Every finding on record at Dove Healthcare - South Eau Claire

Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing of PIs, or prevent new PIs from developing or worsening for 1 of 3 residents (R) (R245) sampled for PIs. R245 was admitted to the facility with a stage 1 PI and was determined to be at high risk for PIs. A turning and repositioning program was not implemented, monitored, or reviewed, education on risk vs benefits of repositioning and offloading to prevent/improve PIs was not completed, and an air mattress was not placed timely. R245's PI worsened to an unstageable PI. This example is being cited at actual harm. This is evidenced by: National Pressure Injury Advisory Panel (NPIAP) guidance recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. The facility policy titled: Pressure Injury Prevention and Management last reviewed September 2024 states: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility policy further describes: Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors: define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. R245 was admitted to the facility on [DATE] with diagnoses of displaced fracture of base of neck of right femur and chronic kidney disease. R245's Minimum Data Set (MDS) assessment, dated 04/14/25, was currently in process at time of survey and identified R245 scored 11/15 during a Brief Interview for Mental Status. On 04/08/25, the facility entered a progress note stating in part . Nurse to Nurse report documentation from Hospital indicates Skin Alterations/Open Area: Pinkness/redness to buttock - zinc and foam dressing every 3 days. On 04/08/2025, the facility entered a skin note: Inner gluteal cleft Blanchable pinkness. On 04/8/2025, the facility completed a Braden Scale for Predicting Pressure Ulcer Risk. Braden Evaluation: Result: At Risk Score: 15.0. A Braden Scale score of 15 indicates a mild risk for developing pressure injuries. On 04/08/25, an individualized care plan was initiated for R245 with a target date of 07/07/25 stating: Risk for skin breakdown related to history of falls, cognitive impairment, decreased mobility after fracture and fall, with a goal of My skin will be kept clean and dry. The care plan had no specific interventions for pressure injury prevention. On 04/10/25, the facility entered a Wound/Skin Healing Note: Weekly wound tracker completed for resident. Wound Information: Coccyx - Pressure: Length = 0.7, Width = 1.0, Depth = 0.1, - Stage Unstageable. This is the first time writer has observed the wound. On 04/10/2025, the facility completed another Braden Scale for Predicting Pressure Ulcer Risk Braden Evaluation: Result: At Risk Score: 17.0. A Braden scale score of 17 indicates a moderate risk for developing pressure ulcers. This means the person is at a level where careful monitoring and preventive measures are necessary to minimize the risk of developing pressure injuries. On 04/10/25, the facility revised R245's care plan to: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. And added interventions of: Administer treatments as ordered and monitor for effectiveness. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Of note: the facility was unable to provide documentation to support education was completed. The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. Use pillows to off-load side to side. On 4/11/2025, the facility entered a Nutritional at Risk (NAR) Note Text: NAR meeting held on this day. Residents skin is not intact at this time. Sacrum - Resident has a small unstageable pressure injury to his sacrum area. On 04/15/25, the facility updated R245's care plan to include a pressure relief cushion to recliner and wheelchair. On 04/16/25 at 7:01 AM, Surveyor began continuous observation of R245 who was positioned on buttocks with head of bed elevated awaiting breakfast and noted the following: -Conducted continuous observation of R245 lying on back with head of bed elevated awaiting breakfast. Of note: No pillows used to off load per care plan. -8:15 AM, Surveyor observed Registered Nurse (RN) C enter R245's room to inform of plan to complete wound treatment after resident was completed with breakfast. -8:24 AM, Surveyor observed R245's call light and staff removed breakfast tray. No direction provided to reposition. R245 remained sitting on backside with HOB elevated. -8:33 AM, Surveyor observed RN C conduct wound care. Upon removing dressing, RN C noted R245's entire buttocks were reddened. RN C stated, Probably from being on buttocks, and pointed out scarred tissue from a past history of open areas. RN C stated last seeing wound on 04/11/25 and stated wound was unstageable and currently measures 0.3 cm x 0.5: Eschar 50% slough/50% granulation. RN C confirmed that area was not open upon admission on 04/08/25 and opened about 2 days later. -8:36 AM, upon completion of wound treatment, Surveyor asked RN C what interventions were in place to prevent further skin break down. RN C stated that on 04/15/25 an offer of an air mattress was declined by R245 and was hoping to talk to spouse who may be able to convince R245 to allow an air mattress. RN C also indicated that R245 has a gel cushion in recliner and wheelchair and is on a positioning program to reposition side to side. Of note, Surveyor requested evidence of conversation with R245 regarding declination of an air mattress as facility was unable to provide. -8:53 AM, Surveyor continued constant observation and observed Certified Nursing Assistant (CNA) D complete R245's morning cares. Surveyor observed heels not floated off of mattress. Surveyor asked CNA D what skin breakdown interventions R245 has on care plan. CNA D stated, [R245] is repositioned every 2 hours when in bed, has a cushion on recliner and wheelchair and should have had heels floated last night. CNA D stated heels are intact and a little red. -9:04 AM, Surveyor observed CNA D assist R245 to transfer to recliner and position on buttocks. Of note: No pillows used to off load per care plan. -10:28 AM, Surveyor observed R245 continue to sit in recliner on buttock. -11:03 AM, R245 placed on call light requesting assistance with urinal. CNA D assisted R245 while resident remained sitting on buttocks. CNA D lowered pants and positioned urinal for R245. Upon completion, CNA D did not offer/encourage repositioning to off load. -12:10 PM, Surveyor observed staff administer R245's medication and lunch tray while R245 remained seated in recliner. No repositioning/offloading offered. On 04/16/25 at 1:17 PM, Surveyor ended continuous observation as R245 was taken to therapy. Of note, R245 was not offloaded/repositioned off of PI on 04/16/25 from 9:04 AM until 1:17 PM (4 hours and 13 minutes). On 04/17/25 at 8:31 AM, Surveyor interviewed R245 who stated usually stays in recliner or wheelchair during day and doesn't believe staff reposition off buttocks. R245 stated that when in bed staff at times do place a pillow behind his back but can tell is still lying on buttocks. On 04/17/25 at 10:14 AM, Surveyor interviewed RN E regarding R245's intervention in place to prevent PI. RN E stated was not aware of what interventions were in place besides every 2-hour repositioning and has no knowledge of whether R245 is repositioned off of PI when in bed. On 04/17/25 at 10:22 AM, Surveyor interviewed CNA D who stated CNA D has never seen R245 on side in bed upon coming on day shift duty. CNA D stated he was talking to RN C of ideas of what to do when R245 prefers to sit in recliner most of the day and was directed to attempt to offload him as much as possible on side in recliner. Surveyor asked if R245 is offered repositioning, CNA D stated R245 has never went back to bed after getting up in recliner for the day. CNA D stated R245's care plan states to reposition every 2 hours and we try to offer. Surveyor shared observations of no repositioning/offloading for any length of time on 04/16/25 from 7:01 AM to 1:17 PM. CNA D indicated R245 likes the recliner and often will turn slightly on left side and curl legs up off PI area. On 04/17/25 at 10:35 AM, Surveyor observed RN F and CNA D have R245 position self on left side and curl up legs. RN F placed palm of hand under R245's buttocks and indicated that R245 was sitting slightly off PI, but still had some pressure applied to PI. On 04/17/25 at 10:51 AM, Surveyor interviewed RN C who reiterated that R245's buttocks were reddened during dressing change on 04/16/25 and appeared to have a past history of skin breakdown. RN C notified Surveyor the air mattress was placed on R245's bed this AM. Surveyor asked what type of mattress was on R245's bed prior to air mattress being applied. RN C stated the previous mattress was just a regular facility mattress. Surveyor requested information regarding appropriate use of current recliner and wheelchair cushions based on R245's current unstageable wound. RN C indicated that recliner cushion was an Equacel cushion, was not sure what rating it is for and will check. RN C stated the wheelchair cushion was just a regular cushion Of note, the facility was unable to provide evidence to support the current PI relief cushions used were appropriate for an unstageable PI.

Based on random 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 and help to prevent the development and transmission of communicable diseases and infections. Staff did not provide or offer hand hygiene to residents prior to meals. This has the potential to affect all 42 residents. Staff did not perform hand hygiene per standard of practice during cares for residents (R) cares. (R14 and R26) Example 1 Surveyor requested and reviewed the facility policy titled Nutritional Services Procedure Responsibilities for Meal Service which was dated as last reviewed on April 2023. The policy in part reads: Purpose: To provide guidance to staff for serving of meals to the residents of the facility. Procedure: ~Nursing is responsible for having residents ready . ~Staff delivering the tray will offer resident hand hygiene. On 03/12/24 at 12:07 PM, Surveyor observed meal service for lunch on the 300 wing hall. Surveyor observed R26, R35, R29 and R33 being transported to the dining room for lunch. R26, R35, R29 and R33 were served lunch and began eating on their own with no hand hygiene offered by staff. Certified Nursing Assistant (CNA) H remained in the dining room throughout lunch and at no point offered hand hygiene to the residents. On 03/13/24 11:52 AM, Surveyor again observed lunch in the 300 hall dining room. Surveyor observed R35 brought in a wheelchair from exercise activity to table in the dining room on 300 wing. R35 had previously been observed participating in exercise activity in the activity room. CNA F served R35 a salad with dressing, a hamburger on a bun, almond milk and coffee. R35 began eating with no hand hygiene offered by CNA F. R29 was brought to the table and served nacho chips, a barbeque on bread with no crust, apple juice and coffee by CNA D. No hand hygiene was offered to R29 before he began eating. R26 was brought to the dining room by CNA E, who served R26 cottage cheese with mandarin oranges, squash and rhubarb pie per resident order. No hand hygiene was offered to R26 before eating. Surveyor observed R35 handling her hamburger on bun with her bare hands and using utensils to eat her salad. At no point was R35 offered hand hygiene. R29 was observed holding bread/barbeque with one hand and cutting it with utensil with the other hand. R29 was observed eating nacho chips, R29 picked up chips with bare hands. At no time was R29 offered hand hygiene. R33 was brought to table and served chicken strips and fries that R33 picked up and ate with R33's fingers. R33 was not offered hand hygiene. R1 was brought to the dining room and served sloppy joe, squash, and pie. R1 began eating the sloppy joe with R1's hands. At no point was R1 offered hand hygiene. On 03/13/24 at 12:14 PM, Surveyor interviewed CNA E about offering residents hand hygiene before eating. CNA E explained it has never been done and she didn't think about it. Residents are just coming back from exercise and therapy where they were touching things and their hands are not clean. It is important to clean their hands before eating. On 03/13/24 at 12:17 PM, Surveyor spoke with CNA F about resident hand hygiene before eating and why it is not done. CNA responded, Good question, not sure why it is not done. I have worked here 7 months and it has never been done. It makes sense to do so. On 3/13/24 at 2:55 PM, Surveyor spoke with Director of Nursing (DON) B about the expectation of resident hand hygiene before eating. DON B expressed everyone should wash their hands before eating, including our residents. Further expressing he would expect residents to be offered hand hygiene before eating. 46694 Example 2 On 03/13/24 at 12:00 PM, Surveyor did continuous observation of CNA I passing lunch trays to residents on the 100 hall who all ate in their rooms. No hand hygiene was provided to or offered to residents prior to the meal. There were no hand sanitizer wipes on the trays delivered to rooms as well. On 03/13/24 at 1:16 PM, Surveyor interviewed Registered Nurse (RN) K, asking, Are all of the residents on this wing able to eat or drink something from their meal trays independently? RN K replied, Yes they can. Surveyor then asked RN K, Is it common practice to offer hand hygiene when you pass meal trays? RN K replied, I don't know, I don't typically pass meal trays. On 03/13/24 at 1:17 PM, Surveyor asked Nurse Technician (NT) L, Is it common practice to offer hand hygiene when you pass meal trays to the residents? NT L replied, Yes we offer them hand sanitizer from the wall in their rooms. On 03/13/24 at 1:20 PM, Surveyor asked CNA I, Is it common practice to offer hand hygiene when you pass meal trays to the residents? CNA I replied, I don't. They don't have wipes available, and the hand sanitizer is on the wall behind the residents in their rooms typically. On 03/13/24 at 1:36 PM, Surveyor asked CNA J, Is it common practice to offer hand hygiene when you pass meal trays? CNA J replied, If they ask for it then we do, but I don't force them. 47657 Example 3 Policy entitled Hand Hygiene last reviewed March 2023 and references of CDC and WHO Hand Hygiene Guidelines states indication for hand washing and hand antisepsis include in part: Before: Putting on gloves Right after: Having contact with residents skin, having contact with body fluids (even when gloves are worn) taking off gloves, moving from parts of the residents body that could be contaminated to clean parts o the resident's body. On 03/13/24 at 10:29 AM, Surveyor observed CNA C conduct morning cares on R14. After gathering supplies CNA C washed hands, donned gloves, removed soiled incontinence product and cleaned frontal peri area with washcloth. CNA C brought the basin to bathroom, dumped water and refilled the basin with clean water. Without removing gloves and conducting hand hygeiene, CNA C washed the frontal peri area again. After completing peri care, CNA C opened the door with soiled gloved hands to alert the nurse that R14 was ready for medicated cream. CNA C, without removing dirty gloves and conducting hand hygiene, performed the following: dumped basin of water, gathered and bagged dirty linens, opened dresser drawer and took out clean clothing, dressed and placed hoyer sling under R14 and took walkie talkie out of pocket and requested assistance for transfer. While waiting for assistance, CNA C removed gloves and without conducting hand hygiene, touched top of water jug and placed within reaching distance of R14. CNA C hooked up the sling for transferring R14 to the wheelchair. After R14 was in the wheelchair, CNA C donned clean gloves and without conducting hand hygiene, wet a clean washcloth, washed resident's face, placed toothpaste on toothbrush and handed the toothbrush to R14 for self brushing. Example 4 On 03/13/24 at 12:16 PM, Surveyor observed CNA C conduct incontinence cares on R14 while in bed. CNA C donned gloves, rolled R14 and removed soiled incontinence product. Without removing gloves and conducting hand hygiene, CNA C proceeded to leave the room touching the handle of door to get some washcloths and a towel to provide peri care. After returning to room, CNA C removed gloves and without conducting hand hygiene, donned a clean pair of gloves. After repositioning R14 to side and conducting peri care, CNA C proceeded to use the left hand to apply barrier cream to R14's buttock area. CNA C removed left glove, and without conducting hand hygiene, donned a clean left glove. Another staff member who was assisting CNA C, left the room, not closing the door securely. CNA C used unclean gloved hands to close the door tightly. CNA C proceeded to do the following: secured clean incontinent product, picked up 2 stuffed animals, and tucked them under bed covers with R14, touched bed remote, grabbed bedside table and placed closer to R14, left room to dispose of garbage and linens, removed gloves and went to a clean linen closet to grab a washcloth. No hand hygiene was conducted during this observation. On 03/13/24 at 1:31 PM, Surveyor interviewed CNA C regarding observation of no hand hygiene during morning cares and afternoon cares which included incontinence care. CNA C confirmed that appropriate glove removal and hand hygiene was not conducted during both observations and stated the expectation would be to remove gloves and conduct hand hygiene after moving from soiled to clean areas. On 03/13/24 at 3:43 PM, Surveyor shared observation of lack of hand hygiene/glove removal with DON B by CNA C with R14. DON confirmed expectation would be to remove gloves and conduct hand hygiene per policy. Example 5 On 3/13/24 at 8:27 AM, Surveyor observed morning care for R26. Surveyor observed CNA G and F perform hand hygiene and go to R26's bedside. CNA F removed R26's hospital gown. CNA G bagged the dirty gown and linens. CNA F went to the bathroom and donned gloves. Neither CNA F or CNA G performed hand hygiene before donning the gloves. CNA G washed and dried R26's upper body. CNA F applied deodorant under R26's left arm and CNA G applied deodorant under R26's right arm. CNA F dressed R26 with a clean shirt. CNA F did not remove dirty gloves or perform hand hygiene. CNA F and G rolled R26 towards the door to wash R26's back of urine with a soapy washcloth. CNA G rinsed and dried R26's back and rolled a chuck pad that was wet of urine from under R26. CNA G went to the bathroom for additional clean washcloths. CNA G did not remove gloves or perform hand hygiene when obtaining the clean washcloths. CNA G returned to bedside, lowered R26's brief, wet a wipe to remove cream from R26's groin. CNA G washed and rinsed R26's groin and CNA F dried R26's groin. CNA G placed the dirty linens in a bag and went back to the bathroom for more clean washcloths from drawer. CNA G did not remove gloves or perform hand hygiene after washing R26's groin and before retrieving additional clean washcloths. CNA G covered R26's groin with a towel after applying A and D ointment to R26's groin. CNA F went to R26's cupboard for a clean brief. CNA F did not remove his gloves or perform hand hygiene. CNA F, with dirty gloves still on, donned R26's clean pants up to R26's ankles. CNA F removed his gloves and donned clean gloves. CNA F did not perform hand hygiene when removing his dirty gloves and before donning clean gloves. CNA G donned clean gloves and applied Calameseptine cream to R26's buttocks. CNA G removed his gloves but did not perform hand hygiene. CNA G placed a clean brief on R26. CNA F removed R26's shirt that was wet with urine. CNA F did not remove his gloves or perform hand hygiene and proceeded to assist CNA G with placing R26's clean brief and clean pants. CNA G, with bare hands, removed R26's shirt that was wet of urine from bed and took it to the bathroom. CNA G did not perform hand hygiene and returned to bedside to assist CNA F with donning R26's clean shirt. On 3/13/24 at 1:16 PM, Surveyor interviewed CNA G about the observation. CNA G indicated CNA G has been on staff at facility since 2013 and trains other CNAs as a CNA mentor. CNA G expressed it makes sense to perform hand hygiene when going from dirty to clean and with removal of gloves. On 3/13/24 at 2:55 PM, Surveyor interviewed CNA F about the observation. CNA F indicated CNA F would expect hand hygiene to be done after direct contact with a resident, before and after every time. Further indicating hand hygiene should be done when going from dirty to clean. Gloves should be doffed, hands should be cleaned and clean gloves should be donned. On 3/13/24 at 2:59 PM, Surveyor interviewed DON B about the observation and staff expectation for hand hygiene. DON B expressed staff absolutely should have performed hand hygiene after all resident skin contact and before proceeding to clean next step. Additionally staff should perform hand hygiene with glove change.

Based on observations and interview, the facility did not ensure proper sanitation of the food thermometer while temping lunch to prevent cross contamination which has the potential to affect 25 of 25 residents. Cook C was using Sani T10 Plus and a blue towel for sanitizing the thermometer in between temping food, that did not follow facility protocols to prevent cross contamination. This is evidenced by: On 01/25/23 at about 11:00 am, Surveyor observed Cook C put a thermometer in the beef stew, Cook C then removed the thermometer from the beef stew and placed it in a cup of clear liquid. Surveyor asked Cook C what was in the cup, and Cook C indicated sanitizing water. Cook C then swished the thermometer in the sanitizing water, removed it from the sanitizing water and wiped it on a blue paper towel. Cook C then proceeded to temp a pot pie, removed the thermometer, swished the same thermometer in the same contaminated sanitizing water, removed it and wiped the thermometer with the same blue paper towel. Cook C continued to temp the soup, french toast, baby carrots and a hamburger the same way, reusing the contaminated sanitizing liquid. At about 12:30 pm, Surveyor interviewed the Nutritional Services Manager (NSM) D and asked how staff are to sanitize the thermometer in between temping food. NSM D indicated that they should be using alcohol swabs in between each food item. Surveyor then told NSM D of the observation of Cook C using a clear liquid to sanitize the thermometer in between temping foods and asked NSM D for the name of the products used. NSM D told Surveyor that cook C was newer and they would talk to Cook C. Surveyor checked the employee list and noted Cook C was hired on 09/20/22. NSM D brought Surveyor the product information for the sanitizing water that was used by Cook C. The clear liquid used was Sani T10 Plus and the blue towel was a food service paper 1 ply all-purpose towel. At about 1:34 pm, Surveyor went back to the kitchen and interviewed Cook E. Surveyor asked Cook E how they cleaned the thermometer in between temping foods. Cook E indicated they use alcohol swabs. On 01/26/23 at about 10:15 am, Surveyor interviewed Cook F and asked what they used to sanitize the thermometer in between temping foods. Cook F indicated alcohol wipes. On 01/26/23 at about 11:05 am, Surveyor interviewed Cook C and asked if they were trained to use the Sani T10 Plus to sanitize the thermometer in between temping foods. Cook C indicated that that was what they were trained to use, and the cook that trained her was no longer working there. Surveyor asked Cook C if she tested the cup of Sani T10 Plus before using it to clean the thermometer. Cook C indicated no that she only tests the buckets of sanitizing water, not the cup she used for sanitizing the thermometer.

Based on observation, interview, and policy review, the facility did not store and distribute food in accordance with professional standards for food safety. This has the potential to affect all 30 residents who reside in the facility. Expired food, undated food, and open food not stored in food grade containers were observed in dry food storage. Kitchen food preparation equipment was observed not in sanitary condition. This is evidenced by: On [DATE] at 8:20 a.m., Surveyor conducted an initial tour of the facility with Cook D. Surveyor found the following items in the dry storage room: -Bag of baking mix-biscuits opened. Twist tie used to close bag. Mix not in food grade container. -Five pound bag of curly egg noodles. No open date. Bag had hole in top of the bag. Bag not sealed and not in a food grade container. -Bag of cheese puffs opened with open date of [DATE]. Expiration date [DATE]. Bag closed with twist tie. Cheese puffs not in food grade container and expired in the dry storage room -One pound box of gluten free elbow macaroni in opened box. Open date of [DATE] on box. Macaroni not in food grade container. Surveyor showed the above items to Cook D as items were found. Surveyor continued kitchen tour with Cook D. The above listed items left in dry storage room in same manner as which they were found by Surveyor. Surveyor toured the kitchen preparation area and the following items were found: -Flour and sugar bins. The sugar bin had residue of sugar on top of the lid of the bin. The scoop for the sugar had residue on it, and the scoop holder for the sugar had residue in the holder. The flour bin had residue of flour on top of the lid of the bin. The scoop for the flour had residue on it, and the scoop holder for the flour had residue in the holder. -The Convotherm Oven had crumbs on the oven top. The side panel and the door front of the oven were spotted and smeared. -The stove had grime/grease noted under the main part of the stove on the stainless platform. Back wall behind the stove had smears of grease. -The can opener attached to the food preparation table had grease and grime down the metal pole attached to the table. The blades of the can opener had grime on them. -The food preparation table had spatters of food debris on the side panel of the table. Surveyor asked Cook D to demonstrate the use of the test strip for the sanitizing bucket. Surveyor asked Cook D how often the buckets are tested . Cook D stated the buckets are tested every 2 hours. Cook D decided to take the bucket and dump the current solution out. Cook D brought sanitizing bucket back to food prep table with clean sanitizing mixture in the bucket. Cook D immersed a test strip in the bucket for 1 second and then read the strip, which Cook D stated the strip read 100ppm. Surveyor asked Cook D what the reading for the strip should be. Cook D stated the reading should be about 200ppm. On [DATE] at 9:30 a.m., Surveyor toured kitchen a second time. The same items were noted in the dry storage room and the kitchen preparation area remained unclean as noted on tour date of [DATE]. On [DATE] at 1:58 p.m., Surveyor interviewed the Director of Nutritional Services (DNS) C. When asked how often the sanitizing bucket solution is changed, DNS C stated, The bucket is usually changed every 2 hours. DNS C stated the staff uses special wipes in the buckets. The wipes are blue in color when clean and then turn yellow color when dirty, and then are discarded. Surveyor asked how long the test strip is to be immersed in the solution. DNS C replied 10 seconds. Surveyor shared observation of Cook D submersing for 1 second. Surveyor asked DNS C how the dietary staff is provided education. DNS C stated education is provided at their stand-up meeting on Wednesdays due to the number of staff being so few in numbers. DNS C stated sometimes in-services are provided if needed on a special circumstance; for example, if a resident is admitted with a gluten allergy. Surveyor asked DNS C for policies on food storage, sanitizing policy for the sanitizing bucket, the policy for food brought in from outside sources, and the cleaning schedules. Surveyor informed/explained the dietary/kitchen concerns found during the inspection. DNS C stated the staff had probably cooked bacon that morning and they were also baking. On [DATE] at 8:00 a.m., Surveyor informed the Nursing Home Administrator (NHA) A of dietary/kitchen concerns. NHA A stated she would meet with the DNS to go over the concerns. On [DATE] at 9:30 a.m., Surveyor reviewed the cleaning schedule for the kitchen. The cleaning schedule states the following, in part, .AM Aide Cleaning Schedule: Friday-scrub down holding oven and change/clean sheet pans. AM Cook Daily Cleaning List: clean & sanitize all equipment used, clean & sanitize all counter/work spaces in kitchen. PM Cook Daily Cleaning List: Thursday-Clean sugar/flour bins & scoops, Sunday-Clean oven and back wall by grill. Daily: clean & sanitize all counter/work spaces in kitchen. Surveyor reviewed Proper Food Storage Policy. Policy states the following, in part, .13. Any opened food should be labeled with an opened on date and stored in suitable containers. 20. Sugar and flour scoops are not stored in ingredient bins. They are sanitized after each use and stored with utensils and equipment until the next use. Surveyor reviewed the Nutritional Services Procedure Sanitation Program. The procedure states the following, in part, Purpose: To provide guidelines to the Nutritional Services Staff with regards to the cleaning and sanitation of equipment. Procedure: 1. The Nutritional Services Director and/or the Consultant Dietitian develops procedures and maintenance schedules. 2. Cleaning schedules are posted in the kitchen. 3. The Nutritional Services Director designee trains the dietary personnel in using proper procedure. [NAME] reviews the procedures with the employees, b. demonstrates the procedures, c. observes the employee doing the procedure. 4. The Nutritional Services Director or designee checks the daily cleaning to insure that the schedule and proper procedure are followed. 5. A Quality Control Audit is done by the Nutritional Services Director or Consultant on a routine basis. Items not up to standard are discussed with the individual assigned the responsibility for the cleaning, Re-training is done as necessary.

Based on interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 2 sampled residents being reviewed for constipation, Resident (R) R14. R14 had 3 incidents of constipation in December. The facility did not follow the bowel protocol for constipation or add interventions to decrease constipation for R14. This is evidenced by: R14 was admitted on [DATE], with [DIAGNOSES REDACTED]. R14's Brief Interview for Mental Status score is 14, meaning R14 is alert and oriented and able to recall information and answer questions accurately. On the initial tour 12/16/19, at approximately 8:35 a.m. Surveyor interviewed R14 and asked if he had any trouble with constipation. R14 stated, My bowel bothers, I get stacked up, I've had some problems with constipation for a few months. Surveyor reviewed medical record for bowel patterns. Surveyor noted the following bowel movement documentation. R14 had a bowel movement (BM) every one to two days until 11/27/19. Bowel Record in part, 11/30/19 large 12/03/19 large 12/08/19 large (five days since last bowel movement) 12/12/19 large (4 days since last bowel movement) 12/16/19 large at 12:46 p.m. (4 days since last bowel movement) R14 has physician orders [REDACTED].>[MEDICATION NAME] 17 grams by mouth daily as needed for constipation Senna S 1 tablet daily as needed for constipation [MEDICATION NAME] Suppository 10 mg rectally daily as needed for constipation [MEDICATION NAME] rectally daily as needed for constipation MOM (milk of magnesia) 30 cc orally up to twice a day as needed for constipation [MEDICATION NAME] Sodium 100 mg 1 capsule oral up to twice a day as needed for stool softening The PRN (as needed) Medication Administration Record [REDACTED]. R14 had no change in his bowel protocol to prevent constipation. The medical record did not document any refusals of the medication. The bowel protocol was not followed from 12/03/19 to 12/16/19, when R14 was having constipation. The bowel protocol, last reviewed (MONTH) (YEAR), in part, Assessment Process 5. Resident's needing to have a bowel movement will be given PRN bowel medication per .protocol . After review of the electronic medical record bowel documentation the licensed staff will: At 3 days with no BM - provide resident with MOM (milk of magnesia) or document refusal. At 4 days with no BM - Provide resident with a [MEDICATION NAME] suppository and document bowel sounds. Document any refusals. At 5 days with no BM - Provide enema. Document bowel assessment. On 12/18/19 at 9:30 a.m., Surveyor interviewed Director of Nursing (DON) B about R14's constipation and bowel protocol. Surveyor asked if any of the as needed laxatives were used. DON B stated she would get more information. On 12/18/19 at 11:10 a.m., DON B came to Surveyor stating they did not use any PRN medications or follow the bowel protocol for the above noted dates. DON B thinks it may be due to miscommunication with staff. DON B gave Surveyor a document dated 11/15/19 that indicated R14 had a BM during the time period Surveyor was asking about. This date was not an area of concern in the investigation.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) for 1 of 2 residents reviewed, in accordance with their advanced directives. On [DATE] upon admission to the facility, R38 indicated that she would like CPR if her heart stopped beating or she would stop breathing. On [DATE], R38 was found without blood pressure, pulse, and not breathing. Nursing staff did not initiate CPR despite R38's advanced directives to be provided CPR in accordance with her wishes. The facility's failure to ensure R38 received basic life support, including CPR, in accordance with her wishes, per her signed CPR consent form and facility policy, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. The Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed of the IJ finding on [DATE] at 3:40 PM. On [DATE], the facility took steps to correct the deficient practice and ensure compliance. Based upon this determination, the immediate jeopardy was removed and corrected on [DATE]. Findings include: The Facility's Nursing Policies and procedures last reviewed on (MONTH) (YEAR) titled Code Status includes in part, the following: It is the policy Facility will provide basic life support, including CPR- Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order [REDACTED]. Another of the Facility's Nursing Policies and procedures last reviewed on (MONTH) (YEAR) also titled Code Status includes in part, the following: Purpose: To provide guidelines to staff with regards to determining and recording resident wishes related to code status and initiating cardiopulmonary resuscitation (CPR) . 9. The initiation of CPR will be provided in accordance with the resident's Critical Care Plan, advanced directives or in the absence of a DNR order on all witnessed and un-witnessed arrests. 11. When a [MEDICAL CONDITION] has been determined the following basic steps will be taken: a) the order of these steps may vary according to the situation and will be directed by the licensed staff member utilizing their nursing clinical judgement. b) The facility staff is notified of the emergency by activating the emergency call light system / yelling for help by stating Code Blue. c) Verify the resident's code status. This information is entered as a single entry and can be found in multiple locations in the electronic medical record. d) Designate someone to call 911. e) Staff begins CPR according to established standards of practice while designating someone to get AED crash cart. f) Bare resident's chest and attach AED. Following the instructions as noted on the machine until EMS arrives. DQA memo ,[DATE] dated (MONTH) 24, 2013 states: Per CMS S & C ,[DATE], nursing homes must have staff certified in CPR on duty every shift. These individuals must provide CPR for any resident who becomes pulseless and non-breathing unless: (1) the resident has a do not resuscitate (DNR) order; (2) the resident has obvious signs of clinical death (e.g., rigor mortis, dependent lividity (pooling of the blood that occurs after death and may look blue, purple or black and is similar to bruising), decapitation, transection, or decomposition) or (3) the initiation of CPR could cause injury or peril to the rescuer. Surveyor reviewed R38's medical record on [DATE]. R38 was admitted to the facility, for short term rehabilitation, on [DATE] with [DIAGNOSES REDACTED]. R38's CPR consent signed and dated on [DATE] indicated that it is her desire to have CPR. This form was also signed by the resident's physician on [DATE]. R38's physician orders [REDACTED]. R38's Nursing Notes include, in part, the following entries: [DATE] 20:57 O2 saturation 92% On room air. Blood pressure ,[DATE] Respiratory rate 16 pulse 75 temperature 97 temporal [DATE] 8:01 a.m. Call placed to Dr. office. Patient observed on floor without vital signs and cold extremities. Pager number of Doctor was given 8:04:01 Call placed to: Dr. pager comments: call back number left on pager 8:09 Call received from Dr. (doctor), Dr. suggested calling the medical examiner's office in an unwitnessed death. 8:14 call placed to Eau Claire medical examiner. Message left on medical examiner's phone to call back. Awaiting return call 8:17 Order received from MD - ok to release body to funeral home 13:35 Date/time of death: [DATE] Time: 8:10 Actions: Body readied for release, funeral home notified, family notified. There is no other contemporaneous documentation describing the condition of R38. The next documentation is an Incident Report dated [DATE]. [DATE] Incident type: Resident found on floor; Date of incident: [DATE]; Time 07:20; Staff involved: No staff involved; Other witnesses: none; Location: in room; Environment: uncluttered in unusual place; Lighting: OK; Quiet; Clothing: Patient own PJ's (pajamas); Activity at the time: Alone transferring; Assistive device: independent Injury: None noted; First aid: None needed; Assessment of resident condition: no c/o pain. Resident was unresponsive. Description of incident: Resident position upon entering room: head was facing towards the bed with body curled up lying on her right side. CNA alerted nurse R on floor and is unresponsive. Writer immediately assessed R for a pulse and she did not have one. Writer listened for heart sounds and she did not have any. Attempted to move R legs forward and back and sternal rub. Resident was rolled on her back with CNA and writer with blanket under her. Writer attempted a BP (blood pressure) and there was no BP that would register. Mottling was noticed on both her hands and her hands were cold. Her face was very pale and eyes closed patient was unresponsive. Attempted to move resident's legs forward and back and sternal rub and no responds at all Director of Nursing entered room as well as charge nurse. See charting for their assessment. Resident was lifted with the Hoyer with 3 assist with no incident. Proceeded to smell bowels and cares were performed to present her to the family. Primary contact was notified and stated she would be there in approx. 30 min. (Documented by RN G) On [DATE] at 1:05 PM, Surveyor interviewed Certified Nursing Assistant (CNA) I regarding R38's death on [DATE]. CNA I stated he is not CPR certified, and has worked at the facility for 7 years. CNA I stated he was coming in with the breakfast tray. When he went into the room, it was dark, the bathroom door was open, and he didn't see R38 at first. CNA I turned around and asked another CNA if R38 was in therapy, but that CNA said she was not to therapy. CNA I stated he set down the meal tray and turned on the light, then saw R38. CNA I stated R38 was half caught in her bed rail, her armpit area, he could tell she was gone. When asked if the rail caused any pressure on her chest area, neck or throat, CNA I stated no. It looked like R38 was coming back to bed from the bathroom. R38 was up independently to the bathroom. R38 was fully dressed in her pajamas, all clothes were in place. It looked like she had maybe been reaching for the blankets and slumped over. The bed helper rail was near/under her arm pit. R38's head and her shoulder were up on the bed face down. It didn't look like she was stuck, just looked like that is how she fell . CNA I stated he lifted her from that position to the floor. R38's body moved freely. R38 was easily placed on to the floor, and she laid flat. When CNA I placed her on the floor, he put on the emergency call light. Registered Nurse (RN) G arrived and took over, then RN F or the DON arrived and CNA I left. When CNA I left, RN G was looking for signs of life, and did not get a pulse, and did not have any vital signs, etc. After they determined R38 was deceased , CNA I went to get the Hoyer and lifted her into bed. R38's color was ashen, touched her and she was cold on her face, she was clothed. CNA I added when he first got to her room and saw her, he had called R38's name three times and gotten no response. CNA I stated when RN G was in the room he heard RN G say, I wonder if she is a full code. CNA I said he told her he didn't know. CNA I then reached into his pocket, pulled out his care plan sheets, and stated sometimes it lists full code on care plan sheets but I didn't think of it until then. When asked again if R38 could have gotten entrapped by the bed rail, CNA I stated, R38 was facing the wrong way to get entrapped in the bed. As she was facing the bed, and did not appear to be entrapped. CNA I stated he lifted R38 off the bed to the floor, everything went well. RN G was there about 30 seconds after he found her. CNA stated, things went really well, RN G arrived there quickly. Within one minute. On [DATE] at 11:13 AM, Surveyor interviewed RN F regarding R38's death on [DATE]. RN F stated she was the fourth person in the room as she was the nurse on other hall that day, and a CNA came to get her but she could not recall who. RN F stated when she arrived to the resident's room, R38 was on her back, and RN G was already taking vitals. RN F stated, we went through procedure wise, what we were going to do. R38's extremities were cold, she had been there awhile, and the DON called RN H to get further instruction. Knowing R38 was CPR, according to our policy, in a certain situation the procedure/policy refers to a nurse's discretion. Knowing she had been there awhile, the decision was made not to attempt CPR. On [DATE] at 1:02 PM, Surveyor interviewed RN G regarding R38's death on [DATE]. RN G stated she had worked the evening before [DATE]. RN G stated while working with R38, she talked about missing her husband and R38 stated she was ready to be with him. R38 had gone out with family the evening before, and she had such a good time. RN G stated, on the morning of [DATE], CNA I said, she's on the floor. RN G stated when she entered the room she got on the floor and did an assessment. There was no pulse, so she rolled R38 on her back and tried to get a set of vitals but nothing. No BP (Blood pressure), nothing. RN G performed a sternal rub and got nothing. RN G moved her legs, and got nothing, no response. RN G took her temperature. RN G stated if it isn't in my charting notes, it should be on my papers I keep in my locker. When asked if this surveyor could see those papers, RN G said, I will check and give you a copy, if I find it. RN G stated CNA I was bringing R38 a breakfast tray when he found her. RN G stated she listened for R38's heart, and didn't hear anything. RN G stated R38 was cold. RN G stated she told CNA I to go get the DON. While he did that, RN G held R38's hand. When CNA I returned, they lifted R38 from the floor with the Hoyer and placed her in bed. We took care of making her presentable for family. When asked why she didn't start CPR, RN G stated she was aware of the code status. R38 was a full code, but she was cold. RN G stated: I thought to myself, do I start CPR? The DON affirmed that she was gone; R38 had cold feet/hands. RN G stated she was once ACLS (advanced cardiac life support) certified, I know how to do CPR. When asked if she knew what the facility policy stated regarding CPR, RNG stated the policy states if a resident is a full code you do CPR. When asked why she did not do CPR, RN G responded she got direction from the DON not to do CPR. RN G said R38 is cold and she has passed. We talked about CPR, the DON saw no vitals on the machine I used. I thought about CPR and am prepared to do it. But she was very cold the DON didn't say not to do it, out loud, she just confirmed she was gone. When asked did you notice any signs of lividity, RN G stated R38 had mottling on her feet, and asked if that is what the surveyor meant. At that time RN G, who was working the floor, was called to another resident room, and the interview ended. Surveyor reviewed RN G's documentation again looking for a body temperature, as RN G stated she had taken it. None could be located in the medical record. RN G also did not provide any further documentation regarding the resident's temperature. On [DATE] at 1:24 PM, Surveyor interviewed the DON regarding R38's death on [DATE]. The DON stated someone came to inform her R38 was dead. The DON stated R38 was already mottled, cool to the touch with no vital signs. The DON stated RN G was in there when I arrived to the room. The DON stated it wasn't witnessed and our policy speaks to a nurse's discretion. The resident was cool to the touch, and had no vitals; obviously we are not going to do CPR. R38 was independent in bathroom. The DON stated she was aware the resident's code status was CPR. The DON repeated, she was gone, there were no vitals, cool to touch, death was evident, she expired and not that minute. The DON stated it was hard to track down when someone last saw R38. Later they found out someone had been in R38's room around 3:00 AM to shut off the light. The DON estimated the death occurred before 8:00 AM, shortly after she got here. The DON stated she was in the building and had just gotten to the office when RN F came to get her. The DON confirmed R38 had an assist bar on her bed to help maintain her mobility. The facility does not use half rails, they only use loop bars. The DON stated there were no signs whatsoever of life, R38's lips were blue. The DON stated the facility policy talks about discretion by the licensed staff member utilizing their nursing clinical judgement. The DON provided a copy of the policy on [DATE] at 1:35 PM [DATE] 2:12 PM The DON and NHA stated they feel there were signs of obvious death, that three nurses were in the room, and R38 was clearly dead. No further information was provided by the facility as to why the facility did not provide R38 with basic life support, including CPR, in accordance with R38's advanced directives. Although it is not certain that CPR would have been effective in reviving this resident, the failure to honor her wishes and to provide the care she wanted denied her the only opportunity she had for living. Immediate action was needed to try to revive her and this was not forthcoming. There is no contemporaneous documentation that lividity or rigor mortis existed and the nurses based their decision on professional judgment rather than the AHA (American Heart Association) guidelines. The facility's failure to ensure R38 received CPR following her designation on [DATE] that she desired to receive CPR created a situation of immediate jeopardy on [DATE] when R38 was found pulseless and without vital signs and CPR was not provided to R38 by nursing staff. The facility removed the immediate jeopardy and corrected this deficiency on [DATE]. On [DATE], the facility submitted a plan of removal which required all nursing staff receive mandatory training outlining facility's updated CPR policy prior to working with residents. Facility provided training to all nursing staff on CPR in accordance with CMS S&C Memo 14.01 Cardiopulmonary Resuscitation (CPR) in Nursing Homes. Facility updated CPR Policy to reflect standards of CPR as outlined in memo and trained all staff on updated policy.

Based on observation and interview, facility staff did not prepare and distribute food under sanitary conditions. Dietary staff were observed to work with food with contaminated gloves or hands. This has the ability to affect at least 11 of the facility's residents who drank juice. Dietary Aide (DA) C was observed to wash her gloved hands after they had become contaminated and continued to use those gloved hands touching multiple items in the kitchen. DA J was observed to pick up a dirty item off the floor and continued about her duties with contaminated gloves. This is evidenced by On 01/07/19 at 12:00 p.m., Surveyor observed in the dining room kitchenette DA C with gloved hands touch the lid of the garbage can and then touch a pitcher of orange juice and put it into the refrigerator. With the same gloved hands DA C touched 11 glasses of juice and water in the cold well of the serving table. DA C with the same gloved hands opened the garbage can lid to throw garbage away and went to cold well and again touched the 11 glasses of juice and water and placed the towel over the rest of the silverware. DA C washed her gloved hands and touched the lid of the garbage can. DA C with the same gloved hands took out plastic glass lid covers for use during tray line. At 12:09 p.m. DA C removed gloves and washed hands. On 01/08/19 at 11:14 AM, Surveyor observed Dietary Aide J drop the lid off the skim milk onto the floor, as she was pouring milk. She picked up the lid off the floor and set it on the counter. DA J then continued to pour glasses of milk. When DA J was done pouring she carried the glasses of milk to the cold well area. DA J then placed lids on each of the glasses and used a marker to mark the lids. DA J then filled other glasses, then emptied the jug, went to the sink and rinsed it, and threw it away. DA J then washed her hands.

Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with professional standards, including expiration dates. This involved 1 of 6 insulin pens reviewed. An insulin pen for R34 contained no label to identify the specific resident for whom it was prescribed and the medication was expired. As Evidenced by: On [DATE] at 7:23 AM, Surveyor observed Registered Nurse (RN) B give R34 8 units of [MEDICATION NAME] NPH ,[DATE] insulin and the insulin pen was expired and also contained no label to identify who the medication was for. Surveyor interviewed RN B who acknowledged the [MEDICATION NAME] NPH ,[DATE] Insulin was expired. RN B also informed surveyors that normally there should be a label on the insulin pen with the resident's name. RN B informed surveyors that when the nurse takes a new insulin pen, the nurse writes the expiration date on the sticker. Interview with Assistant Director of Nursing (ADON) E regarding R34 who reported no other residents receive [MEDICATION NAME] NPH ,[DATE] on the hall R34 resides. ADON E was unable to determine when the insulin pen was first used or where the expired medication came from.

Based on observation and interview, the facility did not ensure that standard and transmission based precautions were followed to prevent the spread of infection for 1 of 6 (R34) residents that received insulin, and 1 of 2 (R12) residents on precautions. R34 was administered insulin via an unlabeled insulin pen which did not have the resident's name and other identifiers to verify that the correct pen is used on the correct resident. Dirty towels observed on the carpeted floor in R12's room which is on precautions for [MEDICAL CONDITION]. As evidenced by: On [DATE] at 7:23 am, Surveyor observed Registered Nurse (RN) B give R34 8 units of [MEDICATION NAME] NPH ,[DATE] insulin via an insulin pen that was not labeled with resident's name. RN B was interviewed and informed surveyors that normally there should be a label on the insulin pen with the resident's name. Interview with Assistant Director of Nursing (ADON) E regarding R34 who reported no other residents receive [MEDICATION NAME] NPH ,[DATE] on the hall R34 resides. ADON E was unable to determine when the insulin pen was first used or where the expired medication came from. Surveyors reviewed the above findings with the Nursing Home Administrator and Director of Nursing and about the potential harm this may cause with any new residents admitted requiring the same insulin as the facility has many short term rehabilitation residents. On [DATE] at 8:22 a.m., Surveyor interviewed RN D about the type of precautions R12 has currently. RN D indicated R12 came in with positive [MEDICAL CONDITION] from the recent hospital stay and has had loose stools since being back to the facility. MD was notified and continued to be on precautions. Surveyor observed staff using PPE appropriately. Review of R12's medical record documented on [DATE] (Name) - SHH lab, States that stool sample for resident came back [MEDICAL CONDITION] positive. (Name) ADON notified. On [DATE] at 6:38 a.m., Surveyor observed R12 sleeping in bed. Surveyor observed in R12's room on the carpeted floor were used towels with a blue plastic bag on top of the towels. At 7:14 a.m., Surveyor observed in R12's room the used towels with the blue plastic bag on top of the towels in the same place on the carpeted floor. At 7:18 a.m., Surveyor interviewed ADON E about the towels. ADON E indicated the towels should not be on the floor and should be put in the bin in the resident's room or double bagged and put into the soiled utility. The floor will be cleaned with a bleach solution.

Based on observation and interview, the facility did not prepare and distribute food in accordance with professional standards of practice for 2 of 3 survey days. This was evidenced by: 12/04/17 9:00 AM: During the initial kitchen tour, Surveyor observed Cook F slicing melon and pineapple. Cook F has a beard and mustache and was not wearing facial covering. During an interview on 12/05/17, when asked about facial covering, Cook F stated, I didn't even know I was supposed to wear one until last night. 12/04/17 11:42 PM Surveyor observed Cook F during lunch steam table service. No observation of hand hygiene. Wearing gloves, Cook F served deli meat, cheese, topping and breads by hand after touching the outside of the microwave, the edge of the steam table and the edge of the cart holding the toppings for the sandwiches. Next, Cook F removed bread from a package, and placed the turkey by hand onto the bread. Then Cook F reached into a bin holding shredded lettuce and placed a portion onto the bread with his hands, and repeated this process with a slice of cheese and potato chips. Cook F then cut the sandwiches and placed them on a plate. This was observed initially three times. Then Cook F reached into the steam table and removed a hamburger by hand and placed it onto a bun which had been removed by hand from a package. Cook F then cut the hamburger in half and placed it on a plate. This process was repeated two times. Then, without changing gloves or performing hand hygiene, Cook F prepared two additional sandwiches, alternating preparation with (6) hamburgers in the same manner. At the end of the service, Cook F removed gloves and performed hand hygiene. On 12/05/2017 at 7:10AM Surveyor observed Cook F in the main dining room steam table serving breakfast for residents. Surveyor observed Cook F serving pancakes for residents and scooped up the pancakes for residents with the gloved hands, from the steam table. During the breakfast period, Surveyor observed Cook F touch multiple surfaces with the gloved hands while preparing plates and serving breakfast for residents. 12/05/17 7:41 AM: Surveyor informed NHA of the above observations. Surveyor conducted an interview with NHA and Cook F. Cook F stated that he has not been trained to use utensils when perparing/handling cold food. Cook F stated that he has been trained to use utensils for hot food, such as soup. Cook F stated that he has not been using utensils for cold food service (such as sandwiches) since he started working here (a few months ago). Cook F stated that he had not been taught about cross contamination or food contamination except to wash hands and apply gloves before beginning service. Cook stated that he did not know that he could not touch food about to be served after touching other surfaces and items.

Based on interview and record review, the facility did not provide care and treatment in accordance with professional standards of practice related to assessment and monitoring of [MEDICAL CONDITION] in a resident with [MEDICAL CONDITIONS] for 1 resident (R123) of 12 sampled residents. R123 was not assessed or monitored on a regular basis for [MEDICAL CONDITION]. This is evidenced by: Facility Policy entitled Medical Provider Notification in Acute Change in Condition with review date of [DATE] states in part: .Recognition-The nurse and interdisciplinary team through routine assessment and monitoring will recognize risk factors for acute changes in condition. These guidelines for medical provider notification related to [MEDICAL CONDITION] state: [MEDICAL CONDITION] - Immediate - Abrupt onset of unilateral leg [MEDICAL CONDITION], with tenderness, redness [MEDICAL CONDITION] - Non-immediate - Rapidly progressive unilateral or bilateral [MEDICAL CONDITION]. Resident #123 R123 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. [DATE] 01:22 PM Surveyor interviewed R123. R123 stated that she was hospitalized because of severe swelling in her legs and because her body had been stripped of magnesium and potassium. R123 stated that her legs were so swollen when she went to the hospital that they were weeping. R123 stated that the doctors told her that she was close to heart failure. R123 stated that she believed that she would have died if she went into heart failure. [DATE] 01:21 PM Record review: The History and Physical (H&P) from R123's hospitalization , dated [DATE], states in part: History of present illness: The patient has been having a problem with swelling of the lower extremities for the last few days. This morning, she has had more problem with swelling of the right leg and she started to have skin breaking and oozing fluid .Physical Examination .Extremities: Reveal 3+ [MEDICAL CONDITION] of right lower extremity and 2+ [MEDICAL CONDITION] of the left lower extremity .Impression: Hypertensive cardiovascular disease with severe leg [MEDICAL CONDITION] . R123's Care Plan dated [DATE] states: monitor [MEDICAL CONDITION] amount to obtain baseline condition AM PM x 3 days. R123's Care plan, dated [DATE] states: Cardiac Output-I am admitting after issues with [MEDICAL CONDITION]-I have a hx of [MEDICAL CONDITION], aortic valve disease, and [DIAGNOSES REDACTED]-I am on diuretics for my heart failure .Cardiac Output Approaches-monitor my circulation for changes in weights and [MEDICAL CONDITION] which may indicate worsening of my [MEDICAL CONDITION] . The care plan does not indicate the implementation of potential treatment for [REDACTED]. [DATE] 02:28 PM Surveyor requested documentation of [MEDICAL CONDITION] monitoring as surveyor was unable to locate in the electronic health record (EHR). DON B provided nurse charting showing [MEDICAL CONDITION] was assessed four days: [DATE], [DATE], [DATE], and [DATE]. Charting indicates that R123 had 1+ [MEDICAL CONDITION] in both legs on each those days. No assessments were documented after [DATE]. When asked if R123 should have had her [MEDICAL CONDITION] assessed after [DATE], DON B stated that the Certified Nursing Assistants (CNAs) would have let nurses know if they noticed that the [MEDICAL CONDITION] had increased. However, monitoring for lower extremity [MEDICAL CONDITION] requires pressing the thumb firmly in the affected area to see how large an indentation is made in the tissue (pitting). The assessment may also involve assessing for a pedal pulse (a pulse in the top of the foot). These are skilled nursing assessments which may reveal issues with [MEDICAL CONDITION] beyond what can be observed visually. [DATE] 3:20 PM Surveyor asked the facility for a policy or protocol on monitoring, assessment and treatment of [REDACTED]. The facility did not provide routine monitoring of R123's lower extremity [MEDICAL CONDITION] related to her [DIAGNOSES REDACTED].

Based on observation, record review, interview and policy review, the facility did not ensure R220 had pain management consistent with professional standards of practice for 1 of 4 sampled residents reviewed. R220 was experiencing pain since her admission. The facility did not complete a comprehensive pain assessment or schedule additional pain medication to manage R220's pain. This is evidenced by: The facility policy, entitled Pain Assessment and Management, dated April 2005, states in part, 3. On admission a baseline assessment for pain will be completed . 13. For residents on scheduled pain medications and receiving PRN medications for breakthrough pain consider contacting the MD for readjustment of resident's pain mediation when .pain control is not maintained to the resident and/or family goals. R220 was admitted on [DATE] after being hospitalized with severe pain and weakness. R220 was diagnosed with [REDACTED]. R220 has some confusion, but is alert and can answer most questions accurately. R220 needs assist of one to two persons for transfers, and uses a walker. The physician orders [REDACTED]. [MEDICATION NAME] 25 mg every 6 hours prn (as needed for pain 4-6) [MEDICATION NAME] 325 mg (2 tablets) four times a day [MEDICATION NAME] 10 mg tablet by mouth at bedtime as needed for muscle spasms [MEDICATION NAME] 5% patch daily for pain Observations 12/04/17 11:16 AM R220 observed grabbing at mid stomach and right side of ribs and and back. 12/04/17 11:18 AM R220 stated, Now I am on something with a T. Surveyor asked if it is [MEDICATION NAME]. R220 stated on a number scale of 1-10 (10 being most painful), is at a 6 for pain, and further stated, At times it is a 10, if I don't have the medicine. 12/04/17 11:25 AM Observed R220 moaning when lowering and raising lift chair occurred. R220 cannot get comfortable. 12/04/17 11:25 AM R220 stated, I think I am thinking about pain too much. I should have the TV on to distract me. R220 was reaching at right side rib area, and lower back. At 1:20 p.m., an interview with R220's daughter was done asking about pain. The daughter indicated R220 had a kidney stone recently. The daughter indicated she had just talked to the nurse. The daughter stated the nurse, Registered Nurse (RN) B, will look into it and call the doctor. The daughter indicated R220 had [MEDICATION NAME] in the hospital and it cut the pain. The pain was severe at home so she went back to the hospital on Sunday and was in the hospital until Friday, 12/01/17 and then came here. The daughter indicated R220 has been in pain for two weeks and they are not doing anything about it. 12/05/17 07:14 AM R220 states pain is somewhat better today. R220's breakfast was served by Certified Nursing Assistant (CNA) E. CNA E raised the head of the bed. R220 moaned and stated, I will never get better. When the head of the bed was raised again, R220 moaned, stating the pain was in her lower back and right side. At 8:40 a.m., CNA C helped resident to sit up, and did not raise the head of the bed. R220 stated, Ow, oh. CNA C asked, Does it hurt? R220 stated, Yes. I feel weak. Oh. R220 immediately laid back down and stated, I can't sit like that. R220 looked at CNA C and stated, You are not strong enough. I need two strong people to help me. R220 was moaning, grabbing her lower back, and right side. CNA C went to get CNA D. R220 asked about pain medication. CNA D said the nurse had just given it to her. CNA D assisted R220 up to walk with a walker. Surveyor asked, How does it feel when you walk? R220 stated, It hurts a lot. It is even worse when walking. Surveyor reviewed the Medication Administration Record [REDACTED]. R220 had been given the [MEDICATION NAME] on 12/1 and 12/2/17 at bedtime. The physical therapy note 12/2/17 in part: Pt (patient) reporting high levels of pain in her back on this date. Patient requesting pain pills. discussed with RN who reported pt(patient) had pain med 15 minutes ago. Patient reported she is not feeling relief. Patient reporting 'I just need to go back to the hospital so they can help me.' .Pt reporting spasm like pains. Patient was not willing to participate in exercises on this date. Pt continuously requesting a pain pill . The nurses' notes document pain levels 4-6 or moderate pain, except on 12/1/17, pain level is 8. A pain level of 10 is documented on the physician fax 12/4/17. 12/05/17 09:08 AM Surveyor asked the DON if he was aware of R220's pain. The DON indicated he was, and that he did not like the doctor's response yesterday. The DON indicated he had asked RN A to assess the resident. Surveyor shared the observations of pain, the difficult transfer, and family concerns about the untreated pain. The DON indicated he would do something now and got up to go to the resident. The medical record documents a fax was sent on 12/4/17 stating resident's pain was 10, and wanted more aggressive treatment for [REDACTED]. The medical record documents an elevated blood pressure on 12/4/17 190/80, and on 12/1/17 BP 190/105, with a pain level of 8. On 12/05/17 at 9:55 a.m., the resident was sent to the ER for evaluation. Surveyor had reviewed the medical record for pain assessments and could not locate one. The DON stated a pain assessment was not completed on admission or since the resident had complained of severe pain yesterday. The DON stated R220 was not on any scheduled pain medications other than Tylenol. The DON indicated the staff were being trained at this time to do comprehensive pain assessments on admission and with changes. The DON reported that R220 would be returning to the facility. The emergency room had not found any cause for the pain. The DON indicated labs were completed and R220 was tested for a Urinary Tract Infection that came back negative. The DON indicated they would schedule the pain medication when R220 returned and do a comprehensive pain assessment.

Based on interview, medical record review and facility policy review, the facility did not ensure that 1 (Resident (R)1) of 1 resident was free of abuse. A Certified Nursing Assistant (CNA) took a digital photograph of Resident 1's (R1) inner thighs and genitals while R1 sat on the toilet and sent the picture via Snapchat social media site to a former employee. This is evidenced by: R1's medical record states [DIAGNOSES REDACTED]. R1 requires staff assistance for personal care needs. On 02/16/17, CNA B, who previously worked at the facility, notified the Western Regional Office (WRO) that CNA A had sent her a picture via Snapchat social media site at 8:27 a.m. on 02/15/17. CNA B opened the Snap between 7:15 and 7:30 p.m. on 02/15/17. The caption had CNA A's name, with the following caption: Delete that picture Thought you would miss someone It was a squirl (sic) Normally, Snapchat pictures disappear after 10 seconds if a screenshot of the picture is not taken. CNA B found the picture to be disturbing, took a screenshot of the picture, and CNA A typed, Why did u screen shot that. The picture was determined to be of R1 sitting on the toilet, with her sweater covering her lower abdomen; her inner thigh and genitals were exposed in the picture. R1's face was not in the picture, but CNA B, who had worked at the facility and knew R1, recognized R1's sweater. According to CNA A's timesheet, he continued to work at the facility for the remainder of his shift, which ended at 2:30 p.m. The facility was unaware that the picture had been taken and sent to CNA B until the next morning. Surveyor interviewed the Nursing Home Administrator (NHA) and Director of Nursing (DON) on 02/16/17 at 11:00 a.m. The NHA stated he received a call this morning (02/16/17) from CNA B who was a former employee. CNA B explained the above to him, and stated that she recognized R1's sweater in the picture. The NHA stated CNA B had talked to a counselor at her new place of employment, who instructed her to also call the State Survey and Certification Agency WRO. The DON stated she checked in R1's hamper and saw the same sweater in the photo on top of the soiled clothing, indicating that it had been recently worn. The DON stated the sweater was now in the laundry so it can be set aside (for evidence). CNA B shared the picture and the messages with the WRO and with the facility. The DON stated in the above interview that she immediately hit the floors to ensure staff did not have their cell phones on them per facility policy. Mandatory in-services were scheduled at 1:00 p.m. and 2:30 p.m. on 02/16/17 to inform staff of the situation, and to remind them of the social media policy to not carry handheld devices on them during work hours. The DON stated she reviewed the schedule and CNA A was not working, was suspended and noted that he would have been suspended pending the investigation if he was working. Social Worker (SW) E joined the above interview, and stated she had just planned on faxing the initial facility self-report to the Office of Caregiver Quality (OCQ), and left the room to do so. SW E provided a copy of the page which was faxed to Surveyor , plus the facility's abuse prevention policy, and the policy addressing social media and personal wireless handheld devices, last updated in January 2017. This policy states, in part: 1. Devices are never to be used to record images of residents unless the resident and/or responsible party consents to the recorded image. 2. Use or possession of personal electronic devices capable of audio and/or video recording and/or transmission is prohibited in any open area to or adjacent to, areas of resident access. 6. Cell phones and other wireless recordable devices are not to be carried on the person while on the job without specific permission from management. 7. Dove Healthcare prohibits the use of personal cell phones and other electronic devices during working hours for incoming or outgoing calls, text messaging, photographs, or video recordings. 9. Employees found using these devices during working hours will have them removed by the supervisor until the end of the shift and corrective action will be taken. 10. Employees found using personal devices to take photographs of residents will have the equipment confiscated and receive corrective action up to and including termination of employment. 16. Failure to follow this policy may result in disciplinary action including termination of employment. Surveyor observed R1 in her room on 02/16/17 during a facility tour at 11:22 a.m. R1 was in recliner and had eyes closed. During this tour, Surveyor saw no cell phones being used by staff in resident living areas. Surveyor interviewed Family Members (FM) C and D on 02/16/17 at 2:05 p.m. FM C stated R1's cognition cycles, and noted R1 was alert at times and other times was not. FM C stated lately R1 has been more quiet and withdrawn. FM C stated that if something happened (if she was harmed), she would say something. Surveyor asked FM C, How would your mother react if she knew this had happened? FM C reached for a tissue, wiped his eyes, paused a moment, then stated, Not very well. FM C's wife, FM D, stated, She (R1) is the most God-loving woman who wouldn't hurt a flea. The kindest woman .and for someone to do this to her . (FM D shook her head.) In the above interview, FM C stated his concerns were whether the facility vetted CNA A thoroughly (checked his background), and if CNA A had taken other pictures as well. FM C stated he understood CNA A was in violation of the facility's cell phone policy. FM C stated concerns this policy has not been enforced. CNA A no longer works for the facility and was unavailable for interview by Surveyor as his cell phone has been confiscated by the police. According to the facility's investigation, when CNA A was interviewed on 02/17/17 at 9:00 a.m., he stated that R1's eyes were closed, so she was not aware when the picture was taken. In this interview, CNA A admitted to having his personal phone on his person during his shift on 02/15/17, but that he initially denied having taken a picture of (R1). He stated he took a picture of a squirrel but then later admitted he in deed (sic) took a picture of (R1's) private area while she was toileting. The photo was taken at 8:27AM on 2/15/17. CNA A also admitted that he used Snapchat and sent CNA B a photo on 02/15/17. During this interview, CNA A admitted that he violated the facility's policy of not taking a resident's photo without consent. According to the police report included in the facility's investigation, CNA A admitted to taking the close up photo of (R1) while she was half asleep on her toilet. He did not believe that she knew he did this. He claimed that he .intended the nude photo as a private joke between he and (CNA B). This report stated that there was probable cause to arrest CNA A for a Class I felony of taking and transmitting a nude photo of a vulnerable adult.

Based on observation, interview and policy review, the facility staff did not provide cares and services in a manner to prevent the spread of infection for 3 of 3 residents observed during personal cares (Residents (R)6, R1 and R4) from a sample of 10 residents and during removal of infectious waste from 1 supplemental sampled resident's room, R11. This is evidenced by: The undated facility policy entitled Female Peri-care Competency Procedure read in part: 3. Place garbage and soiled linen basket for within easy reach 7. Removed (sic (spelling incorrect)) soiled incontinence products and place in garbage 8. Remove gloves and perform hand hand hygiene 9. Apply clean gloves 12. Explained procedure for peri care. 13. Dispose of soiled washcloth Steps 14-20 further covered peri care and rectal care 21. Dispose of soiled washcloth 22. Remove gloves and perform hand hygiene 23. Apply clean gloves 24. Apply clean incontinence products as indicated 25. Remove gloves and perform hand hygiene 26. Arrange resident clothing . 1. R6 has [DIAGNOSES REDACTED]. R6 requires extensive assistance of two with hygiene. On 01/04/17 beginning at 10:35 a.m., Surveyor observed Certified Nursing Assistant (CNA) A and CNA B provide urinary incontinence care for R6. After CNA A washed R6's peri area, there was not a container for the soiled washcloth. CNA B obtained a paper towel for CNA A. CNA A placed the paper towel on R6's tray table and then placed the wet soiled washcloths on the the paper towel. CNA A dried R6's periarea. CNA A did not remove her gloves and wash or sanitize her hands. With the soiled gloves on, CNA A obtained a container of powder and applied the powder to R6's peri area. CNA A then removed her gloves and applied new gloves, without washing or sanitizing her hands. The CNAs assisted R6 to turn onto her right side. CNA B cleansed and dried R6's rectal area and inner buttocks. CNA B applied barrier cream to R6's buttocks and coccyx area, handling the barrier cream container with her soiled gloves. CNA A placed the soiled incontinence brief in the garbage. CNA A did not remove her soiled gloves and wash or sanitize her hands and touched the clean brief, R6's pants and bed linens. The CNAs turned R6 side to side to place lift sling under R6. CNA A then picked up supplies from R6's tray table. The CNAs did not disinfect R6's tray table. CNA B set R6's glasses and TV remote on the the tray table very near to where the soiled wash cloths had been. The CNAs then transferred R6 to her wheelchair. While still wearing the same soiled gloves, CNA A made R6's bed. After R6 was in her wheelchair, the CNAs removed their gloves and washed their hands. R6 was taken to therapy. At 11:42 a.m., before R6 returned to her room, Surveyor spoke with CNA A. Surveyor shared the concerns of the soiled washcloths that had been used to clean R6's peri area and buttocks being placed on R6's tray table on a paper towel and the tray table not disinfected afterwards. Surveyor also shared with CNA A about R6's glasses and TV remote being placed on the soiled tray table and the concerns of CNA A not removing her gloves and washing or sanitizing her hands after performing peri care and touching soiled items before touching clean items. CNA A acknowledged understanding and indicated she would disinfect the tray table. The above concerns were shared with the Director of Nursing (DON). 2. On 01/03/17 at 1:10 p.m., Surveyor observed CNA C and D assist R1 with peri-rectal cares. The CNAs entered R1's room, performed hand hygiene and donned gloves. CNA C then obtained a total lift device and the CNAs transferred R1 onto the bed. R1 stated that she needed to use the bedpan. The CNAs removed R1's pants and briefs via a rolling motion and CNA C placed a fracture pan under R1's hip/groin area. CNA C then performed hand hygiene, donned gloves, and covered R1 with a bath blanket. After providing privacy for the resident, R1 stated, I am done. CNA C removed the bedpan and placed it on the floor in the bathroom. CNA C then returned to the bedside with a packet of disposable wipes. CNA C cleansed R1's peri area. Then CNA D assisted R1 to roll onto her right side. CNA C then cleansed stool from the buttocks, using a fresh wipe with each area, using several wipes. Without changing gloves or performing hand hygiene, CNA C obtained a clean brief. The CNAs assisted R1 onto the brief and secured the sides. Next, the CNAs applied R1's pants and applied the lift sling and assisted R1 back into the wheelchair. CNA C then disinfected the bedpan. After disinfecting the bedpan, CNA C removed gloves and performed hand hygiene. 3. On 01/04/17 at 9:05 a.m., Surveyor observed CNA E and CNA F assist R4 by performing peri rectal cares. R4 was in the bathroom sitting on the commode and had her pants, socks and shoes on. CNA F assisted R4 in removing her nightgown, prepared a washcloth and assisted R4 with cleansing her upper torso. CNA F then removed gloves and performed hand hygiene. Next, CNA F placed a under shirt and sweater on the resident, as requested. CNA E washed R4's peri area. Next, CNA E performed rectal care in the same manner, and using a front to back motion. After rinsing and drying the areas, CNA F lowered R4 back onto the commode to rest. Then, without performing hand hygiene or changing gloves, CNA E wheeled R4's wheelchair into the bathroom. CNA F asked R4 to stand. R4 stood, while CNA F applied a clean brief, pulled up her pants and guided her to the wheelchair seat. After R4 was seated in the wheelchair, CNA E gathered the soiled linen and placed them into a plastic bag. After placing the items in the plastic bag, CNA E removed gloves and performed hand hygiene. Surveyor reviewed a poicy entitled Female Peri-care Competency Procedure. The procedure stated in part .remove gloves and perform hand hygiene .apply clean incontinence products as indicated . The DON was informed of the above observation of R1 and R4, and concerns on 01/04/17. The facility policy, entitled Dove Healthcare South Housekeeping Procedure Isolation Room Clean, dated March 2014 states: Purpose: To provide direction to staff in the proper cleaning of a residents room. Procedure: 1. Bag and empty all trash and garbage in the room. The policy and procedure do not contain language addressing the use of personal protective equipment (PPE) in the policy to clean an isolation room. On 01/04/17 at 9:13 a.m., Surveyor observed Housekeeper (HK) H enter R11's room that was marked for contact precautions for[DIAGNOSES REDACTED] infection. HK H was not wearing any PPE. Standards for Contact Precautions were posted on the wall outside the door which explain the proper PPE to wear when performing different tasks. HK H entered the room and took the garbage can liner from the trash can that contained the contaminated gowns and gloves from the room. HK H pulled the liner from the can, tied the liner, then walked out of the room and put the trash in a larger wheeled trash that was in the hallway. HK H then pushed down on the contents of the larger trashcan with her hands and arms. HK H was wearing a long sleeve shirt and had her arms in the trashcan up to mid-bicep. HK H had the potential to contaminate her hands and clothing by not wearing PPE and following Standard Contact Precautions policy and procedures. On 01/04/17 at 12:00 p.m., Surveyor discussed with the DON the observation of HK H.

Based on observation, interview and record review, the facility did not provide services as outlined in the care plan for 1 of 9 residents whose care plan services were reviewed, out of a sample of 10 residents. R1 did not have left heel suspension device or pillows to float heel during observations. This is evidenced by: R1's [DIAGNOSES REDACTED]. R1 requires total assistance with Activities of Daily Living (ADLs). R1 had a deep tissue injury (DTI) to left heel. On 01/02/17 at 11:30 a.m., Surveyor reviewed R1's comprehensive care plan. The care plan stated, Please encourage elevation when up in chair and in bed. Prop up with pillows as indicated. Float heels when in bed, place a Prevelon boot (a type of boot that suspends the heel) on left foot at all times, place a pillow under RLE (right lower extremities) when in wheelchair. At 12:30 p.m., Surveyor observed R1 sitting in a wheelchair in the dining area. R1's left heel was in direct contact with a pillow that had been placed under her legs and on top of the wheelchair footrest. R1 did not have a Prevalon boot on. Surveyor observed R1 from 1:45 p.m. to 3:00 p.m. R1 was sitting in the wheelchair in her room and then in the recreation room. R1's left heel was in direct contact with a pillow that had been placed under her legs and on top of the wheelchair footrest. R1 did not have a Prevalon boot on. R1's heels were not floated. On 01/03/17 at 1:45 p.m., the Director of Nursing (DON) and Surveyor gained permission from R1 to observe the left heel. R1 was lying in bed with the left heel in direct contact with the bed. The DON stated, (R1), you should have your heel floated on a pillow. R1 stated, Yes, I know. I know it should. I don't know why it isn't. R1 then stated to Surveyor and the DON that .the doctor told me I did not have to wear that boot. Surveyor reviewed the nurses' notes. The most recent note regarding R1 wearing the Prevalon boot was documented on 08/29/16. This document stated: Writer and NP (Nurse Practioner G) discussed the importance of wearing the Prevelon boot when up in the chair, and R1 agreed to this. R1 will float heels on a pillow when in bed. No mention of a conversation with the doctor regarding the use of the Prevalon boot was noted. There was no evidence in the documentation that R1 refused to wear the boot, or that the facility had contacted the physician stating that R1 refused to wear the boot. The DON was informed of the above concerns at the time of the observation.

Based on observation, record review, interview and policy review, the facility did not maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for 1 of 8 resident observations during medication pass (Resident #11). As evidenced by: Facility policy and procedure titled, Hand Hygiene, dated January 2016, states, 4. Indications for Hand Washing v.s. alcohol-based hand sanitizer: b. Wash hands with soap and water when caring for a resident with confirmed or suspected infectious gastroenteritis such as[DIAGNOSES REDACTED] or Norovirus as alcohol-based hand sanitizers are not effective at killing these organisms. On 02/04/16 at approximately 8:00 a.m., Surveyor reviewed the medical record for Resident #11 and noted the following: - Resident #11 currently has a [DIAGNOSES REDACTED]. - Resident #11 has a current physician order, dated 02/01/16, for [MEDICATION NAME] 500 mg. to be taken twice daily for CDiff. On 02/04/16 at approximately 8:10 a.m., Surveyor reviewed the Certified Nursing Assistant (CNA) bowel records and noted the following: - 02/01/16: AM Stool: Soft blobs with clear cut edges (passed easily). - 02/02/16: Night Stool: Fluffy pieces with ragged edges, a mushy stool. - 02/03/16: AM Stool: Fluffy pieces with ragged edges, a mushy stool small On 02/04/16 at 8:15 a.m., Surveyor reviewed the nursing notes for Resident #11 from 01/02/16 - 02/04/16 and noted on 02/01/16 nursing staff entered, Resident is on a [MEDICATION NAME] already. Family is concerned that he is still having loose stools. On 02/03/16 at 12:44 p.m., Surveyor observed Licensed Practical Nurse (LPN) A during the routine task of medication pass. Resident #11 had an isolation bin outside his door which requested all staff and guests to wear a gown and gloves. Inside Resident #11's room right by the door, there was a hand sanitizer machine with a large sign posted over it stating staff are not to use hand sanitizer and are to wash their hands with soap and water. LPN A donned a gown and gloves and entered Resident #11's room. Surveyor donned a gown and gloves and entered the resident's room behind LPN A. LPN A took Resident #11's blood sugar and entered the results into the computer. Resident #11 asked LPN A turn up the brightness on his television. LPN A then picked up the television remote and attempted to adjust the brightness. LPN A then adjusted the blinds to diminish the lighting in the room to assist Resident #11 in seeing the television better. A facility staff member entered the room with a tray of food for Resident #11. LPN A took the tray and placed it in front of Resident #11, who was sitting in his lounger chair. LPN A then opened the resident's refrigerator and took out a container of applesauce and assisted Resident #11 in scooping out some applesauce. Resident #11 used the applesauce to take his medication(s). LPN A then removed his gloves and gown and disposed of them in the garbage can. LPN A then took a Clorox bleach wipe and wiped down his computer. LPN A then left the room and proceeded to pass medications to another resident in room [ROOM NUMBER]. Surveyor noted LPN A did not wash his hands after removing his gloves with either hand sanitizer or soap or water. Surveyor asked LPN A if he knew why Resident #11 was on isolation, and LPN A stated he did not know what type of infection Resident #11 had. On 02/03/16 at 12:34 p.m., Surveyor interviewed Registered Nurse (RN) B in regard to the above noted observation. RN B stated Resident #11 was currently being treated with an antibiotic for an infection of CDiff. RN B stated Resident #11 was currently having loose stools and was considered still infectious. RN B stated LPN A should have washed his hands with soap and water after removing his dirty gloves. On 02/04/16, Surveyor interviewed the Director of Nursing (DON) in regard to the above observation. The DON stated LPN A should have washed his hands with soap and water after removing his dirty gloves due to Resident #11 having a contagious illness.

Based on interview and record review, the facility failed to ensure clinical records are maintained in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for 1 of 10 sampled residents (#1). Resident #1 has dementia and an order for [REDACTED]. This is evidenced by: Resident #1 has a [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The nursing care plan in part, dated 04/07/14, identifies, "Behavioral approaches: assess me for pain and offer pain medications. Assess me for signs of pain as I may not be reliable in confirming that I have pain. Encourage my friends to visit...Assist me in tuning baseball games on TV. I love watching these games...I respond well to 1:1's, at times being left alone and returning later, reorientation, discussions about baseball, reading the newspaper. Behavioral symptom documentation: Resident has been confused, agitated with staff, and refuses cares at times...chart on any behaviors, interventions provided..." The nurses' notes include in part: 01/21/15 3:42 p.m., "[MEDICATION NAME] 2 mg/ml concentrate (0.25 ml/0.5 mg) for restlessness/anxiety" 01/21/15 23:57 (11:57 p.m.),"[MEDICATION NAME] 2 mg/ml concentrate (0.25 ml/0.5 mg) for agitation swearing, swinging at staff, throwing water glass, etc..." 01/22/15 4:50 a.m. "[MEDICATION NAME] 2 mg/ml concentrate (0.25 ml/0.5 mg) for agitation hitting at staff, yelling out and inability to sit still..." The above documentation does not include the non-pharmacological interventions that were tried prior to giving the medication. The care plan identifies specific interventions that are effective for Resident #1. On 01/27/15 at 12:55 p.m., Surveyor interviewed Registered Nurse (RN) A, Resident #1's case manager about the Lorazepan. Surveyor asked for any documentation of interventions tried prior to giving the medication and who charts the behaviors and interventions tried. RN A said the Certified Nursing Assistants (CNAs) report to the nurse and the nurse charts. Surveyor stated that the nurses' notes did not contain non-pharmacological interventions that were tried prior to giving the [MEDICATION NAME].. RN A replied that if the Director of Nursing (DON) can not find it, then it was not done. On 01/27/15 at 3:45 p.m., Surveyor interviewed the DON about the above. The DON said she had called one of the nurses who administered the medication and the nurse said she tried several interventions, but did not chart anything. The DON was unable to reach the other nurse involved. The DON acknowledged that the nurses know they have to try the non-pharmacological interventions first, and document that they have been tried. The DON stated she expects this to be documented and will educate the nurses.

Based on observation, interview and record review, the facility did not periodically conduct accurate and ongoing assessments related to bowel continence in 1 of 1 (#1) residents reviewed that are incontinent of bowel. Resident #1's recent significant change in status Minimum Data Set (MDS) documents a decline in bowel function. There was no bowel assessment completed to determine accurate information for the MDS. This is evidenced by: The facility policy entitled, "Incontinence Assessment and Management," last reviewed December 2014: Purpose: To provide guidance to clinical staff regarding the assessment and management of bladder and bowel incontinence. Procedure: 1. All resident's bowel and bladder continence status will be evaluated at the time of their admission to the facility and documented in the electronic medical record. Ongoing assessment will be completed at minimum quarterly, annually and with change in condition." Resident #1's annual MDS, dated [DATE], documents the resident is continent of bowel. Resident #1 has severe cognitive impairment related to dementia. The significant change in status MDS, dated [DATE], documents Resident #1 is occasionally incontinent of bowel. Surveyor completed a medical record review on 01/27/15; no bowel assessments were found in the chart. Surveyor requested the bowel assessments for the past six months for Resident #1 from the Director of Nursing (DON). At 1:30 p.m., Surveyor reviewed the documentation, finding it contained information on bowel sounds and gastrointestinal symptoms. The documentation did not contain an assessment of Resident #1's bowel patterns, or what may have contributed to the decline in bowel function documented on the 01/20/15 MDS. The Certified Nursing Assistant (CNA) assignment sheet states, " Cares - Bowel: Incontinent at times." Surveyor reviewed the most recent CNA charting. The charting documents Resident #1 has been continent of bowel in the past seven days. On 01/27/15 at 12:55 p.m., Surveyor interviewed Registered Nurse (RN) A, Resident #1's case manager. RN A indicated they do not do bowel assessments for everyone at each MDS. RN A indicated he does not do the MDS, and was not aware that the decline was on the MDS. RN A acknowledged that the only bowel information provided to Surveyor was not a complete assessment. Surveyor asked if any tracking for time of day and frequency were gathered to determine a pattern. RN A replied they have not done this for Resident #1 in a long time. Surveyor interviewed the DON at 3:00 p.m. about the bowel assessments. The DON said their policy clearly states they are to do a bowel assessment with a significant change in status or when a decline is noted and it should have been done for Resident #1.

Based on observation, interview and policy review, the facility did not assess 1 of 6 residents observed during medication pass for safe self administration of medication. Resident #11 was observed on 04/03/14 to have his [MEDICATION NAME] ([MEDICATION NAME]) mixed in his coffee and was left alone in his room with it to self administer. The facility had not assessed Resident #11 as being able to safely self administer this medication. This is evidenced by: Policy: The 12/2013 facility policy titled "Self-Administration Of Medications" read: It is the policy of Dove Healthcare that an individual resident may self-administer drugs if the interdisciplinary team determines that this practice is safe. Procedure: It is the intent of Dove Healthcare South to allow our residents to practice their right to self-administer medications. The resident will be allowed to self administer their own medications upon receipt of a physician order, completion of a comprehensive assessment of their ability to perform the task safely and the resident indicates the desire to administer their own medications. 1. Nursing will perform assessment of the resident's cognitive and physical ability of being able to safely administer medications. The assessment will include at a minimum of the residents ability to: ? identify the medication by sight ? verbalize the medication use and effects ? verbalize the medication side effects ? physically administer medications (orally or injectable) safely and as ordered ? lock and unlock the safety devices used to house medications If the assessment indicates that the resident is able to safely administer medications, a physician order [REDACTED]. 2. Once the physician order [REDACTED]. 3. The IDT (interdisciplinary team) will assess the resident's ability to self medicate on a routine basis, at a minimum quarterly, annually and when a significant change in status is identified. On 04/03/14 at 8:00 a.m., Surveyor observed Licensed Practical Nurse (LPN) D prepare medications for Resident #11. Resident #11 requested his [MEDICATION NAME] be mixed in his coffee. LPN D did this and left Resident #11's room prior to Resident #11 consuming his coffee containing the [MEDICATION NAME]. At 9:52 a.m. on 04/03/14, Surveyor shared the above observation with Nurse Manager (NM) C and requested the self administration of medication assessment for Resident #11. On 04/03/14, Surveyor spoke with the Director of Nursing (DON) regarding the above observation. Surveyor told the DON a physician's orders [REDACTED].#11's medical record. The DON informed Surveyor the facility had a standing order for self administration of medications. Surveyor was provided with a copy of Resident #11's physician standing order sheet and it included the following: "May self administer medication if determined appropriate following a Self Administration of Medication assessment." On the afternoon of 04/03/14, Surveyor was provided with a copy of Resident #11's 03/15/14 assessment that read: GIVE MEDS: whole RESIDENT DESIRE TO SELF ADMINISTER medications: [REDACTED]. Further assessment at this time is not necessary.

Based on interview and record review, the facility did not develop a comprehensive care plan for sleep that included measurable objectives and timetables to meet medical, nursing, and mental and psychosocial needs for 2 (Residents #7 and #8) of 10 sampled residents whose care plans were reviewed. Residents #7 and #8 receive a hypnotic medication for sleep. This is evidenced by: Review of Resident #8's medical record revealed Resident #8 [MEDICATION NAME] sleep. Resident #8 did not have a sleep hygiene care plan. Review of Resident #7's medical record revealed Resident #7 [MEDICATION NAME] sleep. Resident #7 did not have a sleep hygiene care plan. On 04/07/14 at 02:45 p.m., Surveyor met with Nurse Manager (NM) A to discuss the above findings. NM A stated Resident #8 is alert, oriented, her own person, and reported difficulty sleeping and requested a sleep aid and the facility honored her request by contacting the physician. NM A stated Resident #8 had used the medication while in the hospital as well. NM A stated that the facility's procedure is when the medication is started, they begin monitoring hours of sleep and then do a risk/benefit review 14 days later. NM A stated they do not typically do a sleep care plan which documents other nonpharmacological interventions used for sleep, unless they find the medication is ineffective when they do the 14 day assessment. Surveyor asked if anyone had met with Resident #8 to interview her about sleep, and sleep preference or patterns. NM A stated no one had. On 04/07/14, Surveyor reviewed Resident #7's medical record, which included a physician's orders [REDACTED]. May we have a (sic) order for a sleeping aid per resident's request? Provider Response Section:[MEDICATION NAME] mg (milligrams) take 1 PO (by mouth) @ (at) HS (hours of sleep) prn (as needed); MR (may repeat) x1 dx ( diagnosis) [MEDICAL CONDITION]" Review of Resident #7's medical record revealed Resident #7 [MEDICATION NAME] night from 03/31/14 through 04/07/14. Review of Resident #7's care plan on 04/07/14 did not reveal a sleep hygiene care plan. On 04/08/14 at 8:30 a.m., Surveyor met with Resident #7. Resident #7 stated she never used anything for sleep at home, and does not like to use anything for sleep, but has been unable to sleep at the facility and asked for something and has been taking it. Resident #7 stated it has not been helping so was going to try a different medication. On 04/08/14 at 9:00 a.m., Surveyor met with Nurse Manager (NM) B to discuss the above findings. NM B stated Resident #7 is alert and oriented and her own person, and reported difficulty sleeping, requested a sleep aid and the facility honored her request by contacting the physician. NM B stated she met with Resident #7 to discuss her sleep pattern at home prior. NM B stated that the facility's procedure is that when the medication is started they begin monitoring hours of sleep and then do a risk/benefit review 14 days later. NM B stated they do not typically do a sleep care plan, but after speaking to the Director of Nursing yesterday, a sleep care plan was initiated. Surveyor noted a sleep care plan was completed late in the day on 04/07/14 that included approaches to assist in sleep.