Every finding on record at Deerfield Care Center, LLC

Based on observation and interview, the facility did not ensure garbage and refuse were properly disposed of in the outside garbage storage receptacles. This had the potential to affect all 46 residents.-Surveyor observed garbage was falling out of chute and on the ground next to the dumpster and the dumpster was open.Findings include:Facility policy titled, Infection Prevention and Control Manual Environmental Services/Housekeeping/Laundry, dated 2020, reads in part: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surfaced to be cleaned, type of soil present and tasks being performed in the area.the purpose is to provide standard operating procedures for a clean, safe, and sanitary environment for the residents.Facility policy titled, Infection and Control Manual Maintenance, dated 2020, reads in part, Enforce proper bagging and containment of waste.On 02/16/26 at 10:20 AM, Surveyor observed the garbage room. The garbage/dumpster area had several garbage bags lying on the floor due to a broken compactor. Garbage was observed to be overflowing in the compactor and with bags of garbage falling out onto the floor. The dumpster is located inside the building and the lid was open. Surveyor noted a pungent odor inside the room.On 02/16/26 at 4:15 PM, Surveyor observed the garbage area. Multiple bags of garbage remained falling out of the broken compactor, garbage bags were lying on the floor between the compactor and dumpster, and the lid to the dumpster was open. Surveyor observed a greasy, dirty substance on floor next to the bags.On 02/17/26 at 2:11 PM, Surveyor interviewed Maintenance Director (MD) D. MD D stated the compactor has been broken since last week. MD D stated a cylinder in the compactor blew and they were waiting for the new part to come. MD D stated that maintenance staff and sometimes laundry staff will help pick up the garbage that comes down the chute into the garbage room. MD D stated it gets done every couple of hours on weekdays and 2-3 times per day on the weekends. MD D stated the dumpster remains open inside the building and gets closed when taking it outside. Outside the garbage room there are additional green dumpsters they swap out if the one they are using is full. MD D stated they have the broken dumpster sitting out back currently. MD D was unsure if they had a policy regarding garbage disposal. On 02/18/26 at 7:37 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated NHA A stated the dumpster was not closed because it is inside the building. NHA A acknowledged the garbage that had been falling out of the chute and lying on the floor in the room could cause a pest control issue.

Based on interview and record review, the facility did not ensure resident (R) (R23) received a written notice of transfer to include reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure residents received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R23 was transferred to the hospital on [DATE] and 04/11/2025. A bed hold notice with daily rate to reserve bed and a written notice of transfer is not available in the medical record nor documented completed in a progress notes. Notification and sharing of information for a smooth transfer was not documented completed in R23's medical record either. Documentation of required communication with receiving facility is not in the medical record. R23 was transferred to the hospital on 1/7/26. A written notice of transfer was not documented or available in R23's medical record.Findings include:The facility policy titled, Discharge and Transfer Policy, approved October 2017/modified: October 2025, states: Purpose: Presbyterian Homes and Services (PHS) will follow the requirements by CMS (Center for Medicare and Medicaid Services) for all transfers and discharges from the facility.Process for Emergency Transfers to Acute Care:3. The facility will issue the Emergent Transfer Notice and Bed Hold Policy which notifies the resident and or resident representative of their emergency transfer for ongoing care.a. A copy of the Emergent Transfer Notice and bed hold will be maintained in the medical record.References:CMS State Operation Manual, Appendix PP- Guidance to Surveyors for Long Term Care FacilitiesF627 S483.15(C) Inappropriate Transfers and DischargesF628 S483.15(c-d) (2) Transfer and Discharge ProcessPolicy does not say anything about documentation or keeping a copy of what was sent. Per the State Operations Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities, dated 7-23-25, states:S483.15(c)(2) Documentation.When the facility transfers or discharges a resident under any of the circumstances . the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. S483.15(c)(3) Notice before transfer.Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.(ii) Record the reasons for the transfer or discharge in the resident's medical record .S483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-(i) The duration of the state bed-hold policy.(ii) The reserve bed payment policy in the state plan, under S 447.40 of this chapter, if any;(iii) The nursing facility's policies regarding bed-hold periods. R23 was admitted [DATE] with the diagnoses of multiple sclerosis, paraplegia, age related osteoporosis, hypertension, hyperlipidemia, type 2 diabetes, major depression and dementiaR23's Minimum Data Set (MDS) assessment, dated 12/9/25, indicated that R23 is cognitively impaired but has clear speech and often understands if directions are direct and simple. R23 is able to feed herself and complete her own oral hygiene if set up first but is dependent or requires maximal assistance for all other activities of daily living (ADLs) and for mobility and transfers from bed to chair via a full body mechanical lift.Record review identified R23 was transferred to the hospital on the following dates:On 4/8/25, R23 was transferred to the Emergency Department due to malaise and fatigue. R23 had lab work, IV antibiotics and a portable chest x-ray. Diagnosis was UTI (Urinary Tract Infection).Review of progress notes identified the following note that does not have the required information completed.4/8/2025 1:09 PM Change of Condition:Change in Condition-situation, s/sx [signs/symptoms] noted (refer to assessment if applicable): POA is NOW taking Resident d/t decline in alertness.Background-vital signs, medications, diagnoses (refer to assessment if applicable): Appearance-summary of observations (refer to assessment if applicable): Notification of MD/NP and Emergency Contact: Interventions and Effectiveness (new orders if applicable): For transfer to ER: time, how resident was transferred, bed hold/emergent transferOn 4/11/25, R23 was transferred to the Emergency Department due to swelling of the right eye. R23 was diagnosed with preseptal cellulitis of right eye and was hospitalized until 4/17/25. For the 4/11/25 transfer there are progress notes dated 4/10/25 but the next note is not until 3 days after admission of 4/14/25. The note on 4/14/25 does not document the required information. The next note is 4/17/25 when R23 returned to the facility. There is no documentation of notification of receiving provider/facility and information shared for a smooth transfer, no documentation that the bedhold and written notice of transfer was completed, no copy available in the medical record.4/14/2025 09:34 BIMS, Delirium, and Communication: Note Text: Resident discharged to the ER due to an eye infection. Her cognition was not affected and remains at baseline. Resident has varying alertness and often falls asleep mid-conversation and mid-activity. She needs verbal and physical cues to reorient. Resident's orientation to situation and her short-term memory vary as well. Her POA is activated, which remains appropriate.On 1/7/26, R23 was transferred to the Emergency Department due to shortness of breath per hospital discharge notes. R23 was diagnosed with community acquired pneumonia and hospitalized until 1/11/26.For the 1/7/2026 transfer, there is no written transfer notice completed and documented in the medical record.On 2/17/26 at 3:30 PM, Director of Nursing (DON) B stated she gave Surveyor what she could find, regarding R23's bed holds, written transfer notice or ombudsman notice. There is no written transfer notice for the hospital transfer on 1/7/2026 and no written transfer notices or signed bed hold for April transfers. There is no written documentation or progress note that they let the ER know they were coming in April either. DON B stated she does not have a bed hold either for 4/8/25 or 4/11/25.On 2/18/26 at 9:38 AM, Surveyor interviewed DON B who stated there is no form used to communicate with receiving facility of transferring resident. DON B stated they send to receiving facility/provider the resident's Face Sheet, MAR (Medication Administration Record), TAR (Treatment Administration Record) and POLST (Provider/Physician Orders for Life-Sustaining Treatment) and call with report, letting them know the resident is coming.

Based on record review, observation, and interview, the facility did not ensure the residents remain free of possible accidental hazards. Facility did not ensure staff were applying the correct size mechanical full body lift sling to prevent accidents for 1 of 3 residents (R) reviewed. (R5) R5 had a sling size that was too small for R5. Findings include:The facility policy, titled CC Resident Transfer Assessment Policy, approved May 2011, modified April 2025, states: The residents of Presbyterian Homes and Services in the Care Center will be properly assessed to assure residents abilities to transfer are evaluated on a regular basis to assure safety of resident and staff. Mechanical lifts may be used for residents who have non-weight bearing status or require the assistance of staff to provide weight bearing support.2. The assessment will be completed by a licensed nurse or therapist.4. If the resident requires a mechanical lift, either full or standing, the resident will be assessed for proper sling or harness.6. Once the determination of the required assistance for transfers has been made, the resident care plan d and nursing assistant care sheets will be updated.The LikoTM Sling and Vest Sizing Guide, dated 7/2024, states in part:LikoTM Sling Type: Universal SlingSize: Medium SlimColor Coding: GrayRecommended Weight Range (in pounds): 99-154 lbs. LikoTM Sling Type: Universal SlingSize: MediumColor Coding: YellowRecommended Weight Range (in pounds): 132-198 lbs. LikoTM Sling Type: High Back SlingSize: Medium SlimColor Coding: GrayRecommended Weight Range (in pounds): 66-110 lbs. LikoTM Sling Type: High Back SlingSize: MediumColor Coding: YellowRecommended Weight Range (in pounds): 88-176 lbs R5 was admitted to the facility on [DATE], and has diagnoses that include multiple sclerosis, muscle weakness and wheelchair dependence, osteoporosis, and dementia.R5's Minimum Data Set (MDS) assessment, dated 1/9/26, indicated that R5 has difficulty communicating some words and does not always understand, direct simple communication is recommended. R5 can feed herself and complete oral hygiene with set up but is dependent or needs substantial assistance for all activities of daily living (ADLs). R5 is dependent on facility staff for all mobility from moving her wheelchair to transferring with a full body mechanical lift to her bed, wheelchair, or the shower/tub.R5's CNA Quick Guide to ADLs, dated 12/19/25, states in part: Transfer and Device A-2 Full Lift Medium Yellow sling. Ok to leave sling under for skin integrity This indicates that R5 requires the assistance of 2 staff members using a full mechanical lift and the yellow sling.Per medical record review, R5's weight has fluctuated during the past 90 days and has had frequent weights 12/6/25 through 2/14/2026. R5's lowest weight was 168.4 lbs; the highest weight was 175.4 lbs. On 2/14/26, R5 weighed 173.0 lbs. R5 fits into a Universal Sling Medium Yellow or a High Back Sling Medium Yellow. The Certified Nursing Assistant (CNA) Quick Guide for ADLs does not clarify which type of sling to use, just that it is yellow.On 2/17/26 at 7:18 AM, Surveyor observed morning cares for R5. CNA E and CNA F used a full lift stand and a green full lift sling to transfer resident to her wheelchair after morning care.On 2/17/26 at 8:24 AM, Surveyor observed R5 transported via wheelchair to the downstairs to use the Sci fit machine. R5 never left her chair and remained sitting on the same green sling.On 2/17/26 at 10:15 AM, Surveyor observed CNA E and CNA F transfer R5 using the green sling to her bed so her brief could be checked and changed. After cares, R5 wanted to go back to R5's wheelchair. CNA E and CNA F used the same green sling to transfer R5 back to her chair. Surveyor observed all the cares provided for R5 since R5 got up on the morning of 2/15/26 from 7:18 AM through 10:18 AM.On 2/17/26 at 10:37 AM, Surveyor interviewed CNA E, who stated CNAs know what the abilities of residents are and how to transfer them because of the guide they have. CNA E showed Surveyor the printed guide with today's date, 2/17/26. The guide stated R5 should transfer with a full lift via a yellow sling. CNA E stated they get a freshly printed guide every day for the unit they are working on. CNA E is not sure of the process for determining the sling size and who does that, but she knows she finds the information on the guide. Surveyor saw a green sling being used with R5 this morning. Surveyor and CNA E went to R5's room and looked at what sling was under her. It was green but CNA E stated the size goes by the stripe that runs down the back of the sling. Observation of the stripe was identified as grey. CNA E stated the stripe should be yellow; I need to change that when we get her back to bed. The slings are washed at night and must have been switched. On 2/17/26 at 12:41 PM, Surveyor observed CNA E and CNA F transfer R5 back to her bed via the full mechanical lift and sling so R5 could be changed and repositioned for skin integrity. Sling was removed from under R5 while resting in bed. CNA E stated that with the help of the clinical coordinator they now have the right sling to use with R5.On 2/18/26 at 12:30 PM, Surveyor interviewed Director of Nursing (DON) B regarding if there was a process to determine which lift to use with residents and what size of the sling should be, or doesn't it matter which sling they use. DON B stated it matters. Therapy or the nurses decide which lift and assess what sling to use. The sling is then documented on the Quick Guide. CNAs know what sling to use with the lifts because it is on the Quick Guide. DON B stated they should use what is listed. On 2/18/26 at 12:05 PM, Surveyor observed what sling was under the 3 full body mechanical lift residents on [NAME] 3. CNA G watched Surveyor do this. When Surveyor looked at R5's sling who was sitting at same table CNA G was at, CNA G stated, they all have the right one I made sure. They wash them on night shift and sometimes they get switched around. It happened the other day, but we caught it. So, I always double check.

Based on observation, interview and record review, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Kitchen staff had beard hair exposed and uncovered while preparing food, and door hinges located above food serving areas were unclean. This had the potential to affect all 43 of 43 residents residing in the facility. Findings Include: The facility policy, titled Hair Restraint Policy, dated June 2021, states: Beards must be covered with a beard bag, and must be on before entering the kitchen or any area where the food is being prepared. On 11/26/24 at 11:23 AM, Surveyor observed food preparation for nursing home in the main kitchen. Surveyor observed Dietary Aide (DA) G who had facial hair on chin, sides of mouth, and mustache area that was not covered with a beard net. Hair was approximately 3/4 of an inch long. Surveyor observed DA H who was preparing food and had uncovered facial hair on upper chin and mustache area. DA I had noticeable hair on their chin and was also moving around the kitchen helping with lunch preparations without any beard covering. Surveyor interviewed DA G and DA H regarding their understanding of the facial hair policy. They were not sure, but they thought the hair length was ok, although they were not entirely sure what the policy stated. On 11/26/24 at 11:25 AM, Surveyor interviewed Dietary Manager (DM) K regarding their expectations regarding beard nets. DM K felt that a small amount of facial hair was okay. DM K also felt the definition of a beard is subject to some interpretation as well. DM K mentioned they agree that DA G did have longer facial hair than they would prefer, and they would relook at the rules regarding a beard net. On 11/27/24 at 6:45 AM, Surveyor observed kitchen preparation with DA J on the third floor serving area. Surveyor observed the mechanism that slowly opens and closes the door was covered with a significant amount of dust. Surveyor asked DA J if they noticed the unclean area that was directly above the serving area, and DA J said they did and had not noticed it before. DA J stated it is rare staff would look in that area, and DA J was not sure who was supposed to be cleaning that area. On 11/27/24 at 7:14 AM, Surveyor requested Nursing Home Administrator (NHA) A go to the second-floor food preparation area to look at the dust accumulation above that serving area as well. Surveyor observed dust on the door hinges above the food serving area on the second floor. Surveyor asked NHA A if they would expect the hinges to be cleaned regularly on the second and third floor. NHA A said it was expected the hinges should be cleaned regularly. On 11/27/24 at 10:14 AM, Surveyor interviewed DM K regarding their findings and facial hair policy. DM K said they plan to start having the employees with facial hair shave.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infection. This had the potential to affect all 12 residents (R) residing on unit. R8 is on enhanced barrier precautions (EBP) and staff did not apply personal protective gown when emptying R8's urine catheter bag. This is evidenced by: Facility's policy titled Enhanced Barrier Precautions Policy and Procedure with the modified date of April 2024, document in part: .Policy: 1. EBP (targeted gowns and gloves) are used in conjunction with standard precautions and will be implemented during high contact resident care activities for residents who: .b. when caring for residents with wounds or indwelling medical devices even if the resident is not known to be colonized or infected with a MDRO (multidrug-resistant organisms) .Procedures: 4. When performing high-contact resident care activities staff should: a. Perform hand hygiene b. [NAME] gloves and a gown . R8 was admitted to the facility on [DATE] and current diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant, congestive heart failure, pulmonary disease, type 2 diabetic neuropathy, dysphagia, neuromuscular dysfunction of bladder, polyneuropathy, chronic pain, traumatic subdural hemorrhage, and vascular dementia. Surveyor observed at the entrance of R8's room there is a sign on the cabinet door stating enhanced barrier precautions. On 11/26/24 at 1:28 PM, Surveyor observed Certified Nursing Assistant (CNA) F empty R8's catheter bag. CNA F washed hands appropriately and applied gloves. CNA F did not apply a gown. CNA F placed a paper towel barrier on the floor and placed graduate on the paper towel. CNA F removed the catheter bag from the dignity bag, wiped the port with an alcohol wipe and started to empty the urine into the graduate. Surveyor interrupted CNA F by asking if R8 was on enhanced barrier precautions. CNA F indicated yes R8 is on precautions and CNA F should have a gown on. CNA F removed gloves, washed hands appropriately and applied a gown and clean gloves. CNA F completed emptying of the catheter bag. On 11/27/24 at 2:36 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A about EBP and reviewed Surveyor's observation with CNA F. NHA A indicated expectation is to have a gown on when providing care for a resident that is on EBP.

Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 3 of 4 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen. (R2, R12, and R15) The MDS assessments are coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment for R2, R12 and R15. Findings include: Example 1 R2 was admitted to the facility on [DATE] with diagnoses including in part, schizophrenia, anxiety disorder, and schizoaffective disorder. Record review identified R2 had a PASARR level 2 screen completed on 10/03/23. R2's annual MDS assessment, dated 10/08/24, and significant change MDS assessment, dated 11/21/24, indicated for question A1500 that no PASARR level 2 had been completed. Example 2 R12 was admitted to the facility on [DATE] with diagnoses including in part, bipolar disorder, major depressive disorder, and anxiety disorder. Record review identified a PASARR level 2 was completed on 10/22/24. R12's admission MDS assessment, dated 10/01/24, indicated for question A1500 that no PASARR level 2 had been completed. On 11/26/24 at 12:58 PM, Surveyor interviewed Nursing Home Administrator (NHA) A who completes the PASARR screenings for the facility. Surveyor reviewed R2, R12 and R15 with NHA A, and NHA A agreed that all three residents had a serious mental illness and had a PASARR level 2 screen completed. Surveyor asked NHA A why the MDS Assessment section A1500 was answered no for all three residents when all three resident did have a PASARR level 2 screen completed. NHA A stated their corporation has a centralized MDS nurse who is not on site and based in Minnesota. NHA A believes they are misunderstanding the MDS A1500 question and answering no based on the fact that the level 2 screen determined the resident did not require specialized services for their mental illness. NHA A agreed that the MDS section A1500 question was coded incorrectly for R2, R12 and R15. 31086 Example 3 R15 was admitted on [DATE] with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of R15's medical record documented a PASRR level II screen was completed on 02/16/21. An annual MDS assessment, dated 03/12/24, documented A1500 was coded no for consideration of a level II PASRR process for a serious mental illness and/or intellectual disability or a related condition. A significant change MDS assessment, dated 09/10/24, documented section A1500 was coded no for consideration of a level II PASRR process for a serious mental illness and/or intellectual disability or a related condition. On 11/27/24 at 2:55 p.m., Surveyor interviewed NHA A about the MDS coding for PASRR level II. NHA A indicated the MDS was coded incorrectly.

Based on observation, interview and record review, the facility did not ensure 1 of 4 residents (R)(R15) who are unable to carry out activities of daily living receive the necessary services to maintain good oral care. This is evidenced by: R15 was admitted on [DATE] and has current diagnoses of type 2 diabetes mellitus with diabetic polyneuropathy, morbid obesity, major depressive disorder, congestive heart failure, anxiety disorder, edema, venous insufficiency peripheral, post-traumatic stress disorder, weakness, polyosteoarthritis, pain in left shoulder, reduced mobility, and chronic pain. The Minimum Data Set (MDS) a significant change assessment dated [DATE] documented R15 needing substantial/maximal assistance of staff with the staff doing more than half the effort. R15's brief interview for mental status (BIMS) score of 10 out of 15 indicates R15 has moderate cognitive impairment. Review of the quick guide for ADLs (activities of daily living) for R15's care documented in part: Standards: .Oral care -twice daily (both unless otherwise specified) .Setup A-1 (assist of 1 staff) PRN (as needed) oral cares, encourage tongue brushing daily . On 11/27/24 at 9:34 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D provide personal cares for R15. CNA C and CNA D appropriately washed and clothed R15 and transferred R15 to the broda chair. CNA D combed and braided R15's hair. CNA D removed gown, sanitized hands and brought R15 to the dining room. Surveyor did not observe R15 be provided oral care. After breakfast R15 continued to be in the dining room and received hospice music therapy. At 11/27/24 at 12:55 PM, Surveyor observed R15 being transferred to their room. Surveyor interviewed CNA C about oral care being provided to R15. CNA C indicated R15 will do her own oral care when staff provide R15 with a toothette or R15 will start, and CNA C would have to finish the oral care. Surveyor reviewed with CNA C when observing morning cares R15 was not provided oral care. CNA C stated this morning was mixed up and R15 did not get up at her usual time and was later. CNA C stated we got R15 up in her chair and brought to the dining room for breakfast so oral care was not completed. Surveyor asked if oral care was completed after breakfast and CNA C indicated no.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility did not identify a whitish yellow film present throughout the soft tissue in resident's mouth timely leading to a delay in treatment. This has the potential to affect 1 of 1 resident (R) who resided in the facility (R196). Findings include: R196 was admitted to the facility on [DATE]. R196 was diagnosed with malignant neoplasm of lung, malignant neoplasm of brain, malignant neoplasm of spinal cord, rheumatoid arthritis with, malignant neoplasm of adrenal gland, retention of urine, history of other venous thrombosis, and lymphedema. R196 entered the facility with a Brief Interview for Mental Status (BIMS) assessment score of 14 out of 15 meaning intact cognition. R196 was their own person upon entering the facility. R196 was alert and oriented and was able to direct own care. R196 enrolled themselves into hospice care upon admission to the facility. Surveyor reviewed dental appointment notes dated 07/05/24 stating, There was a whitish yellow film present throughout the soft tissue in her mouth that I was not able to wipe off. Including her cheeks and lips. I sent provider support photos of film to attach to her chart. I am going to request our dentist to come and look at this film. Surveyor reviewed progress note dated 07/05/24 stating, Late Entry: Type of appointment: Healthdrive dental New orders or recommendations: Person notified of new orders * There was no indication of resident change in heath condition noted in progress note related to dental appointment. Surveyor reviewed medical administration record dated 07/01/24 - 07/31/24 indicated that Clotrimazole Lozenge 10 MG was started on 07/23/24, 18 days after dental hygienist indicated a whitish yellow film present throughout the soft tissue in R196's mouth. Order indicated to give 1 lozenge by mouth five times a day for Oral thrush. On 11/27/24 at 12:12 PM, Surveyor interviewed Clinical Coordinator (CC) E regarding procedure for reviewing resident appointment information. CC E said yes they do review the notes from the dentist and after review we will update the resident's progress notes with any updates. Surveyor then asked CC E if they had any progress notes related to R196's dentist appointment. CC E said they will need to look. On 11/27/24 at 1:04 PM, Surveyor interviewed CC E who said the hygienist did leave a note, and it should have been charted and reviewed by leadership. CC E said the hygienist notified their dentist and maybe that is why it was not charted. The dentist would come every two months and R196 passed away prior to the next dentist visit. Surveyor asked if the note regarding the whitish yellow film present throughout the soft tissue in R196's mouth should have been charted and reviewed. CC E said it should have been addressed, the progress note should have been reviewed, the concern should have been investigated, and the physician should have been contacted for treatment orders.

Based on record review and interview, the facility did not provide medications as ordered by the prescriber, to meet the needs of each resident for 1 of 12 residents (R) medication orders reviewed for accuracy. (R34) This is evidenced by: The facility's policy Medication Administration Error Policy with modified date of May 2021, read in part: CMS Regulatory Definitions: Medication Error the observed preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order; . R34 was admitted on [DATE] with current diagnoses of chronic obstructive pulmonary disease, congestive heart failure, chronic respiratory failure with hypoxia, hypertrophic cardiomyopathy, atrial fibrillation, cyst of pancreas, osteoarthritis, prediabetes, obstructive sleep apnea, morbid obesity, insomnia, hypertension, major depressive disorder, history of transient ischemic attack, and anxiety disorder. Review of R34's progress notes documented on 10/31/24 at 4:07 p.m., Hospice, Note Text: PRN (as needed) RN (Registered Nurse) visit made to see this resident to f/u (follow up) on increased edema and hypoxia. Res in bed upon arrival and will not open eyes but uses head nods to answer writer. O2 was 90% on 1L wirter (sic) increased to 3L and 02 up to 93% via NC. She denies pain but states SOB (shortness of breath) and does have increased RR (respiratory rate) rate at 28. PRN MS (morphine sulfate) administered for SOB. Edema is 4+ pitting to BLE (bilateral lower extremities). Dr. [Name] notified and new orders transcribed to increased torsemids (sic) 40mg qd (everyday) x 3 days and reassess on Monday. NP/POA updated on changes POC (plan of care) remains appropriate. Site encouraged to call [Hospice] with any changes. Surveyor reviewed physician order for Torsemide was entered on 10/31/24, started on 11/01/24 and discontinued on 11/03/24. Surveyor reviewed Medication Administration Record (MAR) for Torsemide 40 mg orders. The October MAR documented on 10/31/24 Torsemide 20 mg was given. The November MAR documented nursing staff signed the Torsemide 40 mg medication was given on 11/01/24 and 11/02/24. The MAR did not have the Torsemide 40 mg medication order to be given on 11/03/24 which would be the third day of the increased dose. The MAR documented no orders for Torsemide of any dosage was to be given to R34 on 11/03/24. On 11/27/24 at 1:16 PM, Surveyor interviewed Clinical Coordinator (CC) E about R34's missed dose of Torsemide. CC E indicated this was a transcription error and R34 did not receive the medication as ordered. CC E indicated she was not aware of the missed dose because of how the order was entered into the computer and will be doing a medication error report and notifying the physician and hospice.

Based on observation and interview, the facility failed to prepare and distribute food under sanitary conditions. This has the ability to affect all 45 residents in the facility. The dietary staff did not restrain hair under hair nets in the kitchen and serving areas. The dietary staff did not allow time, after using an alcohol swab on a thermometer, for the thermometer to dry off before inserting the thermometer into the food. This is evidenced by: Example 1: The facility policy and procedure entitled Infection Prevention and Control Manual Dietary - F812 Regulation - Food Safety Requirements, last revised in 2020, states in part, Dietary Staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food. On 09/18/23 at 9:00 AM, Surveyor performed an initial tour of facility's kitchen. During the initial tour, Surveyor observed Dietary Aide (DA) D with a hair net on their head, but bangs were protruding from the hairnet. DA D's hair was not contained in the hair net. On 09/18/23 at 12:05 PM, Surveyor observed DA E dishing up plates from the dry heat table in the kitchen on the third floor. DA E had on a hair net, but hair was protruding from the hairnet below where the hairnet would cover DA E's neck. DA E's hair was not contained in the hair net. On 09/19/23 at 7:57 AM, Surveyor observed DA F taking food temperatures before breakfast. DA F had on a hair net, but hair was protruding below the hair net near the base of the neck. DA F's hair was not contained in the hair net. On 09/20/23 at 8:44 AM, Surveyor interviewed Dietary Manager (DM) C about DM C's expectations for hair restraints in the kitchen. DM C said they would expect staff always to have hair nets on; if hair were out, they would need to get larger hair nets. They plan to look into larger hair nets for staff with more hair. Example 2: The facility policy and procedure entitled Proper Use and Calibration of Food Thermometers, last revised in July 2020, states in part, Proper Use: Sanitize the stem of the thermometer upon each use with an alcohol wipe or 5 seconds in a sanitizer solution. Allow to probe to air dry completely before next use. On 09/19/23 at 7:57 AM, Surveyor observed DA F checking food temperature before serving residents on the third floor. DA F first wiped the thermometer with a sanitation wipe, and after 7 seconds, they put the thermometer in the oatmeal. DA F then wiped the thermometer with a sanitation wipe, and after a count of 5 seconds, they checked the temperature of the pancakes. DA F then wiped the thermometer with a sanitation wipe and, after a count of 2 seconds, put the thermometer into the eggs. DA F took the thermometer out of the eggs, wiped the thermometer off with the sanitation wipe, and immediately put the thermometer into the pureed eggs. On 09/19/23 at 7:57 AM, Surveyor interviewed DA F about checking food temperature at the point of service. Surveyor asked if DA F knew what type of wipes were being used to clean the thermometer, and DA F responded by saying they are alcohol wipes. Surveyor then asked if she knew of an allotted time that DA F should wait after wiping off the thermometer before taking the temperature of the following food item. DA F did not know of a time they should wait after wiping off a thermometer with an alcohol swab. On 09/20/23 at 8:44 AM, Surveyor interviewed DM C about DM C's expectations for checking food temperature before serving. DM C would expect the thermometer to be cleaned each time. Surveyor asked about the time it might take for alcohol to dry on the thermometer, and DM C said they did not think about the time it would take for the alcohol to dry off the thermometer and possibly contaminate food with alcohol.

Based on interview and record review, the facility failed to notify the resident's practitioner of the delay in obtaining a chest x-ray (CXR) and failure to immediately consult with the resident's practitioner concerning a change in the condition of a resident for 1 of 2 residents (R39). R39 was prescribed blood thinners and started to have hematuria (blood in the urine) with nickel size blood clots, an adverse consequence of taking blood thinners. The facility neglected to notify R39's practitioner until almost 5 hours later after the symptoms started. Findings include: The facility policy, entitled Communication and Notification - Staff, Practitioners, and Resident Representatives, dated November 2022, states: .Staff will notify the practitioner any time there is a significant change in clinical condition; including but not limited to a need to discontinue or change an existing form of treatment due to adverse consequences, or to initiate a new form of treatment .Any significant change in status must be reported to the practitioner team immediately which may be life threatening in nature or risk to self or others . R39 was admitted to the facility on [DATE], and had diagnoses including in part Alzheimer's disease, dementia, gross hematuria, malignant neoplasm of prostate, benign prostatic hyperplasia with lower urinary tract symptoms, acute embolism, and thrombosis of DVT (deep vein thrombus) right lower extremity (blood clot), fracture of right femur. On 9/19/23, Surveyor reviewed R39's medical record and identified the following: R39's Physician's Orders: Aspirin EC (enteric coated) 81 mg (milligram) Give 2 tablet by mouth one time a day for blood clot prevention. Start date: 5/25/23 End date: 6/08/23. Enoxaparin sodium injection solution prefilled syringe 40 mg/0.4ml (milliliter) Inject 0.4 ml subcutaneously every 24 hours for blood clot prevention for 9 administrations. Start date: 5/25/23 End date: 6/03/23. Xarelto oral tablet Give 15 mg by mouth two times a day for DVT. Start date: 6/08/23 End date: 6/09/23. Per Medication Administration Record (MAR), R39 started on Xarelto 15mg 6/09/23 two doses and one dose given 6/10/23 at am dose. R39's Progress Notes: 6/10/23 at 5:16 AM Resident [R39] had several nickel sized clots in catheter bag with 400ml bloody urine, and blood in pad. Started on Xarelto 6/9/23 for DVT in right leg . 6/10/23 at 12:32 PM .Change in Condition-situation .Resident [R39] had significant amount of blood in catheter bag with nickel sized clots present. On-Call contacted and wanted resident to be seen in ER [emergency room ] for further evaluation. Cather is patent and still draining bladder, bladder scan showed 27mL. Concerns with bleeding due to resident starting Xarelto 15mg BID [twice a day] on Thursday [6/08/23] for DVT .Notification of MD/NP: On- call provider notified at 10:00 [AM] . Surveyor noted R39 was prescribed blood thinners and started to have hematuria (blood in the urine) with nickel size blood clots, complications of taking blood thinners. The facility neglected to notify R39's practitioner until almost 5 hours later after the symptoms started. On 9/19/23 at 9:13 AM, Surveyor spoke with Registered Nurse (RN) H to ask if a resident on an anticoagulant (blood thinner) starts to have hematuria with blood clots in the urine, what is the expectation to notify the provider. RN H said we need to notify the provider immediately as there could be something serious going on and the resident would need intervention right away. Surveyor asked RN H where the nurses would document this conversation with the provider. RN H said it would be documented in our progress notes. On 9/19/23 at 12:32 PM, Surveyor spoke with Director of Nursing (DON) B to ask what the expectation would be for when the nurse needs to notify the provider if a resident on an anticoagulant started with hematuria with blood clots. DON B said the provider should be notified as soon as possible.

Based on observation, interview and record review, the facility did not ensure that the facility used the least restrictive alternative for the least amount of time and documented ongoing re-evaluations of the need for restraints for 1 of 1 resident (R15) using restrictive devices. The facility did not assess the use of a tray attached to R15's wheelchair for use as a restraint. This is evidenced by: The facility policy, entitled Physical Restraint Policy, dated November 2022, states: Procedure for Use of Restraints: 1. An assessment will be reviewed quarterly, and a new assessment will be completed annually, with significant change, with use of a new device, and with discontinuation of and existing device. R15 was admitted to the facility on [DATE] and has been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and has a Brief Interview for Mental Status (BIMS) of 15. On 09/18/23 at 11:19 AM, Surveyor observed R15 in their room with a tray attached to his electric wheelchair. The tray was attached to both arms of the chair and in front of R15 while sitting in a wheelchair. On 09/18/23 at 11:19 AM, Surveyor asked R15 if they could remove the tray attached to the electric wheelchair, to which R15 replied they could not. However, they had no issues asking one of the nurses or Certified Nursing Assistants (CNAs) to remove it when they wanted it removed. Surveyor attempted to locate an assessment related to the restraint observed on R15's electric wheelchair and could not locate one. On 09/19/23 at 12:12 PM, Surveyor interviewed Registered Nurse (RN) I about the tray on R15's Chair. RN I said the chair is relatively new, and they work with a company specializing in ALS; the chair should help R15 as the disease progresses. The tray is nice and allows R15 to read, and if R15 ever needs it off, he knows to ask any of the aides on the floor. R15 can communicate well with staff. When Surveyor asked if RN I had seen any assessments related to the tray on R15's chair, RN I said they did not know of any. On 09/19/23 at 12:26 PM, Surveyor asked Director of Nursing (DON) B for a copy of an assessment related to the attached tray on R15's electric wheelchair. No assessment related to the tray was received. On 09/19/23 at 2:45 PM, Surveyor interviewed Clinical Coordinator (CC) G regarding a restraint assessment. CC G presented Surveyor with a copy of the assessment created on 09/19/23 and said they had not started it until that day. There was no assessment completed prior to the one presented. They believed it had been missed due to working with a different company providing R15 with ALS-specific equipment, including the electric wheelchair and the attached tray. Surveyor asked how long R15 had had the electric wheelchair, and CC G said that R15 had applied for the chair with the tray in the spring and received the new electric chair in the middle of the summer but could not remember the exact dates. Surveyor asked CC G what their expectations would be if someone had added a possible restraint to their wheelchair. CC G said they would expect an assessment to be created for the restraint.

Based on observation, interview and record review, the facility did not ensure that the comprehensive care plan was implemented for 1 of 13 residents (R) reviewed, R15. R15 did not have a care plan regarding the tray attached to R15's wheelchair which R15 could not physically remove. This is evidenced by: The facility policy and procedure entitled Physical Restraint Policy, last revised in November 2022, states in part, Procedures for use of restraints: . 3. The care plan will be updated to include the following: a. Least restrictive type of restraint. b. Length of time the restraint will be used. c. Medical symptom requiring the use of the restraint. d. Who may apply the restraint. e. The time and frequency the restraint should be restraint f. When/how direct monitoring and supervision would be provided when the restraint is in use . R15 was admitted to the facility on [DATE] and has been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and has a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. On 09/18/23 at 11:19 AM, Surveyor observed R15 in their room with a tray attached to his electric wheelchair. The tray was attached to both arms of the chair and was located in front of R15 while sitting in wheelchair. On 09/18/23 at 11:19 AM, Surveyor asked R15 if they could remove the tray attached to the electric wheelchair, to which R15 replied they could not. However, they had no issues asking one of the nurses or Certified Nursing Assistants (CNA) to remove it when they wanted it removed. Surveyor attempted to locate a care plan related to the restraint observed on R15's electric wheelchair and could not locate one. On 09/19/23 at 12:26 PM, Surveyor asked Director of Nursing (DON) B for a copy of the care plan related to the attached tray on R15's electric wheelchair. No care plan related to the tray was provided. On 09/19/23 at 2:45 PM, Surveyor interviewed Clinical Coordinator (CC) G regarding the care plan. CC G presented Surveyor with a new copy of the care plan created on 09/19/23 and said they had not created it until that day. No care plan relating to restraints was completed prior to the one presented. They believed it had been missed due to working with a different company providing R15 with ALS-specific equipment, including the electric wheelchair and the attached tray. Surveyor asked how long R15 had had the electric wheelchair, and CC G said that R15 had applied for the chair with the tray in the spring and received the new electric chair in the middle of the summer but could not remember the exact dates. Surveyor asked CC G what their expectations would be if someone had added a possible restraint to their wheelchair. CC G said they would expect a care plan to be created.

Based on record review and interview, the facility did not conduct testing of facility staff that is consistent with current standards of practice for conducting COVID-19 testing. This had the potential to affect 37 of 37 residents. Frequency of testing for staff not done twice weekly for unvaccinated staff when County Transmission Level was high. Findings include: Facility Policy Titled, COVID-19 Staff Vaccination Policy with a revision date of 02/03/22 states in part The following precautions apply to exempt unvaccinated staff complete testing based upon the CDC County Transmission Rate. The Centers for Medicare and Medicaid Services (CMS) memo: Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, dated August 26, 2020, and revised on 03/10/22 states, in part: .Routine testing of staff who are not up-to-date should be based on the extent of the virus in the community. Facilities should use their community transmission level as the trigger for staff testing frequency. The facility should test all staff, who are not up to date, at the frequency prescribed in the Routine Testing table based on the level of community transmission reported in the past week . The table states: Level of COVID-19 Community Transmission Minimum Testing Frequency of Staff Low Not recommended Moderate Once a week Substantial Twice a week High Twice a week County Transmission Rate for St. Croix County was high per CMS data report. On 08/31/22, Surveyor reviewed the facility staff vaccination log. Report showed week of 08/14 - 08/20/22 6 of 8 unvaccinated staff reviewed did not test 2 times during that week time period. Registered Nurse (RN) C worked: 8/15, 8/17, 8/19, 8/20 and 8/21/22. Per the staff vaccination matrix RN C has a granted non-medical exemption. Review of the facility testing log shows RN C only tested on [DATE]. Cook D, worked: 8/15, 8/17, 8/18 and 8/19/22. Per the staff vaccination matrix cook D has a granted non-medical exemption. Review of the facility testing log shows Cook D only tested on [DATE]. RN E, worked: 8/14, 8/16 and 8/18/22. Per the staff vaccination matrix RN E has a granted non-medical exemption. Review of the facility testing log shows RN E only tested on [DATE]. Household Coordinator (HHC) F, worked: 8/15, 8/16, 8/17, 8/18, and 8/19. Per the staff vaccination matrix HHC F has a granted medical exemption. Review of the facility testing log shows HHC F only tested on [DATE]. RN G, worked: 8/17, 8/18. 8/19 and 8/20. Per the staff vaccination matrix RN G has a granted non-medical exemption. Review of the facility testing log shows RN G only tested on [DATE]. Resident Assistant (RA) H, worked: 8/14, 8/15, 8/16, 8/18 and 8/19/22. Per the staff vaccination matrix RA H has a granted non-medical exemption. Review of the facility testing log shows RA H only tested on [DATE]. On 8/30/22 at about 6:30 AM, Surveyor interviewed RN I and asked how often staff were being tested for COVID. RN I indicated twice a week if you are not up to date with your vaccinations. On 08/30/22 at about 11:15 AM, Surveyor interviewed Director of Nursing (DON) B and RN J, who is also the facility Infection Preventionist, and asked how often staff are being tested for COVID-19. RN J indicated it depends on vaccination status, if not up to date testing is to be 2 times a week based on high community transmission right now. On 08/30/22 at about 12:48 PM, Surveyor interviewed HHC F and asked how often staff were being tested for COVID 19. HHC F indicated 2 times a week if not vaccinated. HHC F has a granted medical exemption and only tested on e time the week of 08/14 - 08/20/22. HHC F indicated she usually tests Tuesday and Friday and had no explanation as to why she did not test twice that week. On 08/30/22, Surveyor interviewed NHA A and asked how the testing was tracked. NHA A indicated a report was run weekly and if someone has not tested twice a week per policy she would send an email to the employee's supervisor that the employee was not up to date on testing. The NHA A had no further follow up after that if the employee did not comply or explanation for not following the testing protocols.

Based on observation, interview, and record review, the facility did not ensure that perineal cares were performed in a hygienic manner. This occurred for 1 of 12 sampled residents (Resident (R) R36.) Facility staff cross-contaminated clean areas during perineal cares. Facility staff did not perform hand hygiene according to current standards of practice during cares. This is evidenced by: The facility policy, entitled Perineal Care dated 06/21, states: .use clean area of the washcloth for each stroke .remove and dispose of gloves .and perform hand hygiene R36 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R36's Minimum Data Set (MDS), dated [DATE], showed that R36 has severe cognitive impairment. The MDS indicated R36 requires extensive 2 person assist with toileting. R36 requires 2 person assistance with bed mobility. R36's care plan, dated 08/09/14, with a target date of 09/06/21, states I have total bladder and bowel incontinence r/t (sic) advanced Alzheimer's dementia with severe cognitive, communication, and functional deficits. Interventions include: I require staff assist of 2 with transfers, assist of one with changing pad in bed at night; assist of 2 as needed. Assist me every 3 hours. R36's Bowel, Bladder, and Skin Risk, dated 06/01/21, was 12, indicating R36 was at high risk for skin breakdown related to incontinence. On 06/15/21, at 01:55 p.m., Surveyor observed Certified Nursing Assistants (CNAs) C and D assist R36 with transfer from wheelchair into bed and perineal cares. Both CNAs performed hand hygiene and donned gloves. CNA D obtained a mechanical full body lift. After adjusting the lift sling, CNA C and CNA D transferred R36 into bed. CNA C and CNA D assisted R36 onto R36's left side. After assisting R36 onto the left side and using a turning manner, CNA C removed R36's pants and soiled brief. CNA C deposited the soiled brief into a plastic lined garbage bag. Then without removing gloves or performing hand hygiene, CNA C obtained peri wipes from a container. CNA C cleansed R36's perineal area, in a front to back motion, then without changing the cloth, cleansed R36's groin area. Next, after assisting R36 onto R36's left side, CNA C cleansed R36's rectal area. CNA C disposed of the wipe. CNA C obtained a clean wipe, but cleansed the rectal area again with the same cloth, then cleansed R36's buttocks area. CNA C obtained a clean brief from the nightstand without changing gloves or performing hand hygiene. After applying the clean brief, CNA C and CNA D adjusted R36's clothes, and provided positioning assistance. CNA C and CNA D removed gloves and performed hand hygiene. On 06/17/21, at 1:15 p.m. Surveyor interviewed DON B. DON B stated that staff performing perineal care should use a clean cloth for each perineal area cleansed, and staff should change gloves and perform hand hygiene during perineal cares.

Based on interview and record review, the facility did not permit a resident to return to the facility following a transfer to a behavioral health unit. This occurred for one of five residents (R) reviewed for discharge or transfer (R3). R3 was transferred to a behavioral health unit on 05/14/20 and the facility refused to readmit the resident from the behavioral health unit on 07/06/20. There was no documentation in the medical record explaining the basis for the discharge or the specific resident needs that could not be met by the facility. On 07/16/20, the facility issued R3's power of attorney (POA) for health care a letter notifying of 30-day discharge. Findings include: Review of R3's medical record identified R3 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's Brief Interview for Mental Status score was 10, indicating moderate cognitive impairment. Review of nursing progress notes on R3's medical record identified multiple examples of R3 exhibiting disruptive behaviors. The behaviors included yelling, threatening, refusal of cares and medications, throwing self on the floor, and physical aggression to caregivers. Documentation further identified facility staff consulted with R3's family, primary physician, nurse practitioner, and neurologist multiple times about R3's behaviors. Review of R3's care plan identified multiple interventions tried in attempt to resolve the behavior issues. Review of physician orders [REDACTED]. A physician progress notes [REDACTED]. Behavior Concern: Challenging [DIAGNOSES REDACTED]. Increasing behaviors, requiring placement in LTC (Long Term Care). Attempted GDR (Gradual Dose Reduction) of [MEDICATION NAME] (antipsychotic medication) that did not go well. Much improvement since resuming with dose adjustment by neurology .Plan: No new issues were identified today. No changes in management. Review of nursing progress notes identified R3's behaviors began increasing from 05/09/20 through 05/14/20. The behaviors included verbal and physical aggression toward staff. Staff documented multiple episodes of R3 striking out at staff, and at least one time R3 attempted to pin a staff member against the wall with wheelchair. R3 frequently placed self on floor and refused to allow staff to reposition. R3's neurologist was consulted and medications were adjusted. Nursing progress note dated 05/14/20 stated in part, .Call placed to Grace Unit (behavioral health unit) to ask if writer could make a referral. Grace unit intake coordinator stated they are only taking referrals through ER (emergency room ) at this time. To refer a resident for admission this facility would need to send the resident to local ER for evaluation and then the ER would need to call the Mental health crisis coordinator. Phone number received. Grace unit did verify that they had beds available should the resident be approved for admission. Additional Nursing progress note dated 05/14/20 described more physical and verbal behaviors by R3. The note concluded with the following: Medical Director contacted and advised writer to call ED (Emergency Department) MD and let him know that the resident needs to be evaluated in the ED prior to being sent to The Grace Unit for evaluation per the request of The Grace Unit. ED MD is then to contact Allina Mental Health at [PHONE NUMBER] as resident is at risk of harm to self and others. POA/wife agreed to send resident to the ED and then to The Grace Unit. POA gave verbal for bed hold. Writer escorted resident to ED per wife's request and wife is meeting resident there. Nursing progress notes indicate R3 was admitted to The Grace Unit on 05/15/20. Nursing staff communicated with The Grace Unit staff about resident's condition and faxed requested paperwork to the receiving facility. Review of R3's medical record identified a document received from The Grace Unit on 07/06/20. The document contained progress notes about R3's condition and behaviors from 07/03/20 through 07/05/20. The progress notes indicated that R3 continued to have behaviors, but was easily redirected and was not refusing cares or medications. The document from The Grace Unit included a progress note from a Geriatric physician dated 07/03/20. The note stated in part, .Per nursing notes, the patient continues to demonstrate improvement in behaviors .Plan discharge next week. Surveyor identified a document dated 07/16/20 in R3's medical record addressed to R3's POA. The letter stated in part, This is to inform you that Deerfield Gables Care Center is issuing a 30-day discharge to resident (R3) to a more appropriate living environment. The reason for discharge is due to the facility's inability to meet the resident's physical and psychosocial needs. Facility staff reviewed documentation from Regina Hospital Grace Unit and determined that the Deerfield Gables Care Center is not able to provide the level of care required by (R3's) current circumstances . Surveyor did not identify any documentation on R3's medical record that showed facility staff consulted with R3's physician about the facility's inability to meet R3's needs if R3 returned to the facility. Surveyor reviewed facility policy and procedure titled, Discharge Policy and Procedure, last modified June 2019. The policy stated in part, Process for Planned Facility Initiated Discharges: 1. Facility initiated discharges are only allowed in the following situations: a. The resident's welfare cannot be met in the facility as substantiated by documentation in the medical record and confirmed by the resident's primary physician .2. The facility will ensure that the medical record contains evidence of the basis for discharge. a. The resident's physician must document the basis for discharge and must include: i. Specific needs of the resident the facility cannot meet. ii. The facility efforts to meet those needs . Surveyor interviewed Registered Nurse (RN) C on 01/05/21. RN C reported R3 was transferred to The Grace Unit behavioral health unit due to increasing behaviors that were not responding to interventions. Staff was no longer able to keep R3 safe as R3's behaviors caused a risk to R3, other residents and staff. RN C stated the Nursing Home Administrator (NHA) A receives all referrals for new admissions or re-admissions, so NHA would have reviewed the referral from The Grace Unit to re-admit R3 in July. RN C stated the NHA also has either the Director of Nursing (DON) or one of the nursing coordinators also review any referral documentation from a referring facility to help determine if the facility could meet the resident's needs. RN C stated RN C did not remember the details, due to the referral happened many months ago, but thought the decision not to readmit R3 was made because R3's behaviors had not changed much and they did not think they had the staffing capacity to meet R3's needs. Surveyor interviewed NHA A who stated the reason R3's readmission was rejected was due to evidence in the referral documents from The Grace Unit that R3 had continuing behaviors that the facility staff could not handle. NHA A stated the local ombudsman was consulted and recommended the facility issue a notice of discharge to R3's POA. When asked if R3's physician or the facility medical director was consulted, or provided documentation of the basis for discharging R3, NHA A stated NHA would look for additional documentation. On 01/06/21, Surveyor interviewed NHA A who reported no additional documentation was found in R3's medical record that explained the basis for discharging R3, or outlined the specific resident needs that the facility was unable to meet.

Based on interview and record reviews, the facility did not conduct testing of staff based on the county level positivity rate according to the recommended frequency. This has the potential to affect all 41 residents that reside in the facility. The facility did not test weekly when the county positivity rate required it and did not require staff to test two times a week when the county positivity rate was high. This is evidenced by: On 11/10/20, Surveyor did a record review of the facility's COVID Testing Policy effective 10/28/20 where it reads in part; For 'routine testing' of staff, documentation to show that the facility monitored its county positivity rate and activated the testing frequency corresponding with that rate (low, medium, high). This includes but is not limited to: i. The facility's county positivity rate ii. The corresponding testing frequency indicated . On 11/10/20, Surveyor reviewed weekly county positivity percentage rates listed on the website document: Activity level Low is green with <5% county positivity rate in the past week requires minimum testing frequency of once a month. Activity level Medium is yellow with 5% - 10% county positivity rate in the past week requires minimum testing frequency of once a week. Activity level High is red with >10% county positivity rate in the past week requires minimum testing frequency of twice a week. Week ending 08/26/20 the rate of 6.2% is in the yellow. Week ending 09/02/20 the rate of 6.4% is in the yellow. Week ending 09/09/20 the rate of 5.1% is in the yellow. Week ending 09/16/20 the rate of 5.3% is in the yellow. Week ending 09/26/20 the rate of 7.0% is in the yellow. Week ending 09/30/20 the rate of 7.4% is in the yellow. Week ending 10/07/20 the rate of 7.6% is in the yellow. Week ending 10/14/20 the rate of 8.8% is in the yellow. Week ending 10/21/20 the rate of 11% is in the red. Week ending 10/28/20 the rate of 13.3% is in the red. Week ending 11/04/20 the rate of 15.2% is in the red. On 11/10/20, Surveyor reviewed testing dates for employees. Testing was completed on 05/19/20, 10/05/20, 10/19/20, Surveyor reviewed the infection control line listing that showed the first positive COVID-19 in the facility was a staff member on 10/19/20. 10/26/20 (Monday) 98 staff tested , 10/29/20 (Thursday) the second test date of the week 55 staff tested , 11/02/20 (Monday) 98 staff tested , on 11/05/20 (Thursday) the second testing date of the week 56 staff were tested . On 11/10/20 at 9:40 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) C asking when staff get tested for COVID-19. CNA C indicated staff get tested every Monday and can do Thursday if they wanted. Thursday is not mandatory and Monday is mandatory and cannot work if you refuse. CNA C indicated COVID-19 testing every Monday started about one month ago. On 11/10/20 at 10:00 a.m., Surveyor interviewed CNA D and asked how often they are currently being tested for COVID-19. CNA D indicated on Mondays it is a mandatory test and on Thursdays it is voluntary to be tested . Surveyor interviewed DON B and asked how often staff are being tested for COVID-19. DON B indicated twice a week testing for staff began on 10/29/20, prior to that weekly testing, Mondays are mandatory test days and Thursday is optional. Surveyor asked DON B if a staff member does not come in to test on Thursday if that was considered a refusal. DON B indicated it was not. DON B indicated staff were offered a Point of Care Test (POC) test the next day they work. If staff refused they were allowed to work. Surveyor interviewed DON B asking when the facility received their (POC). DON B indicated that they received it on 09/10/20. Surveyor reviewed the [MEDICATION NAME] test log. [MEDICATION NAME] testing was completed on 10/22/20 only 1 staff tested , 11/01/20 only 1 staff tested , 11/02/20 only 1 staff tested , 11/05/20 only 1 staff tested and 11/10/20 only 1 staff tested . Surveyor reviewed with DON B the QSO-20-28-NH memo documenting, If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. Surveyor interviewed Nursing Home Administrator (NHA) A and asked why weekly testing was not started on 08/26/20. NHA A indicated they did not have the supplies. Surveyor asked NHA A for documentation that demonstrated their attempts to obtain testing supplies. NHA A indicated they did not request any supplies, they were waiting for the state to assign them a lab. Surveyor reviewed with NHA A the QSO-20-28-NH memo documenting in part: When necessary, such as in emergencies due to testing supply shortages, document that the facility contacted state and local health departments to assist in the testing efforts, such as obtaining testing supplies or processing test results.

Based on observation and interview, the facility did not ensure their infection control program was implemented during 1 of 3 observations of insulin administration (Resident (R) 12), 2 of 3 observations of blood glucose monitoring (R16, R14), and 1 of 1 observations of eye drop administration. Registered Nurse (RN) B was observed to complete blood glucose monitoring and subsequent insulin administration for R12. R12 had an [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) infection.[MEDICAL CONDITION] is a multi-drug resistant organism and considered a super bug. During the observation, RN B had multiple breeches in infection prevention practices including moving back and forth from clean to dirty without utilizing appropriate infection prevention practices and not removing contaminated gloves and sanitizing her hands. Glucometers were not cleansed and sanitized according to manufacturer's recommendations after use for R16 and R14. A sani wipe, which has no disinfecting properties, was utilized. Additionally, staff were unaware of the manufacturer's specifications regarding contact time to ensure glucometers were thoroughly cleansed and sanitized prior to re-use. Standards of practice were not followed when administering eye drops. Eye drops were administered to R27 without the use of gloves. Findings. It was the facility's practice to utilize a common glucometer. The glucometers were housed in every medication cart. The glucometer was utilized for all residents residing on the wing who required blood glucose monitoring. 1. On 05/09/18 at 11:31 AM, Surveyor observed RN B complete an accucheck and subsequently administer insulin to R12. R12 was noted to be on precautions related to [MEDICAL CONDITION] infection. RN B gathered her supplies from her medication cart including a glucometer and small plastic bin containing gauze, accucheck strips, and alcohol wipes. RN B entered R12's room. RN B placed her supplies directly on R12's over-the-bed table. There was no barrier placed. RN B obtained R12's insulin pen from a locked cabinet in R12's room. RN B placed the insulin pen directly onto R12's over-the-bed table. There was no barrier placed. RN B donned a pair of gloves. RN B gathered R12's insulin pen and a disposable needle. RN B placed the sterile disposable needle onto the end of R12's insulin pen. RN B did not cleanse the end of R12's insulin pen with alcohol prior to placing the needle. It is a standard of practice to cleanse and disinfect the end of an insulin pen prior to placing a sterile needle. Insulin pens are used multiple times. The end of the pen is considered contaminated. RN B obtained a blood sample utilizing a glucometer to obtain a blood glucose reading. Once the blood sugar was completed, RN B removed one glove, obtained the insulin pen in her contaminated gloved hand and bin in her other hand and returned to her medication cart. RN B set the bin as well as the insulin pen on the top of her medication cart and viewed R12's electronic medication record. RN B did not cleanse either the bin or R12's insulin pen prior to setting them on the top of her cart. RN B did not remove her contaminated glove and sanitize her hands once the completed R12's blood glucose monitoring. RN B gathered R12's insulin pen in her contaminated gloved hand, entered R12's room, donned one glove onto her ungloved hand, and administered R12's insulin. RN B removed her gloves, and returned R12's insulin pen into the cabinet in R12's room. RN B did not cleanse R12's insulin pen prior to placing it into the cabinet. RN B returned to her medication cart and placed the bin containing her accucheck supplies into her medication cart. RN B did not cleanse the bin prior to placing it back into her cart. RN B had multiple breeches in infection prevention practices. R12 also had a [MEDICAL CONDITION] infection. RN B practices had significant potential to transmit disease and infection. On 05/09/18 at 1:10 PM, Surveyor spoke with the Director of Nursing (DON). Surveyor shared the observations as noted of RN B. The DON indicated she expected staff to follow their infection prevention policies including placing barriers, removing contaminated gloves and sanitizing hands, and ensuring any contaminated surface or object was cleansed and sanitized appropriately. 2. On 05/08/18 at 11:30 a.m., Surveyor observed RN E obtain an accucheck for R16. RN E gathered the glucometer housed in her medication cart, entered R16's room, obtained a blood sample via the glucometer, and exited R16's room. RN E gathered a sani wipe and cleansed the glucometer and placed it on the top of her medication cart. Surveyor noted the glucometer stayed wet for less than one minute. Surveyor spoke with RN E after the observation. RN E indicated residents did not have their own glucometer and glucometers were shared between residents. Surveyor asked RN E why she used a sani wipe to cleanse the glucometer. RN E stated they were supposed to be using the bleach wipes; however, she knew from her schooling bleach should not be used as it created a film on the glucometer. On 05/08/18 at 5:09 P Surveyor spoke with Licensed Practical Nurse (LPN) D about the facility's practice for cleansing and sanitizing glucometers. LPN D indicated there were two types of cleansing wipes in their medication carts. One being the sani wipes and the other bleach wipes. LPN D indicated the bleach were used to disinfect surfaces including glucometers. LPN D indicated sani wipes were used to cleanse skin. Surveyor asked LPN D if she used sani wipes to cleanse and disinfect glucometers. LPN D stated no as the sani wipes don't have same germ killing properties. Surveyor asked LPN D what the required contact time was when sanitizing glucometers with the bleach wipes. LPN D indicated she did not know. Surveyor observed the sani wipe directions for use. The directions indicated the sani wipes were to be used to cleanse skin. The indications for use did not include sani wipes could be utilized for disinfecting. Surveyor reviewed the manufacturer's instructions for the facility's glucometers. The instructions indicated bleach or peroxide were to be used to cleanse and disinfect the glucometers. The specifications also indicated there was a specific contact time required for each specific disinfectant used. Surveyor observed the bleach wipes the facility was utilizing. The directions for use indicated for thorough cleansing and disinfecting the glucometer needed to be completely wiped down with the bleach wipe followed by a 4 minute contact time where the glucometer was to be kept visibly wet with the bleach solution for 4 minutes. Neither nurse was aware of the appropriate infection prevention practices to ensure safe use of glucometers. On 05/09/18 at 10:41 AM, Surveyor spoke with the DON and RN C. The DON indicated staff should be adhering to their policy for cleansing and disinfecting glucometers. The DON indicated this included the use of bleach wipes and contact time according to the manufacturer's directions. 3. On 05/08/18 at 6:50 a.m., Surveyor observed RN A perform testing for blood sugar for R14. RN A took R14 to a sink in the common area and washed R14's hands. She then returned her to the medication cart in the common area. The blood glucose monitor had been taken from a plastic container lined with a paper towel, and placed on the top of the medication cart without a clean barrier beneath. RN A did not clean and sanitize the blood glucose monitor before using it for R14. RN A donned gloves and performed the test. Surveyor observed RN A place the blood glucose monitor back in the plastic container without cleaning and sanitizing it. Surveyor asked RN A if each resident has their own designated blood glucose monitor, and RN A stated there is one on the medication cart for all diabetic residents. They used to each have their own. On 05/08/18 at 11:00 a.m., Surveyor interviewed RN A and asked how many residents with diabetes reside on the dementia care unit. RN A stated there were two, R14 and another resident. Surveyor asked RN A to explain how the blood glucose monitor is cleaned and sanitized. RN A stated, We have the clean wipes. After we take the blood sugar we clean it with bleach wipes. Surveyor told RN A that Surveyor did not see RN A clean and sanitize the blood glucose monitor before or after using it for R14. RN A verified this. Surveyor asked when the blood glucose monitor was used next. RN A stated she used it for the other diabetic resident at 8:15 a.m., and she had cleaned it before using it on the other resident. Surveyor asked RN A to explain the process for cleaning and sanitizing the blood glucose meter. RN A stated, If there is time we rub it until the wipes get dry. If a short time, we wipe it for 15 - 30 seconds. RN A verified the nurse uses the same blood glucose monitor for all residents who need their blood sugar tested , and stated, We used to have them in resident rooms. Now we just have one. 4. Observation of eye drop administration On 05/08/18 at 7:15 a.m., Surveyor observed RN A instill [MEDICATION NAME] 0/15% eye drop into R27's right eye. RN A washed her hands, and then instilled the eye drop into R27's right eye without first donning gloves. On 05/08/18 at 11:00 a.m., Surveyor interviewed RN A and noted she had not worn gloves to instill the eye drop. RN A verified she had not worn gloves, stating, I forgot to put them on. Surveyor spoke to the DON on 05/09/18, and asked if is to be expected that nurses wear gloves for the instillation of eye drops, and the DON stated yes. The DON provided the facility's Medication Administration Policy updated (MONTH) (YEAR) which states, 13. Infection control practices will be followed including gloves and hand washing with the administration of eye drops .

Based on observation and interview, the facility did not prepare or distribute food to ensure sanitary preparation and serving. The facility staff did not serve items in a sanitary manner. The facility ovens were unclean. This had the potential to affect 43 of 44 residents who dine in the facility. This was evidenced by: On 06/21/17 at 7:30 a.m., Surveyor observed Server C during the breakfast food service. Prior to beginning the service, Server C preformed hand hygiene and donned vinyl gloves. Server C then removed a plastic wrapped loaf of bread from the refrigerator by grasping the outside handle. After placing the loaf of bread on the counter, Server C removed several pieces of paper wrapping from the counter and, using the foot mechanism but also lifting the lid manually with her left hand, placed the pieces of paper wrapping into the garbage can. Then without performing hand hygiene or changing gloves, Server C removed two pieces of bread by hand and placed them into the toaster. When the bread was toasted, Server C removed the bread by hand, placed the toast on a plate, buttered, and served the toast to a resident. Server C then touched the edge of the steam table, the counter and the steam table lids. Then without performing hand hygiene or changing gloves, Server C opened the refrigerator by hand and removed a container of strawberries. Without changing gloves or performing hand hygiene, Server C opened a drawer and removed a knife. After removing a knife, Server C sliced the strawberries by hand into a bowl. Server C then placed the stems into the garbage can without touching the lid; however, Server C did not remove gloves or perform hand hygiene either before or after preparing the strawberries. Server C then removed two slices of bread by hand from the loaf of bread on the counter. When the bread was toasted, Server C, via hand contact, removed the toast from the toaster, placed the toast on a plate, buttered the toast and served it. Server C was observed several times preparing toast by removing the bread by direct hand contact after touching other surfaces such as the edge of the steam table, the counter and the outside handle of the refrigerator. At 8:15 a.m., Surveyor observed Server C while serving a waffle. Using tongs, Server C placed a waffle onto a plate. After placing the waffle onto a plate, Server C quartered the waffle by turning it on the plate and slicing it with a knife by stabilizing the waffle with her left hand. Server C then served the waffle to the resident. Server C then removed gloves and performed hand hygiene. Surveyor reviewed a policy entitled Bare Hand Contact with Ready to Eat Foods. The policy stated, in part, .the purpose of this policy is to provide residents with foods that are free from contamination .staff members will be provided with clean gloves, deli papers, and a clean knife or fork this is to assure a physical barrier between you and your clean hands and ready to eat foods .wash hands between any cross contamination during your meal preparations .change gloves often . Surveyor interviewed the Nursing Home Administrator (NHA). The NHA stated that the facility policy was to use deli paper or tongs for food handling. Dirty Ovens and Microwave On 06/20/17 at 9:45 a.m., Surveyor completed the initial tour of the kitchen with Dietary Manager (DM) A. Surveyor observed the Southbend Oven doors and inside of the oven were soiled with burnt debris and grime. The inside of the Vulcan oven was soiled with burnt debris. Surveyor requested the cleaning schedules of the ovens. The schedules documented the ovens are to be cleaned every week. The ovens were not cleaned on 05/29/17 and were last cleaned on 06/04/17. On 06/20/17 at 2:30 p.m., Surveyor observed the microwave on the 3rd floor Willow River household unit to be food soiled. Surveyor interviewed Resident Assistant (RA)/Server B who stated the microwave is cleaned weekly by the RA/servers. On 06/20/17 at 7:30 a.m., Surveyor requested the cleaning schedules for the microwave. Certified Dietary Manager (CDM) A provided Surveyor with cleaning schedules that documented the microwave is cleaned daily. CDM A stated the microwave is cleaned daily and as needed.

Based on interview and record review, the facility did not ensure each resident's drug regimen is free from unnecessary drugs, without adequate indications for use. This occurred for four of eleven residents (Residents (R) 1, 10, 7, and 4) who were reviewed for unnecessary medications. 1. R1 was tested and given an antibiotic for a urinary tract infection without clinical rationale for use, and without documented signs or symptoms of having this type of infection. 2. R10 has an indwelling catheter. The resident was tested and given an antibiotic for a urinary tract infection without clinical rationale for use, and without documented signs or symptoms of having this type of infection. 3. R7 was administered an antibiotic without indications for use. 4. R4 was administered an antibiotic without indications for use. This is evidenced by: According to the Centers for Disease Control (CDC) campaign, and the American Medical Directors Association (AMDA), Long term care facilities should have clear policies and procedures to ensure patients are not started on antibiotics without a credible clinical picture. Facilities should establish minimum criteria for initiating antibiotics, using the McGeer, Loeb, or modified Loeb criteria as a starting point (AMDA Common Infections in the LTC Setting, 2011). On 06/22/17, Surveyor received and reviewed a facility policy, entitled Antibiotic Stewardship. The policy, dated 2015, states the following, in part: .Antibiotic stewardship involves a system that will lead staff and practitioners to follow a process to identify the microbe responsible for disease .selection of the appropriate antibiotic with documentation to indicate the indication for use and rationale and to ensure that the antibiotic is discontinued when no longer needed .Medical Director: Responsible for ensuring standards on antibiotic prescribing for quality are set and followed for the care of residents in the facility. DON (Director of Nursing): Responsible for ensuring proper Policies, Procedures and Protocols for care are in place to include the entire nursing process (assessment, plan, implementation and follow-up) for use of antibiotics in the care of the residents .will include adequate education and monitoring, to ensure the process is implemented . 1. On 06/20/17 at 2:07 p.m., Surveyor reviewed R1's medical record. The resident is always continent of bladder function. On 04/20/17, R1 had an appointment with a physician. The physician's progress note states, in part: Reason(s) for Today's Visit: Dementia .Urinary incontinence .Recommended Lab Test(s) UA Conditional UC (Urine Analysis, Urine Culture) .Patient looks like she has UTI (Urinary Tract Infection). Culture pending. Let's go ahead and treat her with Bactrim DS (an antibiotic) .bid (twice a day) x 3 days. Check her culture when returns to ensure that it was sensitive to this med .(UA/UC Result) Bact (Bacteria): Many . The UA/UC identified the resident's urine had many bacteria, which indicated the resident had a possible UTI. R1's nurses' notes for 04/20/17 states, in part, .Resident is afebrile (without fever), no reports of pain for burning with urination (some symptoms of a UTI) .Current Treatment: Bactrim DS BID x3 days . There is no documentation the resident had any symptoms of a UTI in the medical record. Surveyor reviewed R1's bladder voiding patterns, from 04/01/17 to 04/20/17. The resident was always continent of bladder function during this time, except for being incontinent one time, on 04/18/17. There is no other documentation the resident was incontinent of bladder function. The resident's medical record identifies R1 received the first dose of the antibiotic, on the evening shift of 04/20/17, until the morning shift of 04/23/17. There was no culture and sensitivity results in the resident's medical record, to determine if the bacteria present in R1's urine was susceptible to the Bactrim medication. R1 was checked for a UTI without having any signs or symptoms of this type of infection. The resident was then administered an antibiotic medication for a UTI, prior to the results of the urine culture and sensitivity report. 2. On 06/21/17, Surveyor reviewed R10's medical record. The resident has an indwelling Foley catheter. Surveyor reviewed R10's nurses' notes, from 05/01/17 to 05/20/17. On 05/21/17, the notes state the following, in part, New order from NP (Nurse Practitioner) for Keflex (an antibiotic) 500 mg (milligrams) .BID x5 days for UTI . There is no documentation the resident had any signs or symptoms of a UTI in the medical record. The resident's medical record identifies R10 received the antibiotic for five days. On 06/22/17 at 7:10 a.m., Surveyor interviewed the DON. The DON stated the facility does not typically start a resident on an antibiotic medication before the culture and sensitivity results for a UA/UC returns. The DON stated a culture and sensitivity was never ordered for R10, and the physician ordered the UA/UC due to the resident having urinary incontinence. The DON stated the facility's NP started R10 on an antibiotic for a UTI, without any documented rationale for the antibiotic's use. The DON indicated there was no documentation in the medical record to show R10 was having any signs or symptoms of a UTI. The DON indicated the facility follows the McGeer standard of practice criteria when testing a resident for a UTI. According to the McGeer et al 2012 standards of practice, a resident without a catheter should be tested for a UTI when the following are present, in part: 1. At least one of the following signs or symptoms subcriteria: a) Acute painful urination, acute pain . b) Fever .and at least one of the following urinary tract sub criteria: i. Acute costovertebral angle pain or tenderness (around the kidneys) ii. Suprapubic (central, lower part of the abdomen) pain iii. Gross hematuria (visual blood in the urine) iv. New or marked increase in incontinence v. New or marked increase in (urinary) urgency vi. New or marked increase in frequency c) In absence of fever .then two or more of the following urinary tract criteria: i. Suprapubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urinary urgency v. New or marked increase in frequency . According to McGeer et al 2012 standards, a resident with an indwelling catheter should be tested for a UTI when the following are present, in part: 1. At least one of the following signs or symptoms sub criteria: a) Fever, rigors (shaking chills), or new onset [MEDICAL CONDITION] (abnormally low blood pressure), with no alternate site of infection b) Either acute change in mental status or acute functional decline, with no alternate diagnosis . c) New-onset Suprapubic pain or costovertebral angle pain or tenderness d) Purulent (pus) discharge from around the catheter or acute pain, swelling, or tenderness of the testes .or prostate . 3. On 06/20/17 at 1:00 p.m., Surveyor reviewed R7's medical record. On 10/31/16, the physician ordered [MEDICATION NAME] 100 milligrams (mg) at bedtime for UTI (Urinary Tract Infection) [MEDICATION NAME]. There is no documentation in the medical record of indication for the use of this medication. On 06/21/17 at 3:20 p.m., Surveyor requested documentation from the DON of the indication for the use of [MEDICATION NAME] antibiotic for R7. On 06/22/17 at 7:10 a.m., the DON told Surveyor the facility had no documentation of the indication for the use of [MEDICATION NAME] antibiotic for R7. The DON stated they would now start the use of a new audit form for [MEDICATION NAME] use that would include the need to document appropriate diagnosis, risk and benefits discussed with the resident and/or legal representative, justification for use, care plan to reflect non-pharmaceutical interventions and documentation of absence of adverse effects related to [MEDICATION NAME] antibiotic use. 4. R4's [DIAGNOSES REDACTED]. On 06/21/17 at 12:15 p.m., Surveyor reviewed R4's medical record. The record indicated that on 04/20/17, R4 was irritable and yelling when touched. Preferred music intervention was effective in calming R4. On 04/24/17, R4 was yelling at staff, striking and kicking at staff with cares. Once cares were complete, R4 calmed. On 04/27/17, the documentation showed that R4 was awake throughout the night, and was agitated and hallucinating. R4 appeared exhausted and red in the face. The nursing staff attempted to obtain vital signs, but R4 would not allow the staff to obtain accurate readings. Attempts by the staff to assist R4 with a bed bath were unsuccessful, due to R4's refusal and screaming. R4 was provided with 1:1 monitoring and any attempts at assisting R4 with food, fluids or medications was refused. Music therapy was attempted and was not successful. On 04/28/17 at 10:47 a.m., the documentation said: Res (sic) left alone in safe setting and was able to self sooth and calm down which was effective. The next entry, at 2:45 p.m., read: Physicians Order Note: CBC (Complete Blood Count), BMP (Basic Metabolic Profile) and a Urinalysis (a test of the urine to determine infection) with culture (a test to determine the type of microorganism present in the urine) related to increased sleepiness, behaviors and urinary frequency. There was no documentation to indicate that R4 was experiencing urinary frequency. On 04/29/17 at 5:48 p.m., a physician's orders [REDACTED]. At 10:09 p.m., a nurses note read: Res (sic) afebrile, temp (sic) 97.8. Res denies dysuria. No s/sx (signs or symptoms) of pain. Res had no behaviors or hallucinations this p.m. Res noted to seem sleepy and refused dinner. Surveyor reviewed R4's laboratory results from the urinalysis collected on 04/29/17. The urinalysis indicated that the final report showed urogenital flora, which is a normal component of the urogenital tract. On 05/03/17, a physician's orders [REDACTED]. On 06/22/17 at 9:45 a.m., Surveyor interviewed the DON and NHA. The DON stated that the facility follows McGeer (a standard of practice for infection control) guidelines to determine antibiotic use. The DON admitted that R4 received the antibiotic from 04/29/17 to 05/03/17 without proper indications for use, since R4's urinalysis did not meet the McGeer criteria for a urinary tract infection: In absence of fever .then two or more of the following urinary tract criteria: i. Suprapubic pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urinary urgency v. New or marked increase in frequency.

Based on observation, interview and record review, the facility did not provide necessary treatment and services to promote healing, prevent infection and prevent new open areas from developing for 2 of 2 residents (Residents #3 and #5) reviewed with pressure ulcers and 1 resident at high risk for pressure ulcers (#6). 1. Resident #3 developed three stage III facility acquired pressure ulcers. The facility did not upgrade a chair cushion according to the pressure ulcer stage. The facility did not use aseptic technique when providing wound care to prevent infection. 2. Resident #5 developed a stage IV facility acquired pressure ulcer. The facility did not upgrade a chair cushion according to the pressure ulcer stage. The facility did not reposition the resident per the resident's care plan. The facility did not use aseptic technique when providing wound care to prevent infection. 3. Resident #6 is at high risk for pressure injury and facility nursing staff did not repositon every two hours per the current plan of care. This is evidenced by: 1. On 06/15/16, Surveyor reviewed Resident #3's medical record. Resident #3 has [DIAGNOSES REDACTED]. On 02/07/16 per the time line provided by the facility: the Braden Scale for pressure ulcer risk scored Resident #3 at a 14 for moderate risk for skin integrity issues with loss of sensation and some independent function of bilateral upper and lower level extremities. Resident #3 had blanchable redness noted to buttocks after two hours of sitting in recliner. Resident #3 made frequent small changes in position but was unable to make significant changes. Resident #3 was a one assist with stand lift for all transfers. On 02/16/16, per the Minimum Data Set (MDS), Resident #3 was alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15. Resident #3 was at risk for development of pressure ulcers and did not have any pressure ulcers. Resident #3 was not able to ambulate and required extensive assistance of two staff with bed mobility, transfers, dressing and toileting. Resident #3 had limitations in both upper and lower extremities on both sides. On 03/15/16, per the facility's time line, a body audit was completed and found Resident #3 to have no Macerated Associated Skin [MEDICAL CONDITION] (MASD). On 03/16/16, the nurse's note stated Resident #3 was unable to use her arms. Resident #3 was occasionally incontinent of urine and bowel. Resident #3 wore incontinent pads at all times. On 03/18/16, per the facility's time line, Resident #3 sat in a broda chair and had a full air mattress on the bed. Res (Resident) is confined to chair. No s/sx (signs or symptoms) of infection. Area appears macerated . (The product information states the air mattress was appropriate for stage III to stage IV wounds.) On 03/18/16 at 2:05 p.m., the nurse's note stated, Upon changing pad, staff noticed two red, open areas to coccyx. (No measurements are documented in the medical record.) On 03/18/16, Resident #3's care plan had the following interventions: Broda chair- encourage me to sit in it during the day. Encourage me to lay down in bed during the day. New air mattress and w/c cushion provided by hospice. On 06/20/16 at 1:00 p.m., Surveyor requested the measurements of the open areas found on 03/18/16. The Interim Director of Nursing (IDON) stated the nurse did not document the measurement. On 03/23/16 per the Wound Assessment Flow Sheet, Resident #3 had MASD on the coccyx measuring 1.6 centimeters (cm) by 0.5 cm. with 100% granulation, no drainage, surrounding skin intact but with macerated and [DIAGNOSES REDACTED]tous, no undermining/tunneling and no odor. Current treatment was [MEDICATION NAME]. Res noted to have MASD to buttocks. Res noted to have physical decline due to dx of spinal stenosis of cervical region. Res reports being unable to tell when she has to use bathroom and is not always sure when she is done going. Res is noted to be more incontinent of B&B (Bladder and Bowel) and wears incontinence products at all times. Area is healing well with current tx: [MEDICATION NAME]. Change weekly and PRN. On 03/30/16 per the Wound Assessment Flow Sheet, Resident #3 had MASD on the coccyx measuring 8 cm by 9 cm. with 100% granulation, moderate serous drainage, surrounding skin intact but with macerated and [DIAGNOSES REDACTED]tous, no undermining/tunneling and foul odor. Current treatment was [MEDICATION NAME] three times per day. Open area resolved. Area remains red and has MASD noted without any open areas. Heavy drainage with foul odor noted. New TX order. [MEDICATION NAME] TID (three times per day) to buttocks. Will cont. (continue) to monitor. On 03/30/16, per the facility's time line, the open areas had resolved. MASD was noted without open areas. On 03/30/16 per the Wound Assessment Flow Sheet, Resident #3 had MASD on the coccyx measuring 8 cm by 9 cm. with 100% granulation, moderate serous drainage, surrounding skin intact but with macerated and [DIAGNOSES REDACTED]tous, no undermining/tunneling and foul odor. Current treatment was [MEDICATION NAME] three times per day. On 03/31/16, per the facility's time line, Resident #3 was admitted to hospice due to cervical stenosis slowly taking away physical abilities to control extremities and ability to control bowel and bladder. On 04/03/16, per the facility's time line, Braden- Res (Resident) currently at high risk for skin integrity issues with braden score of 12 d/t (due to) loss of sensation and some independent functions of BUE's (Bilateral Upper Extremities) and BLE(Bilateral Lower Extremities). Res currently has open area to buttocks Res with indwelling urinary catheter and wears incontinent pad and is incontinent of bowel . Res currently requires assist of 2 with stand lift for transfers/repositioning. Res always ask to be toileted but cannot feel/ without sensation to defecate . On 04/04/16, per the facility's time line, Open area remains present with maceration. Foley remains present controlling some moisture. Full air mattress and sits in Broda during day. On 04/06/16 per physician orders, Continue [MEDICATION NAME] to buttocks, mix with HC 1% apply to buttocks and cover with calmo TID (three times per day). The MDS, dated [DATE], documented Resident #3 was totally dependent on staff for bed mobility, transfers, dressing and toileting. Resident #3 continued to have limitations in both upper and lower extremities on both sides. The Care Area Assessment stated, Pressure ulcer CAA triggered r/t skin breakdown. Resident is noted to have MASD to her buttocks. Resident is noted to have recently admitted to hospice r/t severity of spinal stenosis. Resident has a dx of spinal stenosis, dysphagia, lymphedma, right BBB (Bundle Branch Block),[MEDICAL CONDITION](Hypertension), hearing loss.[MEDICAL CONDITIONS] Reflux Disease, depression, chronic pain, postural kyphosis, and hx of falls. Resident is currently dependent on staff for the completion of ADL's (Activities of Daily Living). Resident is unable to move her arms independently and has very limited voluntary movement of legs. Resident requires a full lift with staff assistance for transfers and toileting. Resident needs assist of 1 staff for w/c mobility and 2 staff for repositioning. Resident is alert and oriented, able to make needs known. On 04/06/16, per the Wound Assessment Flow Sheet, Resident #3 had a macerated area measuring 8 cm by 9 cm with 100% granulation, moderate serous drainage, surrounding skin intact but with macerated and [DIAGNOSES REDACTED]tous, no undermining/tunneling and foul odor. Current treatment is HTC cream and [MEDICATION NAME] cover with calmo. On 04/11/16, the nurse practitioner note stated, She has had a progression of her spinal stenosis in which she is no longer able to use her arms. She has lost sensation in her legs, she is no longer able to feel the urge to urinate and defecate . Neurological- paralysis distal to proximal pattern, bilat upper extremities, bilat lower extremities, c/o parathesia loss of mobility due to progressive [DIAGNOSES REDACTED]. On 04/13/16, per the facility's time line, Area almost healed, blanchable redness present. Maceration present. On 04/13/16, per the Wound Assessment Flow Sheet, Resident #3 had a macerated area measuring 4 cm by 4 cm with 100 % granulation with no drainage. Surrounding skin was intact but with [DIAGNOSES REDACTED]tous, no undermining/tunneling and no odor. On 04/20/16, per the facility's time line, Appears to be healing. Encouraging to lay down in bed during the day. New air mattress and w/c cushion provided by hospice. On 04/27/16, per the facility's time line, No longer macerated, now has an open area 2.5 by 1.5 cm. Resident continues to refuse to lay down in bed during the day. Dressing orders: [MEDICATION NAME] to wound bed. ABD over [MEDICATION NAME], no tape, change daily and PRN (as necessary). On 06/20/16 at 1:00 p.m., the IDON told Surveyor the open area was a stage II pressure ulcer. On 04/27/16, per the Wound Assessment Flow Sheet, Area is no longer macerated however one area is now noted to be an open area. Wound bed is pink tissue at this time . Resident cont (continues) to refuse to lay down in bed during the day. Res sits in broda chair throughout the day and evening. New dressing [MEDICATION NAME] to wound bed, place ABD over [MEDICATION NAME]- no tape. Change daily On 04/29/16 per physician order, Change dressing order to: [MEDICATION NAME] to wound bed, place ABD pad over [MEDICATION NAME] - no tape. Change daily PRN. On 05/02/16, per the facility's time line, Encouraged to lay down in bed throughout day. No change in dressing. On 05/02/16, per the Wound Assessment Flow Sheet, Area is 2 by 1.6 cm. Res sits in Broda chair during day. Writer encouraged res to lay down in bed through out day to get off of pressure area. Will continue current dressing- [MEDICATION NAME] to wound bed and cover with ABD. Change daily and PRN . On 05/09/16, per the facility's time line, Wound bed noted to be pink tissue with granulation tissue present. Res continues to refuse to lay down during day. On 05/09/16 per the Wound Assessment Flow Sheet, Area is 2.4 by 2 cm. Wound bed is noted to be pink tissue. Serous drainage present. Res continues to refuse to lay in bed during day. Will continue with current dressing On 05/18/16 per the Wound Assessment Flow Sheet, Area is 3 x 1.4 cm .Wound bed noted to be 100% slough. Res also noted to have a bilateral open area to left buttocks. Wound bed is 25% slough and 75% granulation tissue. Foul odor noted. Continue to encourage res to lay down (side to side) during day. Res refuses to lay down and refuses side to side . On 05/18/16, per the facility's time line, 100% slough- hospice was updated and did not want to change the dressing. Bilateral open area to buttocks. Continue to encourage to lay down side to side during day. Changed incontinence product to cotton underwear with liner d/t skin sensitivity. On 05/25/16 per the Wound Assessment Flow Sheet, Area to right thigh is 2.5 x 2.4 cm and 0.1 cm deep. Stage 2. Area is 50% granulation and 50% slough. Gluteal crease is 2.8 x 1.4 cm and 0.3 cm deep stage 3 50% granulation and 50% slough. L(left) buttocks is 3.3 x 2.4 cm stage 2 25% slough and 75% granulation. Right buttocks has a 1.4 x 2.4 cm blister. Dressing changed to: cleanse with NS. Apply thera honey and cover with [MEDICATION NAME], change every 7 days and PRN. Skin prep to blister and calmo to skin. No odor. No drainage .Continue to encourage res to lay down in bed side to side . On 05/25/16, the physician ordered the following wound treatment: Cleanse pressure ulcers with NS (Normal Saline), apply therahoney and cover with non-adherent [MEDICATION NAME] Q (every) 7d (days) and PRN (as necessary). Apply sure-prep no sting barrier wipe to blisters. Apply calzime cream to surrounding skin one time a day every 7 days for pressure ulcers. On 05/25/16, per the facility's time line, Open area to right thigh. Dressing -NS(Normal Saline), apply thera-honey, cover with optiform, change every 7 days and PRN. Blister also noted- skin prep to blister. Calmo to surrounding skin. On 06/01/16, per the facility's time line, Blisters resolved. 2 new open areas below coccyx (gluteal crease) ulcer, Hospice updated. Continue dressing and laying down in bed. On 06/01/16 per the Wound Assessment Flow Sheet, Area to right thigh is 3 x 1.5 x 0.1 cm. Granulation 50 % granulation and 50% slough. Gluteal crease is 2.3 x 1.5 cm 25% granulation and 75% slough. Below gluteal crease area is a 1.0 x 0.5 and 0.5 x 0.5 cm stage 2 pressure ulcer. L (Left) buttocks is 3.5 x 1.8 cm granulation 75% and 25% slough. Will continue current dressing. Will continue to encourage laying in bed and side to side. No odor present. Serosangninous drainage present. On 06/01/16 per the nurse practitioner note, The resident has developed progressive stage 3 pressure ulcers in spite of optimal care .Initially she had minor skin breakdown moisture related due to urinary incontinence, in which a foley catheter was placed in aid in reducing moisture and allow healing .Wound #1 left buttocks 3.5 cm x 1 cm 75% granulation and 25 % slough present. Moderate amount of serosanguinous drainage with [DIAGNOSES REDACTED]tous surrounding tissue. No tunneling or undermining present. Wound #2 coccyx 2.8 cm x 1.5 cm x 0.3 cm. 50% granulation and 50 % slough present. Moderate amount of serosanguinous drainage with [DIAGNOSES REDACTED]tous surrounding tissue. No tunneling or undermining present. Wound #3 coccyx right thigh 2.0 cm x 1.5 cm x 0.1 cm 50% granulation and 50 % slough present. Moderate amount of serosanguinous drainage with [DIAGNOSES REDACTED]tous surrounding tissue. No tunneling or undermining present. The pressure ulcers were unavoidable due to progression of cervical spinal stenosis with [DIAGNOSES REDACTED]. She has co-existing signs and symptoms of automonic dysreflexia affecting respiratory, bowel, bladder and musculoskeletal systems. The likelihood of healing is low based on the palliative care healing probability assessment tool. She has had a significant decline in functional status .She has a lack of sensory perception, neurongenic bowel and bladder; with urinary and fecal incontinence. She is non-ambulatory; spending 20 or more hours in a dependent position. She has the inablitiy to perform ADL's independently due to decreased ROM in upper and lower extremities that is non-responsive to therapy. She had [MEDICAL CONDITION] due to worsening circulation, She has chronic shortness of breath with 3-4 word dyspnea, requiring oxygen at times; labs show she is hypercapnic. All of which plays a role in the bodies abiltiy to heal. The goal at this point is not healing, its to maintain quality of life and dignity. She is followed by a wound care certified hospice nurse. On 06/08/16 per the Wound Assessment Flow Sheet, Area to R thigh is 3 x 2 x 0.2 cm 50% granulation 50% slough. Moderate serosanguinous drainage. Foul odor present. Area to gluteal areas is 2 x 1.5 x 0.3 cm 50% slough/ 50% granulation. No open areas below gluteal crease area resolved,. Area to left buttocks is 3.5 x 2 cm 75% granulation and 25% slough. Will continue with current dressing. Cleanse with NS, apply thera honey with cover with [MEDICATION NAME]. Change every q days/PRN. Calmo to surrounding skin. On 06/08/16, per the facility's time line, 2 open areas resolved. Hospice updated- continue same dressing. On 06/15/16 per the Wound Assessment Flow Sheet, Area to right thigh is 3.5 x 2 cm 50 % granulation 50% slough. Area to coccyx is 2.5 x 1.5 cm 50 % granulation 50% slough. Area to left buttocks is 3.3 x 2.5 cm 75% granulation 25% slough. Foul odor. On 06/15/16, per the facility's time line, No change. Hospice updated- recommendation for [MEDICATION NAME] powder to wound bed. Resident #3's current care plans provided to Surveyor on 06/15/16 included, Maceration to Buttocks has the following interventions: Broda chair- encourage me to sit in it during the day. Encourage me to lay down in bed during the day. New air mattress and w/c cushion provided by hospice with revision date of 04/20/16. I have an ADL Self Care Performance Deficit care plan- Skin inspection- I ask that you observe my skin during cares for redness, open areas, scratches, cuts bruises and report changes. Bed /Chair mobility: Assist of 2 every 3 hours. The current Certified Nursing Assistant (CNA) care plan states Reposition: A-2 (Assist of 2) every 3 hours. Encourage me to lay down in bed during the day. On 06/17/16 per the nurse practitioner note, Despite repositioning, decreasing excess moisture, pressure relieving devices and efforts to promote adequate nutrition she still has minimal to no healing to pressure ulcers. The pressure ulcers were unavoidable they are due to skin failure in end-of-life and other comorbidities. On 06/17/16 per the hospice wound certified nurse, 1. Left buttocks: healing stage 3 pressure ulcer. No slough observed today. 100% granulation tissue measurement: L 2.5 cm x W 1.5 cm x 0 depth. 2. Coccyx: stage 3 pressure ulcer measurement: L 2.5 cm x W 2.0 x 0.2 cm 50% slough, 50% granulation tissue. Drainage unable to determine amt/type d/t treatment of [REDACTED]. R thigh posterior stage 3 pressure ulcer measurement: L 0.5 cm x W 2.7 cm x 0 cm slough 75%, granulation 25%. 4. Periarea- fungal infection mid buttocks to inner groin. Skin discolored maroon and has yeast odor. New order for [MEDICATION NAME] 500 milligrams 3 x day. Based on my clinical assessment, the pressure ulcers were unavoidable. Res had received individualized preventative cares. Due to [DIAGNOSES REDACTED]. On 06/20/16 at 1:00 p.m., Surveyor interviewed the IDON and Registered Nurse (RN) N, who stated the resident currently had three stage III pressure ulcers. The IDON stated the pressure ulcers were unavoidable due to Resident #3's diagnoses, decrease in intake and mobility and age. RN N stated prior to Resident #3 having skin breakdown, Resident #3 was using a pressure reducing mattress and was sitting in a broda chair with no cushion. The staff were also offering every two to three hours of repositioning. On 03/18/16, Resident #3 was provided with an air mattress which was appropriate to treat stage III - stage IV pressure ulcers. On 04/20/16, hospice provided Resident #3 with a new air mattress which was appropriate to treat stage III - stage IV pressure ulcers and a Roscoe Gel Wheelchair cushion. Surveyor requested and received product information related to the Roscoe Gel Wheelchair cushion, which stated the cushion was designed to assist in the prevention of pressure ulcers. Surveyor asked if the facility had used other chair cushions in the broda chair. RN N stated, No. The IDON stated Resident #3 was offered repositioning every two to three hours but often refuses. RN N stated the facility started offering repositioning every two hours on 06/17/16. Surveyor asked if any wound cultures had been performed. The DON provided information to Surveyor that labs were done on 03/27/16 but they did not include a wound culture. On 06/21/16 at 9:00 a.m., Surveyor informed the Nursing Home Administrator (NHA) of the surveyor's concerns related to Resident #3's cushion not appropriate for stage of wound. On 06/21/16 at 10:00 a.m., RN N informed Surveyor that she had given the surveyor the wrong information related to type of wheelchair cushion used. RN N stated the cushion Resident #3 was provided on 03/18/16 and still using is a JAY DUO cushion. RN N provided Surveyor with the product information, which states the product provides optimal comfort and skin protection without affecting seat-to-seat floor height for the client with moderate risk of skin breakdown, who requires mild positioning. RN N further stated hospice has now ordered a different cushion for Resident #3, which the facility has not received. On 06/21/16 at 10:10 a.m., RN M stated a new cushion was ordered and on its way that was appropriate for Resident #3. WOUND CARE The facility's policy and procedure entitled Pressure Ulcer Policy and Procedure, dated 02/2016, states in part, Procedure for Dressing Change:14. Put on gloves. Loosen tape and remove dressing. 15. Pull glove over dressing and discard into plastic bag. 16. Wash hands. 17. Put on gloves. 18. Cleanse with Normal Saline from the center of the wound to the outer edges. 19. Dry the skin surrounding the pressure ulcer by patting with gauze .21. Apply skin sealant to surrounding intact skin as ordered or per house orders. 22. Dress the pressure ulcer with the prescribed dressing . On 05/25/16, the physician ordered the following wound care: Cleanse pressure ulcers with NS (Normal Saline), apply therahoney and cover with non-adherent [MEDICATION NAME] every 7 days and PRN (as necessary). Apply sure-prep no-sting barrier wipe to blisters. Apply calzime cream to surrounding skin one time a day every 7 days for pressure ulcers. On 06/16/16 at 8:50 a.m., Surveyor observed RN P perform wound care. RN P washed her hands and placed dressing supplies on a paper towel barrier on Resident #3's bed. Resident #3's dressing had fallen off. Resident #3's buttocks were covered in blood. RN P opened the sterile [MEDICATION NAME] dressing and peeled the wrapper back. RN P had a clean gauze with therahoney applied, lying on the clean barrier. RN P gloved and squirted normal saline on a piece of clean gauze and wiped Resident #3's buttocks of blood, repeating this process three times to wipe the blood off. RN P opened a normal saline wipe packet and wiped Resident #3's ulcers, repeating this process three times. RN P did not change her gloves and continued the dressing change. RN P then applied therahoney with a clean gauze to Resident #3's ulcers. RN P then opened a packet of skin barrier and applied it to the edges of the ulcers. RN P dabbed the ulcers with clean gauze and applied the [MEDICATION NAME] dressing. RN P next applied [MEDICATION NAME] cream to clean gauze and applied it to macerated area. RN P wiped Resident #3's rectal area with a disposable wipe and dry towel. RN P then degloved and washed her hands. RN P described the ulcers as stage III with serosanguinous drainage. RN P stated she noted no odor and no tunneling of the ulcers and the wound edges looked okay. On 06/20/16 at 1:00 p.m., Surveyor informed the IDON of the observation of wound care with breaks in aseptic technique. On 06/21/16 at 9:00 a.m., Surveyor informed the NHA of the surveyor's observation of wound care. 2. On 06/15/16, Surveyor reviewed Resident #5's medical record. Resident #5 has [DIAGNOSES REDACTED]. Per revised care plan, care plan intervention of an air mattress overlay was implemented on 01/16/15 with upgraded air mattress on 02/02/16. Product information states air mattress is utilized for stage III and stage IV wounds. Repositioning with toileting every 1.5 hours was initiated on 08/20/15. On 11/21/15, per the MDS, Resident #5 had problems with short and long term memory. Resident #5 was moderately impaired for daily decision making. Resident #5 was at risk for development of pressure ulcers and did not have any pressure ulcers. Resident #5 required extensive assistance of two staff with bed mobility, transfers, dressing and toileting. On 11/24/15, the time facility time line: a Braden assessment was completed on Resident #5 which scored Resident #5 at a 14 moderated risk for skin integrity issues. Resident #5 was alert and oriented to person and confused and forgetful. Resident #5 was noted to be frequently incontinent of bladder and bowel. Resident #5 had varied intakes. Resident #5 was able to eat and drink independently after set up. Resident #5 often prefered to sit in a recliner chair during the day and slept in bed with HOB elevated at night. Resident #5 sometimes refused to sleep in bed and chose to sleep in the recliner chair at night. Resident #5 transfered with assist of two and sometimes required a sit to stand lift. Resident #5 was an assist of two with repositioning and toileting. Resident #5's heels were floated when in the recliner. Plan was to watch Resident #5's knees when in bed and encourage Resident #5 to lie down in bed for 15 minutes every AM and PM. Tissue tolerance was assessed with [REDACTED]. Care plan addressed current repositioning plan. On 01/05/16, per the facility time line, a body audit was completed and Resident #5 had no open areas. On 01/08/16, per the facility time line stated, Area found to upper coccyx. New intervention: repo side to side, repo every 1.5 hours. (Care Plan intervention of repositioning side to side in bed was documented to have been initiated on 05/22/15). On 01/08/16, per the Wound Assessment Flow Sheet, Coccyx- upper. 3 cm x 3 cm x 0 cm. Minimum drainage. serosanquinous, [DIAGNOSES REDACTED]tous, no undermining/tunneling. Border foam, skin prep and cleanse with NS. On 01/13/16, per the facility time line stated, Dressing: NS, skin prep and [MEDICATION NAME] border q (every) 5 day and PRN (as necessary). Nutritional drink BID (twice a day). On 01/13/16, per the nurse's note, Resident is noted to have a unstageable pressure ulcer to coccyx. Area is butterfly shaped; 2.5 x 2.2 cm in size at the longest point and 2.2 x 2.0 cm at the shortest. Wound has a dark area in the middle. 75% slough present. Surrounding skin is firm and blanchable. No s/sx of infection noted. Area noted to be tender upon assessment. Res has dx of Alzheimer's, muscle weakness, hs [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococus Aureus). hx of pressure ulcers, and postural kyphosis. Resident is incontinent of bowel and bladder, and wears incontinence pads at all times. Resident is an assist of 2 for every 2 hours for toileting and repositioning. Resident has an air mattress, and a coccyx cutout cushion in recliner. Resident is repositioned side to side. Resident is noted to have inadequate meal intake. Resident started on supplemental juice. New intervention: Will reposition side to side q 1.5 hours and education to staff regarding importance of repositioning. Current treatment: Cleanse area with normal saline, skin prep to wound edges, and cover with [MEDICATION NAME] border. Will change q5 days and PRN. Will continue to monitor daily. On 01/18/16, per the nurse practitioner note, Resident remains in bed, family has initiated comfort cares .Resident is taking in minimal nutrients, refusing all meals however, will eat a 1/4 of a half of toast with jelly with staff persuasion .She does have two open areas, one on her coccyx that has a sero/sang drainage; unstageable due to % of slough. The wounds characteristic butterfly shape with blue/purple hue is consistent with a Kennedy Terminal Ulcer; skin failure. She has a second wound on the left buttock. Both wounds are cleaned, skin prep applied, and dressing as needed. Patient is repositioned every 1- 1.5 hours. She is incontinent of bowel and bladder .Assessment and Plan: 1. Failure to thrive. Will continue to encourage oral intake. Comfort measures are in place. 2. Terminal Kennedy Ulcer, skin failure. Will manage with keeping the area clean and dressing changes as needed, with frequent repositioning. On 01/20/16, per the nurses' notes, Resident continues to have an unstageable pressure ulcer to coccyx. Area is same in measurements; 2.5 x 2.2 cm in size at the longest point and 2.2 x 2.0 cm at the shortest. Foul odor present. Purulent drainage on old dressing. Area is tender to touch. 100% slough. Wound border is [DIAGNOSES REDACTED]tous; surrounding skin is firm and blanchable. NP (Nurse Practitioner) in to asses, and [DIAGNOSES REDACTED]. Dressing order changed to the following: cleanse with normal saline, skin prep to wound edges, alginate to wound bed, and cover with [MEDICATION NAME] border. Change dressing q 5 days and PRN. Will continue to monitor daily. On 01/22/16, per the MDS, Resident #5 had short and long term memory problems and continued to be moderately impaired for daily decision making. Resident #5 was at risk for development of pressure ulcers and had one unstageable pressure ulcer that measured 2.5 x 2.2 centimeters (cm). Resident #3 was not able to ambulate and required extensive assistance of two staff with bed mobility, transfers, dressing and toileting. On 01/22/16, per the facility time line stated, Braden completed. Res (Resident) scored a 13 on the Braden Scale and is at moderate risk for skin integrity issues. Res alert and oriented to person. Res confused and forgetful. Res is noted to be frequently incontinent of bladder and bowel. Varied intakes noted. Res needs assistance of 1 with meals/eating. Res sleeps in bed with HOB (Head of Bed) elevated at night. Res currently has an air mattress on bed and cut out cushion in recliner. Res transfers with assist of 2 and sometimes requires sit to stand lift. Res is assist of 2 with toileting q 1.5 hours, check and change. Res requires assist of 2 with repositioning with toileting. Heels floated while in recliner. Will gatch knees while in bed and encourage res to lay down in bed for 15 minutes every AM and PM. Tissue tolerance assessed with [REDACTED]. Res is currently being treated with an unstageable pressure ulcer to coccyx. Care plan addresses current repositioning plan. Will continue to monitor and update care plan and NP as needed. On 01/27/16, per the facility time line, Increase slough and size. Dressing changed to NS (Normal Saline), santyl/[MEDICATION NAME] to wound bed, skin prep, cover with [MEDICATION NAME] border change BID (Twice a day). On 01/27/16, per the nurse's note, Resident continues to have an unstageable pressure ulcer to coccyx. Measurements: 3.1 x 2.2 cm.No odor present. Note to have moderate purulent drainage on old dressing. Area continues to be tender to touch. 100 % slough. Surrounding skin is denuded, and blanchable. Dressing order changed to the following: cleanse with normal saline, apply santyl and [MEDICATION NAME] to wound bed, skin prep to surrounding skin, and cover with [MEDICATION NAME] border. Change BID. Will continue to monitor. On 02/03/16, per the facility time line, Increase in size. Noted eschar area. Order changed following previous wound rounds by NP to calcium alginate to wound bed and cover with allevyn, change q 3 days. New dressing orders: [MEDICATION NAME], skin prep, [MEDICATION NAME] 500 mg (milligrams) tab crushed with santyl and cover with allevyn change daily and PRN. On 02/03/16, per the nurse's note, Resident continues to have an unstageable pressure ulcer to coccyx. Measurements: 3.6 x 2.1 cm and depth indeterminable. Resident also noted to have a black area proximal to ulcer, 2 x 1.3 cm in size, unblanchable. Foul odor present. Noted to have moderate purulent drainage on old dressing. Area continues to be tender to touch. 75% slough, 25% [MEDICATION NAME]. Surrounding skin is denude, and blanchable. Previous dressing order was changed following wound rounds to, calcium alginate to wound bed and covert with allevyn and change q 3 days. NP updated following wound rounds. New order: Cleanse area with Anisept, skin prep to wound edges, apply [MEDICATION NAME] 500 mg tablet crushed with Santyl 250 units/gram and cover with allevyn dressing. Change daily. Will continue to monitor. On 02/04/16, per the facility time line, New order for PT (Physical Therapy) to eval and treat as indicated. On 02/09/16, per the facility time line, PT completed eval and was an eval only. On 02/09/16, per the facility time line, Juice supplement increased to 3 x daily with comfort focus. On 02/10/16, per the nurse's note, Resident continues to have an unstageable pressure ulcer to coccyx. Measurements: 3.5 x 3.7 cm and depth indeterminable. Foul odor present. Noted to have moderate purulent drainage on old dressing. Area continues to be tender to touch. 75% slough, 25% granulation. Surrounding skin is denuded, and blanchable. Order for cleanser changed from [MEDICATION NAME] to Hibaclean

Based on observation, interview and medical record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 5 sampled residents (#15,#8,#6,#1, #5) reviewed for falls and 1 of 15 (#7)residents who had a outlet within reach while in bed. The facility did not ensure that the resident environment remained as free of accident hazards as is possible for 4 of 4 Survey days. The facility did not operationalize its wandering policy to include monitoring of exit doors, including all outside balcony and courtyard doors. All outside balcony doors were unmonitored, unlocked and unalarmed, as well as the courtyard doors on the Memory Care Unit. Based on observation and interview, the facility did not ensure that the enviornment was as free of accidents and hazards as possible for in 1 of 4 kitchenettes checked for safe water tempature. This is evidenced by: 1. Resident #15 experienced nine falls between October 2012 and January 2013. Falls were not thoroughly investigated, new interventions were not initiated after each fall and the care plan was not updated with interventions added. On 12/5/12, Resident #15 fell , resulting in a hip fracture. 2. Resident #8 fell in the facility on 07/10/13 trying to self transfer and fractured her left hip, upon return to the facility on [DATE] her safety care plan was not updated with new interventions to prevent future falls. On 08/28/13, Resident #8 tried to self transfer again, fell and broke her right hip requiring hospitalization and surgery. 3. Resident #6 fell out of his wheelchair when he was left unsupervised in his room. The follow-up note identified Resident #6 was care planned not to be in his room alone in his wheelchair for safety. 4. The facility did not ensure that the resident received adequate supervision to prevent accidents for Resident #1. The resident care plans were not updated to include specific interventions related to each fall for Resident #1. Interventions noted by the facility did not include appropriate staff monitoring or supervision to prevent falls. 5. The resident care plans were not updated to include specific interventions related to each fall for Resident #5. Interventions noted by the facility did not include appropriate staff monitoring or supervision to prevent falls. 6. Resident #7's bed was placed against the wall. Resident #7's bed was placed in the low position when she was in bed. When the bed was in the low position two wall outlets were visible. 7. The facility did not operationalize its wandering policy to include monitoring of exit doors, including all outside balcony and courtyard doors. All outside balcony doors were unmonitored, unlocked and unalarmed, as well as the courtyard doors on the Memory Care Unit. 8. Water tempatures in a common area of the facility, accessable to residents were above recommended tempatures. This is evidenced by: The facility policy titled Fall Prevention and Management Program Policy last modified on April 2012 includes in part: Purpose: To establish policy, assign responsibility and provide procedure for residents at risk for falls; to systematically assess fall risk factors... Policy: Upon admission, quarterly and with significant change in condition residents will be assessed of their risk for falls. A. Delegation of Authority 2. Clinical coordinator or designee is responsible for implementation and oversight of individualized residents fall prevention care as follows: b. Determining risk for fall and establishing appropriate interventions in the care plan related to fall risk in the plan of care c. Implementing the interventions specific to fall risk data collection. e. Evaluating interventions for effectiveness in relation to the resident specific plan of care. B. Procedure b. Upon admission, quarterly, and with significant change the Clinical Coordinator or designee will assess each resident for risk for falls using the fall assessment form... 3. Prevention Interventions/strategies b. Nursing staff will implement interventions according to resident specific risk factors. 4. Post fall management d. -Assess all factors contributing to the fall event such as environment, equipment, medication factors and which interventions were in place at the time of the fall using fall follow up form as a guideline. -Recommend interventions and changes to plan of care to prevent repeat fall. 5. Communication/Documentation d. The new intervention will be monitored for effectiveness every shift for 48 hours after implementation notation of effectiveness should occur in the medical record. 1. Resident #15 was originally admitted to the facility on [DATE] after a fall at home. Resident #15 does have a [DIAGNOSES REDACTED]." Surveyor requested the care plans being used for the time period of 10/24/12-1/1/13, including any new or updates to the care plans. The facility provided the surveyor with two care plans; the care plans are not dated, however each intervention has "date initiated" for each intervention. One of the care plans includes the following information: FOCUS: I am at risk for falls r/t unaware of safety needs, poor communication/comprehension, deconditioning, psychoactive drug use, wandering Date initiated: 5/31/2012 Revision on: 5/31/2012 GOALS: I will be free of falls through the review date. Date initiated: 5/31/2012 Target date: 11/26/2012 INTERVENTIONS: - Be sure my call light is within reach and encourage me to use it for assistance as needed. RAsst (Resident Assistant) Date initiated: 5/31/12 - Complete a fall risk assessment per protocol. Date initiated: 5/31/2012 Revision on: 5/31/2012 - Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. RAsst Date initiated: 5/31/2012 - Ensure I am wearing appropriate footwear. RAsst Date initiated: 5/31/2012 - Evaluate effectiveness of my interventions on an ongoing basis Date initiated: 5/31/2012 - Follow facility protocol. RAsst Date initiated: 5/31/2012 - Inform me, my family or responsible party about safety reminders. Date initiated: 5/31/2012 - Observe me for acute illness Date initiated: 5/31/2012 Revision on: 5/31/2012 - Observe me for side effects of my medication per policy. Date initiated: 5/31/2012 Revision on: 5/31/2012 - PT eval and treat PRN Date initiated: 5/31/2012 - See mobility care plan (this care plan identifies: independent with ambulation, independent with chair/bed mobility, bilateral grab bars for bed mobility, invite me to activity programs that encourage activity, physical mobility, PT (physical therapist), OT (occupational therapist) referrals or ordered PRN, independent with transfers Date initiated: 5/31/2012 - See toileting care plan (there was no toileting care plan found, toilet use was identified under an incontinence care plan which stated: do not leave me in the restroom unsupervised) Date initiated: 5/31/2012 The second care plan given to surveyor read as follows: FOCUS: I am at risk for falls r/t unaware of safety needs, poor communication/comprehension, deconditioning, psychoactive drug use, wandering, L hip fracture Date initiated: 5/31/2012 Revision on: 12/27/2012 GOALS: I will not sustain serious injury through the review date. Date initiated: 12/27/2012 Target date: 11/26/2012 INTERVENTIONS: The interventions were the same as the above care plan with the addition of: - I have a motion sensor in my room to alert staff to self-transferring. Date initiated: 12/27/2012 - See mobility care plan (this care plan identifies: nonambulatory at this time d/t L hip fracture with surgical repair, assist of 2 for bed/chair mobility, grab bars for bed mobility, invite me to activity programs that encourage activity, physical mobility, PT, OT referrals or ordered PRN, transfer with assist of 2 and stand lift, place pillow between my legs when moving to prevent leg crossing Date initiated: 5/31/2012 Revision date on: 12/27/2012 - See toileting care plan (there was no toileting care plan found, toilet use was identified under an incontinence care plan which stated: do not leave me in the restroom unsupervised) Date initiated: 5/31/2012 Handwritten on this falls care plan dated 1/3/13 it stated: - If I am trying to stand up, assist me to stand in the stand lift - Please place me in front of a table with an activity when not attending large group activities Resident #15's falls and fall follow up is as follows: 10/24/12 - Nurses' note states "Fall: housekeeping observed res falling mid-fall. Res was observed falling backward and head hitting carpeted floor. Res neuros intact. VSS. REs c/o (complain of) pain in head and feet. Res was wearing grippy socks at time of fall. Res c/o pain in feet r/t (related to) 1+ pitting edema. When feet were touched res pulled back stating 'that hurts'. Intervention: MD (Medical Doctor) was updated and awaiting return fax about TED stockings r/t swollen feet" The occurrence report statement says, "I saw her falling, but I did not see her before she fell - I don't know what caused it. She hit her head. She told me her head hurt." The occurrence report indicates Resident #15 was walking, "if the resident had an alarm was it sounding?" is marked "no." Was the resident using devices is marked "no" and footwear at time of fall is marked "grippy socks." Other questions that are left blank on the occurrence report include: - When was the last time the resident was assisted to the restroom or incontinent pad changed - What did the resident say they were trying to do prior to fall - What action needs to happen to prevent this from occurring again - Household team members on duty at time of occurrence The occurrence report is not dated or signed. Follow-up charting dated 11/7/12 describes the fall as stated above. It goes on to say that an order for [REDACTED]. This was written by CC (Clinical Coordinator) S. Surveyor interviewed CC S and CC Q on 9/12/13 regarding falls and interventions. CC S and CC Q stated Resident #15 was ambulatory and walking a lot at this time. Resident #15 did not elevate her feet, had pain in her feet and therefore had a shuffled gait. They felt that if the edema was decreased she would feel sensation in her feet causing her gait to improve. CC S and CC Q stated ted hose were added as a new intervention. A review of the care plan given to Surveyor as the care plan in use does not list the ted hose as a falls intervention. Resident #15 also has a cardiac care plan related to edema. Ted hose are not listed on this care plan problem until an "initiated date" of 12/27/12. 11/7/12 - Nurses' notes state, "Resident was dancing in the auditorium with a staff member. Res wanted to go up on stage to see the musicians. When she reached the stage steps, she turned and sat down on the step. When she did this she hit her back on an amp." Intervention: this space is left blank The occurrence report has the same information regarding the falls as the nurses' note. It indicates the resident was wearing grippy socks. The occurrence form does not list the household team members on duty at the time (as requested). The form is not dated or signed. The falls "follow up form" was completed on 11/24/12. The form is blank in the spaces requesting a "[DIAGNOSES REDACTED]." The long-term intervention listed is "have res wear shoes when leaving the household to go to activities." This form was filled out by CC S. Surveyor interviewed CC S and CC Q regarding falls and fall interventions on 9/12/13. CC S and CC Q stated the intervention after this fall was to have Resident #15 wear shoes when leaving the unit (as opposed to grippy socks). The falls care plan states "Ensure I am wearing appropriate footwear." Date initiated is 5/31/12. There was no change or clarification as to what is appropriate footwear for what situation following this fall. 11/23/12 - The nurses' notes identify Resident #15 had 3 falls on this day. 10:44 a.m. - Resident was observed, by staff, sitting herself down on the floor in common area. Intervention: Full body lift to chair, assessed for needs. 1:44 p.m. - Res was ambulating and trying to walk in between two wheelchairs, when she tripped over the foot pedals of one of them. Intervention: Assisted to area of choice 3:45 p.m. - Res seen walking in circle and stumbled over her feet and landed on her buttock Intervention: To continue 30 minute safety check. To observe behavior and note/check numbers of hours of sleep per shift. ** None of the interventions listed in the nurses' notes are on the care plan. It is unclear whether these were immediate responses to the fall or were long-term new interventions. An occurrence report was completed for 1 of the 3 falls. It states, "R.N. was preparing noon meds for res (resident initials) in entryway of (resident initials) room. Res (resident initials) and (resident initials) were standing directly behind RN in doorway, res (resident initials) was sitting in w/c behind (resident initials) and (resident initials). RN attempted to guide (resident initials) then tripped over res (resident initials) feet, who was sitting in w/c in adjacent doorway. All parts of the form are filled out, two CNA (Certified Nursing Assistant) and one nurse were "household team members" when this occurred. The form does not indicate who filled out the form or when. The falls summary and the falls follow up indicate that resident's ears were checked for wax buildup that could be related to balance problems and a vision assessment to be done (vision assessment was completed on 6/13/12 - before this fall). Surveyor interviewed CC S and CC Q on 9/12/13. CC S and CC Q stated they felt Resident #15 may have an inner ear infection or wax buildup resulting in balance issues. When questioned they were unable to verify if an ear infection was confirmed or if any wax was removed from the resident's ear. 11/30/12 - Nurses' notes "Description: During lunch, res would not sit still to eat. Res was getting up to wander the unit. Intervention: RA brought res to the restroom and attempted x3 to have res sit down and finish her lunch. Effectiveness of intervention: Resident continued to wander the unit. Describe injury: RA turned her back to the res for a brief moment and when RA turned back around, res was observed to be laying on the floor in front of room 285. Resident stated she was tired and her legs hurt. No injuries noted." The fall occurrence report states the same information as the nurse's note. The falls follow up form states: "Analysis and summary of causal factors: Res was tired and laid down on the floor." "Short-term interventions: Res went to take a nap" The long-term interventions list calming music to help relax and discussed psych eval with daughter. In an interview with CC S and CC Q on 9/12/13 these interventions were confirmed as what was put into place following this fall. These interventions were not added to the care plan. The Minimum Data Set (MDS) dated [DATE] indicates the resident is supervision only for transfers and ambulation, set up only for eating and frequently incontinent of bowel and bladder. 12/2/12 - Nurse's note "Resident ambulating in hallway. Resident dropped book she was carrying. Resident bent downward to pick up book, lost her balance and landed on her knees... Intervention: Assist resident to area of choice, assess for immediate needs." A follow up nurse's note on 12/14/12 stated "...The lack of sleep may have made the res's muscle fatigue. Writer provided the res with calming music to listen to if she was having trouble falling asleep." This note was written by CC S. This intervention was already noted from the fall on 11/30/12, however, was not added to the care plan. In an interview with CC S and CC Q on 9/12/13, CC S and CC Q stated they would look into what intervention was added. No additional information was provided to Surveyor. No new interventions were added to the care plan. 12/5/12 - Nurse's note "Res fell at 12:10 this shift. Fall witnessed. Res go too close to pillar in activities area and fell backwards. Res c/o pain in L hip/leg, res sent to hospital, daughter notified. Interventions: this area is left blank Nurse's note on 12/17/12 has a fall follow up entry. This entry describes the fall as stated above and notes a L hip fracture, with surgery performed. It goes on to state "...has been working with therapy as ordered. Res has been using a wheelchair for ambulation at this time, res has not made any attempts to self-transfer since return. Will determine interventions as needed upon completing therapy." The falls care plan interventions are the same as prior to the hip fracture. The MDS dated [DATE] (following the hip fracture) indicate Resident #15 requires extensive assist of two persons for transfers and ambulation, limited assistance of one person for eating and is always incontinent of bowel and bladder. 12/28/12 Nurse's note "...upon re-entering memory care unit res was noted by staff member to be sitting with buttocks on footrest of wheelchair... Interventions: Res will continue to wear grippy socks for safety. Res will continue to be encouraged not to self-transfer. Res will continue to have motion sensor in room for safety to alert staff to self-transfers." There is no prior note indicating a motion sensor is used. A motion sensor in room to alert staff of self-transferring was added to the care plan with an initiated date of 12/27/12. The fall follow up report and the nurse's note dated 1/3/13 "F/U on fall 12/27/12 (date different but description is the same fall as above) included interventions of "If I am trying to stand up, assist me to stand in the stand lift. And place me in front of a table with an activity when not attending large group activities." These additions were handwritten on the care plan provided to surveyor, the interventions were dated 1/3/13. The facility staff utilize CNA care plans titled "My Best Day." During a phone conversation with the NHA on 9/13/13 at 1:00 p.m., copies of "My Best Day" were requested. The NHA stated, "We do not keep copies of My Best Days, everything should be on the care plan." 2. Resident #8 has [DIAGNOSES REDACTED]. The MDS with assessment reference date of 07/19/13 documents one fall with major injury. The falls assessment form completed on 06/23/13 indicates that Resident #8 has intermittent confusion, forgets to call for assistance, and refuses to use assistive devices, and that the resident has lack of safety awareness. Resident ambulates with assist of one, and assistance device. The nursing care plan has the focus: I am at risk related to unaware of safety needs, confusion, deconditioning, wandering, date initiated 02/01/12. Goals I will not sustain serious injury through the review date. Target date: 08/08/13. Interventions: -Be sure my call light is within reach and encourage me to use it for assistance as needed 02/01/12 -Complete a fall risk assessed per protocol 02/01/12 -Ensure that I am wearing appropriate footwear, grippy socks or shoes Revision on 05/03/12 -Evaluate effectiveness of my interventions on an ongoing basis 02/01/12 -Follow facility fall protocol 02/01/12 -I have a nightlight in my room 05/03/12 -Observe me for acute illness Revision on 05/02/12 -Offer activities that promote exercise...revision 05/02/12 -PT evaluate and treat prn 02/01/12 -See my mobility care plan 05/03/12 -See my toileting care plan 05/03/12 An updated safety needs care plan was emailed to Surveyor on 09/16/13 that had a written in update on 07/16/13 - My daughter took my purse home. If I ask for it remind me my daughter took it home. This was not on the care plan that Surveyor received in the facility and reviewed with Clinical Coordinator (CC) S while at the facility. Mobility Care Plan I have limited physical mobility related to dementia and weakness 02/01/12. Interventions: -Ambulation: I am only ambulating with therapy at this time rescission 08/08/13 -Transfer: I require assist of one with gaitbelt and walker, pivot transfer revision 08/08/13 Toileting Care Plan I am incontinent of bowel and bladder, I am able to communicate my need to use the restroom but sometimes I forget. I do require assistance. Revision 02/01/12. Interventions: -Have my call light within reach 02/01/12 -See my mobility care plan 08/02/12 -Treat absence of bowel function per facility protocol or standing orders 02/01/12 -Take me to the bathroom every two hours 08/30/13. My Best Day care plan for the Resident Assistants was updated on 09/09/13 and includes in part: Transfer: Assist of two with stand lift medium vest Walking: not ambulatory at this time Toileting: Assist of two with stand lift, take me every two hours Safety: Call button in reach at all times, nightlight in room, grippy socks or shoes for ambulation. Clip button to Resident #8's shirt when in bed. Motion sensor when in bed. The My Best Day care plan for 07/13/13 when the resident returned from the hospital with the left hip fracture was requested. The facility stated they do not keep the "My Best Day" care plans, so there was no care plan to refer back to. The nurses' notes include in part: 07/10/13 10:35 p.m. "Staff heard yelling at 2020. Resident observed on floor of room in supine position. Resident was moaning and rubbing left lower extremity. Resident would not move left lower extremity. Resident barefoot. Resident not wearing glasses. Resident wearing long night gown and pants..no dentures or pants on thirty minutes prior when staff toileted. ..Left foot remained still while pointing outward. Left foot noticeably shorter than right foot when lying supine. ...Resident continued to grimace and moan intermittently. Tears in eyes noted. 911 called." 07/11/13 10:50 F/u on fall: "Resident was heard to be yelling from her room, res was found laying on the floor of her room, between her dresser and the foot of her bed. Resident had been assisted into bed about twenty minutes prior...Resident family came to the facility today to report that the resident did break her hip and will be having surgery this afternoon/evening. The resident's daughter stated that she had moved her purse to a different area than where her mother kept her purse to try to decrease her need to get her purse and go home. The resident's daughter has decided to take her purse home as she was afraid her mother was trying to find the purse when she fell . Will initiate appropriate interventions related to fall when resident readmits to the facility based on her level of functioning." The falls follow up form dated 07/11/13 includes in part;Non compliance: Self transferring: Yes Assist device and call light within reach? Had it prior to transferring. Analysis and summary of causal factors: Resident self transfer had call light, took it off resident confused, sent to ER. Short term intervention: 30 minute checks. The documentation for the 30 minute checks was reviewed by Surveyor and started on 07/13/13 at 9:00 a.m. and continued through 07/19/13 at 11:30 p.m. with 50 of the 30 minute checks left blank. Long term interventions: Family took purse home. Will assess interventions upon return. On 07/13/13, Resident #8 returned to the facility after her left hip surgery. Nurses' notes in part: 07/13/13 9:54 a.m. "Resident returned to the facility this shift. Was reported by hospital staff resident is an assist of 2 standing. Walks well with walker. Continent of bowel and bladder. Will be evaluated by therapy..." 07/13/13 11:39 a.m. "Resident returned at 09:15 and was accompanied by son and hospital staff..." The fall risk assessment completed on 07/13/13 upon resident's return to the facility includes in part: Level of consciousness: disoriented, intermittent confusion, forget to call for assistance. History of falls: 1-2 falls. ambulates with assistive device, requires assist of one with ambulation. Potential interventions checked are: monitor meds for side effects, monitor for acute illness, OT/PT (occupational therapist/physical therapist) screen, toileting schedule, footwear, pain medication. The analysis: Resident at risk for falling related to being weak from recent surgery. ...Assist of two for standing. New interventions are not on the care plan and the falls risk assessment contained no new interventions. There is no mention of the purse being present or absent as an intervention when she returned to the facility. The nurses' notes indicate that Resident #8 continued with therapies and gained in strength. The nurses' notes include in part: 8/02/13 11:05 a.m. "2 assist with transfers, stays in bed most of the time..." 08/10/13 6:35 p.m. "...Able to ambulate with walker and assist of one..." 08/15/13 8:03 a.m. "Resident is assist of one pivot transfer with walker and repositioning with grab bars. Assist of one with pivot transfers for toileting..." 08/26/13 8:43 p.m. "No complaints of pain during shift...resident is an assist of 1 with transfers..." 08/28/13 9:45 p.m. "Resident was found laying on ground in room at 1545 (3:45 p.m.). Resident was in bed at 1540 (3:40 p.m.) when TMA was in room and gave medication to resident. Resident had call light clipped to her shirt. Resident had shoes on. At 1542 (3:42 p.m.) RA went into room and resident refused assist with toileting...Resident was found laying on ground with head by the foot of the bed. Resident could not move right leg...Resident has right hip fracture. Resident being admitted to the hospital. Resident due to have surgery tomorrow." The falls follow up form dated 08/30/13 includes in part: Type of footwear: shoes Non-compliance: yes Assist devices in reach, call light within reach: yes Analysis and summary of causal factors: Resident self transferred self. Short term intervention: toilet resident after med pass. Nurses' notes: 08/30/13 2:40 p.m. "Follow up on fall. Resident was asked if she needed to use the bathroom at about 1500...The resident stated that she was trying to use the bathroom. The resident did not have her call light on prior to trying to transfer. This resident has a history of self transferring in the past...The resident has been progressing well with therapy and was beginning to return to baseline prior to fall. ...resident appeared to be feeling more confident with transfers. Therapy was starting to implement maintenance programs for the resident as she was becoming close to getting out of therapy...interventions were discussed and agreed upon with IDT team and added to the my best day and care plan to take the resident to the bathroom every 2 hours...resident may not be able to tell a staff member that she needs to use the bathroom at the time that they ask, so encouraging the resident to go the time the staff member is there will lessen the chances of self transferring to the bathroom after the staff member leaves..." On 09/11/13 at 1:00 p.m., Surveyor interviewed CC S for 2nd floor. Surveyor asked what interventions were put in place when Resident #8 returned to the facility after the first hip fracture. CC S stated that she was referred to physical therapy. Surveyor asked if that was standard for any resident who had a hip fracture. CC S stated, "Yes, it is." Surveyor asked if any other interventions were tried as the care plan was reviewed with CC S. There were no new interventions on the safety care plan since 05/03/13, until after the resident returned to the facility on [DATE] after the second hip fracture. CC S indicated that the purse had been removed by the family and that was the possible cause. Surveyor asked what happened with that intervention when she returned. CC S said it did not seem relevant since she could not ambulate independently. CC S indicated that Resident #8 had been improving in therapy and was walking with a walker at the time of the most recent fall. Surveyor asked if putting the bed in a low position, or using a floor mat, hip protectors or other interventions had been considered. The falls assessment form used by the facility lists multiple interventions to be considered. CC S said, "No, I did not think of any of those interventions." 3. Resident #6's admission information identified he had a history of [REDACTED]. He was unable to walk independently and required assist with all ADLs (activities of daily living). Resident #6's CAAs (Care Area Assessment) 11. Falls dated 11/15/12 identified Resident #6 needed assistance with mobility, transfers, and ambulation. Resident #6 had [DIAGNOSES REDACTED]. Resident #6 required assistance of two staff with a stand lift for transfers. Resident #6 had a lack of safety awareness, had made attempts to self transfer and was at risk for falls. Resident #6 had difficulty maintaining his sitting balance. Resident #6's admission care plan contained a problem, "I am at risk for falls r/t (related to) Unaware of safety needs, Poor communication/comprehension, Psychoactive drug use, bowel incontinence, Cognitive Impairment, Visual impairment, Hearing problems, anemia." The interventions included: Be sure my call light is within reach and encourage me to use it for assistance as needed. Ensure that I am wearing appropriate footwear. On 05/21/13, "Low bed when I am in bed" was added as an intervention. On 06/12/13, "Do not leave me alone in my room when in my w/c" was added as an intervention. Resident #6's nurses' notes on 05/18/13 at 8:21 p.m. stated, "Resident was found laying on floor in room. Res (resident) was laying on his left side. When asked it he was in pain he stated yes, all over. After assisting Res up with full lift, and assessing again he denied pain. No injury noted. Res stated he was reading his paper and was leaning too far and fell . Res had been toileting 20 minutes prior to the fall. Res refused to leave room after being toileted. Call light in reach, not on. On-call RN (Registered Nurse) updated. MD (Medical Doctor) updated, POA (power of attorney) update. Intervention: Position Res so he is able to read the paper easier." Resident #6's nurses' notes on 05/20/13 at 4:54 p.m. stated, "Follow-up to fall dated 5/18/13. Resident was found laying on the floor on his R (right) side. Resident had taken himself to his room and would not allow staff to take him out of his room for an activity. Resident is care planned not to be in his room alone in his w/c (wheelchair) for safety. Resident is currently being seen by OT for w/c positioning and was in a new w/c at the time of the fall. Therapy to continue their evaluation and make further adjustments as indicated for resident safety and mobility." On 06/12/13, Do not leave me alone in my room when in my w/c was added as an intervention for the care plan problem, "I am at risk for falls." On 09/12/13 at 9:00 a.m., Surveyor interviewed the Clinical Administrator (CA)related to the fall on 05/18/13 in his room. The CA stated Resident #6 was not to be left unattended in his room while seated in his wheelchair at the time of the fall. Surveyor requested information related to the first date the intervention "Do not leave me alone in my room when in my w/c" was added to Resident #6's care plan. Surveyor discussed during review of Resident #6's IPOC (interdisciplinary plan of care) and MBD (My Best Day) RA (Resident Assistant) care plan had some interventions on one that was not included on the other care plan. The CA stated the two care plans should contain the same information. Surveyor requested to review Resident #6's incident/accident report and investigation related to the fall on 05/18/13. On 09/12/13, the Administrator provided a Resident/Visitor Occurrence Report which stated, "Res was found laying on ground on right side. w/c (wheelchair) pedals under buttocks." The date of occurrence was 5/18/13 at 1610 (4:10 p.m.). Surveyor was provided with the two additional copies of the IPOC but no

Based upon medical record review and interview, the facility failed to honor the resident's right to refuse treatment for 1 of 15 sampled residents. Resident #4 had a straight catheterization performed on the evening of 08/07/13 and in the morning of 08/08/13. Resident #4 screamed throughout the procedure and made statements to have the staff stop what they were doing. The facility staff continued with the catheterization. This is evidenced by: Society of Urologic Nurses and Associates standard of practice for emptying the bladder: Keep bladder as empty as possible by having patients catheterized at least four to six times a day or to maintain bladder urine volume less than or equal to 400 mls. Resident #4 is recently admitted to the facility from another facility and has [DIAGNOSES REDACTED]. Resident #4's minimum data set (MDS) with assessment reference date of 08/01/13 reveals she was unable to answer the cognitive questions. The staff assessment documents Resident #4 has severe cognitive impairment. The behavior section documents that [MEDICAL CONDITION] were present and zero for hallucinations. The nursing care plan with focus: I use [MEDICAL CONDITION] medications related to depression, delusional disorder, sleep. Date initiated 08/14/13, revision on 08/14/13. Goal: I will reduce the use of psychoactive medication through the review date. Target date: 08/13/13. Interventions: -Administer my medications as ordered. Monitor/document for side effects and target behaviors. -Consult with pharmacy... -Encourage me to have a daily routine -Monitor occurrence for target behavior symptoms and document -Provide me with a quiet environment. Focus: I have impaired cognitive function and impaired thought processes related to short and long term memory loss, impaired decision making. Goal: I will maintain current level of decision making ability through review date. Target date: 08/13/13 Interventions: -At times I scream and pinch, hit and kick people if I am unable to express my feelings another way. 08/20/13 -I am fearful and paranoid of process that I do not understand, please reassure me that you are qualified to complete the tasks. Initiated 08/20/13. -I like when you sing songs to me, this helps calm me. 08/20/13 -Reapproach me if I am anxious and agitated. 08/20/13 All the interventions are after the date of the incident, no other care plan was provided. The nurses' notes in part read: 07/27/13 10:48 "On call MD (Medical Doctor) updated regarding urine. MD ok with inserting Foley cath and f/u (follow up) with urology." 07/28/13 12:14 p.m., "Resident was doing leg exercises and Foley tube became untaped from leg, leg strap now used, Foley cath is in place and patten. She is alert and keeps calling, 'Help me, help me.'" 07/29/13 3:43 a.m., "Resident has been awake and yelling out 'help me, help me' throughout the night. When approached resident wants a drink of water. Resident encouraged to use her call light. Resident c/o (complaint of) generalized pain and was given [MEDICATION NAME] per prn at 11:45 p.m. Resident denies pain at 1:00 a.m., but continues to holler out for help. CNA sat 1:1 with resident while available." 08/03/13 14:16 p.m., "Resident yelling out continuously this AM prior to daughter's arrival. Resident would yell staff names but have no specific need when staff responded...Resident has been pulling at her Foley cath as well indicating that she was going to take it out...Behavior improved when family arrived. Behavior resumed after family left facility." 08/04/13 2:02 a.m., "Resident became increasingly agitated attempting to get out of bed and screaming as loud as she could. Resident was accusing staff of stealing her furniture, and believed she was in her own home. When this writer attempted to put her back in bed, she kicked out and struck the writer...resident continued screaming and yelling out until after 0200, reality orientation was attempted repeatedly without success." 08/04/13 8:18 a.m., "Resident screamed upon staff approach this shift. Resident reported they were coming to hunt her down and 'they walked into the room this morning, all bright and shiny' and reported being terrified. Resident closed the statement with, 'What kind of existence is this?'" 08/05/13 12:25 p.m., "Resident confused today, yelling out for help, appears to be hallucinating and talking to people that are not there, redirected to current time and place seems to work for a short time." 08/07/13 11:12 a.m., Fax received from MD regarding abx. New orders to D/C keflex, Start [MEDICATION NAME] 500 milligrams po daily x 7 days. Continue [MEDICATION NAME] 500 milligrams PO Bid x 7 days. 08/07/13 3:18 p.m,. "Type of appointment: urology. New orders: D/C [MEDICATION NAME] D/C Foley. If unable to void within 4 hours, in and out cath. Repeat x 24 hours. If still unable to void in 24 hours, then repeat every 4 hours until resident can void on own..." 08/07/13 8:35 p.m., "...Catheter was pulled. 5 hours later bladder scan was performed, 80 cc noted in bladder. Will check bladder again at 2130..." 08/07/12 10:01 p.m., "Upon bladder scan at 2140 (9:40 p.m.), 240 cc noted in bladder. Straight cath done with 5 staff. Resident yelled at top of lungs, 250 cc output." 08/08/13 7:31 a.m., "At 0700, writer bladder scanned resident 599 cc of urine noted in bladder. Writer calmly talked to resident about what the plan was...resident voided minimal amount when laying down. Staff kept calmly talking to her. ...Resident continued to tell staff, 'You are not trained to do this.' 600 cc of output with straight cath...resident appeared to have calmed down a little..." 08/08/13 1:00 p.m. "...at 1250 resident requested to use the toilet. Resident able to void..." 08/08/13 3:57 p.m. "Skin assessment performed today upon assessment there was no evidence of abuse or trauma related to allegations made today by resident..." 08/08/13 5:21 p.m. "Fax received from MD regarding cath and behaviors. MD response: You should be able to straight cath if becomes necessary, not appropriate to transfer to ER for this." Surveyor reviewed the self report made by the facility that a resident had made an accusation of rape on 08/08/13. Initial Report: Speech Language Pathologist (SLP) DD, on 08/8/13 was attempting to treat patient at breakfast meal, in which resident stated that she felt as if she had been raped, specifically stating..."You should have caught me two rapes ago." Resident interviews performed by facility on 08/08/13 about the events that happened on the evening shift of 08/07/13 contained in part: Interview conducted by Household Coordinator (HC) Q...Asked Resident #4 whether there has been anything distressing happen to her here and she responded by saying, "Yes," followed by nonsensical statements which she was unable to clarify. Asked whether the staff had done anything concerning her, she stated, "Yes." Like what? "I felt like I was a victim of a rape. I don't know exactly how it started...they said something about having to catheterize me. They attacked, there were four of them. They subdued me." How? "Pinning my arms down, extending my legs and hips so I couldn't be moved. They are very physically powerful. Object of it was to drain the bladder because I couldn't expel the urine. My son-in-law and I had talked to the doctor and he had given that order. They took advantage of that because they weren't qualified and the more often they did that, they were likely to cause infection. That should have been done by someone with a medical background." Like who? "The head of the class." ... "Then it was the manner in which it had been done. There was no indication that it needed to be done at time." ... Writer spent quite a bit of time discussing the orders from the urologist for this procedure... Writer asked Resident #4 if she feels that she was abused and she stated, "Absolutely." Writer asked what we can do to help her to feel better about the situation and she stated, "Promise me it would never happen again, but that's difficult to say because, I don't know. I lost a lot of respect for them, I thought they were superior trained but I have reversed my thought on that." Writer offered reassurance and consoled Resident #4. Resident #4 was unable to identify specific staff involved by name and denied she would be able to remember faces either. Interview conducted by DON (Director of Nursing) and NHA (Nursing Home Administrator). Began the conversation by asking Resident #4 how she was doing today and she responded that she was doing well. The resident was observed to be resting comfortably in bed with no signs or symptoms of distress. The resident was asked about statements she had made last week regarding the rape that had taken place. The resident was asked if when she stated rape she was referring to the incidents where staff used intermittent catheterization to empty her bladder. The resident stated, "They had done that the other time and I subjected myself to it because doctor was supervising but this time there was no one supervising except the nurses. They tried several times-forcing whatever it was up my vagina and it didn't feel very good either." ... "Talk show hosts usage of terms exempting/okaying ideas of what that means. I don't know. I wish I would have asked first. I depend on those girls to take care for me." Then writer attempted to clarify the resident's comments by asking if she was referring to the catheterization and the resident stated, "I suppose-I don't know what the instrument was but I'm sure it must have been a catheter. Even with the catheter there are dangers-the more times you insert it into the bladder, don't know if they did or not, the more chance of inflammation and bacteria." Resident assessment: Progress note written 8/8/13 indicates that the body audit indicated no signs of abuse or trauma. BIMS (Brief Interview for Mental Status) interview was not completed for ARD (Assessment Reference Date) of 7/31/13 as resident was unable to successfully participate in interview process d/t (due to) cognitive deficits, confusion. Staff interviewed completed instead indicating short and long term memory problems and disorientation to reality at that time. SLUMS (Saint Louis University Mental Status) test administered 7/29/13 indicated score of 17/30, dementia level. POA (Power of Attorney) was activated prior to resident's admission to the facility d/t cognitive deficits. No complaints of pain were noted from the resident. Resident is currently receiving scheduled Tylenol three times a day and [MEDICATION NAME] to left lateral buttocks daily. Resident also had orders for [MEDICATION NAME] to use as needed for pain. Staff interview completed by the facility stated: Resident Assistant (RA)BB states she was asked to go to the household where the resident resides to assist in keeping the resident calm while straight catheterization is to be completed. RA BB stated that she held the resident's hand, well, rather that the resident held her hand, as the resident was screaming, continuously throughout the event. RA BB stated that Registered Nurse (RN) M was holding her other hand, Licensed Practical Nurse (LPN) U was attempting to do the catheter, LPN V was helping with the catheter, and RA Y was just in the room, and wasn't sure what she was there to do. RA BB left to go home immediately after the event, as it was the end of her shift. There were no other statements made by the resident, no behaviors witnessed. On 09/11/13 at 10:50 a.m., Surveyor interviewed RA BB. RA BB recalls the evening of 08/07/13 around 10 p.m., RN M came to get her because they needed help with the catheterization. RA BB recalls there were five people in the room, three nurses and two RAs. RA BB stated they could not get the catheter in, and Resident #4 screamed the whole time. RN M was holding the leg of Resident#4, and the resident was squeezing the hand of RA BB really hard. RA BB states when LPN V came into the room, she was able to get the catheter in. RA BB says this lasted about ten minutes, and the resident screamed the entire time. Surveyor asked if any of the staff present ever said they should stop. RA BB, said, "No." When asked about education received after the event RA BB said they did computer based training on resident rights; she is not sure why. Surveyor asked if RA BB was educated they should have stopped the procedure. RA BB stated, "No." Facility interview of LPN V in part: On 08/07/13, LPN V was called by RA Y around 9:30 p.m. and requested she come and assist with the catheterization. The four other staff were already present. LPN V assisted in finding the urethra, cleaned it and inserted the catheter, urine flowed. The entire time everyone was attempting to soothe Resident #4 with little success. Resident #4 was yelling the entire time. Resident #4 was obviously uncomfortable and it was clear because of her dementia she was not understanding what was going on despite being told. On 09/11/13 at 11:40 a.m., Surveyor interviewed LPN V about the above. LPN V recalls talking with RN M about the bladder scan with about 200 cc of urine. LPN V stated, "When I was called to the room, Resident #4 was yelling and shouting. I believe RN M had attempted to cath her, and LPN U also had tried. I recall the lights were very dim so the first thing I did was turn the lights on so I could see. RN M then held the legs and labia apart so I could insert the catheter, Resident #4 was screaming." Surveyor asked if Resident #4 resisted, LPN U, said, "Not really." LPN V stated HC Q talked with her and had education on vulnerable adults and dealing with dementia. Surveyor asked if HC Q told her she should have done anything differently or should have stopped. LPN V, "Not exactly, but I learned from it and would not do this again." LPN V stated, "Resident #4 had a Foley removed the same day, so the area was red and swollen, so I guess it would have been really uncomfortable." Surveyor interviewed HC Q on 09/11/13 at 1:50 p.m. about the above. HC Q said her responsibility is to deal with all the social issues for the residents on her floor. HC Q recalls Resident #4 reported to Speech Language Pathologist (SLP) DD she had been raped. HC Q said she then interviewed all staff. Since this time they have discontinued the straight cath and she has voided on her own since 08/08/13. HC Q said someone with dementia could easily misunderstand this. HC Q said she reassured the resident and explained it was a catheter placed in her urethra, not in her vagina as the resident thought. All the staff interviews said they tried to explain and console her. HC Q said they educated staff with computer based training on resident rights. Surveyor asked when HC Q investigated if she thought it was abuse, HC Q stated, "No, but maybe they should have taken a step back and taken a minute to consider if they should have continued." The facility interview of RN M includes in part: RN M scanned the bladder of Resident #4 right before 10 p.m. last night...bladder scan indicated Resident #4 had over 200 cc's of urine...orders indicated she needed to be straight cathed at that time...Knowing that the resident was anxious about a lot of things she had RA BB and RA Y come into the room as well. RN M was positioning the resident's legs and labia. .. RN M stated that Resident#4 was yelling the whole time but that this was not new behavior for her. RN M stated once the catheter had been inserted and the bladder was drained that Resident #4 did not appear to be distressed and that she was fine. Surveyor interviewed RN M on 09/11/13 at 2:10 p.m. about the above. RN M said she had orders to cath Resident #4, and tried to explain it to Resident #4, but she did not understand. She then had LPN U try to explain it to the resident, which did not work either. LPN U tried to insert the catheter and could not, so we got LPN V to come in and try it. RN M says she was holding her leg back, she was pushing against me. The RA BB and RA Y were holding her hands. Surveyor asked if she was screaming or said to stop. RN M stated, "I do not recall". Surveyor asked how long this went on. RN M said for about 10 -15 minutes. Surveyor asked if RN M noted any irritation in the labia area, RN M said, "Yes, it was red there because she had a Foley in and would pull on it and had irritated the area." RN M went on to say the next morning she worked and again Resident #4 had a bladder scan of 599 ccs. RN M went in to the room to cath her. RN M recalls Resident #4 said, "Don't do it again, but I do not recall that she was yelling." RN M stated she did computer training on vulnerable adults and residents rights. Surveyor asked why the training on resident rights. RN M stated, "Because Resident #4 has a right to be toileted, I guess." Surveyor asked if RN M was ever told she should have done anything differently. RN M stated, "No, just to reapproach and try again, or try another nurse like we did." The facility interview of LPN U in part: On 08/07/13, RN M requested assistance to catheterize Resident #4....All staff were consoling Resident #4, she was inconsolable. ..LPN U noticed some redness in the genital area which she associated with trauma related to recent Foley catheter which resident is known to have continuously tugged and pulled at. Over 200 cc of urine was expelled. During the entire procedure everyone present was attempting to explain and console . Resident #4 was screaming but there was no rationalizing with her. On 09/11/13 at 2:00 p.m., Surveyor interviewed LPN U about the above. LPN U recalls that on the evening of 08/07/13, RN M came to get her to have her try to do the catheterization for Resident #4. LPN U stated she is a new nurse and needed the experience. LPN U said they supported and held the legs on each side of the resident because of her history of a pelvic fracture. LPN U said she tried to cath first, could not find the urethra. LPN U stated that it was difficult because Resident #4 was yelling, kicking, and swinging her arms. RN M went to get another nurse, LPN V. Surveyor asked if Resident #4 continued to yell. LPN V stated, "Yes." Surveyor asked if Resident #4 ever said stop or do not do that. LPN U stated, "Yes, she said that several times." Surveyor asked if LPN U saw any irritation in the labia area. LPN U said, "I definitely saw redness and the swelling, that is what kept me from visualizing the urethra." Surveyor asked why Resident #4 would have reported this as a rape. LPN U stated, "I suppose because there were five of us in the room over her bed, holding her legs and hands. LPN U stated that after the event HC Q had her watch the resident rights video. Surveyor asked what the resident right issue was. LPN U said, "I am not sure." Surveyor asked if there was anything she should have done differently. LPN U stated, "No, I do not believe so, no one has ever said we should have done anything else, we had a physician order [REDACTED]. Facility interview of RA Y in part: RA Y states on the evening of 8/07/13 she heard yelling coming from Resident #4's room so she went in to assist, LPN U, RN M, and RA BB were already in there. RA Y went up by Resident #4's head and was stroking her and holding her hand and consoling her while explaining what was going on...Resident #4 was screaming. On 09/11/13 at 2:23 p.m., Surveyor interviewed RA Y. RA Y said she heard the commotion in the resident's room. RA Y said she heard a lot of yelling, "Help, help". RA Y said she went in to hold her hand and rub her shoulder. Surveyor asked if they had tried to cath her by then, RA Y said, "Yes, but she was moving so much and kicking at them that they were having trouble." Surveyor asked if Resident #4 said stop. RA Y said, "No, but she was scared." Surveyor asked how she knew Resident #4 was scared. RA Y said, "Because they were so many people over her and she did not understand." Surveyor who was in the room at this time. RA Y stated, RN M, LPN V, LPN U, and RA BB and myself. Surveyor asked how long this lasted. RA Y said, about 7 minutes. RA Y said after this they did the SilverChair resident rights training. Surveyor asked why resident rights. RA Y said, "I guess so I understand it." Surveyor asked if anyone told her they had done anything wrong or should have done anything differently, RA Y said, "No." Surveyor asked if they make residents eat food they do not want, or if they make them take medicine when they refuse it. RA Y said, "No they do not, I guess we should have stopped what we were doing." The facility interviews of the incident on the morning of 08/08/13 include in part: RA P stated staff attempted to get Resident #4 to void on the toilet...she did not void. RA P was on Resident #4's left side holding her hand and Resident #4 was grabbing onto it holding it tightly... Resident #4 was screaming throughout the entire episode, she was not using words, just screaming. On 09/11/13 at 10:45 a.m., Surveyor interviewed RA P. RA P stated that Resident #4 squeezed her hand tightly. RA P knew they had a hard time cathing her the night before so RN FF was called in to help. RA P said that Resident #4 screamed during the procedure and said, "Stop that." RA P indicated it did not last long and the catheter was inserted. Facility interview of LPN T in part: On 08/08/13 AM, RN M saw on the bladder scanner that Resident #4 had 599 cc of urine...RA P stayed in the bathroom with her, she did not void. We transferred her to bed and LPN T was reassuring her. Resident #4 did say, "Don't do this to me." Staff all continued to explain and reassure. LPN T had her right leg and was keeping it aside but was not using any force to hold it, she was not resisting at all. ...Resident #4 was screaming the whole time, using no words, just screams... On 09/13/13 at 3:25 p.m., Surveyor had a telephone interview with LPN T. LPN T stated she was helping by holding her legs apart and spreading the labia apart. RA P and RN FF were by the resident's head holding her hands. LPN T said Resident #4 was making noises the whole time. LPN T did not think this would be so distressing. After the incident LPN T stated they did computer training on resident rights. Surveyor asked if they were told they should have done anything differently. LPN T stated, "No, I was not told that." Surveyor asked why resident rights training was given. LPN T said, "I do not know, that is confusing to me, we did not do anything wrong so I am not sure why we did it, it must have been a refresher." Surveyor interviewed RN FF on 09/11/13 at 11:50 a.m. RN FF recalled that Resident #4 was uncomfortable, "yelling out help..oh...help." I was working on the other floor when the nurse called me. I just basically comforted her. Another girl was holding her leg up while the nurse inserted the catheter. Nobody was holding her arms but she was flailing. I was rubbing her shoulder telling her, "We have to do this," because she was flailing her arms. I think it was perceived by her wrong. After the catheter was inserted she seemed more comfortable. Surveyor asked if the procedure was stopped. RN FF said, "No, no one stopped, the nurse paused, explained it and continued. During the procedure nothing was inappropriate, she was more relaxed and comfortable afterwards. She never said stop." Surveyor asked about education provided after the incident. RN FF said it was something about dealing with residents with difficult behaviors and memory problems. It may have covered resident rights, I am not sure. The facility conclusion of the investigation in part: Resident received orders during urologist appointment on 08/07/12 (D/C [MEDICATION NAME], D/C Foley, if unable to void within 4 hours, in and out cath, Repeat x 24 hours. If still unable to void in AM after 24 hours then CIC (Clean Intermittent Catheterization) every 6 hours or leave 16 French Foley 5 ml balloon and change monthly. Resident has a history of [MEDICAL CONDITION], hallucinations, paranoid statements, and behaviors calling out frequently when family is not present. Resident has [DIAGNOSES REDACTED]. Will review with staff-caring for residents with cognitive impairment. ...Facility received orders for inpatient psych evaluation and [MEDICATION NAME] In review of the facility interviews and surveyor interviews, there was no mention of trying non-pharmacological interventions to decrease the reaction that Resident #4 was experiencing. Surveyor interviewed Resident #4 on 09/11/13 at 3:08 p.m. to inquire about the care she is receiving. Resident #4 indicated that in general the staff have been good to her. Surveyor asked if anyone had ever treated her badly. Resident #4 stated, "I do not want to release this, we have made up." Surveyor asked if she recalls having a catheter in place. Resident #4 said, "Yes." Surveyor asked if she recalls any problems with her bladder or the catheter. Resident #4 stated, "Yes, I had infections." Surveyor asked if there were any problems with the procedure of being catheterized. Resident #4 stated, "It is not a pleasurable experience you know, it was resolved." Surveyor then went on to ask if she was afraid of anything or had problems sleeping at night. Resident #4 stated, "I sleep well." Surveyor interviewed the NHA on 9/12/13. The NHA indicated that all staff recieve training on care for cognitively impaired, residents rights and dealing with difficult behaviors. The NHA stated they also recieve training on how to work with residents who cannot make informed health care decisions or are not making good decisions for themselves. Surveyor asked NHA what her expectations would be if a resident was upset or refusing a specific care. The NHA stated that it depends on the resident and what works with that family. The NHA stated that Resident #4 had behaviors prior to this particular incident and that to staff "this was her norm." NHA stated that Resident #4 has an inability to understand what is happening. Staff tried to console her. The NHA informed the surveyor that the staff did talk to the doctor and the doctor did not support sending the resident out for catheterization. (According to the nurses' notes the catheterizations took place 8/7 at 10:01 p.m. and 8/8 at 7:31 a.m., a fax from the doctor on 8/8/13 at 5:21 p.m. stated, "You should be able to straight cath if becomes necessary, not appropriate to transfer to ER for this." This was after the procedure had been completed on two occassions.) The NHA stated she did not feel the resident's rights were violated as she can not make informed decisions. The NHA suggested that Surveyor discuss this issue further with SW OO. SW OO was asked if a resident is yelling, swinging, etc. what should staff do. SW OO stated, "Generally they should not continue due to residents rights, unless it is medically contra-indicated." SW OO stated he had spoken to some staff following the incident and did not get the feeling the procedure was forced. SW OO thought the staff had left and reapproached later but agreed if they hadn't, they should have.

Based on observations, record review and staff interviews, 3 of 9 residents (Resident #6, #11 and # 3) reviewed for pressure ulcers and pressure ulcer risk had not received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Resident #6 was assessed to be at risk for the development of pressure ulcers. Resident #6 requires extensive assistance with positioning and transfers. Resident #6 developed a Stage 1 pressure ulcer after admission to the facility on his right buttocks. Resident #6 has developed recurrent Stage 2 pressure areas on his buttocks, coccyx and deep tissue injuries on his right foot/toes since 12/09/12. No changes in interventions were added to the care plan until 05/21/13. Resident #6 developed a Stage 3 pressure ulcer on his right heel on 06/10/13. The type of ulcer was changed to a diabetic ulcer. There is no documentation by the physician or nursing staff how the determination was made it was a diabetic ulcer. Resident #6, at the time of the survey, had a Stage 2 pressure ulcer on his right buttocks. The dressing change was not performed using aseptic techniques. Resident #6's care plan was not followed. Resident #11 was assessed to be at risk for the development of pressure related ulcers on admission. Resident #11's medical record did not identify a history of any ulcerations on her lower extremities prior to admission. On 05/17/13, Resident #11 was observed to have a pressure area on the right lateral foot, below the pinky toe that was black. On 05/21/13, the area on the right lateral foot was changed from pressure to deep tissue injury. Resident #11 developed an open area on her right inner ankle on 06/18/13, which the facility identified as other for the type. The type of ulcer was changed to stasis on 06/19/13. There is no documentation why the types of ulcers were changed. Resident #11's medical record also identified she developed a pressure ulcer on her right outer ankle. Resident #11's care plan related to skin integrity was updated on 06/19/13. The right ankle was identified as having a stasis ulcer and the type of ulcer on the right lateral foot was not identified. No new interventions have been added to the care plan problem since 06/19/13. Resident #3 had a history of [REDACTED]. Resident #3 was identified as having pressure area on her left 2nd metatarsal on 07/25/13 related to her Ted stocking. The Ted stocking was placed on hold. On 09/04/13, Resident #3's nurses' notes identified she had an open area on the 2nd metatarsal on her left foot that was scabbed. The note identified the area was caused by the Ted stocking. The note also identified Resident #3 had a scabbed area on the 3rd metatarsal. The facility did not implement the wound care flow sheets or document weekly skin progress notes as per facility policy. During the survey, Resident #3 was observed with her heels resting directly on the mattress and the blankets resting directly on her toes/feet. Per interviews with facility staff and Resident #3's spouse, no new interventions had been implemented to decrease the pressure on Resident #3's feet/toes while in bed. This is evidenced by: 1. Resident #6's admission information (history, physical and hospital discharge summary) did not identify skin breakdown. The discharge summary identified he had a groin rash. On 11/12/12, a wound assessment flow sheet was initiated. The type of wound was a pressure ulcer - Stage 1 on the right buttocks near midline and was acquired in the facility. The current dressing/treatment plan was to reposition every two hours. The flow sheet did not identify if he utilized a pressure relieving mattress/device. On 11/13/12, a fax was sent to Resident #6's physician related to a reddened, blanchable coccyx area with a light purple area on the right buttock measuring 1.2 cm by 0.6 c.m. in size. The skin was intact. Staff would apply "Calmo" BID (2 times daily). On 11/15/12, Resident #6's CAAs (Care Area Assessments) identified he required extensive assistance with bed/chair mobility, was frequently incontinent of bowel, and was at risk for pressure ulcer development and other skin integrity issues. The extrinsic risk factors identified were that he needed a special mattress or seat cushion to reduce or relieve pressure and required a regular schedule of turning. The assessment did not identify a history of current or healed pressure ulcers. On 11/18/12, the fax sent to the physician identified the area on the buttocks had opened. The measurements were 2 cm by 0.25 cm and 1 cm by 0.25 cm. Resident #6 was started on a multi-vitamin with minerals daily. Resident #6's care plan initiated on 11/21/12 identified he was at risk for alteration in skin integrity related to diabetes, had decreased mobility and incontinence of bowel. The interventions identified were: a pressure reducing mattress and wheelchair cushion, any breaks in his skin were to be treated per facility protocol and to see his nutritional, toileting and mobility care plans. Resident #6's mobility care plan identified he transferred with a stand lift and assistance of two and he required assistance of one staff to reposition him every two hours. On 12/04/13, a fax sent to Resident #6's physician identified the wound to the right buttocks was healed. On 12/09/12, a wound assessment flow sheet was initiated for a Stage 2 pressure ulcer on the right buttocks. The measurements were 3.5 cm by 2 cm by 0.25 cm. The area was denuded. The current dressing/treatment was identified as [MEDICATION NAME] every shift. The flow sheet identified Resident #6 used a pressure relieving mattress/device. On 12/11/13, a fax was sent to the physician which identified the pressure ulcer was healed. On 02/11/13, a wound assessment flow sheet was initiated for an inherited Stage 1 pressure ulcer on the buttocks. The measurements were 0.75 cm by 0.75 cm. The current dressing/treatment was skin prep to surrounding skin and border foam dressing. A fax was sent to the physician which identified Resident #6 had two open areas on his buttocks, and he was to be repositioned every two hours. The wound assessment flow sheet and fax did not identify which buttocks the pressure ulcers were located on. On 02/18/13, a wound assessment flow sheet was initiated for a pressure ulcer Stage DTI (deep tissue injury) to the right great toe. The area was 0.3 cm by 0.2 cm and the current dressing/treatment was identified as skin prep. A fax sent to the physician on 03/19/13 identified the right great toe had healed. On 02/26/13, a fax sent to the physician identified the wound to the buttocks was healed. The fax requested an order for [REDACTED]. On 03/19/13, a fax was sent to the physician which identified the right great toe had healed. On 05/09/13, Resident #6's comprehensive skin assessment identified Resident #6 was at risk for skin breakdown. He had a history of [REDACTED]. He used a pressure reducing mattress and was repositioned every two hours. On 05/21/13, Resident #6's care plan was updated: -"I have an air mattress. Please be sure it is plugged in at all times," was added to the potential alteration in skin integrity problem. -"Please clean my incontinent BM (bowel movement) by patting my skin rather than wiping to ensure skin integrity," was added to the frequent bowel incontinence problem. -"Please place me in the day room recliner for up to 2 hours after breakfast as I will tolerate," was added to the limited physical mobility problem. On 06/10/13: -Resident #6's comprehensive skin assessment identified Resident #6 currently had a Stage 3 pressure ulcer on his right heel. Friction and shear were potential problems. Resident #6 was using a pressure reducing mattress and pressure reducing cushion in his wheelchair. The analysis identified Resident #6 was at risk for skin integrity issues related to [DIAGNOSES REDACTED]. He currently had a pressure area on his right heel. He is chair bound and friction/shear is a potential problem. Due to requiring assistance with repositioning he was to be repositioned with assist of one every two hours in bed and chair. -A wound assessment flow sheet was initiated for an inherited Stage 1 pressure ulcer to the right heel. This was changed to an unstageable diabetic ulcer (no date identified). The measurements were identified as 1.5 cm by 1.5 cm. -Resident #6's nurses' notes identified Resident #6 had a calloused area on the right heel that was somewhat brown/light purple in color. Grippy socks were placed instead of slippers. MBD (My Best Day) (RA (Resident Assistant) care plan) was updated to include floating heels while laying in bed. On 06/11/13, the wound assessment progress note identified a diabetic ulcer presented to the left heel and was 100% eschar. The fax sent to the physician identified Resident #6 had a Stage 3 pressure ulcer on his right heel. On 06/13/13, Resident #6's dietary progress note identified Resident #6 had a deep tissue injury to his heel. The area was scabbed and not open. On 07/01/13, the wound assessment flow sheet identified the right heel ulcer was an acquired ulcer described as "other - unstageable diabetic ulcer." On 07/06/13, Resident #6's comprehensive skin assessment identified Resident #6 had a history of [REDACTED]. He used a pressure relieving mattress, a pressure relieving cushion in his wheelchair and was to be repositioned every two hours. On 07/16/13, the wound assessment progress note identified the right heel ulcer had healed. Staff were to continue with skin prep for prevention. On 07/18/13, a wound assessment flow sheet was initiated for an acquired Stage 2 pressure ulcer to the right buttocks. Resident #6's comprehensive skin assessment identified Resident #6 had a pressure reducing mattress and cushion in his wheelchair, he was to be repositioned every two hours and a pillow was to be placed to float his heels. Resident #6 had a history of [REDACTED]. He currently had a Stage 2 open area on his right buttocks. On 07/22/13, Resident #6's wound assessment progress note identified he had a history of [REDACTED]. Resident #6 additionally had [DIAGNOSES REDACTED]. Resident #6 had been seen by OT (occupational therapy) for wheelchair positioning through 07/10/13. Resident #6 had an air flow overlay mattress and a cushion in his wheelchair. Resident #6 had a pressure ulcer on his right buttocks. On 08/06/13: -Resident #6's comprehensive skin assessment identified Resident #6's heels were to be floated, he was to be turned every two hours and he used a pressure relieving mattress. The assessment identified Resident #6 had an open area on his left lower sacral area. The analysis stated, "Adjacent pressure ulcer (existing) on right buttocks in same area. Resident may need greater pressure reducing adjustment in w/c (wheelchair) and be laid down more frequently." -A wound assessment flow sheet was initiated for an acquired Stage 2 pressure ulcer to Resident #6's left lower sacral area. The measurements were 1 cm by 0.5 cm. This pressure ulcer was noted during the dressing change to the right buttocks pressure ulcer. -Resident #6's nurses' notes identified he had an acquired pressure ulcer on his left lower sacral area that was found while the dressing change to the right buttocks was being completed. Wife has concerns about his position changes during the day. Would like resident to lie down between breakfast and lunch as well as in the afternoon. On 08/07/13. the wound assessment progress note stated, "Interventions added to the MBD and CP (care plan): complete air flow mattress (ensure it is turned on at all times), repositioning for bed mobility - every 2 hours side to side in bed (not on back). Please assist to bed for up to 2 hours after breakfast and lunch. OT orders to assess wheelchair positioning and continue with current treatment order." On 08/09/13: -Resident #6's nurses' notes identified he had two small open areas on his buttocks that had been reported by the PM nurse. The area around the scrotum and perineal area was reported as red. -Resident #6's physician's progress note stated, "He has a couple of ulcers that are improving. These are sacral pressure ulcers." On 08/11/13, Resident #6's comprehensive skin risk assessment identified he used pressure relieving cushions and pillows and had an open area on his right buttocks. The analysis identified Resident #6 was wheelchair dependent and required assistance of two for positioning and transfers. He was very limited in extremity movement. He is repositioned every two hours, staff were to use pillows and specially designed wheelchair padding to help him maintain positions while in the wheelchair. Resident #6 was unable to position himself and had considerable muscle weakness. On 08/13/13: -Resident #6's nurses' notes identified he had a history of [REDACTED]. -Resident #6's wound assessment progress note identified the pressure ulcer to the left lower sacral area was resolved. On 09/03/13, Resident #6's wound assessment progress note identified the open area on his right buttocks was still present, was slightly larger than previous measurements and was 100% granulation tissue. On 09/10/13, Resident #6's wound assessment progress note identified the open area on his buttocks appears smaller. Wound bed was 100% granulation. A gel pad, pressure relieving pad has been added to his wheelchair. Resident also recently received a new wheelchair. Resident often rocks back and forth in chair. MD updated. Current treatment: cleanse with normal saline, skin prep to peri wound, cover with foam dressing. Resident #6's care plan provided by the facility on 09/09/13 identified the problem for potential alteration in skin integrity was updated on 08/07/13: "I have pressure areas on my bottom at this time d/t (due to) DM (diabetes mellitus), decreased mobility, incontinence, [MEDICAL CONDITION]." New approaches included: 08/07/13 "Have a complete air flow mattress. Ensure it is turned on at all times. OT to assess w/c positioning as indicated." On 09/09/13, "I have a gel cushion in my wheelchair," was added. Resident #6's MBD care plan provided by the facility on 09/09/13 identified the following: -Reposition of 1 every two hours when in bed. Assist of two every two hours while in chair. Please assist me to bed after breakfast and lunch for up to 2 hours as tolerated. Raise my arm rests if I am showing signs of fatigue or increased lateral lean. -Toileting: Pat to remove BM, do not wipe. -Skin: I have a gel pressure relieving device in my wheelchair. I have a full air mattress. I have a pressure reducing pad in my wheelchair. I wear black slippers. Float my heels while in bed. Observations: On 09/09/13 at 9:25 a.m., on the initial tour of the facility Surveyor observed Resident #6 laying on his back in bed with his feet not elevated. Resident #6 had a Direct Supply alternating pressure mattress on his bed. A thin black cushion was visible in Resident #6's Broda chair. Clinical RN (Registered Nurse) Coordinator (CRNC) A informed Surveyor that Resident #6 had an open area on his buttocks which had developed in the facility. Clinical Consultant (CC) L stated this area is shearing and has been ongoing. CC L stated Resident #6 propels his own wheelchair, rocks back and forth while seated in the wheelchair and slides down while seated in his wheelchair. CC L stated Resident #6 had been provided a new wheelchair. On 09/09/13 at 1:23 p.m., Surveyor observed Resident #6 laying in bed on his back. His heels were not elevated off the mattress. On 09/09/13 at 2:21 p.m., Surveyor observed Resident #6 laying in bed on his back. When Resident #6 was uncovered his heels were resting directly on the mattress. No positioning device to float his heels was in his bed. On 09/10/13 at 7:12 a.m., Surveyor observed RNs CRNC A and C perform Resident #6's treatment on his right buttocks pressure ulcer. Resident #6 had been incontinent of BM (bowel movement). CRNC A was observed to wipe the rectal/buttocks area with disposable wipes. Resident #6 continued having a BM. Upon completion of having the BM, CRNC A was observed to wipe the rectal/buttocks area with the disposable wipes. Resident #6 was transported to the bathroom where he had another BM. CRNC C was observed to wipe Resident #6 with the disposable wipes. CRNC A and RN C did not "pat" to remove the BM as directed on the care plan during the three observations when BM was removed. Surveyor observed RNs A and C perform Resident #6's dressing change on the right buttocks pressure ulcer. -The dressing supplies were set on the bed side stand without a barrier being placed under them. -RN C opened the foam dressing, dated and initialed the dressing with the magic marker on the bedside stand and laid the dressing on the bedside stand without a barrier. -CRNC A measured the ulcer and wrote the measurements of the ulcer on her left gloved hand with the magic marker from the bedside stand. Upon completion of the measurements CRNC A transcribed the measurements from her glove to the measuring device. -CRNC A moved all the dressing supplies on the foot of the bed on the left side without a barrier being placed. -CRNC A opened and removed a sterile normal saline wipe from the package, laid the wrapper on the foot of Resident #6's bed and placed the normal saline wipe on top of the outside of the wrapper. -CRNC A applied the foam dressing from the bedside stand over the pressure ulcer. -While repositioning Resident #6, all the dressing supplies on the foot of the bed fell on to the floor. CRNC A picked up the items from the floor and placed them on top of the dresser. -After Resident #6 was in the bathroom, RN C took the dressing supplies from the top of the dresser into the bathroom. RN C laid the dressing supplies on the countertop to the left of the sink without a barrier. -RN C opened the jar of [MEDICATION NAME] 1%/[MEDICATION NAME] and the tube of Calmo ointment, placed the lid/cap of the containers directly onto the countertop and set the supplies back onto the countertop. -RN C opened the foam dressing, dated the dressing with the magic marker and laid the foam dressing and magic marker on the countertop without a barrier. -RN C after cleansing the pressure ulcer with the sterile normal saline wipe and applying the skin prep waved her gloved hand back and forth to dry the skin. Resident #6 was standing in the lift in front of the toilet at the time. BM was present in the toilet, the insert in the elevated toilet seat and on the toilet seat. -RN C washed and applied gloves, picked up the jar of [MEDICATION NAME] 1%/[MEDICATION NAME] from the countertop, placed her right gloved hand into the jar and applied the ointment to Resident #6's rectal/buttocks area. RN C picked up the tube of Calmo ointment with her gloved hand, handed the tube to CRNC A who placed some of the Calmo ointment onto RN C's right gloved hand. RN C then applied the Calmo ointment to Resident #6's buttocks and rectal area. The tube of Calmo ointment was placed back onto the countertop. -RN C placed the jar of [MEDICATION NAME] 1%/[MEDICATION NAME] and the tube of Calmo ointment back into the locked cupboard in Resident #6's room without disinfecting the items. -RN C placed the unused packets of sterile normal saline wipes, skin prep packets and five measuring strips on top of the accu-check book that is taken into residents' rooms who require an accu-check. -RN C placed the sterile normal saline wipe packets, skin prep packets and the measuring strips into the boxes they were removed from in the room identified "Linen." The facility keeps all nursing supplies in this room. CRNC A and RN C did not assess Resident #6's heels or apply skin prep to the heels during the observation. On 09/12/13 at 7:30 a.m., Surveyor observed Resident #6 laying in bed on his back. A pillow was laying on the floor directly in front of the foot of his bed. Resident #6's feet were wrapped in blankets. Resident Assistant (RA) G entered the room and stated Resident #6's feet are to be elevated on pillows when in bed. RA G stated she had been employed at the facility over a year and had not seen Resident #6's feet elevated on anything other than pillows. RA G stated Resident #6 was to lay on his sides in bed not on his back. RA G stated a couple weeks prior the facility had tried a different wheelchair. The wife did not like the wheelchair so it was changed back to the prior chair. RA G stated Resident #6 is now using the chair tried a couple of weeks ago. RA G stated when Resident #6 received the new chair he also received a different seat cushion. Resident #6 had a Skil Care Design Original cushion in his chair. RA G stated Resident #6 is to be repositioned every two hours in bed and when in his chair. RA G stated prior to recently Resident #6 had not laid down in the mornings. RA G stated Resident #6 would be placed in his chair before breakfast and laid down after lunch. RA G stated staff would stand Resident #6 for a couple of minutes and then place him back into his chair. RA G stated the reason Resident #6 lays down in the morning currently is that Resident #6's wife stated she wanted him laid down between meals. RA G stated occasionally Resident #6 becomes aggressive when asked to lay down and he does not want to. RA G stated when this occurs the RAs report this to the nurse. When RA G uncovered Resident #6's lower extremities his feet were not floated, he was wearing no stockings and his heels were directly resting on the mattress. RA G stated Resident #6 has had recurrent open areas to his buttocks for quite a while. RA G stated not long ago a new mattress was placed on Resident #6's bed. RA G stated Resident #6 had a black area on his heel for awhile. On 09/12/13 at 8:00 a.m., Surveyor interviewed RN C who stated Resident #6 was at risk for pressure ulcers. He required assistance of two staff and a stand lift to transfer. He was to be repositioned every two hours. RN C stated Resident #6 could kick the pillow out from underneath his feet when in bed. RN C stated she did not recall if any other devices were used to float Resident #6's heels in bed other than pillows. RN C stated Resident #6 is to be on his sides in bed to relieve the pressure on his buttocks. RN C stated she did not know when the cushion in Resident #6's wheelchair or the mattress on his bed were changed to pressure relieving from pressure reduction. On 09/12/13 at 8:30 a.m., Surveyor interviewed the Clinical Administrator (CA) related to Resident #6's skin breakdown. The CA stated she believed Resident #6 had a history of [REDACTED]. The CA stated she believed on 06/10/13 the black area was first noted on Resident #6's heel. The CA stated the nurse who initiated the wound assessment flow sheet charted the area was a pressure ulcer on his right heel. The CA stated she changed the type of ulcer to a diabetic as the ulcer was not on the right heel but rather on the side of the back of his foot. The CA stated the charting was inaccurate related to the location of the wound. The CA stated at the time the area was noted, Resident #6 had an air flow mattress on his bed. The CA stated Resident #6 had been evaluated by occupational therapy on several occasions related to wheelchair positioning. The CA stated currently Resident #6 was using a Broda chair not a wheelchair. The CA stated she did not know the specifics related to the type of cushion used in Resident #6's wheelchair. The CA stated Resident #6 had not laid down routinely between breakfast and lunch each day as his wife had requested that he not be laid down until after lunch. The CA stated staff did stand Resident #6 every two hours with the stand lift to decrease the pressure. The CA stated at times Resident #6 did not want to lay down and it was his right to not lay down. The CA stated not long ago Resident #6's wife informed staff she wants him laid down between meals. The CA stated the facility had spoken with the wife on occasions related to Resident #6 needing to lay down due to skin breakdown, however the wife refused. Surveyor asked the CA where this information was documented as it was not found in Resident #6's medical record or on his care plan. The CA stated she did not know if it had been documented. If the conversations had been documented they would be in the progress notes. The CA stated the open areas on Resident #6's coccyx were recurrent. The CA stated she did not know if other devices had been utilized to float Resident #6's heels. The CA stated she would have to check on that. The CA stated Resident #6 is able to move his lower extremities and push the pillow out from under his legs/feet. The CA stated Resident #6 would not have been able to push the pillow out from under his legs, over the foot of the bed so the pillow landed directly on the floor in front of the foot of the bed with Resident #6's feet wrapped in the blankets. The CA stated Resident #6 would not have been able to wrap the blankets around his feet after pushing the pillow over the foot of the bed. The CA stated Resident #6's care plan is to be followed related to positioning and transfers. The CA verified the dressing supplies which were placed on the bedside stand, bedding, top of the dresser after falling on the floor and on the countertop in the bathroom should have been placed on a barrier. The CA verified the dressing change was not performed using aseptic technique. The CA stated she was wound care certified. The CA stated she does not do wound rounds each week. She has RN A do wound rounds on those occasions. The CA stated RN A is not wound care certified. Surveyor requested to review any additional information the facility had to determine how the pressure ulcers were not avoidable. On 09/12/13 at 11:00 a.m., CA provided Surveyor with information related to the type of cushion Resident #6 was currently using in his wheelchair. The cushion was identified as a gel lift cushion which was gel-filled and waffle like. The cushion provided pressure relief, decubitis prevention and comfort. The CA provided no information related to the type of cushion Resident #6 used prior to the implementation of this cushion. (Resident #6's FMP (functional maintenance plan) developed by OT (occupational therapy) dated 08/22/13 identified Resident #6 had a blue wedge cushion that was to be placed with the large side towards the front of the wheelchair. There is no documentation when this cushion was changed to the gel lift cushion.) No additional information was provided by the facility to show the pressure ulcers were unavoidable. 2. Resident #11 was admitted following a closed fracture of her ankle. Resident #11's care plan problem dated 05/09/13 identified she had the potential for alteration in skin integrity. The approaches included to float heels in bed, place a piece of lamb's wool between her calf and cast to decrease friction and she required a pressure reducing mattress and cushion in her chair. The ADL (activities of daily living) self care performance care plan identified to observe her skin during cares. Resident #11's orthopedic notes dated 05/10/13 identified Resident #11 was in a short leg cast. The cast was removed and her skin appeared clean and dry. The incision was healing well. Resident #11 was placed in a CAM (Controlled Ankle Movement) boot. On 05/16/13, the physical therapy recommendation identified, "Splinting/Range of Motion: CAM Boot - pt (patient) may remove for cares and dressing. Have pt wear at night in bed and when up in wheelchair. Make sure heel is all the way back and down in boot. Should be able to see pt toes in front when applied correctly. If pt complains of discomfort in boot, take off and re-apply boot correctly. The rehabilitation progress report identified staff were trained on proper placement of the CAM boot. Surveyor was provided with three interdisciplinary care plans revised since admission. Resident #11's care plans were not updated to include the use of the CAM boot and proper placement. No skin concerns were identified in Resident #11's nurses' notes until 05/17/13. On 05/17/13, a fax was sent to Resident #11's physician related to a pressure area that was noted on the right lateral foot, below the pinky toe. The measurements were 1 cm by 1 cm, the area was dark black and had a circular area in the middle that was lighter in color and appeared softer. A white hardened area was noted medial to the black area. Resident reported pain with pressure to the area. Skin prep applied. The physician ordered "No new orders." Resident #11's dietary progress notes on 05/20/13 identified she had a pressure ulcer on her right lateral foot. On 05/21/13: -A fax was sent to Resident #11's physician which identified Resident #11 continued to have a blackened deep tissue injury to the plantar surface of the right foot at the base of the pinky toe. The wound specialist had recommended to change the treatment to skin prep to the wound every three days and change foam covering as needed. -Resident #11's nurses' notes identified she had a deep tissue injury to the planter surface of the right foot at the base of the pinky toe. On 05/24/13, Resident #11 was seen by the physician's assistant for a follow-up visit related to the right ankle fracture. The progress note identified Resident #11 had a blood blister on the bottom of her foot. A corn pad (or similar) was to be placed over the blister area. On 05/26/13: -Resident #11's comprehensive data collection did not identify any skin concerns. -The comprehensive skin risk assessment identified Resident #11 received repositioning every two hours, had a pressure reducing mattress and pillows for positioning aides to help with her skin integrity. Resident #11 was identified as having a [MEDICAL CONDITION] ankle, had dementia, was diabetic and required assistance with her ADLs. Resident #11's lower extremity concerns identified she did not have signs or symptoms of arterial disease, [MEDICAL CONDITION] or [MEDICAL CONDITION]. The analysis identified she required assistance of two with a full lift for all transfers, was occasionally incontinent of bowel and bladder and was repositioned every two hours. Resident #11 had no new wounds or skin issues at that time. On 05/31/13, Resident #11's CAAs (Care Area Assessment) for pressures ulcers identified she required extensive assistance with bed mobility, was frequently incontinent of bladder, was at risk for development of pressure ulcers and had one unstageable pressure ulcer due to suspected deep tissue injury in evolution. Resident #11 currently had a deep tissue injury on the bottom of her right foot which was healing from the inside out. The eschar was beginning to detach from the wound. "The deep tissue injury to bottom of right foot consistent from CAM boot. Eschar present but decreasing." Will pressure ulcer functional status be addressed in the care plan? Yes. The overall objective was "improvement." On 06/06/13, a fax was sent to Resident #11's physician which identified the wound to the right outer aspect of the foot below the pinky toe measured 1.6 by 1.7 cm in size, was 100% eschar, the edges were lifting revealing healthy tissue below, there was no drainage or open area. Will apply skin prep daily. On 06/14/13, Resident #11's orthopedic note stated, "Unfortunately, she developed an ulceration on the lateral side of her right foot on the lateral side. Her wounds on examination today, reveal; they are healed nicely on the lateral side. Medially also appears to be relatively well-healed. There appears to be a fresh abrasion in and around the wound area, but this is rather small and is not draining." On 06/18/13: -A fax was sent to