 8/14/14 (WNC) - "(Resident's name) has developed an open superficial area to her mid coccyx. Measures 2.3 cm x 1.6 cm x 0.0 cm. Top half of wound is white macerated skin from ruptured blister and is still attached to healthy peri wound. Bottom half of wound is pink, moist, and superficial. Roho cushion was offered to her when she was first admitted and she declined to have one. She now agrees to roho use and has had an air mattress on her bed for years. She also declined a turning and repositioning schedule in bed as she wanted her airbed to turn her. She stated her and her care givers have done this for years with no problems. She has now agreed to be turned and repositioned Q (every) 2 hours and PRN except when she is sleeping. She has been encouraged to be down between meals as she is able. She does have a history of a pressure ulceration to her bottom in the past. She has been explained the risk of declining roho and turning and repositioning. Good nutrition habits have also been explained to her..." 8/14/14 (PO) - [MEDICATION NAME] dressing to coccyx wound every 3 days and prn until healed; Measure coccyx wound every week and document on wound sheet; Assess wound for dressing, odor, drainage signs and symptoms of infection and pain. document changes in nursing notes; 8/28/14 (PT) - "Anticipated Goals: 1. Patient to show wound healing with no increase in signs or symptoms of infection to the coccyx area;" 9/3/14 (PT) - "...Patient received sharps debridement to the coccyx area with feces initially being cleaned up...;" 9/10/14 (PT) - "...prepped for debridement by cleaning feces out of the area...;" 9/14/14 (WAW) - Odor present; 9/24/14 (PT) - "A slight odor was noted and dressing was removed and patient reports that the dressing was just changed last night secondary to feces on the dressing...Wound has a slight odor...;" 10/1/14 (PT) - "...cleaned prior to debridement as she has had a bowel movement...No appreciable wound odor is noted however this could be masked from the odor of the feces...also requesting an order to culture the wound as the patient has had [MEDICAL CONDITION]([MEDICAL CONDITION]-resistant Staphylococcus aureus) in the past...;" 10/1/14 (PO) - Minnesota Solution 1 application topically two times daily to coccyx for wound care; Wound culture; 10/6/14 (NFS) - (MD's name) called. States pt (patient) needs abx (antibiotics) for wound N.O. (New Order)[MEDICATION NAME] mg (one tablet) PO BID x 1 wk (week);" 10/6/14 (PO) -[MEDICATION NAME] mg one tablet PO BID times 1 week for wound infection; 10/8/14 (PT) - "RN reports that the patient is taking Cipro, since Monday, and the cultures did not [MEDICAL CONDITION] significant odor was detected with wound debridement today...;" 10/9/14 (NFS) - "Res(ident) continues on abx for coccyx wound infection..." (similar nurse's notes on 10/9, 10/10, 10/11, 10/12 and 10/13/14.); 10/15/14 (PT) - "...is no longer taking an antibiotic...;" 10/22/14 (PT) - "...It is likely that a wound vac will keep the wound cleaner as feces continue to contaminate the wound on a near daily basis...;" 10/22/14 (PO) - Wound vac to coccyx change 3 times per week; 10/25/14 (NFS) - "Wound vac placed to coccyx...;" 11/1/14 (WAW) - Odor present; 11/5/14 (PT) - "...necrosis in the wound with an odor...;" 11/5/14 (WAW) - Odor present; 11/7/14 (PO) - Wound culture; 11/7/14 (PT) - "...no odor detected...;" 11/8/14 (NFS) - "(MD's name) returned his phone call from yesterday. N.O...wound culture...While (changing) pts drsg to coccyx, a foul odor was noted. Odor was not noted yesterday...;" 11/12/14 (NFS) - "...Res(ident) started on abx tx (treatment) r/t (related to) wound culture...;" 11/15/14 (NFS) - "...She is on abx for wound...;" and, 11/20/14 (PT) - "...No odor was detected with the wound dressing was removed...." On 11/19/14 at 9:50 a.m., the dressing change to the coccyx was observed with LN #1 and CNA #2 present. After the LN cleansed the pressure ulcer and applied [MEDICATION NAME] gel, an [MEDICATION NAME] dressing was placed over the wound. The dressing was not tucked into the gluteal crease to prevent contamination of feces; there was a direct tunnel from the anus to the wound. On 11/19/14 at 11:11 a.m., LN #5 clarified the typed date on the care plan correlated with the typed interventions. The LN said Resident #1 had a bowel regimen in the evening which was to have a bowel movement during the night and was then cleaned up. On 11/20/14 at 1:40 p.m., the DON was asked how often incontinence care was to be performed for Resident #1, and she stated, "As needed." The resident had a supra pubic catheter and had a bowel routine with smearing during the day. When asked what the care plan said about the concern, the DON stated, "Nothing very specific." Resident #1 developed a Stage 2 pressure ulcer the day before risks and benefits of the resident's choices to decline skin preventative measures were explained. The resident's care plan did not provide instruction on how often to perform incontinence cares for bowel movements, nor did it describe the bowel regimen. A dressing change was observed and showed how easily feces could get into the coccyx wound. The resident was harmed when the pressure ulcer became infected. b. An Incident/Occurrence Report for Resident #1, dated 9/3/14, documented a closed blister to the resident's right upper, inner thigh approximately 0.5 cm in length. The resident thought it was caused by the catheter frog (tubing) when she was seated. The corrective action included repositioning the frog so it did not rest under the resident's abdominal fold. A Nursing Flow sheet, dated 9/3/14, documented, "When (changing) res(ident) for bed found closed (0.5) cm blister to (the right upper) inner thigh. Res (states) she thinks it was caused by catheter frog when sitting." Resident #1's Care Plan was updated on 9/3/14 with the problem documented as a blister to the right upper inner thigh, would resolve without signs and symptoms, and the intervention was to monitor and position the frog so it did not touch in the abdominal fold. Resident #1's Care Plan did not include interventions to ensure skin breakdown did not occur from the catheter tubing. A Physical Therapy Progress Note for Resident #1, dated 9/3/14, documented, "...A discussion is also made, during today's visit, regarding blistering which are occurring from the catheter along the patient's upper thigh and abdominal region. Some strategies were discussed to alleviate this blistering and [MEDICATION NAME] was applied by the CNA..." There was no documentation in Nurses's Notes, physician's orders [REDACTED]. In addition, the blister was not assessed or tracked after the initial assessment on 9/3/14. On 11/19/14 at 11:10 a.m., LN #5 was asked about the blister to Resident #1's right inner thigh and she said she was not involved with the blister. On 11/19/14 at 1:40 p.m., the DON said she thought Resident #1's blister was from the catheter tubing or frog and that the frog was supposed to help with pressure. When asked if the blister had resolved, the DON said, "Yes," and was unsure of when. On 11/19/14 at 5:25 p.m., the Administrator and DON were informed of the concerns with the development of a pressure ulcer which became infected, and of the pressure ulcer caused by catheter tubing. No further information or documentation was provided.

Based on observation, staff interview and record review, it was determined that the facility failed to prevent Resident #1 from harm due to the development of two Stage II pressure sores to his buttocks. The resident sustained [REDACTED]. In addition, the resident was admitted with two Stage II pressure areas that progressed, according to the most recent quarterly assessment, to three Stage III and two Stage IV sores. The facility failed to prevent, monitor, provide skin care and care plan for skin problems for 1 of 12 (#1) sampled residents. Findings include: Resident #1 was admitted to the facility 6/2/09 with [DIAGNOSES REDACTED]. Resident #1's annual MDS assessment, dated 5/30/10, documented at section M: Skin Condition, that the resident: * Had three Stage II pressures ulcers, and * Had treatments in place of: -Pressure relieving device for chair, -Pressure relieving device for bed, -Nutrition/hydration intervention to manage skin problems, and -Ulcer care. Resident #1's quarterly MDS assessment, dated 8/22/10, documented at section M: Skin Condition, that the resident: * Had one Stage I pressure ulcer, two Stage II pressure ulcers, one Stage III pressure ulcer, and two Stage IV pressure ulcers. * Had treatments in place of: -Pressure relieving device for chair, -Pressure relieving device for bed, -Nutrition/hydration intervention to manage skin problems, -Ulcer care, -Application of ointments/medication, and -Other preventative/protective skin care. Note: The resident's MDS pressure sore documentation indicated three Stage II pressure sores on 5/30/10 and on 8/22/10: one Stage I, two Stage II, one Stage III and two Stage IV. This represented an increase from three to six pressure sores in approximately three months. Resident #1's quarterly MDS assessment, dated 11/16/10, documented the resident: * Had one Stage II pressure ulcer and four Stage IV pressure sores, The 11/16/10 quarterly MDS assessment documented at "M0900. Healed Pressure Ulcers....Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessments." B. Stage 2. "2" C. Stage 3. "1" D. Stage 4. "4" The most recent quarterly MDS assessment, dated 2/8/11, documented the resident: * Was severely cognitively impaired,(C0500 = 6) * Require total to extensive assistance of one to two staff for transfers, dressing, personal hygiene and bathing, * Was continent of bladder and occasionally incontinent of bowel, * Had three Stage III and two Stage IV pressure sores, and * Had treatments in place of: -Pressure relieving device for chair, -Pressure relieving device for bed, -Ulcer care, -Application of dressings to feet. Note: To summarize, the resident's pressure sores progressed from three Stage II on 5/3/10 to three Stage III and two Stage IV pressure sores on 2/8/11. Resident #1 Care Plan was originally dated 6/17/10 and had been carried forward with the most current date of 2/22/11. The Problem for "Skin at Risk" was the only skin problem that the facility developed a care plan for. The multiple continuing open sores did not have a care plan developed to address treatment and care. The "Skin at Risk" problem documented the following interventions: "* Skin assessment upon admission, quarterly, and PRN (as needed) with change of condition. * Weekly skin assessments. Document each incident of bruising, skin tear, and pressure area and tailor interventions to prevent further occurrences. * Monitor weight per protocol. * Air mattress on bed. (this intervention was discontinued on the care plan) * Seat cushion in W/C: Type Foam. * Monitor food and fluid intake. * Monitor Labs per physician order. * Offer to turn and reposition every 2 hours and PRN when in bed. * If resident refuses to be turned, notify LN.... * Consultation w/Dietitian PRN. * Skin care after incontinent episodes. * Moisturize skin paying special attention to bony prominences with AM and PM cares and apply lotion when needed. * Avoid shearing force---lift--- DO NOT SLIDE THEM. * Keep bed and chair free from wrinkles, crumbs and other objects. * If redness persists, or pink skin areas occur, notify your floor nurse at once. * If skin integrity is not maintained, document location, stage, Undermining, odor, size, appearance, inflammation. Drainage on wound documentation sheet, and consult with Wound nurse as necessary. * Encourage good nutrition and fluid intake to enhance skin turgor and elasticity." The "Weekly Skin Checks" for Resident #1 documented: 6/30/10 - Dressing intact to bilateral heels and red area to the resident's coccyx. 7/7/10 - Dressing intact to bilateral heels, dressing intact to anterior surface of the right foot and coccyx area was fragile. 7/14/10 - Dressings to bilateral heels. 7/21/10 - The documentation documented that an area was fragile, there was an open area covered with Allevyn dressing and another area was fragile.(NOTE: the areas are not clearly documented for locations) 8/4/11 - Both left and right heels were open areas and covered with Allevyn dressing and coccyx area was fragile. 8/11/11 - The anterior surface of the right foot had 4 wounds, heel of the left foot had one wound, and the coccyx was fragile. 8/18/11 - Right and left heels had open areas covered with Allevyn and coccyx was fragile. 8/25/11 - Coccyx had a dressing intact, and right and left heels had dressings intact and the left hip area had an Allevyn dressing in place. 9/1/10 - Coccyx was fragile and "Bilat(eral) feet (with) dressings intact." 9/8/10 - Scabs noted to anterior surface of the right foot, "pressure wound" to left heel, and coccyx fragile. 9/15/10 - Coccyx was fragile and "feet wrapped in Kerlix intact" condition of the feet was not documented. Documentation continued with notations on a weekly basis. The "Weekly Skin Checks" prior to the two Stage II sores that were documented in the nursing noted on 2/14/11 were: 1/31/11 - The diagram shows the left and right heels with notation of "dry scabs on heels," and multiple areas on the anterior surface of the right foot. No documentation on the coccyx area. 2/14/11 - The diagram shows two areas one on each buttock with a notation of "Shearing," and documentation of scabbed areas the left and right heels. 2/21/11 - The documentation was fragile coccyx and both left and right heels identified but no documentation as to condition. 2/28/11 - The coccyx documentation was "fragile coccyx" and the left and right heels document "scabs." The "E-Z Graph Wound Assessment Worksheet,"dated 2/14/11, documented an area about 9 cm (centimeters) in diameter with two "shearing" areas identified on each side that measured 2 cm x 3 cm and 1.5 cm x 1 cm. The form had areas to describe the open areas but the facility failed to complete it. The "Nursing Flow Sheets" documented about the multiple skin issues. The documentation failed to describe characteristics of wounds, presence or lack of granulation, staging of the wounds, presence or absence of necrotic tissue, presence or absence of [DIAGNOSES REDACTED], and description of the location of each wound. Some examples of documentation were: 6/6/10 - 1340 (1:40 p.m. - "...PT (physical therapy) debrided (L) heel and cleaned up (R) ankle. Applied [MEDICATION NAME] to (L) heel for pain control. Cleaned wounds and applied ultrasite gel (with) Allevyn dressing. Covered (with) Kerlix...." 6/10/10 - 1025 (10:25 a.m.) - "(Changed) drsg to bilat ft(feet) (R) ankle wounds. Red periwound. Bone is exposed in both openings. Cleaned (with) NS (normal saline) and applied [MEDICATION NAME] (with) Allevyn. (L) heel looks good a few small noted to wound bed.(sic) Measures 2 x 2 cm cleaned (with) NS...." 6/13/10 - 1000 (10:00 a.m.) - "...Changed drsg's to bilat feet (R) ankle very red and warm to touch shiny around periwound. Sm (small) amt(amount) sanginous (sic) drainage to upper (bone) wound. Sm amt serosanginos(sic) drainage from lower tendon wound. No odor noted. cleaned(with) NS applied [MEDICATION NAME] gel to wound...(L)heel wound - sm amt purulent drainage noted. No odor noted...." 6/19/10 -1320 (1:20 p.m.)- "....Cont(inues) on ABX (antibiotics) for wounds on feet ...dressing (change) done...." 7/14/10 - 10:30 a.m.- "....Drsg (change) (after) PT debrided (B) (both) heels...." 7/15/10 - 2:00 p.m.- " Periwound measures 3.5 cm L(long) (unknown word) wound 2 cm. depth 0.25 on (L) heel. PT debrided previous day. (no) slough sm amt drainage. No odor noted. (R) ankle - measures 1 cm on bone wound. 1 cm on tendon wound. 2 wounds on lateral aspect of foot are scabbed. Each wound cleaned (with) NS...." 8/9/10 - 10:30 a.m. - "Changed drsg to wounds. No odor noted. Copious amt of bloody discharge on (R) ankle. Moderate amt serosanguinous discharge on (L) heel. 1+ [MEDICAL CONDITION] to Bilat LE(lower extremity)...Periwound to (R) ankle - red, warm, and shiny cleaned...." 8/18/10 10:50 a.m. - "(changed) drsg to (R) ft and (L) heel. No odor noted. Measures 1 cm round (R) ft (bone) 1 cm (tendon) (L) heel 2 cm round....Skin on ft very shiny (R) ft in red around periwound (sic)...." 8/19/10 - 10:05 a.m. - "Res(ident) has a 3 x 2 cm open blister on her (sic) right hip. Also on the back of upper thigh he has white fragile skin. Allevyn applied to blister and put in bed to be turned on his right side...." 9/20/10 - 1:30 p.m. - "(changed) drsgs to wounds on ft. (R) ft very red, swollen and hot to touch. No odor noted...Large scab to (L) heel very dry...." 10/25/10 - 1:15 p.m. - "Changed drsg to LE. No odor noted. Swelling and redness (with) heat noted to (R) ft...." 2/14/11 - 9:30 p.m. - "...shearing areas to coccyx. Wound nurse notified, Allevyn dressing applied...." 2/28/11 - 12:50 p.m. - "...(changed) drsg (dressing) to bilat(eral) feet. Heels are healed very nicely. Top of (R)(right) foot still open...Coccyx is very fragile (no) open areas. Several scab to feet bilat from pressure." The medical record contained two "Inter-office correspondence" to the physician. * The first was dated 2/5/11 and documented: "May we dc(discontinue) air mattress and change to regular mattress with and egg crate? He is not happy with the air mattress. Since wounds are only on his feet and feet are always floated a regular mattress may be more comfortable..." * The second was dated 2/14/11 and documented: "(Resident #1) skin has declined since air mattress was dc' d. He now has 2 open shearing wounds to coccyx. Explained we may need to get him back on an air mattress. He stated he would be fine with it...also may we have an order for [REDACTED]. The DON was interviewed, on 3/31/11 at 9:45 a.m., about the shearing and a history of fragile skin. The DON referred to the wound nurse. The wound nurse was interviewed, on 3/31/11 at 2:30 p.m., about the vague documentation and the lacking of good descriptions of the resident's multiple wounds. The wound nurse confirmed that the shearing had two areas that were Stage II. The wound nurse was also the nurse that assisted with completing MDS assessments. She indicated that she does not always do the "Weekly Skin Checks" or the "E-Z Graph Wound Assessment Worksheet." The nurse was asked about how the information was obtained for the medical record and she indicated that the nurse working the unit at the time filled out the forms. The nurse confirmed that the unit nurses did not complete the required information so it was difficult to track the multiple sores. The wound nurse indicated that the MDS assessments were taking up most of her time. The facility failed to: * Provide clear and accurate documentation to describe characteristics of wounds, presence or lack of granulation, staging of the wounds, presence or absence of necrotic tissue, presence or absence of [DIAGNOSES REDACTED], and description of the location of each wound. * Ensure Resident #1's pressure sores did not get worse and new ones develop. The administrator and DON were informed 3/31/11 at 4:30 p.m. of the harm that Resident #1 received as a result of multiple pressure sores. The facility provided further information to assist in clarifying that the resident was harmed by facility actions, which has been included in this report.