Every finding on record at Court Manor Health Services

Based on observation, interview, and record review, the facility did not ensure 2 of 12 residents (R22, R3) out of a total sample of 15 had appropriate Transmission Based Precautions (TBP) in place.-R22 had a stage 2 pressure injury (PI). No Enhanced Barrier Protection (EBP) were implemented. Staff did not use appropriate Personal Protective Equipment (PPE) when providing direct care. ~R3 had a pressure injury and required EBP. Observations were made of no signage or PPE available for R3.Findings include: Facility policy titled, Enhanced Barrier Precautions revised 08/08/2024, states, Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove use during high contact resident care activities. An order for EBP will be initiated for residents with any of the following: wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices. High-contact resident care activities include:a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linens f. Changing briefs or assisting with toiletingg. Device care or useh. Wound care Example 1 R22 was admitted to the facility on [DATE]. On 05/20/26, documentation indicated R22 acquired a suspected deep tissue injury to her left heel. On 07/14/26, R22 was seen at local wound care clinic and wound debridement was performed. R22 was then diagnosed with a Stage II PI. On 07/21/2026 at 7:11 AM, Surveyor observed Certified Nurse Assistant (CNA) E put on gloves, provide morning cares, and dress R22 without putting on a gown. CNA E and Registered Nurse (RN) F wore gloves and used the sit-to-stand device to transfer R22 to the toilet and then off the toilet into wheelchair. CNA E and RN F did not put on a gown prior to transferring R22; R22 should have been on EBP due to the open pressure injury. Surveyor noted R22 had no EBP signage or personal protective equipment (PPE). On 07/21/26 at 7:35 AM, Surveyor interviewed RN F, who reported she thought a gown is only needed if dealing with wound care. RN F reported she did not think R22 was on EBP at all since her admission. On 07/21/26 at 7:38 AM, Surveyor interviewed CNA E, who stated she does not recall R22 ever being on EBP. On 07/21/26 at 7:45 AM, Surveyor interviewed Infection Preventionist (IP) C, who reported R22 did not have open wound until it was debrided on 07/14/26. IP C agreed that R22 should be on EBP since 07/14/26 and was not. IP C also verbalizes understanding that gown and gloves should be worn with direct or high contact resident cares such as when transferring, toileting, or dressing. On 07/22/27 at approximately 9 AM, Surveyor met with Nursing Home Administrator (NHA) A, to confirm her awareness of Surveyor's observation of lack of proper PPE with R22, who has an open wound. NHA A replied she was aware and had no questions. Example 2 R3 was admitted to the facility on [DATE] from hospital with a stage 2 pressure ulcer following a fall at home with right femur fracture. R3's Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13/15 indicated R3 is cognitively intact. On 07/20/26 at 9:11 AM, Surveyor interviewed R3 regarding concerns with skin. R3 stated they have a pressure wound on coccyx. Surveyor observed no enhanced barrier precautions (EBP) signage or PPE available upon entering R3's room. On 07/21/26, the facility entered orders for R3 Enhanced barrier precautions due to presence of pressure area to coccyx every shift for infection prevention. On 07/22/2026 at 10:02 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding donning of PPE to assist the nurse with wound care. Surveyor asked CNA D if wearing PPE was utilized prior to today. CNA D they just wear PPE. Surveyor asked CNA D if it started yesterday as that is when the facility wrote the order. CNA D confirmed it was put into place yesterday and CNA D stated they were told the reason was R3 has a wound on their coccyx. On 07/22/2026 at 10:11 AM, Surveyor interviewed Infection Preventionist (IP) C regarding when R3 was placed on EBP. IP C stated R3 was placed on EBP on 07/21/26.

Based on observation, record review, and interviews, the facility did not ensure that a resident (R) received tracheal/stoma (soft tissue opening in tracheal airway) suctioning of respiratory secretions to maintain adequate respiratory care in accordance with professional standards of practice for 1 of 1 resident (R17) with a tracheostomy/stoma. R17 has tracheostomy from a laryngectomy. R17 has a build-up of secretions and a history of mucous plugs in R17's airway, which have required emergency room (ER) visits on 7 occasions from 1/13/25 - 4/28/25. On five of these ER visits, suctioning was required to remove mucous plugs and to receive respiratory care. Facility failure to ensure staff provided appropriate tracheal/stoma care including suctioning, created a finding of immediate jeopardy that began on 01/13/2025. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 05/22/2025 at 3:15 PM. The immediate jeopardy was removed on 05/22/25; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement their interventions for residents requiring respiratory care services. Findings include: Facility policy titled, Tracheobronchial Suctioning, reviewed on 07/06/2022 states in part: Tracheobronchial suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for patients who are unable to clear their secretions when coughing. Indications - 1) Accumulation of secretions in the airway 2) Obstruction of airway due to secretions . Policy Explanation and Compliance Guidelines: 1). Review physician order . 9). Turn on suction . Facility policy titled, Tracheostomy Care, reviewed on 07/06/2022 states in part: Indicates care for cleaning and the buildup of mucus . 1) review physicians orders . 6) Suction the trach as necessary . Facility Assessment indicates: B. Services provided .Therapy . Respiratory . and Other special care needs . tracheostomy care. According to Tracheal Education. (2019, May 30). Tracheal Suctioning. https://tracheostomyeducation.com/suctioning/, .Suctioning is an important part of care for both the individual with a tracheostomy as well as a laryngectomy. Tracheal suctioning is performed to remove secretions from the trach tube and airway in order to maintain a patent airway and avoid tracheostomy tube blockages. Suctioning is a lifesaving procedure requiring timely and precise methodology. If done appropriately with caution, it decreases the risk of infection, pooling of secretions, and prolonged hypoxia . According to Tracheostomy Education. (2024, February 6). What is a Laryngectomy? https://tracheostomyeducation.com/blog/laryngectomy/ states, in part: .The patient does not breathe through the upper airway. Instead, breathing occurs through the stoma. Breathing, speech, and swallowing are significantly changed after the procedure. Since the stoma is the only passageway for breathing, it is important to maintain the airway and suction the trachea through the stoma as needed, using a sterile technique. It is also important to clean the stoma, as crusting of the secretions may develop that can block or occlude the stoma . R17 was admitted to the facility on [DATE] with diagnoses including laryngeal cancer, absence of larynx (laryngectomy), hemiplegia and hemiparesis following cerebral infarction affecting R17's right dominant side, chronic obstructive pulmonary disease (COPD), weakness, anxiety disorder, and tracheostomy. R17's Minimum Data Set (MDS) assessment dated [DATE] documents R17 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicates intact cognition. R17 requires extensive assistance to total dependence on staff for activities of daily living (ADLs). R17's physician orders for suctioning as needed (PRN) started on 05/11/2023 and were discontinued on 03/26/2025 with no documentation as to why this occurred. R17 has an order for oxygen (O2) at 2L/minute (min) via nasal cannula to keep oxygen saturation levels at or above 88% for respiratory distress as needed. R17's care plan indicates R17 is resistive/noncompliant with treatments/care of respiratory/stoma/tracheostomy related to coping with disease process and life situation. Will verbalize understanding of consequences of refusal/noncompliance. R17 will comply with care routine/medical regimen. If R17 resists care, leave (if safe to do so) and return later, inform R17 of ADL that is required ahead of time and give two options of times to be done. Give R17 a choice and allow for flexibility in routine. R17's care plan indicates R17 is at risk for change in mental status or acute confusional state as evidenced by multiple ER visits, history of respiratory infections secondary to noncompliance with tracheostomy/stoma care. R17 has difficulty communicating as evidenced by tracheostomy due to laryngeal cancer. R17's care plan indicates R17 is at risk for respiratory impairment related to COPD, tracheostomy. Per resident requires upright position due to shortness of breath (SOB) while lying flat . Interventions include maintain patent airway, will have no acute respiratory distress, administer medications as ordered, administer oxygen per providers orders, ensure head of the bed (HOB) is elevated at least 45 degrees and/or use of 2 or more pillows to prop resident up to prevent feelings of SOB, educate resident/representative on diagnosis, treatment and risks for complications, encourage deep breathing exercises, evaluate lung sounds and vital signs (VS) as needed. Care plan states to report abnormalities to physician, obtain pulse oximetry (pO2), and report abnormal findings. Position R17 as upright as possible during and after meals, provide assistance with ADLs to conserve energy, report signs of infection or edema, suction per physician orders, therapy evaluation and treat as ordered, and trach care per protocol. Surveyor noted multiple emergency room visits in R17's medical record. Surveyor reviewed Emergency Medical Service (EMS) reports regarding R17. On 01/13/25 at 11:03 AM, EMS was called to facility. EMS documentation states R17 was breathing rapidly. A non-rebreather mask was applied with oxygen at 8 liters (L)/minute, EMS documented R17's vitals at 11:15 AM, blood pressure (B/P) 166/82, pulse (P) 88, respirations (R) 44, and O2 saturation 87%. On 1/13/25, ER documentation states R17 presented with some shortness of breath (SOB). O2 sat improved with blow-by oxygen to 92% and B/P improved to 130/76. Documentation states facility does not have a respiratory therapist (RT) and is unable to perform deep suctioning. Following suctioning by cardiopulmonary a large mucous plug was removed. Documentation states R17 said if facility was able to provide the suctioning R17 would not have to come to the ER. On 1/17/25 at 2:21 AM, EMS called to facility. Documentation states R17 in obvious distress with difficulty breathing. EMS personnel suctioned R17 and mucous plug removed from tracheostomy. R17's vital signs per EMS at 2:39 AM, B/P 145/87, P 97, R 20, O2 sat 87%. R17's vital signs at 2:43AM, B/P 138/85, P 88, R 18, and O2 sat 92%. On 1/17/25, ER documentation states O2 sat at 2:51 AM was improving at 90%. Respiratory Therapy (RT) was called and R17 was suctioned which did result in removal of some secretions. A saline nebulizer (neb) was then given, and another suction attempt resulted in some more sputum. Hospital record on 1/17/25 at 3:07 AM, Patient Updates, Patient reports that when his trach was clogged, he felt like he was going to die. On 1/23/25, R17 was seen by an Ear, Nose, and Throat (ENT) specialist at the clinic due to having mucous plugging with tracheostomy. ENT documentation states R17 is experiencing recurrent mucous plugging, which is unfortunately a common complication of laryngectomy. R17 needs to be treated with very diligent humidification including use of heat moisture exchanger (HME). Additionally, R17 should utilize irrigation and suctioning as needed. Should be seen in the emergency room if needed. On 1/23/25, facility documentation states R17 returned from appointment with ENT. Documentation states R17 had some dried green secretions in proximal trachea. ENT debrided those, distally mild amount, white bronchial secretion. Facility documentation worded ENT note stating if needs suctioning will need to be seen in the ER. This differs from quoted documentation as stated above. On 1/23/25 at 8:11 PM, facility progress note states R17 kept heated humidity on for about half of the shift. R17 wanted it off the rest of the time. No documentation provided by facility showing education was provided to R17 emphasizing the importance of humidification with a tracheostomy. On 1/31/25, ER documentation states R17 arrived by ambulance with SOB. Documentation stated R17 not in acute distress. Stoma looks good. R17's vital signs B/P 122/58, P 64, R 26, O2 sat 92, and T 97.7. Note states tracheostomy mucous plug was relatively easily removed. Mucous plug removed with assisted cough by R17 and superficial suctioning. ER documentation states, The care provided in ER is clearly within the nursing home Registered Nurse (RN) scope of practice. There is no reason for hospitalization. R17's needs are ongoing regular tracheostomy care to prevent recurrence or a situation that is worse. On 1/31/25 at 3:20 PM, facility documentation states facility spoke with hospital and R17's plan of care will be for facility to suction at bedside the surface of trach for discomfort with mucous. There will be new order for albuterol and hypertonic saline for nebulization to help R17 cough and release mucous plugs. Of note, there is no evidence education was provided to R17 on ways to prevent mucous plugs, or any new intervention implemented to assist with needed respiratory care. On 3/29/25, R17 was transferred from the facility to the ED for fever and decreasing oxygen saturations. VS at 2:04 AM were as follows; temperature (Temp) 101.3 F, Pulse (P) 82, Respirations (R) 35, BP 130.60, SpO2 95% on 5l/min of oxygen. Records indicate: Hypoxia, increased oxygen needs, suspected pneumonia. ED course indicated, Mucus plug, inadequate humidification, infection, poor trach care. R17 was admitted to the hospital, was followed by RT, respiratory panel was positive for Corynebacterium propinquum (bacteria in the oral pharyngeal). R17 was diagnosed with pneumonia, treated with vancomycin and sent back to the facility on doxycycline (an antibiotic). R17 was discharged back to the facility from the hospital on 4/2/25. Findings at discharge include supplemental oxygen requirement which is not his baseline. On 04/16/25 at 10:41 AM, facility documentation states R17 displayed agitation while taking nebulizer off. R17 had expressions of disgust and irritability. On 4/19/25, ER records indicate R17 was taken to ER by ambulance with difficulty breathing. Review of ER notes indicate R17 stated it's been a while since they suctioned him at the nursing home and his breathing got worse yesterday and today. R17 felt and looked improved after neb with RT, who knows him well. ER discharge note indicated that neb was given, and suctioning was not done at this time. On 04/21/25 at 10:03 AM, EMS at facility. Documentation states R17 felt like something stuck in trach. EMS documentation states RN at facility stated suctioning was performed on R17. EMS performed visual inspection and trach appeared clear. EMS performed vital signs on R17. At 10:08 AM, B/P 159/99, P 70, R 16, O2 sat 97%. At 10:16 AM, B/P 164/107, P 70, R 16, O2 sat 96%. Surveyor reviewed facility documentation and R17's medical records did not show RN performed suctioning on R17 prior to EMS arrival. Facility did not implement any new interventions for R17 after this ER visit. On 04/21/25 at 10:21 AM, ER documentation states R17's prearrival vital signs: B/P 159/99, P 70, R 20, O2 sat 98%. ER documentation states R17's chief complaint is trach problems, care. R17 presents from nursing home after having trach suctioned. The nursing home reports R17 still has phlegm stuck in the trach and sent R17 to ER to be evaluated. In ER at 10:26 AM, R17's vital signs: B/P 163/67, P 67, R 22, O2 sat 94%. R17 not in acute distress. Nebulizer treatment given and suctioning performed by RT and large mucous plug removed. ER documentation states diagnoses of poor trach care, mucous plug, and inadequate humidification. On 04/21/25 at 12:08 PM, facility documentation states R17 was transported back to facility. Facility RN called ER and received report that R17 was suctioned with no results. R17 received a duo neb treatment and no new orders given. Of note, facility note does not align with ER visit note; a mucous plug was removed. Of note, the facility documentation on 4/21/25 does not align with the ER note that documents a large mucous plug was removed. On 04/24/25, Nurse Practitioner (NP) E saw R17 at facility. NP E's documentation states nursing home is unable to deep suction R17 due to regulations, so R17 requests ER transport. NP E documents NP E discussed R17's case with hospital RT and agreed with RT ER transport is not likely needed. NP E documentation states, We are working with the nursing home and RT/EMTs for a better plan of care. NP E documentation states R17 has a history of non-compliance with trach filter and nebulizer treatments. On 04/28/25 at 4:07 PM, EMS called to facility and EMS suctioned 10 ml phlegm from R17's trach. EMS documentation states R17's vital signs: B/P 139/74, P 78, R 14, O2 sat 96%. At 4:36 PM, R17's vital signs: B/P 129/70, P 80, R 18, O2 sat 94%. On 04/28/25 at 4:38 PM, ER documentation states R17 has cough, SOB, and wheezing. R17's vital signs: B/P 134/67, P 81, R24, temp 98.9, and O2 sat 92%. ER documentation states breath sounds reduced. Chest x-ray results were clear. Electrocardiogram (EKG) results normal sinus rhythm. ER report stated, He is able to do basic suctioning but not deep suctioning at the nursing home (NH) and the nurses are not trained to do this nor do they have the equipment. He comes to the ED frequently requesting deep suctioning. He has been having increased SOB the past few weeks and has come over for suctioning. Discharge instructions - attempt suctioning at NH as well as possible when he can. Return if there is severe blockage. R17 is unable to suction trach per self. The facility had no evidence that education was given to staff on providing suctioning to R17 after this ER visit. NP E's progress note dated 05/23/25 states on 05/22/25 NP E spoke with ENT and NP's documentation states R17's case was discussed. ENT recommends having suction available for patients with a tracheostomy but makes exception for R17. Documentation states ENT states R17 is in a skilled facility with nursing and care staff 24/7 and R17 is able to produce a productive cough to help control secretions. R17 wears the HME, is alert and oriented, and able to make needs known. Documentation states Yankauer suctioning would not prevent plugs from forming and would not decrease need for emergency room visits. R17 states he is unable to clear mucous plugs. **Note-this progress note and conversation between NP E and ENT took place after the facility was made aware by surveyors of the respiratory/trach/stoma care and suctioning concerns. On 05/20/2025, Surveyor observed R17 had nebulizer equipment in room. R17 did not have suctioning equipment in room or at bedside. Surveyor observed facility airway suctioning equipment is kept on a crash cart in the facility medication room. On 5/22/25 at 10:21 AM, Surveyor interviewed DON B and NHA A, who reported the facility does not do deep suctioning. Later, DON B reported deep suctioning is anything beyond the opening of the trach. On 5/22/25 at 10:35 AM, Surveyor interviewed NP E, who reported, I think we had an order for Yankauer (shallow oral cavity) suctioning. NP E reported that R17 wants to go to the ER. He likes the attention. His nebs are effective. I have a direct line to the ER. NP E reported R17 doesn't need deep suctioning. NP E reported RT from the hospital has told NP E this. Surveyor asked NP E how facility staff determine when to send R17 to ER. NP E stated, They call me. I have them get vital signs, cleanse trach site, administer nebs and humidified air. I have him attempt cough and deep breath and then send him to the ER if he wants to go. He is his own person, if he wants to go to the ER, we have to honor that. On 5/22/25 at 10:55 AM, Surveyor interviewed DON B who reported the facility would provide oral cavity suctioning if R17 needed it. DON B stated, We are not doing any deep suctioning. DON reported the facility could suction around the outside of the stoma but that's not what he needs. He will tell us when he has a mucus plug. DON B reported the facility does not consider suctioning in the trach part of trach care. Surveyor asked DON B what was considered trach care. DON B replied, Cleansing and caring for it. Surveyor asked DON B how would a new nurse know what to do if R17 experiences respiratory issues. Surveyor asked if a plan of care is in place which lists steps to take when R17 has difficulty breathing. DON B reported the facility would train on trach care, site care, and oral suctioning. DON B stated, We don't have a respiratory therapist. DON B further stated, We took [R17] because [R17] was supposed to be short term. We will never take another trach patient. DON B reported they have not done any type of suctioning to R17. Facility did not have any suctioning orders from March 26, 2025, until suctioning PRN order signed by physician on 04/03/25. Surveyor requested any documentation of suctioning provided to R17 since his admission. No documentation was provided. On 5/22/25 at 11:10 AM, Surveyor interviewed R17. Surveyor asked if R17 feels nervous when he cannot breathe well and needs to be suctioned. R17 nodded his head up and down indicating yes. R17 does not recall if the facility has ever tried to suction him. Surveyor asked R17 if he requests to go to the ER. R17 replied he has asked to go sometimes and sometimes the facility has just sent him to the ER. R17's replies were with use of a voice amplifying device. Surveyor asked if R17 is concerned or has anxiety when he must wait for the ambulance to go to the ER to be suctioned instead of the facility doing the suctioning. R17 nodded his head up and down indicating yes. When Surveyor asked if R17 ever suctions himself, R17 shook his head side to side indicating no and opened his eyes wide. Surveyor asked if R17 would allow facility to perform trach/stoma suctioning rather than going to the ER. R17 used his microphone and stated, If they knew what they were doing. When Surveyor asked if R17 can cough and clear the secretions himself, R17 shook his head side to side indicating no. Surveyor interviewed facility staff and found staff were not aware to suction R17's trach/stoma, nor did they provide suctioning to R17. There was no suctioning equipment at R17's bedside for emergency suctioning that could be needed. On 5/22/25 at 1:00 PM, Surveyor interviewed Registered Nurse (RN) C about respiratory trach/stoma training. RN C reported RN C was trained on managing R17's trach/stoma and to never stick anything in the stoma. RN C stated, I never had specific cannula care training. Surveyor asked RN C how RN C would know if R17 was having problems with R17's trach/stoma. RN C reported that R17 will tell them. On 5/22/25 at 1:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D, who reported LPN D would assess for secretions, call the on-call provider, and send R17 to the ER. The facility's failure to provide appropriate tracheal/stoma care including suctioning of respiratory secretions in accordance with professional standards of practice created a reasonable likelihood for serious harm, which led to a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on 05/22/25; however, the deficient practice continues at a scope/severity level of D as the facility continues to implement the following action plan: -R17 had a trach/stoma care and lung assessment completed by DON B or designee on 05/22/25. -Emergency suctioning equipment placed at R17's bedside. -On 05/22/25, DON B contacted R17's primary care provider (PCP) and obtained orders for trach/stoma suctioning as needed. -Starting on 05/22/25 facility licensed nursing staff reeducated on tracheostomy stoma care including suctioning of tracheostomy by DON B or designee prior to the start of each licensed nursing staff's scheduled shift. -On 05/22/25, AD HOC Quality Assurance and Performance Improvement (QAPI) meeting held.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infection, for 2 out of 2 residents (R), (R33, R17) observed on Enhanced Barrier Precautions (EBP). Staff did not wear required Personal Protective Equipment (PPE) for R17 who is on droplet precautions. Facility staff did not ensure R33's uncovered urinary catheter bag stayed off the floor and allowed the uncovered urinary catheter to lie directly on the floor. Findings include: Facility policy titled, Enhanced Barrier Precautions, with most recent revised date of 08/08/24, stated in part: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high-contact resident care activities .4. High-contact resident care activities include: .g. Device care or use .urinary catheters .tracheostomy. Facility policy titled, Transmission-Based (Isolation) Precautions with the most recent revised date of 09/24/2024 states in part: 'Droplet precautions' refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions .11 .f. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. Example 1 R17's medical record documents report R17 was admitted to the facility on [DATE] with diagnoses that included laryngeal cancer, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic obstructive pulmonary disease (COPD), weakness, anxiety disorder, and tracheostomy. Review of most recent Minimum Data Set (MDS) assessment dated [DATE] reported R17 had a Brief Interview for Mental Status (BIMS) score of 13/15 indicating R17 is cognitively aware. R17 required extensive assistance to dependent on staff for activities of daily living (ADLs). On 5/21/25 at 7:52 AM, Surveyor observed R17 has an Enhanced Barrier Precautions (EBP) sign and a droplets precautions sign with writing on it that indicates During Nebulizer only and that an N95 mask is to be worn with eye protection, gown and glove at door. Surveyor could hear nebulizer running in R17's room. On 5/21/25 at 8:13 AM, Licensed Practical Nurse (LPN) F donned a gown, practiced hand hygiene and donned gloves. LPN F entered R17's room without a mask or eye protection. LPN F removed R17's nebulizer and turned it off. LPN F put on R17's humidified air. Surveyor interviewed LPN F about R17's precautions. LPN F stated R17 is on EBP. Surveyor referred to the droplet precautions sign on R17's door and asked LPN F's understanding of the droplet precaution sign. LPN F reported, I should have worn an N95 mask and eye protection and not just glasses before taking off his nebulizer. He usually takes it off himself, so I didn't even think about it. On 5/21/25 at 9:18 AM, R17 had on humidified air. Surveyor observed Certified Nursing Assistant (CNA) G don gown, gloves, and put on regular masks, no eye or other face protection. On 5/21/25 at 10:33 AM, Surveyor interviewed Infection Preventionist (IP) H who reported R17 is on droplet precautions with use of the nebulizer or humidifier trach because R17 does not wear a filter over trach and has potential for respiratory spray. IP H agreed the expectation would be that staff wear N95 mask or face covering and eye protection when in R17's room if nebulizer or humidified air is in use. On 5/22/25 at 10:21 AM, Surveyor interviewed Director of Nursing (DON) B. DON B agreed the expectation would be that staff wear eye protection and N95 masks when entering R17's room while nebulizer or humidifier are on and running. Example 2 The Agency for Healthcare Research and Quality, states in part: Catheter Care and Maintenance .Drainage bag care . Keep drainage bag below level of bladder and off the floor at all times R33's medical records indicate R33 was admitted to the facility on [DATE] with a diagnosis that included urinary infection and inflammatory reaction due to indwelling urethral catheter. Review of most recent Minimum Data Set (MDS) assessment reported R33 had a BIMS score of 13/15 indicating R17 is cognitively aware. R33 required extensive assistance to dependent on staff for activities of daily living (ADLs). R33's care plan, dated 1/22/25, with a target date of 4/16/2025, states in part: At risk for infection r/t Indwelling medical device: indwelling catheter and G tube . Will remain free from infection through review date . Interventions include Enhanced barrier precautions when performing high-contact activities. On 05/20/25 at 12:35 PM, Surveyor observed catheter bag on the floor in covered bag. R33 stated, I can't reach it. Surveyor observed Certified Nursing Assistant (CNA) G transfer R33 using sit to stand lift. On 05/21/25 at 7:54 AM, Surveyor observed R33 in bed. R33's uncovered Foley bag was lying on the floor next to R33's bed. R33 was awake. On 05/21/25 at 8:33 AM, IP H donned gown and gloves and entered R33's room. R33's air mattress was beeping. IP H looked at R33's air mattress system at the end of the bed. It stopped beeping and IP H left room. R33's uncovered urinary bag remained on floor. On 05/21/25 at 8:40 AM, Surveyor interviewed CNA G, who reported R33's bed has a weird frame and that R33's urine catheter bag has been on floor once a week or more. It's because they put it on this side, if they put it on the other side they can put it in the catheter bag cover, and it stays better. On 05/21/25 at 10:18 AM, Surveyor interviewed DON B who agreed R33's catheter bag should not be uncovered lying directly on the floor.

Based on interview and record review, the facility did not comprehensively assess resident sleep disturbance or monitor the effectiveness of psychoactive medications used to promote sleep for 1 of 5 residents reviewed for unnecessary medications (R21). R21's orders include Trazodone (antidepressant) 25 mg tablet at bedtime for insomnia. The facility did not comprehensively assess R21's sleep disturbance or have a system in place to monitor the medication's effectiveness. This is evidenced by: Surveyor reviewed R21's record and noted R21's diagnosis includes primary insomnia. R21's most recent quarterly Minimum Data Set (MDS) dated [DATE] indicated she received an Antidepressant medication 7 of 7 days. R21's Physician orders indicated: ~ 4/22/2022: Trazadone take 1/2 (25mg) tablet by mouth every day at bedtime related to primary insomnia. R21's MAR (Medication Administration Record) shows daily administration of Trazodone at bedtime related to primary insomnia from 4/22/23 to present. The TAR (Treatment Administration Record) notes to record Hours of sleep every shift. The documentation ceased on 11/25/2023 with no further documentation to date. On 03/22/23 at 9:35 a.m., Surveyor spoke with Resident Care Management Director/Licensed Practical Nurse (RCMD/LPN) C about R21's Trazadone use for promoting sleep and the facility's system to monitor its effectiveness. RCMD/LPN C expressed R21 is taking Trazodone for sleep, and they check sleep daily. RCMD/LPN C went on to explain if anyone is on Trazodone, they are supposed to have sleep monitoring due to the drug's effects on sleep. When the surveyor asked where the information was recorded, RCMD/LPN C brought up the MAR and TAR on her computer. RCMD/LPN C did not see where sleep was being recorded. Surveyor could not locate a comprehensive sleep assessment in R21's record. Surveyor requested a comprehensive sleep assessment from Director of Nursing (DON) B. R21's care plan states, Focus: At risk for sleep pattern disturbance related to diagnosis/history of insomnia and sun downing episodes that occur for consecutive days in row with little sleep, then sleeps many hours for days, and repeats Goal: Will sleep 8 to 10 hours without interruption even when sun downing. [R21] will exhibit no sleep related behavioral symptoms, such as restlessness, irritability, lethargy, or disorientation Interventions: Document the number of hours resident sleeps each shift. Assess usual pattern of sleep. Administer sleep medications as ordered by MD. Assess for adverse side effects. Re-evaluate psychotropic ordered medications if sleeping too much during the day after once up. >then 10 hours per day. Report to MD any persistent problems with insomnia. Although the care plan directs the facility to document hours of resident sleep, there was no system in place for monitoring the medication's effect to promote sleep for R21. In addition, the plan directs assessment of R21's sleep pattern, and no comprehensive assessment was completed to assess R21's sleep pattern. On 3/22/2023 at 12:19 p.m., DON B indicated no comprehensive sleep assessment was completed for R21. The facility has no system in place to monitor R21's sleep and whether the medication is effective in promoting sleep for R21. DON B further explained she would expect a sleep assessment to be done before initiating medication. DON B would also expect a system to be put in place to monitor resident sleep to evaluate the medications effectiveness. DON B indicated the facility does not have sleep monitoring in place for R21. The monitoring was removed from the Medication Administration Record (MAR) after November 2022. The DON expressed the facility is unsure how and why the monitoring was removed.

Based on observation, interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary antibiotics for 1 of 5 residents (R) reviewed for unnecessary medications (R9). R9 received an antibiotic ongoing since 4/27/2021 without indication for use, lacking evidence of an infection, and with an order that states no antibiotics for infections. Findings Include: R9 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set, dated dated dated [DATE] does not indicate any open wounds or infections. On 2/2/2021, R9's activated Power of Attorney (POA) requested R9 receive comfort care at the facility. On 2/5/2021, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's care plan, dated 12/04/2020, with revision date of 4/26/2021 reads, comfort care as follows: no labs, no emergency department visits, DNR, no hospitalization s, no antibiotics for infections, no IV fluids, no imaging, weigh only monthly, and discontinue unnecessary medications. On 4/27/2021, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/27/2021, Nurse Practitioner (NP) D progress note reads, in part .open wound of left knee with complication .history of [CONDITION(S)] and often picks at the wound making infection control difficult because of her dementia. From 3/27/2022 to 03/29/2022, during the survey process, Surveyor did not observe R9 picking at her skin. Review of R9's care plan does not indicate a focus area regarding picking at skin or include non-pharmacological interventions to prevent R9 from picking at her skin. Medical records indicate R9 is still receiving the prescribed antibiotic from 4/27/21. Review of R9's skin assessments from 04/26/2021 through present do not indicate an infection or open wound of left knee. On 3/29/2022 at 7:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F confirmed that R9 does not have any current open areas or wounds. CNA F reported that R9 does pick at wounds and staff dress her in long pants and long sleeves for prevention, no other interventions for picking at skin were reported. CNA F stated that at night R9 wears a nightgown as her room is warm and this makes it easier for R9 to pick at her skin. On 3/29/2022 at 8:04 AM, Surveyor interviewed Registered Nurse (RN) E. RN E confirmed that R9 does not have any current open wounds and that R9 does pick at her skin. RN E described R9's knee as healed and scarred. RN E was unable to provide a date but stated, It has been a while since her knee has opened up. RN E reported that it is difficult to keep dressings on R9's wounds due to her picking.

Based on interview and record review, the facility did not implement antibiotic use protocols for indicated use of chronic antibiotic therapy and did not utilize a system to monitor antibiotic use for 1 of 5 residents (R) reviewed for unnecessary medications (R9). R9 received an antibiotic ongoing since 4/27/2021 without evidence of an infection and with an order that states no antibiotics for infections, resulting in the potential to develop antibiotic resistance. Findings Include: Review of facility's Antibiotic Stewardship Policy with revision date of April 2021, indicates the purpose of the Antibiotic Stewardship Program is to monitor the use of antibiotics in residents. Policy states that clinical infections treated with antibiotics will undergo review by the Infection Preventionist to help identify situations that are not consistent with the appropriate use of antibiotics. Policy reads those situations for further review include: the organism is not susceptible to antibiotic chosen, the organism is susceptible to narrower spectrum antibiotic, therapy was ordered for prolonged surgical prophylaxis, or therapy was started awaiting culture, but culture results and clinical findings do not indicate continued need for antibiotics. The facility's Antibiotic Stewardship Policy did not identify measures for assessment of infections using standardized tools or criteria (e.g., Loeb or McGeer Criteria). R9 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's Minimum Data Set, dated dated dated [DATE] does not indicate any open wounds or infections. On 2/2/2021, R9's activated Power of Attorney (POA) requested R9 receive comfort care at the facility. On 2/5/2021, physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/27/2021, a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 5/27/2021 Nurse Practitioner (NP) D progress note during nursing home rounds, reported that R9 is on chronic [MEDICATION(S)] for open wound of left knee. R9 has history of [CONDITION(S)] and often picks at wound making infection control difficult because of her dementia. On 3/29/2022 at 7:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F confirmed that R9 does not have any current open areas or wounds. On 3/29/2022 at 8:04 AM, Surveyor interviewed Registered Nurse (RN) E. RN E confirmed that R9 does not have any current open wounds. RN E described R9's knee as healed and scarred. RN E was unable to provide a date but stated, It has been a while since her knee has opened up. RN E stated that when monitoring R9's knee for signs of infection, staff are monitoring vitals every shift as part of COVID protocol. R9's care plan, dated 12/04/2020, with revision date of 4/26/2021 reads, comfort care as follows: no labs, no emergency department visits, DNR, no hospitalization s, no antibiotics for infections, no IV fluids, no imaging, weigh only monthly, and discontinue unnecessary medications. R9's care plan, dated 10/22/2021, included focus area: Resident on long-term antibiotic use due to history of [CONDITION(S)]. Interventions include administer medications per Medical Doctor (MD) order, encourage fluids, monitor vitals and intake and output for signs and symptoms of infection or adverse effects from antibiotic use, obtain labs/diagnostics per MD order, notify MD of results. R9's skin assessments from 04/26/2021 through 3/29/2022 did not indicate an infection or open wound of left knee. Review of R9's medical record did not reveal laboratory results, including culture and sensitivity testing to determine R9 had an active infection. Pharmacy review notes indicated R9 has not had laboratory testing since 2018. R9 was still receiving the anitibiotic prescribed 4/27/21.

Based on resident observations, interviews and record review, facility did not ensure 1 of 5 residents(R27) reviewed for unnecessary [CONDITION(S)] medications, received these medications with adequate monitoring and in the lowest dose possible. R27 was receiving multiple [CONDITION(S)] medications with no system in place to measure outcomes as improved or worsening nor adequate indications for use. R27 was admitted to the facility on [DATE]. R27 has diagnoses of Unspecified Dementia with Behavioral Disturbances, Primary [CONDITION(S)], Major Depressive Disorder, and Recurrent Unspecified Anxiety Disorder. R27 takes the following psychoactive medications: [MEDICATION(S)] 20mg daily (antidepressant), [MEDICATION(S)] Tablet 0.25mg twice daily (anti-anxiety), [MEDICATION(S)] Tablet 3mg (to promote sleep), [MEDICATION(S)] 0.25mg BID (Antipsychotic), and Trazadone 25mg at HS (anti-depressant). Observations: On 3/27/22 at 12:44PM, R27 was observed to be sleeping in wheelchair in their room, and did not respond to voice. On 3/28/22 at 1:00PM, R27 was observed in bed sleeping. At 3:50PM, R27 was noted to be in spouse's room, R14, sleeping in wheelchair while family was visiting. On 3/29/22 at 7:20AM, Surveyor observed R27 up in wheelchair in room, sleeping with half full cup of coffee almost overturned in lap. At 7:25AM, Surveyor noted R27 had spilled coffee and was awake. At 8:40AM, R27 was up in wheelchair after having been transferred back into bed for a clothing change, and was taken into the Business Manager's office who is also R27's grandchild. R27 was sleeping and leaning to the right. At 9:30AM, Surveyor observed R27 to be back in bed sleeping. At 11:10 AM, R27 was observed to still be in bed and was snoring. On 3/28/22, Surveyor observed the spouse of R27 enter R27's room to visit, but R27 was in bed sleeping and did not awaken to visit so spouse returned to own room. Interviews: On 3/29/22 at 8:00AM, Surveyor interviewed Director of Nursing (DON) B regarding R27 and the use of [CONDITION(S)] medications. Surveyor noted the facility was tracking data on behaviors, but there was no evidence that the data was being analyzed or that there was a particular measurable goal for R27 to meet that would inform them of when a change in medications was warranted. Surveyor asked DON B who was responsible for monitoring the incidences of behaviors that R27 was having. DON B stated they did not really analyze the data, but that it was reviewed during a meeting with the pharmacist. Surveyor asked to have the data that is used in these meetings to make decisions about increasing or decreasing medication doses. DON B stated there was no documentation that they could give. When asked how the facility knew that what R27 was experiencing was anxiety, DON B stated that R27 rolls wheelchair up and down the halls, wrings hands and grabs things. Surveyor asked DON B if they were aware of the side effects of medications like [MEDICATION(S)], and DON B stated they were not sure of the side effects. Surveyor inquired if R27 had ever been seen by psychiatry to monitor medications, and DON B stated no, that the family did not want that. On 3/29/22, Surveyor interviewed Registered Nurse (RN)-C regarding [CONDITION(S)] medications. Surveyor asked RN-C if they knew the side effects of [MEDICATION(S)] or other drugs in the same class. RN-C stated they did not know right off hand. On 3/29/22 at 10:00AM, Surveyor interviewed R14 who is the spouse of R27. R14 also resides at the facility but does not share a room with R27. R14 was asked about the condition of their spouse. R14 stated they noted that R27 had declined a lot since they had resided at the facility. Surveyor asked if R14 was able to visit with their spouse and converse. R14 stated that R27 was often sleeping but that sometimes they would have ice cream together, but R27 would often sleep through that too. On 3/29/22, Surveyor interviewed the Nurse Practioner (NP) who works with R27 and prescribes medications. NP was asked if they use or have an individual therapeutic goal for R27 to help make decisions regarding increasing or decreasing medications. NP stated no, that they looked at notes but there is no documentation of these discussions. Record Review: On 3/29/22, Surveyor reviewed the Pharmacy Reviews for R27 over the past year. These reviews were done monthly. It was noted that the facility had D/C [MEDICATION(S)] in September and decreased the Trazadone in April to 25mg from 50mg and then on 5/21/22 facility added an additional dose of [MEDICATION(S)] 0.25mg to R27's medication regimen and this dose was increased to twice daily on 6/3/21. There is no data noted on the review to support the increase in antipsychotic medication. As of 3/29/22, R27 remained on 2 anti-depressants, 1 anti-anxiety medication, and 1 antipsychotic medication along with [MEDICATION(S)]. On 3/29/22, Surveyor reviewed R27's care plan. The care plan stated that staff should document the number of hours R27 sleeps each shift. Surveyor reviewed the past 3 months of data regarding sleeping. R27 had one day where the documentation stated they slept 3 hours and then the next day R27 slept 17 hours. This is the highest noted daily amount of sleep with the average being approximately 11 hours a day. This data is available to the facility when making medication decisions; however, there is no documentation to support that the data is being considered in any decisions. On 3/29/22, Surveyor reviewed the goals on R27's care plan. In the focus area it states R27 was at risk for adverse effects related to use of antianxiety and antidepressant medications. The goal was that R27 have minimal or no side effects of the medication, show improvement in mood/behavior, and no signs of hallucinating or delusional thinking. The care plan did not include a method of measuring whether R27 had shown improvement or what R27 needed to specifically accomplish to consider decreasing or discontinuing medications. On 3/29/22, Surveyor reviewed the drug [MEDICATION(S)] on the website for The Mayo Clinic (www.mayoclinic.org). It stated that [MEDICATION(S)] is used to treat [CONDITION(S)], [CONDITION(S)] disorder or irritability associated with autistic disorder. It also stated that [MEDICATION(S)] should not be used to treat behavioral problems in older adults who have dementia. It stated that [MEDICATION(S)] is not recommended to be used in conjunction with [MEDICATION(S)] or Trazadone but if it had to be used should be monitored closely. It lists the side effects as aggressive behavior, agitation, anxiety, restlessness or the need to keep moving, all of which the facility reports that R27 had. On 3/29/22, Surveyor reviewed R27's Minimum Data Set (MDS) for 2/3/2022. Under section D Mood, R27 had a score of 4 which indicates minimal depression. On section E Behavior, it indicates that R27 had no episodes of behavioral symptoms with one incident of wandering behavior. Surveyor reviewed progress notes made by the nursing staff regarding R27's anxiety and behaviors. These notes indicate that when R27 was given 1:1 attention, hand holding, and allowed to stay with staff that these interventions were usually effective in calming R27 down after a time. R27 remained on multiple [CONDITION(S)] medications, without adequate monitoring of effectiveness and side effects.

Based on record review and interview, the facility did not provide the opportunity for residents and/or their representatives to participate in the care planning process when changes were made in their plan affecting 4 of 4 residents reviewed (R1, R2, R3, R4). Example #1: Since the facility recertification survey on 03/03/21, R1's Minimum Data Set (MDS) assessments were completed on 4/01/21, 5/11/21, 6/04/21 and 9/04/21 with care plan revisions based on the assessments. Record shows the facility conducted a care conference review with R1's daughters on 10/12/21. There is no evidence R1 was invited or involved in the care conference. R1 and her involved family were not invited or involved in care plan revisions after MDS assessments on 4/01/21, 5/11/21, 6/04/21 and 9/04/21. Example #2: R4's Minimum Data Set (MDS) assessments were completed on 3/15/21, 5/28/21 and 8/28/21 with care plan revisions based on the assessment. Record shows the facility did not conduct a care conference review of the changes. R4's last noted care conference occurred on 12/16/20. Example 3: R2 has had Minimum Data Set Assessments conducted on 3/2/21, 6/1/21 and 9/1/21. There have been no Care Conferences held to correlate with these assessments in which revisions to the plan of care were made. R2 has missed three Care Conference Meetings since last Recertification Survey dated 3/3/21. Example #4: R3 has had Minimum Data Set Assessments dated 5/13/21, 8/11/21 and 9/24/21. There have been no Care Conferences held to correlate with these assessments in which revisions to the plan of care were made. R3 has missed three Care Conference Meetings since last Recertification Survey dated 3/3/21. Evidence uncovered indicates R3 has not had a Care Conference since 11/4/2020. Findings Include: Example #1: The surveyor reviewed R1's record and noted her Minimum Data Set Assessments were completed during 2021 as follows: ~Quarterly Assessment: 4/01/21 ~5 day Admission (re-admission) Assessment: 5/11/21 ~Quarterly Assessment: 6/04/21 ~Quarterly Assessment: 9/04/21 The surveyor reviewed R1's care plan and noted revisions made tied to the Minimum Data Set Assessments that were completed. The surveyor reviewed R1's record and noted care conference meetings discussing revision to R1's care plan as follows: ~10/11/21: writer and administrator met for ad-hoc care conference with residents two daughters in facility and power of attorney for health care via phone to discuss concerns of mother not being as engaged as previous . (There is no evidence R1, who is her own decision maker, was invited to attend the care conference). On 10/19/21 at 9:24 a.m., the surveyor spoke with R1's daughter, Family Member (FM)-D, regarding R1's care conferences and care planning process. FM-D indicated her brother is R1's power of attorney, that is not yet activated as R1 can make her own decisions. FM-D further expressed she, her sister and her brother are very involved in their mother's care, visiting weekly and calling on a daily basis. FM-D indicated a discussion was held 10/11/21 with the Director of Nursing and Nursing Home Administrator. Prior to the 10/11/21 meeting no conferences were held since December of 2020 or January 2021. FM-D expressed the siblings want to be involved in discussion regarding their mother's care, including care conferences and changes to her plan of care. Example #2: The surveyor reviewed R4's record and noted her Minimum Data Set Assessments were completed during 2021 as follows: ~Quarterly Assessment: 3/15/21 ~Significant Change in Status Assessment: 5/28/21 ~Quarterly Assessment: 8/28/21 The surveyor reviewed R4's care plan and noted revisions made tied to the Minimum Data Set Assessments that were completed. The surveyor reviewed R4's record and noted no evidence of care conference meetings during 2021 to discuss revisions to R4's care plan. The last noted care conference was held on 12/06/20. On 10/19/21 at 11:57 a.m., the surveyor spoke with Social Services Designee (SSD)-C regarding the facility's care conference and care planning process. SSD-C has been in her position a few months and is responsible for coordinating the conferences and inviting the resident, involved family, IDT and outside program representatives such as Inclusa, managed care. SSD-C had previously worked in the facility in the therapy department. SSD-C expressed care conferences are being held sporadically, not as required on a quarterly basis or when the MDS assessment is completed and changes made to the care plan. The surveyor asked SSD-C why the facility is not conducting the conferences as required. SSD-E expressed the Social Services Designee is the person responsible for coordinating the conference, sending out invites and completing a care conference summary showing the meeting was held and topics discussed. SSD-C further expressed the Social Services position has had great turn over and has been vacant during points of 2021. The surveyor requested evidence of care conference meetings for R1, R2, R3 and R4 as noted above. Example 3: R2 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was admitted to the facility 12/5/2018. According to the most recent Minimum Data Set Assessment (MDSA), which was a Quarterly assessment dated [DATE], R2 's cognitive status was indicated with a BIMS (Brief Interview of Mental Status) score of 15/15, indicating she is cognitively intact. She continues to be her own decision-maker. - During the interview with R2, the resident denied any recent Care Conference Meetings (CCM). She stated, .they used to be on a regular basis every three months or so, but I can't remember the last time one was held. Nobody has come in here and actually talked to me one-on-one about my care in a long time. Note: In reviewing R2's Medical Record, there was one CCM held on 8/2/21. This date did not correspond with the MDSA. However, in looking back since the last Recertification Survey dated 3/3/21, there have been no other CCMs noted. Minimum Data Assessments were completed for R2 on the following dates: - 3/2/21 (Quarterly Assessment) - 6/1/21 (Quarterly Assessment) - 9/1/21 (Quarterly Assessment) Generally, a CCM is held to correspond with the above listed assessments. This is an indication that input was received by facility, the resident and resident representatives, where warranted. There were none noted in R2's Medical Record for these assessments. Example 4: R3 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 was admitted to the facility 8/4/2020. According to the most recent Minimum Data Set Assessment (MDSA), which was a Signifiant Change in Status assessment dated [DATE], R3's cognitive status was indicated with a BIMS (Brief Interview of Mental Status) score of 15/15, indicating she is cognitively intact. She continues to be her own decision-maker. - During the interview with R3, she stated that she thought she has had Care Conference Meetings, but could not recall, . sometimes I get a little goofy (laughed) and am unsure if I am having a dream or if it's real. I have hallucinations and they (staff) need to set me straight. Note: In reviewing R3's medical Record and Care Conference Meeting notes going back to the last Recertification Survey dated 3/3/21, there have been no CCMs noted. In fact, the last CCM was dated 11/4/2020. Minimum Data Set Assessments (MDSA's) were completed for R3 on the following dates: - 5/13/21 (Quarterly Assessment) - 8/11/21 (Significant Change in Status Assessment) - 9/24/21 (Significant Change in Status Assessment) Generally, a CCM is held to correspond with the above listed assessments. This is an indication that input was received by facility, the resident and resident representatives, where warranted. There were none noted in R2's Medical Record for these assessments. SSD-C was questioned during an interview at 1:18 PM regarding R3 and stated that the resident has not had a CCM since 11/4/2020

Based on observations, interviews and record review, the facility did not implement pressure injury (PI) prevention interventions for 2 of 3 residents (R) reviewed (R17, R49) for pressure injury risk. - Resident (R) 49 is a very high risk for a repeat development of a PI, as she had a recently healed coccygeal PI. An observation was made in which R49 was not repositioned with offloading for 5 hours 22 minutes. - R17 was not repositioned following her morning meal and remained in bed on her back at a 90 degree angle for 4 hours 50 minutes, creating a high risk for the development of skin breakdown caused by both pressure and shearing forces. When staff did provide repositioning, R17 was saturated with urine and fecal incontinence. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPUIP), revised 2019, skin care and treatment of [REDACTED]. Repositioning techniques should include the following: In wheel chair: - If sitting in a chair is necessary . limit sitting to three times a day in periods of 60 minutes or less. In bed: - Reposition the individual in such a way that pressure is relieved or redistributed. - Avoid subjecting the skin to pressure and shear forces - Avoid lying postures that increase pressure, such as the 90 degree side-lying position, or the semi-recumbent position (in bed on the back with head of bed elevated to 45 degrees or higher). - Limit head-of-bed elevation to 30 degrees for an individual on bedrest unless contraindicated by medical condition or feeding and digestive considerations. This places pressure and shear to the sacrum and coccyx area. Note: Shearing is caused by gravity pushing down on the body and resistance (friction) between the individual and a surface, such as a bed or chair, for example, elevating the head of the bed and sliding down in the chair. - Continue to turn and reposition the individual regardless of the support surface in use . No support surface provides complete pressure relief. The Wound Care Education Institute (WCEI), 2018 recommends the following with repositioning: - For immobile, bedbound individuals, perform a full change of position at a minimum of every two hours. However, some individuals require more frequent position change due to high risk status. - For individuals in a seated, or wheelchair, weight shifts should be conducted every 15 minutes, if unable to reposition patient every hour. Example 1: R49 has medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment (MDSA) completed for R49 was a Quarterly assessment dated [DATE]. According to this assessment, R49: - has both impaired short-term and long-term memory and severely impaired daily decision-making skills. - is 60 inches tall and weighs 85 pounds. - requires extensive assistance of one staff for basic daily tasks such as bathing, personal hygiene and dressing, and extensive assistance of two staff for bed mobility, toileting and transferring. - is nonambulatory - is frequently incontinent of bowel and bladder function - is at risk for the development of PIs - has a poor appetite and is considered malnourished with a recent significant weight loss. Included in the Comprehensive Care Plan, the following was noted: 1. Impaired bowel and bladder (initiated 5/9/19) related to impaired mobility and cognition: - assist to toilet every two-three hours during the day (8/14/19) 2. Skin integrity risk related to impaired mobility, incontinence and refusal to reposition frequently when approached (5/19/19): - assist to reposition every two to three hours. Document refusals (5/2/19) The facility conducted a Braden Risk assessment dated [DATE]. According to this assessment, R49 scored 15. A score of 15-18 indicates the individual is at risk for the development of PIs. Areas that trigger this score for R49 include: - Moisture: Skin is often, but not always moist. Linen must be changed at least once a shift. - Activity: Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. - Mobility: Slightly Limited: Makes frequent though slight changes in body or extremity position independently. - Nutrition: Very Poor: Never eats a complete meal. Rarely eats more than a portion of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is nothing by mouth (NPO) and/or maintained on clear liquids or IV's for more than 5 days. On 11/18/20, R49 developed a Stage II PI on her coccyx that measured 1.0 L x 1.5 W x .1 D. Interventions the facility put into place at that time were an air mattress, specialized wheelchair cushion, specific repositioning schedule, and staff to lay resident down in between meals, vitamin supplements and nutritional supplements for healing. On 1/18/21, the facility identified the wound was fragile-healed. On 3/2/21, Surveyor made the following observation of R49: - From 6:48 AM until 7:48 AM, R49 was seated in her wheelchair in the television lounge area fully dressed, watching television. - At 7:48 AM, R49 received her morning meal in the lounge and was assisted to the table to eat. At 8:00 AM, R49 pushed herself away from the table and positioned herself in front of the lounge television. R49 did not eat any solids and only took the 8 oz milk. R49 stated to the Surveyor she was not hungry. - At 8:05 AM, the Director of Nursing (DON) approached R49. She asked R49 if she was finished eating. The resident indicated she was done. The DNS pointed out to R49 that she hadn't eaten anything and offered her alternative items, of which R49 refused. The DNS then removed the tray from the room. - At 8:10 AM, the DNS returned to R49 and had R49 conduct a microshift in the wheelchair, by a slight shift to her left side. The buttocks was not lifted and the same amount of pressure was being applied to this area. Note a microshift is not considered pressure redistribution or offloading. A microshift does not allow for sufficient blood flow and relief of pressure to the area that had sustained pressure. There was no offer for R49 to stand up, which is the recommendation, in order to completely remove the pressure and allow redistribution of tissue perfusion to her sacrum and coccyx. According to Rehabilitation Engineering & Assisitive Technology Society of North America, a lift from a seated position requires at least 2 minutes in order for tissue to return to off-loading levels. - From 8:10 AM - 11:20 AM, R49 remained in her wheelchair in front of the television. No staff approached to offer toileting or true repositioning or offloading, or to lay down to remove the pressure. - At 11:20 AM, the noon meal tray was delivered to R49 in the television lounge and placed at a table. There was no offer for R49 to be assisted to the bathroom prior to the meal. - 11:43 AM, Certified Nursing Assistant (CNA) I approached R49. CNA I did not offer bathroom assistance, to lay down or to reposition. She removed the meal tray from the area and left. R49 moved herself back in front of the television. - 11:44 AM- 12:10 PM, R49 remained in the television lounge, seated in her wheelchair. - At 12:10 PM, R49 was assisted to bed by the DON and Assistant Director of Nursing (ADON) D. At 1:36 PM, the Surveyor interviewed all three CNA staff responsible on this day for R49's care (CNAs G, H and I) regarding toileting and repositioning of R49. All three CNA staff working on the floor and responsible for her denied assisting resident to the bathroom or offering repositioning. At 2:39 PM, the Surveyor interviewed the DON. DON stated microshifts are not considered actual repositioning as it does not allow for complete removal of pressure to the area. She further stated R49 is very difficult to stand and requires two people, and even standing for 10 seconds is difficult. The DON further stated R49 had a stage II PI that recently healed in January. She remains at high risk and should be repositioned at a minimum of every two hours. Of concern is R49 was not offered toileting or repositioning for a time period of 5 hours 22 minutes, placing her at a very high risk for the development of additional PI's to her sacrum and coccyx areas. Example 2: R17's medical [DIAGNOSES REDACTED]. R17 is also under the services of Hospice. The most recent Minimum Data Set (MDS) assessment completed for R17 was a Significant Change in Status assessment dated [DATE]. According to this assessment, R17: - has both impaired short-term and long-term memory and severely impaired daily decision-making skills. - is 65 inches tall and weighs 111 pounds. - is extensive assist to totally dependent on staff to meet the most basic daily tasks such as bathing, personal hygiene, dressing, bed mobility and toileting - is nonambulatory and requires the use of a mechanical lift for transfers - is always incontinent of bowel and bladder function - Facility has identified R17 as being at risk for the development of Pressure Injuries (PI) and implemented pressure reduction device for chair and bed. However, according to the MDS, they did not implement a turning and repositioning program The most recent Braden Risk Assessment was dated 2/18/21. Resident scored 11. A score of 10-12 indicates the individual is at a high risk for the development of a PI. Areas that placed this resident at risk, according to this assessment include: - Sensory Perception: Ability to respond meaningfully to pressure-related discomfort- Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. - Moisture: Degree to which skin is exposed to moisture- Very Moist : Skin is often, but not always moist. Linen must be changed at least once a shift. - Activity: Degree of physical activity- Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. - Mobility: Ability to change and control body position- Completely Immobile: Does not make even slight changes in body or extremity position without assistance. - Nutrition: Usual food intake pattern-Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or Total [MEDICATION NAME] Nutrition (TPN) regimen which probably meets most of nutritional needs. - Friction and Shear: Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures or agitation leads to almost constant friction. Included in the Comprehensive Care Plan, the Surveyor noted the following: 1. Incontinence of bowel and bladder (initiated 9/12/18) related to [MEDICAL CONDITION], inability to communicate or unaware of toileting needs and or follow directions to participate in a toileting program. - Check resident before and after meals and as needed for incontinent episodes (revised 1/12/21) 2. Activities of Daily Living Self-Care Deficit related to advanced [MEDICAL CONDITION] (initiated 9/25/18) - Encourage and/or assist to reposition frequently (9/25/18) - transfer with a Marissa Lift (revised 6/9/18) 3. Risk for skin integrity impairment related to [MEDICAL CONDITION], impaired mobility, bowel and bladder incontinence and staff assistance required for adequate pressure relief (initiated 9/25/18) - assist to reposition every two to three hours and as needed (revised 2/19/21) On 3/2/21, the following observation was made by the Surveyor: - 07:30 AM R17 was positioned on her back in bed sitting up at 90 degrees. Certified Nursing Assistant (CNA) G was sitting beside her on a chair, feeding her. - at 7:59 AM, R17 completed her meal with an intake of approximately 60%. CNA G left the room with the tray, leaving R17 positioned as stated above. R17 remained in this position until 11:23 AM without any staff entering her room. This positioning increases the amount of force as a result of gravity-causing friction and shearing, as well as pressure to the sacrum, coccyx and buttocks regions. - 11:23 AM: CNA G delivered the noon meal tray to R17, placing it on the nightstand. She then left the room to assist with delivery of additional meal trays to residents on the unit. - 11:40 AM: CNA G sat beside R17 on a chair and assisted R17 with the meal. - 12:05 PM: CNA G removed the meal tray from R17's room, leaving R17 sitting on her back with the head of bed elevated at 90 degrees. R17 accepted 100% of the frozen treat, 75% sweet potato, 75% beets, 90% ham, 14 ounces(oz) of 16 oz milk and the 8 oz apple juice. - 12:20 PM: CNA G and CNA H entered R17's room to toilet and reposition. R17's incontinent brief was saturated with urine and feces to the point in which the two staff had to place clean bed linens and a clean lift sheet underneath the resident. R17's buttocks were dark red in color. No open areas were noted by the Surveyor. It was at this time Surveyor interviewed both staff members and asked what R17's repositioning schedule was. Both staff stated R17 was to be repositioned every two hours. When asked why it was not every two hours on this day, CNA G responded there had been a resident that coded down the hall and that took some of their time. CNA G did agree R17 should still have been checked prior to this time. At 12:30 PM, the Surveyor interviewed the DON regarding the care needs of R17. DON stated R17 was to be repositioned at least every two hours. The Surveyor explained the care observation made and CNA G's response. DON stated, .the resident down the hall coded at 9:55 AM. (R17) should have been taken care of in between that time. She then stated education will be provided. R17 did not receive the opportunity for changing of her incontinent brief or repositioning, of which R17 is dependent on staff to achieve, for 4 hours 50 minutes. R17 was unable to activate her call light or call out for assistance to relieve discomfort. This created a very high risk for the development of a PI from the extensive heat and moisture associated with incontinence as well as unrelieved pressure to her buttocks, sacrum and coccyx regions. According to Wound Care Education Institute (WCEI) there are three levels to skin breakdown: 1. Hyperemia (redness) is the first phase and will occur within 30 minutes of sustained, or unrelieved pressure. This presents as pink to red coloring of the skin. 2. The second phase of skin breakdown is tissue ischemia, which begins within 2-6 hours of sustained pressure, depending on various factors (shearing, friction, moisture or incontinence, immobility, medical conditions, nutrition, mental status, etc.). and age. Tissue ischemia is marked by deep redness over the skin surface. It takes approximately 36 hours to dissipate once the pressure is removed. 3. The third level of skin breakdown is tissue necrosis, which begins after 6 hours of continuous pressure.

Based on observation, record review and interview, the facility did not update care plans for 2 residents (R) (R12, R49) out of 15 sampled residents. R12's cardiopulmonary resuscitation (CPR) status was changed from full resuscitation to Do Not Resuscitate (DNR) on [DATE]. R12's care plan as of [DATE] stated full code. R49 has a care plan that directs staff to transfer with one staff. Observations and interviews indicate R49 requires two staff to transfer. This is evidenced by: Example 1: R12 was admitted to the nursing home on [DATE] due to dementia, arthritis, [MEDICAL CONDITION], and history of a stroke. In [DATE], R12 was deemed incapacitated and unable to make own health care decisions. R12's son was elected the legal health care decision maker. Upon admission, R12 had requested full code response to any life threatening event. Review of the advanced directive document dated [DATE] confirmed the full code status for R12. Review of the advanced directive document dated [DATE] noted R12's son changed the advanced directives from a full code to a DNR. Review of another advanced directive document dated [DATE] noted R12 continued to be a DNR. On [DATE] at 11:25 a.m., Surveyor interviewed R12's son who reported the change in CPR was made because R12 had declined mentally and functionally following the two hospital stays. R12 had been hospitalized on [DATE] to [DATE] and again on [DATE] to [DATE]. The facility held a care conference on [DATE] and reviewed R12's care plan but did not change the CPR status. The care plan titled advanced directives noted R12 was a full code. Surveyor reviewed the electronic medical record and noted R12 was a DNR. On [DATE] at 5:00 p.m., Surveyor met with the Nursing Home Administrator (NHA) and Licensed Practical Nurse (LPN) D to discuss R12's CPR discrepancy. LPN D stated care plan updates should be completed by staff during the care conference. The NHA stated the discrepancy would be corrected. On [DATE] at 5:10 p.m., Surveyor was informed by the Director of Clinical Services (DCS) K that staff are trained to follow the advanced directive document located in the front of the medical record in the event of a code blue. On [DATE] at 6:40 a.m., Surveyor received an updated care plan that indicated R12 was a DNR. The care plan was updated to reflect accurate information on [DATE]. On [DATE] at 8:53 a.m., Surveyor interviewed RN C regarding care conferences, care plan updates, and code status. RN C stated she did attend care conferences but did not update care plans. RN C stated the Director of Nursing (DON) or Assistant Director of Nursing (ADON) was responsible to update the care plans. RN C stated in the event of a code blue, the advanced directive document in the front of the medical record was followed. On [DATE] at 11:04 a.m., Surveyor interviewed LPN E regarding care plan updates and code status. LPN E stated in the event of a code blue, the advanced directive document in the front of the medical record was to be followed. LPN E stated if a change in the care plan was needed, she would inform the ADON to update the care plan. On [DATE] at 11:25 a.m., Surveyor interviewed LPN D who identified self as the ADON. LPN D confirmed when there has been a care plan change, LPN D will complete the change or delegate the change to the proper discipline. Example 2: R49 has medical [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) Assessment completed for R49 was a Quarterly assessment dated [DATE]. According to this assessment, R49 requires extensive assistance of one staff for basic daily tasks such as bathing, personal hygiene and dressing, and extensive assistance of two staff for bed mobility, toileting and transferring. Included in the Comprehensive Care Plan, the following was noted: - ADL (Activities of Daily Living) self care deficit related to: [MEDICAL CONDITION]/ subarachnoid hemorrhage and neuro surgery. [MEDICAL CONDITION]. Weakness. Date initiated [DATE] last revision on [DATE]. Included in the staff interventions for this problem is R49 is transferred with the assistance of one staff and a gait belt. This was last revised on [DATE]. Interview with Certified Nursing Assistant (CNA) H on [DATE] at 1:46 PM, regarding R49's care needs indicated R49 always is a two-person transfer. CNA H stated R49 does not stand well and when she does stand, it is for a short duration. Surveyor interviewed DON B on [DATE] at 2:39 PM regarding basic needs of R49. DON B stated R49 is always a two person transfer. R49 is very difficult to stand up even for just 10 seconds.

Based on observation, record review and interview, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 resident (R) (R12) of 15 sampled residents. The facility completed an annual MDS assessment for R12 on 9/21/20 and a quarterly MDS assessment on 12/22/20. R12 had a decline in Sections B (sensory), C (cognition), D (mood), G (activities of daily living), H (bladder/bowel), J (health conditions), and K (nutrition). In addition to the declines in the MDS, R12 has had a weight loss (253# to 237#) and developed a vascular leg ulcer on 01/16/21. According to the Resident Assessment Instrument (RAI) manual, a significant change in status should be completed when the resident has more than one area of change (decline or improve) and the care plan has been changed to manage these conditions. The facility should have completed a significant change in status MDS assessment for R12. This is evidenced by: R12 was admitted to the nursing home on 5/22/14 due to dementia. R12 had additional [DIAGNOSES REDACTED]. R12 was hosptalized on [DATE] for a blood clot in the left leg and pneumonia. R12 returned to the facility on [DATE]. The facility had an opportunity to review R12's condition; however, they did not identify the change in status and complete the required MDS assessment. R12 was hospitalized again on 01/11/21 to diagnose and treat pancreatitis (inflammed pancreas). R12 returned to the facility on [DATE]. The facility had an opportunity to review R12's condition; however, they did not identify the change in status and complete the required MDS assessment. Review of the advanced directive document dated 12/07/20 read R12's son changed the advanced directives from a full code to a Do Not Resuscitate (DNR). On 12/17/20, the facility held a care conference for R12. Review of the Interdisciplinary Team (IDT) care conference notes read R12 required a diet texture change due to difficulty swallowing and R12's advanced directive request had changed to a DNR. The change in diet texture from regular to puree with nectar thick liquids came on 11/20/20 from speech therapy recommendations. The care plan was changed to puree nectar thick liquids. The advanced directive care plan was not changed following R12's son's request for DNR or during the care conference on 12/17/20. Again, the facility had an opportunity to recognize and complete a significant change in status MDS assessment for R12 but did not. Surveyor compared R12's September MDS assessment with the December MDS assessment and noted the following: ~In September, Section B, R12 was able to make self understood and understand others sometimes. In December, R12 had declined to rarely able to make self understood or understand others. ~In September, Section C, R12 was able to answer the mental status questions and scored a 6 out of 15. In December, R12 had declined and was unable to answer any mental status questions. ~In September, Section D, R12 was able to answer questions regarding mood state. In December, R12 had declined and was unable to answer any questions regarding mood state. ~In September, Section G, R12 was able to feed self. In December, R12 had declined and required extensive staff assist for eating. ~In September, Section H, R12 was frequently incontinent of bladder. In December, R12 had declined and was always incontinent. ~In September, Section J, R12 was able to answer pain related questions. In December, R12 had declined and was unable to answer pain related questions. ~In September, Section K, R12 weighed 253#. In December, R12 had lost weight (not significant) down to 248#. On 03/02/21 at 7:54 a.m., Surveyor observed R12 seated in the wheelchair. R12 was independently eating breakfast once the staff prepared food items. On 03/02/21 at 4:25 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) J regarding R12's care needs. CNA J stated R12 required total staff assistance with hygiene, dressing, and transfers. CNA J stated R12 can feed self but often needs staff to provide extensive assistance with eating. On 03/02/21 at 4:40 p.m., Surveyor interviewed Registered Nurse (RN) C. RN C stated R12 had declined in function following the two hospital stays. RN C stated R12 varied in eating abilities from being independent to needing extensive staff assistance for eating. On 03/03/21 at 8:53 a.m., Surveyor interviewed RN C who stated she was the MDS coordinator until recently. RN C was asked to define the criteria for a significant change in status and was unable to do so. RN C stated the resident must decline in at least 3 areas of section G. RN C was unable to state other aspects of the criteria of a significant change in status MDS. RN C stated her MDS training was minimal. On 03/03/21 at 10:51 a.m., Surveyor interviewed RN F who identified self as the corporate consultant and MDS trainer. RN F stated R12 did meet the significant change in status criteria and RN F would begin completing a significant change in status MDS promptly.

Based on observation, record review, and interview the facility did not ensure the medication pass review error rate was below 5%. The surveyor observed 3 errors out of a sample size of 29 opportunities for error. This calculates to an error rate of 10.34%. RN-D (Registered Nurse) gave R160 an expired vitamin and gave a medication for organ rejection after he had just eaten breakfast when this medication is directed to be given on a empty stomach. Both of these errors have the potential to effect the dosage of the medication. LPN-B (Licensed Practical Nurse) did not give R23 a anti-[MEDICAL CONDITION] medication at the prescribed time. This medication was omitted. This is evidence by: Example 1: On [DATE] at 7:48 a.m. Surveyor observed RN-D give R160 his morning medications. RN-D gave R160 2 Vitamin E 200 mg (milligram) capsule out of a bottle that was expired in (MONTH) of (YEAR). Example 2: During the same observation Surveyor observed RN-D give R160 2 delayed release tablets of [MEDICATION NAME]. The directions on the label and the computer administration record stated that this medication is to be given on an empty stomach. RN-D had just asked R160 what he had for breakfast in order to record the amount of carbohydrates he had consumed. [MEDICATION NAME] acid can cause stomach pain, vomiting, diarrhea, and weight loss. Example 3: On [DATE] at 8:17 a.m. Surveyor observed LPN-B give R23 her morning medications. Included in the list of physician orders [REDACTED]. LPN-B did not give this medication. On [DATE] at 3:05 p.m. Surveyor Interviewed RN-C about how medications are to be given to the residents and what would be considered an error. RN-C indicated that, amongst many other situations, an omission of a medication, giving an expired medication, and giving an medication that was to be on an empty stomach would be considered errors. Review of the facility's own policies and procedures titled Medication Administration - General Guidelines dated 2006 and revised 2014 reflect current standards of practice and RN-C's understanding.

Based on resident and staff interviews, observations and record review the facility did not follow the care plan for 1 of 3 residents reviewed for smoking (R31). R31's care plan indicates her cigarettes and lighter are not to be kept on her person. Observations and interviews reveal R31 keeps her cigarettes and lighter in her jacket pocket in her room. This is evidenced by: Surveyor review of the facility Smoke Free and Tobacco Free Building Policy and Procedure states, Residents are not allowed to keep smoking materials in their rooms due to safety concerns. All resident smoking materials must be kept with facility staff at the nurses station. When a resident wishes to go outside to smoke, he/she may request his/her smoking materials from staff. The materials must be returned to staff for safe keeping when the resident returns to the building. R31's Minimum Data Set Assessment ((MDS) dated [DATE], indicates the following under cognitive: BIMS of 12/15. (Brief Interview of Mental Status). R31's Care Plan includes a focus dated 04/15/19 which states, At Risk for smoking related injury related to: Smokes independently. Interventions include, Patient not to have cigarettes or smoking material on person. On 04/09/19 at 8:29 AM, Surveyor interviewed R31. R31 said that she smokes outside in the back of the building and that she keeps her cigarettes and lighter in her coat pocket. On 04/09/19 at 8:40 AM Surveyor observed R31 putting her coat on and walking with another resident in a wheelchair outside on the sidewalk to the corner of the lot . R31 was observed outside smoking. R31 said they put the cigarette butts in an empty cigarette pack. Surveyor observed R31 taking her smoking materials from her coat pocket. On 04/09/19 at 10:50 AM Surveyor observed R31 walking down the hallway heading to go outside . R31 showed Surveyor her package of cigarettes and a lighter. R31 said that she keeps them in her coat pocket or in a drawer in her room. R31 was observed standing and smoking on the sidewalk outside the side door. At 10:58 AM R31 was observed coming in from outside smoking. R31 did not give her smoking materials to facility staff. R31 went to her room. Her cigarettes and lighter remained in her pocket of her coat. On 04/10/19 at 8:11 AM Surveyor interviewed CNA A (Certified Nursing Assistant). CNA A said she usually works on the wing where R31 resides on. Surveyor asked CNA A where R31 keeps her smoking supplies. CNA A said was not sure where R31 keeps them, but thought R31 usually keeps her smoking supplies at the nurses station. CNA A said R31 spends a lot of time out smoking. On 04/10/19 at 08:52 AM, Surveyor asked LPN B (Licensed Practical Nurse) if she holds any cigarettes or lighters for any residents on the wing. LPN B said they hold smoking materials for a resident, but does not have anything for R31. On 04/10/19 at 4:20 PM, Surveyor spoke with RN C (Registered Nurse). RN C was asked if she had any residents' smoking materials any residents on the wing including R31. RN C looked in the medication cart and medication room and said do not have any cigarettes or lighters for R31. On 04/10/19 at 4:25 PM , Surveyor spoke with the facility administrator who indicated the facility is a non smoking facility. The administrator said all resident cigarettes and lighters are to be locked up in the medication room for safety. The administrator said this has always been the expectation for years.

Based on observation, interview, and record review the facility did not ensure it maintained a medication error rate of 5% of less. Of 29 medications observed, 2 errors were noted, to equal a medication error rate of 6.9%. 2 nurses were observed to administer insulin via an insulin pen without first priming the needle of the insulin pen. Priming an insulin pen needle with 1 to 2 unit of insulin is necessary in order to fill the space within the needle itself. When an insulin pen is not primed, the resident would not receive the full and correct amount of insulin ordered. This is evidenced by: Example 1: On 2/6/18 at 12:14 p.m. Surveyor observed RN-A (Registered Nurse) administer insulin to R28 via an insulin pen. RN-A gathered her supplies including the insulin pen and needle. RN-A applied the needle to the insulin pen, dialed and set the insulin pen to 3 units, and administered 3 units of insulin into R28's abdomen. RN-A did not prime the needle of the insulin pen prior to administering the insulin. Surveyor spoke with RN-A after the observation. RN-A indicated the only time she primed an insulin pen was when it was first opened. Example 2: On 2/7/18 at 7:35 a.m. Surveyor observed RN-C administer insulin to R274 via an insulin pen. RN-C gathered her supplies including R274 insulin pen and a needle. RN-C applied the needle to the end of the insulin pen, dialed and set the insulin pen to deliver 35 units of insulin, and administered the 35 units of insulin into R274's left arm. RN-C did not prime the needle of the insulin pen prior to administering the insulin. 02/06/18 03:32 PM Surveyor asked RN-B about the facility's practice for priming insulin pens. RN-B indicated the needles all pens needed to be primed with 1 unit of insulin prior to setting the pen with the units to be delivered. RN-B indicated this was important to ensure the resident receives the complete and correct dose of insulin ordered.

On 2/7/18 at 10:33 a.m., Surveyor reviewed R11 medical record. R11 was hospitalized for [REDACTED]. The facility did not give a bed hold notice in writing or to the representative. The facility has a bed hold notification in the admission agreement. The administrator that nursing did not provide written bed hold notice to the representative. Based on record review and interview the facility did not provide written information; which specifies the facilities bed hold policy, to the resident and/or resident representative when 2 of 2 residents were transferred to the hospital (R54 and R11). Example #1: Resident #54 was transfer to the hospital on [DATE]. She remained in the hospital until 01/09/18 when she returned to the facility. Resident #54 makes her own decisions. Resident #54 was not provided notice of the facilities bed hold policy upon transfer or during her hospital stay. This is evidenced by: The surveyor reviewed Resident # 54's medical record and noted Resident # 54 was admitted to the nursing home on 7/08/17. Nurses notes indicated on 01/02/18 Resident # 54 was admitted to hospital from an appointment with her personal care provider. Resident # 54 returned to the facility on [DATE]. The surveyor was unable to locate a notice of bed hold in Resident # 54's record. Resident # 54 is responsible for her own decisions. On 2/08/18 at 1:19 PM the surveyor interviewed the Nursing Home Administrator (NHA) regarding the facility transfer and bed hold process. The NHA explained Information on the facility bed hold policy is part of the resident admission agreement. It is also the facility practice for the floor nurse to review bed hold information at time of resident transfer. The NHA further indicated the formal bed hold process was not followed when Resident # 54 was hospitalized . Information was not provided to resident at time of transfer or anytime during her hospitalization . Resident #54's room and bed were saved and resident returned to her same bed/room upon re-admission however the formal bed hold process was not followed.

Based on observation, interview, and record review, the facility did not ensure 1 of 4 sampled residents with a pressure injury (R14) received the necessary care and treatment to prevent the development and promote healing of a pressure injury. R14 was admitted to the facility on [DATE] with intact skin. R14 had multiple co-morbidities putting her at high risk for the development of a pressure injury including historical pressure injuries on both heels. The facility did not, ~Inspect R14's feet in accordance with current standards of practice; ~Place interventions to off-load R14's heels timely; and ~Ensure off-loading devices were utilized properly. On 1/31/17 R14 subsequently developed a DTI (Deep Tissue Injury) to both heels. Additionally, Santyl, a [MEDICATION NAME] agent was implemented. According to current standards of practice the only treatment for [REDACTED]. There was no indication R14 developed unstable eschar on either heel requiring debridement. This is evidenced by: R14 was admitted to the facility on [DATE] from the hospital due to pneumonia, a urinary tract infection and weakness. Admitting [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) was dated 1/17/17 and indicated R14: ~Had a BIMS (Brief Interview for Mental Status) score of 13 indicating R14 was cognitively intact; ~Required extensive to total assistance of 2 staff persons for all aspects of care; ~Did not walk; ~Required extensive assistance of 1 staff person to eat; ~Was at risk for the development of a pressure injury; and ~Had no pressure injuries. R14's skin care plan was dated 1/20/17. The care plan had the following approaches. ~ 1/20/17, .Air mattress .Encourage and assist as needed to turn and reposition . ~ 1/25/17, .Encourage and assist as needed to reposition at least every 2-3 hrs (hours) .Observe skin condition with ADL (Activities of Daily Living) care daily .Use pillows positioning devices as needed . ~ 1/27/17, .Prevalon boots . ~ 1/31/17, .Foot cradle . R14's skin risk assessment dated [DATE] had a cumulative score of 14. According to the facility's scoring system a score of 14 indicated R14 was at moderate risk for developing a pressure injury. R14's admission skin inspection dated 1/10/17 indicated R14's skin was intact. Surveyor # completed a review of R14's hospital admission history and physical dated 1/7/17. The hospital record indicated, .History of foot ulcer, heel . A nursing note dated 1/10/17 indicated, .States she can not stand and has [MEDICAL CONDITION] from waist down. Needs extensive assist for transfers requiring mechanical lift .BLE (Bilateral Lower Extremity) .Unable to stand, reposition self . The facility was aware R14 had historical pressure injuries of the heels, diagnoses, and current illness which included weakness and inability to reposition herself independently. Despite that, there were no interventions put into place to off-load R14's heels until 1/27/17 when Prevalon boots were placed. A nursing note dated 1/31/17 indicated, .Complete skin assessment completed .Left heel is noted with a dark area/SDTI (Suspected Deep Tissue Injury) that measure 4.6cm x 2.1cm (4.6 centimeters by 2.1 centimeters) .Right heel is noted with a dark area/SDTI that measures 0.5cm x 0.5cm . This was the first note indicating R14 had pressure injuries to both heels. There were no further nursing notes regarding R14's bilateral heel pressure injuries until 2/10/17, 10 days later. Nursing notes continue. ~ 2/10/17, .left heel is noted with improvements this week. Measurements are 2cm x2cm (2.0 cm x 2.0 cm) .Unable to determine depth as wound bed is covered with scab .right heel noticed with improvement this week. Measurements continue at 1cm x 1cm (1.0 cm x 1.0 cm) .wound bed is covered with scab . ~ 2/17/17, .DTI left heel measures 2cm x 2cm. Continues with scabbing .surrounding skin is pink .DTI right heel measure 1 cm x 1 cm. Scab present to wound bed .Surrounding skin is pink and healthy . ~ 2/23/17, .DTI left heel measures 2cm x 2 cm. Wound bed continues with scabbing/eschar present .DTI right heel measure 1 cm x 1 cm. Scab/eschar continue to wound bed . ~ 3/2/17, .Right heel continues with measurements of 1cm x 1cm, left heel continue with measurements of 2cm x 2cm .No improvement this week .Areas continue with scabbing/eschar present . On 3/6/17 Santyl and a foam dressing were ordered for R14 bilateral heels. Santyl is a [MEDICATION NAME] agent and used to debride devitalized tissue. According to Pressure ulcer Treatment Quick Reference Guide published in 2009, from the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel, Stable eschar on the heels serves as 'the body's natural (biological) cover,' and should not be removed. There was no indication the eschar to both R14's right and left heel had become unstable necessitating the use of Santyl. There were no further nursing notes describing R14's bilateral heel pressure injuries. On 3/8/17 at 3:07 p.m. Surveyor observed LPN-J (Licensed Practical Nurse) and RN-K complete a dressing change on both R14's right and left heel. RN-K removed the dressing on both R14's right and left heel. Surveyor noted a faint odor and small amount of brownish colored drainage on the old dressing from R14's right heel. The old dressing from R14's left heel had a scant amount of bloody drainage. Surveyor requested to have R14's wounds measured. LPN-J measured the wound as follows. ~ Right Heel: LPN-J measured the eschar (devitalized tissue) at 4.5 cm x 3.1 cm. This measurement only included the eschar and not the entire wound. Surveyor observed wound margins under the dried tissue once covering the blister and requested LPN-K measure the complete wound. The entire wound as measured by LPN-J measured 6.0 cm x 5.3 cm. ~ Left Heel: LPN-J measured the entire wound at 6.0 cm x 5.5 cm. The wound base had eschar measuring 2.2 cm x 1.8 cm. RN-K indicated when the pressure injuries first developed they looked like a big blood blister. LPN-J indicated when R14 was first admitted R14 was weak and only up for meals and therapy. Once R14's wounds were cleansed and a new dressing applied RN-K placed the Prevalon boots. The Prevalon boots were noted as soft, thickly quilted, with a hole cut out in the heel area. When placed appropriately with the heel of the foot securely placed within the opening of the boot, the heel would be completely free from any pressure or off-loaded. When RN-J placed the boots Surveyor # noted R14's heels were not down into the heel opening but resting on the back of the boot itself. The Prevalon boots were not applied correctly. As applied, R14's heels would not be off-loaded but have continued pressure as R14's heels were resting on the back of the Prevalon boot. Surveyor # informed RN-K of the observation. RN-K adjusted the Prevalon boots to ensure R14's heels were into the heel opening. The measurements as obtained by LPN-J indicated the entire wound and eschar on both R14's right and left heel had significantly deteriorated since the measurement of 3/2/17. On 3/8/17 at 9:50 a.m. Surveyor # spoke with R14 and R14's spouse. R14's spouse indicated R14 had historical wounds on both heels. R14's spouse stated R14's left heel wound took 10 to 12 months to heal. R14's spouse indicated R14 was again noted with a wound on the left heel but it healed quickly. On 3/8/17 at 12:20 p.m. Surveyor # spoke with CNA-H (Certified Nursing Assistant). CNA-H indicated she worked full time on the unit in which R14 resided. Surveyor # asked CNA-H about R14 bilateral heel pressure injuries. CNA-H indicated she did not know how R14 obtained the pressure injuries and questioned if R14 came in the them. On 3/9/17 at 7:35 a.m. Surveyor spoke with RN-M. RN-M indicated she was the full time nurse on the unit in which R14 resided. Surveyor # asked RN-M about R14's bilateral heel pressure injuries. RN-M indicated she started having some concerns regarding R14's heels about 2 weeks ago but couldn't recall any specific information. RN-M indicated she would need to look at her documentation and get back to Surveyor # . RN-M indicated she was off during the time R14's developed pressure injuries to each heel. On 3/9/17 at 8:45 a.m. Surveyor spoke with RN-M again. RN-M indicated R14's Prevalon boots had been implemented on 1/27/17 because R14 was at high risk for breakdown on her heels. RN-M indicated she did not recall any issues to R14's heels prior to 1/31/17 when the DTI's were noted. On 3/8/17 at 2:20 p.m. surveyor spoke with RN-I. RN-I indicated she was the facility's wound nurse. RN-I indicated she was not yet certified in wound care. RN-I indicated she consulted with the wound care consultant when she had questions. RN-I indicated she was unaware of any issues with R14's heels until 1/31/17. RN-I indicated she thought R14 developed the pressure injuries from planting her heels into the bed. RN-I indicated she felt the DTI's to R14's right and left heel were not healing and stagnant. RN-I indicated she spoke with the facility's wound care consultant who suggested the use of Santyl. On 3/9/17 at 9:22 a.m. Surveyor spoke with RN-I about the facility's wound care management program. RN-I indicated complete skin assessments were done on admit. Anyone considered high risk had an air mattress placed. RN-I indicated they don't necessarily implement the use of off-loading devices for heels on admission. Surveyor asked RN-I why an off-loading device was not implemented for R14 on admission. RN-I indicated she did not know. RN-I also indicated she was not aware of R14's significant pressure injury history until she talked with R14's spouse. RN-I indicated diabetics were to have their feet checked weekly. According to the American Medical Directors Association, Diabetes Management in the Post Acute and Long Term Care Settings, caregivers should thoroughly inspect feet often and provide daily foot care. RN-I indicated all residents had a weekly skin check completed on their shower day. Surveyor and RN-I reviewed R14's treatment and skin check record. RN-I indicated R14 had evidence of a complete skin check done only once prior to identifying R14's bilateral heel DTI's on 1/17/17. RN-I indicated there was an order on R14's treatment record to check R14's feet every week however nowhere for the nurses to document its completion. RN-I indicated she noted this on 1/31/17 and had since changed R14's treatment record to include when the skin check was to occur and a place to document its completion. RN-I indicated the DTI's to R14's heels have gotten worse. RN-I indicated she did not know why and questioned where the continued pressure was coming from. Surveyor reviewed the observation of R14's dressing change as noted on 3/8/17. RN-I indicated they needed to make sure R14's heels were appropriately placed in the Prevalon boot to ensure off-loading was occurring. RN-I indicated the facility had several different types of off-loading boots however they had never tried a different type of a boot for R14.

Based on observation and interview the facility did not ensure food was served in a sanitary fashion in order to prevent the spread of food-borne illness. Multiple breeches in infection prevention practices were observed when one staff person utilized a contaminated hand towel during the preparation of and process of plating food. This had the potential to affect all residents. On 3/7/17 at 10:45 a.m. Surveyor entered the kitchen. Surveyor noted Cook-L had a heavily soiled white hand towel wrapped around the tie of her apron. Beginning at 10:49 a.m. Surveyor # made the following observations. ~ Cook-L obtained a large thermal container and filled it with water. Cook-L took a drink from the thermal container and wiped her mouth with the white towel wrapped around the tie of her apron. ~ Cook-L washed her hands and obtained a pair of gloves. Cook-L began gathering and obtaining the temperature of each food items from the oven. Cook-L placed each food item into a large cart. ~ Cook-L removed her gloves and wiped her hands on the soiled white hand towel. Cook-L did not wash her hands. ~ Cook-L gathered the cart and brought it to the facility's dining room. ~ Cook-L put on a pair of oven mitts, obtained each container of food item from the cart and placed the food items into the steam table. Cook-L did not wash her hands prior to donning the oven mitts. ~ Cook-L removed her oven mitts, gathered multiple serving utensils, and placed the utensils into each food items. ~ Cook-L then washed her hands at a sink in the dining room, gathered multiple paper towels, and dried her hands. Cook- L then gathered the soiled hand towel from around the tie of her apron and wiped her hands again. ~ Cook-L returned to the steam table, donned a pair of gloves, and began obtaining the temperature of each food item. When obtaining the temperature of a hamburger, Cook-L held a hamburger with one hand and inserted the thermometer with the other. Cook-L then wiped her soiled gloved hands with the white hand towel. Cook-L obtained the temperature of chicken soup and wiped her gloved hand with the soiled white towel. ~ Cook-L began to plate food. Prior to plating food, Cook-L did not remove her soiled gloves and wash her hands. On 3/8/17 at 9:07 a.m. Surveyor # spoke with Cook-L. Cook-L indicated she uses a towel all the time. Cook-L indicated she has never been told not to use one. On 3/8/17 at 9:18 a.m. Surveyor # spoke with the DM (Dietary Manager) and RD (Registered Dietician). The DM indicated any time gloves were removed hands should be washed. Surveyor # asked the DM about their practice of utilizing hand towels. The DM indicated she was aware Cook-L was utilizing a hand towel. Surveyor # reviewed the observation as noted on 3/7/17. Both the DM and RD indicated use of the towel was not appropriate.

Based on observation, record review, interviews, and policy review the facility did not ensure current standards of practice for infection control were implemented in 2 random observations. These 2 random observations affected six residents with a current census of 73. H-F (Housekeeper) cleaned an isolation room without proper PPE (personal protective equipment) then cleaned 2 additional rooms. In addition, H-F did not wash hands between glove change. NA-C (Nursing Assistant) did not wear gloves and wash hands between caring for 2 residents. This is evidenced by: On 03/07/17, Surveyor reviewed the Infection Control and Influenza Outbreak policies and procures and found them to be consistent with current standards of practice. Example 1: During the initial facility tour which began on 03/06/17 at 9:45 a.m., Surveyor was informed by LPN-D (Licensed Practical Nurse) that R4 was placed on droplet and contact precautions due to a positive influenza swab last week. R4's room had a sign posted on the outside of the entrance door instructing staff and visitors to consult with the nurse prior to entering. Also, outside of R4's room was a storage bin with PPE supplies. On 03/06/17 beginning at approximately 9:55 a.m., Surveyor observed H-F in R4's room. H-F was down on the floor wiping off the chair and dresser. Seated immediately next to the dresser, less than one foot, in the wheelchair was R4. H-F was wearing gloves and a mask, but no gown. H-F exited R4's room and retrieved the mop from the housekeeping cart that was outside of R4's room. H-F did not remove gloves or mask and did not wash hands. H-F entered R4's room and damp mopped the floor. H-F removed gloves and mask, then removed the dirty mop pad and placed the mop pad in linen hamper on the housekeeping cart. H-F did not wash hands or use any hand gel to sanitize hands before donning another pair of gloves and entering R17's room to damp mop the floor. H-F again removed gloves and then removed the dirty mop pad and placed the mop pad in the linen hamper on the housekeeping cart. H-F did not wash hands or use any hand gel to sanitize hands before donning another pair of gloves and entering R3 and R18's room to damp mop the floor. H-F removed gloves and then removed the dirty mop pad and placed the mop pad in the linen hamper on the housekeeping cart. H-F did not wash hands or use any hand gel to sanitize hands. On 03/06/17 at 10:38 a.m., Surveyor interviewed the DON (Director of Nurses) regarding the facility practice on infection control. The DON stated staff should don gowns, gloves, and mask with a face shield prior to entering an isolation room. The DON stated the precautions implemented for influenza was droplet and contact. The DON stated the PPE for droplet and contact was gowns, gloves, and a mask with a face shield. The DON stated hand washing with soap and water was required for all staff exiting a precautions room. On 03/08/17 at 8:35 a.m., Surveyor interviewed the HS (Housekeeping Supervisor.) The HS stated all staff had been educated in infection control procedures. The HS stated H-F was trained to don gowns, gloves, and a mask with a face shield anytime she has to enter an isolation room. The HS stated staff are expected to wash hands with soap and water when exiting any isolation room. The HS stated staff are to spray the 1:10 bleach solution directly onto all hard surfaces and allow to contact these surfaces for at least 3 minutes before wiping the hard surface. The HS stated once the isolation room is cleaned, all products and materials used in the room should be disinfected with the same bleach solution or discarded. On 03/08/17 at 8:55 a.m., Surveyor interviewed H-F regarding infection control practices. H-F stated she was aware R4 was in isolation which required donning a gown, gloves, and mask with a face shield. H-F stated she cleaned R4's room and had not donned the required PPE when cleaning room. H-F stated she sprayed a cloth with the bleach solution and then used that cloth to wipe down all hard surfaces. H-F stated she did not spray the bleach solution directly onto the hard surfaces. H-F stated she had not washed hands between resident rooms. On 03/09/17 at 9:55 a.m., Surveyor interviewed the ICP (Infection Control Preventionist.) The ICP stated all staff mush wash hands before exiting an isolation room. The ICP stated substituting hand gel for hand washing in these circumstances was not acceptable. Example 2 R11 was admitted to the nursing home in 2003 for long term care. R11 was totally dependent on staff for all cares including toilet use and hygiene. R11 was totally incontinent of both bladder and bowel. Review of R11's care plan noted she transferred using a mechanical lift and 1 staff. R19 was also a long term resident of the facility since 2006. R19 was totally dependent on staff for all cares including toileting and hygiene. R19 was totally incontinent of both bladder and bowel. Review of R19's care plan noted she transferred using a mechanical lift and 1 staff. On 03/06/17 at 12:21 p.m., Surveyor observed NA-C assist R11 from the wheelchair into bed using a mechanical lift. NA-C was not wearing gloves. Once R11 was lying in bed, NA-C placed both feet onto a heel support and then placed pressure relieving boots on R11's feet. NA-C did not perform any hand hygiene or hand washing once R11 was settled into bed. NA-C then assisted R19 from the reclined wheelchair into bed using the same mechanical lift. NA-C did not don gloves, complete any hand hygiene, or sanitize the mechanical lift. NA-C then removed R19's slacks and wet incontinent brief. NA-C donned gloves, then completed incontinence care for R19, placed a clean brief, and settled R19 into bed. NA-C removed gloves and washed hands. On 03/06/17 at 1:15 p.m., Surveyor interviewed NA-C regarding infection control expectations. NC-C stated she should have worn gloves when caring for R11 and R19. NA-C stated she was nervous and did not think clearly. NA-C stated she had hand gel in her pocket, but did not use it. NA-C stated gloves should be worn with any potential contact with body fluids and changed between residents. On 03/09/17 at 8:45 a.m., Surveyor interviewed the DON. The DON stated staff are expected to wear gloves when caring for residents and there was potential for exposure to body fluids.

Based on observation, interviews, and record review, the facility did not provide care and services for 1 out of 14 (R11) sampled residents reviewed for incontinence. R11 was not provided incontinence care in accordance with the care plan. This is evidenced by: R11 was admitted to the facility for long term care on 07/04/03. The MDS (Minimum Data Set) assessment dated [DATE] indicates R11: ~rarely able to make self understood; ~required total staff assistance for transfers, bed mobility, dressing, hygiene, toilet use, eating, and bathing; ~always incontinent of bladder and bowel; ~was not on any toilet programs. Review of the CAA (Care Area Assessment) titled urinary incontinence that was completed 04/09/16 noted R11 was not aware of toilet needs, had long standing incontinence, and not able to participate in a toileting program. The CAA further noted R11 was to be provided with routine incontinence care every 2-3 hours and as needed. Review of the most recent bladder assessment dated [DATE] noted R11 was incontinent of bladder and bowel and was dependent on staff for incontinence care every 2-3 hours and as needed. Review of the care plan titled At risk for pressure ulcer . dated 10/05/10 noted R11 was to be checked for incontinence every 2-3 hours and provided with thorough skin care after each incontinence episode. Review of the care plan titled Alteration in elimination . dated 10/05/10 noted R11 was to be checked and changed if incontinent every 2-3 hours and as needed. During the initial facility tour that was conducted on 03/06/17 at 9:45 a.m., Surveyor was informed by LPN-D (Licensed Practical Nurse) that R11 was totally incontinent of bladder and bowel and required total staff assistance for all ADLs (Activities of Daily Living.) On 03/06/17 at 12:21 p.m., Surveyor observed NA-C (Nursing Assistant) assist R11 into bed from the wheelchair using the mechanical lift. NA-C settled R11 into bed, placed the call light within R11's reach, then proceeded to care for another resident. NA-C did not provide R11 any incontinence care or check and change R11 for incontinence. On 03/06/17 at 1:15 p.m., Surveyor interviewed NA-C regarding above observation. NA-C stated she was familiar with R11's care plan and care needs. NA-C confirmed she did not check and change R11 or provide R11 with any incontinence care. NA-C stated the she had changed R11 prior to lunch at approximately 10:00 a.m. On 03/08/17 at 11:00 a.m., Surveyor interviewed CNA-E (Certified Nursing Assistant) regarding R11's care needs. CNA-E stated R11's usual routine was to be transferred from the wheelchair to bed prior to and after lunch for incontinence care. CNA-E stated R11 was to be checked for incontinence and changed if needed every 2-3 hours. On 03/09/17 at 8:45 a.m., Surveyor interviewed the DON (Director of Nurses) regarding care plans. The DON stated all staff are to follow care plans. The DON stated NA-C should have checked R11 for incontinence and changed if needed when NA-C assisted R11 back to bed.

Based on observation, interview, and record review the facility did not ensure 1 of 15 sampled residents received the necessary care and treatment to promote the healing of a traumatic buttock wound. R14 had a traumatic wound to the left buttock below the sacrum and adjacent to the lower coccyx due to an injury sustained from a mechanical lift. Observations revealed R14 was not repositioned in the wheel chair to relieve pressure for a period of at least 5 hours and 50 minutes. While the wound was not over a bony structure, undo pressure to the area while seated had the potential to have a negative impact on healing of the wound. This is evidenced by R14 was admitted to the facility on [DATE] from the hospital due to pneumonia, a urinary tract infection and weakness. Admitting [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) dated 1/17/17 indicated R14: ~Has a BIMS (Brief Interview for Mental Status) score of 13 indicating R14 was cognitively intact; ~Required extensive to total assistance of 2 staff persons for all aspects of care; ~Did not walk; ~Required extensive assistance of 1 staff person to eat; ~Was at risk for the development of a pressure injury; and ~Had no pressure injuries. R14's skin care plan was dated 1/20/17. The care plan had the following approaches. ~ 1/20/17, .Air mattress .Encourage and assist as needed to turn and reposition . ~ 1/25/17, .Encourage and assist as needed to reposition at least every 2-3 hrs (hours) . On 3/7/17 beginning at 7:40 a.m. Surveyor # make the following observations. ~ At 7:40 a.m. R14 was noted in her room seated in a wheel chair eating breakfast. ~ At 8:05 a.m. R14 was noted in her room seated in a wheel chair. ~ At 8:40 a.m. R14 was noted in her room seated in a wheel chair. ~ At 10:00 a.m. R14 was noted in her room seated in a wheel chair visiting with her spouse. ~ At 10:35 a.m. R14 was noted in her room seated in a wheel chair visiting with her spouse. ~ At 11:30 a.m. R14 was noted in her room seated in a wheel chair visiting with her spouse. ~ At 11:45 a.m. R14 was noted in her room seated in a wheel chair eating lunch. ~ At 12:12 p.m. R14 was noted in her room seated in a wheel chair. ~ At 2:45 p.m. R14 was noted in bed with the head of her bed elevated to 90 degrees. On 3/7/17 at 3:05 p.m. Surveyor # spoke with CNA-G (Certified Nursing Assistant). CNA-G was working on the unit in which R14 resided. CNA-G indicated she thought R14 was laid down just before 1:45 p.m. On 3/8/17 at 12:20 p.m. Surveyor # spoke with CNA-H. CNA-H indicated she had taken care of R14 on 3/7/17. CNA-H indicated she laid R14 down sometime after lunch and around 12:30 p.m. CNA-H indicated that was the first opportunity she had to reposition R14. According to CNA-G's account R14 was not repositioned for a period of 6 hours and 5 minutes. According to CNA-H's account, R14 was not repositioned for a period of 4 hours and 50 minutes. On 3/8/17 at 3:07 p.m. Surveyor # observed LPN-J (Licensed Practical Nurse) and RN-K (Registered Nurse) complete a dressing change on R14's left buttock wound. Surveyor # noted a small wound on R14's left buttock below the sacrum, adjacent to R14's coccyx in the meaty part of the buttock. LPN-J measured the area at 0.2 cm (centimeters) by 1.0 cm. The wound base was 100% covered with yellow slough. RN-K indicated the wound looked better and was smaller in size since the last time she viewed it. R14 asked RN-K what caused the wound. RN-K responded from laying in bed. LPN-J completed the dressing change. On 3/8/17 at 9:50 a.m. Surveyor # spoke with R14 and R14's spouse. R14 indicated she liked to lay down in the afternoon but it doesn't always happen. R14 indicated the only time she has pressure relieved from the buttock is when staff laid her down. Surveyor # asked R14 if she recalled any staff laying her down or repositioned her on the day before (3/7/17) between breakfast and lunch. R14 stated she did not recall anyone repositioning her. R14's spouse indicated he visited R14 every day from around 10:00 a.m. to lunch time. R14's spouse indicated on 3/7/17 R14 was not laid down or repositioned while he was visiting. On 3/8/17 at 2:20 p.m. Surveyor # spoke with RN-I (Registered Nurse). RN-I indicated she was the facility wound nurse. RN-I indicated R14's left buttock wound was initially a bruised area caused by a mechanical lift. RN-I indicated the bruised area developed into a wound. RN-I indicated she was notified of R14's wound on 1/31/17. RN-I stated she initially noted the wound as completely covered with eschar. RN-I indicated the wound had been stagnant and not healing so she notified their consultant wound nurse who recommended the use of Santyl (a [MEDICATION NAME] agent). Surveyor # relayed the observation as noted on 3/7/17. RN-I indicated R14 should have been repositioned every 2 hours. RN-I stated lack of repositioning R14 could be why the wound has been slow to heal.

Based on observation, family and staff interviews, and record review, the facility did not provide the necessary supervision and assistive devices to prevent falls for 1 of 5 sampled residents. Resident #3 had an electric lift chair. According to facility documentation, once Resident #3 was seated in a comfortable position in the chair, the chair was to be unplugged. On 07/26/11, staff did not unplug the lift chair once Resident #3 was seated in the chair. Resident #3 operated the control on the chair raising the chair to the high upright position. Resident #3 slid out of the chair onto the floor, sustaining a fractured right ankle, fractured distal fibula and impacted transverse fracture of the distal tibia. This is evidenced by: Resident #3 is [AGE] years old. Review of Resident #3's medical record includes [DIAGNOSES REDACTED]. Resident #3 has an activated Power of Attorney for Health Care. Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE], reveals the following: ~highly impaired hearing; ~sometimes understands others and usually is understood by others; ~impaired vision; ~BIMS (Brief interview for Mental Status) score of 9/15; ~extensive assistance of two staff for bed mobility and transfer, does not walk; ~moving from seated to standing position and surface to surface transfer, not steady only able to stabilize with human assistance; and, ~occasional pain. Review of Resident #3's current care plan with a print date of 09/04/10, states a problem of, "At risk for falls related to: Use of medication, mobility deficits, occasional confusion." A goal on this care plan dated 03/23/11 is as follows: "Ok per daughter to unplug chair once resident is in a comfortable position." This was changed on 08/08/11 to the following intervention: "08/08/11 unplug recliner once resident in recliner-may leave Marissa sling under resident-NS (nursing services)." The current CNA (Certified Nursing Assistant) Kardex Report for Resident #3 with a print date of 01/10/11, reveals the following support dated 03/23/11, "per daughter ok to unplug chair once resident comfortable." This was yellowed out (indicating that it was discontinued). A special needs communication dated 08/08/11 states, "Unplug recliner chair once resident in chair-may leave Marissa sling under resident." A nursing progress note in Resident #3's record dated 03/23/11, indicates the following note: "Spoke with resident's daughter regarding chair. Resident found to be moving chair and could possible (sic) be a safety risk. Ok with daughter to unplug chair once resident is in a comfortable position." Review of Resident #3's nursing progress notes reveals a second note dated 07/26/11, "Resident was found on floor by housekeeping. Recliner was in the full standing position and resident slid to floor. VSS-128/82, 81, 97.2, 19. Neuro's are WNL (within normal limits). No injuries. No complaints of pain or discomfort. Resident denied hitting head. Non-skid strips placed in front of residents recliner. Remote is to be kept out of reach of resident and continue to unplug chair once it is in position...." Another note on 07/27/11 indicates the following: "Resident has pain in R (right) leg this shift. Will not let writer touch leg, yells out ouch whenever you try to touch her, is unable to stand on foot in Sara Lift. Contacted....and she stated she wanted resident seen. Resident will be seen with (physician) at 10:30 this shift." Surveyor # 's review of Resident #3's notes and physician orders [REDACTED]. An x-ray was taken of Resident #3's right leg on 07/27/11. Resident #3's Tramadol was increased to 50 milligrams three times a day (pain medication), Celexa (antidepressant) increased to 40 milligrams a day and Cipro 250 milligrams twice a day for a urinary tract infection. The right leg x-ray from 07/27/11 indicates, "....mild cotical irregularity in the distal tibia medially. Cannot rule out distal tibial fracture on this exam. Recommend correlation with the site of pain. Consider ankle x-rays without the wrap if the pain is at the ankle." A follow-up x-ray with the Uuna wrap of Resident #3's right leg was conducted on 08/05/11. Results stated, "Three views of the right ankle were obtained. There is a triamalleolar ankle fracture. There is a transverse fracture through the distal fibula without significant displacement or angulation. There is also an impacted, somewhat transverse fracture through the distal tibia....severe generalized osteopenia....there is severe soft tissue swelling, especially medially. Summary: Fractures of the distal tibia and fibula." On 08/25/11 at 11:50 a.m., Surveyor # observed Resident #3 seated in her lift recliner chair, with the footrest raised slightly. Resident #3 had a splint on her right leg, The lift chair cord was unplugged. Strips were observed on the floor in front of the recliner. On 08/25/11 at 11:15 a.m., Surveyor # spoke with the Director of Nursing (DON). The DON indicated Resident #3's family had brought in the electric lift chair for Resident #3 from home. At that time the decision was made to unplug the chair once Resident #3 was in the chair because it was felt to be a safety risk as Resident #3 was known to "fiddle" with things and had dementia and periods of confusion. The DON indicated at the time the chair was brought in March 2011, Resident #3 was her own decision maker. The DON stated 2 months later, May 2011, her Power of Attorney for Health Care was activated due to increased dementia. The DON said that on 07/26/11, Resident #3 fell out of her chair and was found by Housekeeper-A, on the floor in front of the chair. The DON said the lift chair was in the high raised position when Resident #3 was found. On 08/25/11 at 11:35 a.m., Surveyor # spoke with Housekeeper-A. Housekeeper-A said he had come by Resident #3's room on 07/26/11 and found Resident #3 on the floor in front of her lift chair. Housekeeper-A said Resident #3 was sitting on the floor with her legs stretched out in front of her and the chair was raised in the high position behind her. Housekeeper-A said the chair was high enough to walk away from. Housekeeper-A said he did not see Resident #3 fall, and did not see anyone else in the room or area when he found her. Housekeeper-A said he went to get nursing. On 08/25/11 at 12:05 p.m., Surveyor # spoke with CNA-B (Certified Nursing Assistant). CNA-B said she knew of one instance in the past when a resident had fell from a lift chair so she knew how dangerous they could be. CNA-B said that sometimes Resident #3 can be agitated or restless and would be on the call light button continuously during those times. CNA-B said Resident #3 also had periods of confusion and on one occasion she had the remote for the lift chair in her hand and was fiddling with it. CNA-B said after Resident #3 fell from the lift chair a sign was put in her room reminding staff to unplug the lift chair. CNA-B said unplugging the lift chair was the approach that was on Resident #3's care plan before the fall on 07/26/11. On 08/25/11 at 12:15 p.m., Surveyor # spoke with the DON and the ADON (Assistant Director of Nursing). The DON and ADON were asked if an assessment was done prior to a resident using a lift chair. The DON and ADON said no assessment was completed. The DON and ADON said when Resident #3's lift chair was brought in by her family, no formal assessment was completed; but there was apprehension about using the lift chair and that is why the nurse wrote the note on 03/23/11 adding the approach to unplug the lift chair once Resident #3 was in the chair. On 08/25/11 at 12:30 p.m., Surveyor # spoke via phone with Family-C (Resident #3's Health Care Agent). Family-C said she was on vacation when Resident #3 fell out of her lift chair. Family-C said when they brought the lift chair for Resident #3 from home, there were "orders" for staff to unplug the chair once Resident #3 was in the chair. Family-C said she had spoken to the nurses about this when the chair was brought in. Family-C said even when Resident #3 was at home they had to unplug the chair as she was unsafe with using the control. Resident #3's daughter said that after the fall, a note was put in the room reminding staff to unplug the lift chair. On 08/25/11 at 1:30 p.m., Surveyor # and # spoke with the Administrator and the DON. The Administrator and DON said Resident #3's family brought in the lift chair for Resident #3 in March of 2011. The Administrator and DON said they had family approval to unplug the lift chair when Resident #3 was in the chair as there was a potential for Resident #3 to fiddle with the control for the chair. The DON said Resident #3 had periods of confusion and mild dementia since her admission to the nursing home 2 years ago. The DON said the care plan/care card approach for Resident #3 before the fall was that they may unplug the lift chair for Resident #3. The DON said after the fall they put skid strips in front of Resident #3's chair and a sign in the room to unplug the chair all the time. The Administrator indicated they do not assess residents that have lift chairs to determine if those residents can safely operate the lift chair controls independently. On 08/25/11 at 12:25 p.m., Surveyor # and # received a list of facility residents with lift chairs from the Administrator. The list included Resident #3 and 3 other residents. On 08/25/11 at 2:23 p.m., Surveyor # observed Resident #8 with a lift chair in her room. Resident #8 was not identified as having a lift chair on the list received from the facility on 08/25/11 at 12:25 p.m.. On 08/25/11 at 2:30 p.m., Surveyor # spoke with CNA-D. CNA-D said she helps other CNAs care for Resident #3. CNA-D said Resident #3 seems to be anxious much of the time, complaining about her legs hurting, being cold, pressing on the call light multiple times during the shift. CNA-D said she would tell the CNAs to unplug the cord on Resident #3's lift chair because of her anxiety and because she felt it was unsafe for Resident #3. CNA-D also said Resident #3 would fiddle with the control on her bed in addition to the callight. CNA-D said she was on vacation at the time Resident #3 fell out of her lift chair.