Every finding on record at Dove Healthcare - Spooner

Based on interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 45 residents. -The facility did not test staff or residents with symptoms of COVID-19. -Staff did not use a barrier under the graduate when emptying the catheter for R3.-The facility did not ensure proper infection control measures were conducted when providing a shower and during catheter care for R3 who is on Enhanced Barrier Precautions (EBP). Example 1 The facility policy titled, “COVID-19 Prevention, Response, and Reporting,” last reviewed 01/2025, read in part, ”It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections. 2. Staff will be alert to signs of COVID-19 and notify the resident’s physician/practitioner if evident: a. Fever or chills b. cough c. Shortness of breath d. Fatigue e. Muscle or body aches f. Headache g. New loss of taste or smell h. Sore throat i. Congestion or runny nose j. Nausea or vomiting k. Diarrhea 28. The Infection Preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-19 and date of confirmation.” The facility policy titled, COVID-19 Response Plan, last reviewed 02/2025, read in part .”4. Residents and staff with a suspected or probable case of COVID-19 will receive viral testing in accordance with current CDC guidance.” On 07/22/25, Surveyor reviewed the facility’s line list from 06/2024-07/2025. Surveyor noted the last facility outbreak of COVID-19 was in 02/2025. Surveyor noted since 04/2025, there were no suspected or confirmed cases of COVID-19 on the line list. On 07/22/25 at 12:02 PM, Surveyor interviewed Infection Preventionist (IP) D via phone, as IP D was not present in the facility during the survey. Surveyor asked IP D how she was monitoring and tracking COVID-19 infections. IP D stated she was not testing residents and staff for COVID-19 infections as the community transmission level was low. IP D stated at the end of summer she would begin testing for COVID-19. Surveyor asked how long IP D has not been monitoring or tracking suspected or confirmed cases of COVID-19, [NAME] President (VP) of Clinical Operations E stated, “Sometime in April.” VP of Clinical Operations E agreed this was not the practice of the facility. On 07/22/25 at 3:00 PM, Surveyor held Resident Council meeting. Surveyor asked residents about respiratory symptoms and how the facility manages illnesses in the facility. R36 stated respiratory symptoms come but facility does not test or swab resident to see what he has. R36 was just told to stay in room for 48 hours then he could come out. Surveyor reviewed 04/2025-07/2025-resident line list and noted: -03/28/25, R56 had S&S of nausea and vomiting, with no indication of testing. -04/20/25, R16 had a fever with signs and symptoms (S&S) of the common cold, with no indication of testing. -05/27/25, R50 had diarrhea, with no indication of testing. Surveyor reviewed 04/2025-07/2025-staff line list and noted: -04/18/25, staff with fever and diarrhea, no indication of testing. -No date, staff with symptoms of sore throat with no indication of testing. -05/02/25, staff with cough and fever with no testing. -05/09/25, staff with symptoms of nausea and vomiting with no indication of testing. -06/07/25, staff with cough and nausea with no testing. -06/09/25, staff with vomiting, no indication of testing. -06/13/25, staff with fever and diarrhea, no testing. -06/16/25, staff with gastrointestinal complaints, no testing. -06/20/25, staff with nausea and vomiting, no testing. On 07/23/25 at approximately 7:30 AM, DON B shared an email from IP D. The email stated the following: “I spent a good bit of time last night trying to find guidance from the CDC that indicates that testing should be dependent on levels of transmission in the local or regional area. All the guidance I could find was last updated a year ago. If we followed that guidance, we would have people out of work for three days so that we could test them and then test them 48 hours later with any kind of symptoms. It just is impractical and doesn’t correlate with the levels of Covid transmission. I am monitoring the state’s respiratory reports of transmission levels on a weekly basis and will begin Covid testing again when transmission levels begin to rise. For weeks and maybe even months they have been minimal for Covid influenza and RSV throughout the state and have been stable. When [resident] was coughing I know they did test her for Covid. But we really haven’t had anybody else that we needed to test for Covid in terms of residents. There were a handful of staff members that tested for Covid in the past few months. Anyone who did test for Covid is noted either on the absence report or in PCC. I don’t think that we should get cited for not testing for Covid.” On 07/22/25 at 4:18 PM, Surveyor interviewed VP of Clinical Operations E and Director of Nursing (DON) B. VP of Clinical Operations E and DON B confirmed resident and staff testing had not been completed since sometime in 04/2025. VP Of Clinical Operations E and DON B were not sure where IP D found a resource indicating residents and staff with suspected or confirmed cases of COVID-19 did not require testing. VP of Clinical Operations and DON B acknowledged this was not a standard of practice and stated IP D would receive education. Example 2 The facility policy, titled “Emptying of Catheter,” last revised on 08/01/24, states: “It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.” Under Section 4: Procedure Steps: states in part: . Place a barrier (e.g., paper towel or disposable pad) on the floor under the drainage bag. Place the graduate cylinder on the barrier and open drain to allow the urine to flow into the graduated cylinder. Place a clean barrier on a level, flat surface. Place the graduated cylinder on the barrier and with the graduated cylinder at eye level, read the amount of output. R3 was admitted on [DATE] and has diagnosis of Renal Insufficiency, Neurogenic bladder, History of Multi-Drug Resident Organism (MDRO) of Extended Spectrum Beta Lactamase (ESBL) resistance. R3’s current care plan states R3 has an indwelling catheter related to urinary retention that lists interventions of “FYI Cath Care” and “monitor and document intake and output as per facility policy.” On 07/22/2025 at 1:59 PM, Surveyor observed Certified Nursing Assistant (CNA) C conduct catheter care for emptying and measuring urine output from urinary drainage bag for R3. CNA C, after donning PPE and conducting hand hygiene, placed a graduated cylinder on floor without barrier and open drain to allow the urine to flow into the graduated cylinder. CNA C picked up graduated cylinder and brought to bathroom, and without placing a barrier down, placed the graduated cylinder on bathroom sink counter and read the amount output. On 07/22/2025 at 2:16 PM, Surveyor interviewed CNA C regarding the facility's expectation/policy on infection control and using a barrier between floor and graduated cylinder, CNA C stated was not aware of the facility policy or recent education on catheter care and need of using a barrier. On 07/23/2025 at 9:45 AM, Surveyor interviewed DON B regarding observation of CNA C emptying R3’s urinary bag without a barrier placed between flat service and graduated cylinder. DON B stated the expectation would be to place a barrier under the graduated cylinder, stating usually a paper towel is used. Example 3 On 07/21/25 at 11:58 AM, Surveyor observed EBP signage on door and Personal Protective Equipment (PPE) bin outside hallway of R3's room. On 07/22/25 at 7:52 AM, Surveyor observed CNA C, after preparing R3 for a shower, removed PPE of gown and gloves before exiting resident room and bringing R3 to shower room. During shower process, CNA C was observed not placing on PPE or wearing PPE during showering of R3. On 07/22/25 at 8:05 AM, upon taking R3 back to resident room, CNA C asked Surveyor, “I didn’t wear a gown in shower, was I supposed to?” Surveyor responded with asking what the facility policy was related to wearing PPE during resident shower who is on EBP. CNA C stated not aware of policy. On 07/22/25 at 8:25 AM, Surveyor interviewed CNA F, who entered R3’s room to assist with a transfer, regarding expectation of PPE during a shower. CNA F stated the expectation is PPE should be worn during a shower for R3. On 07/23/2025 at 9:45 AM, Surveyor interviewed DON B regarding expectation of wearing PPE on a resident who is under EBP during a shower. DON B stated expectation would be do wear PPE during a shower.

Based on observation, interview and record review, the facility did not ensure proper sanitation practices to prevent the outbreak of foodborne illness which had the potential to affect all 45 residents.-The facility did not ensure dishes were dried appropriately.-The facility did not ensure proper cleaning of portable steam tables before replacing clean covers.Findings include:The facility policy entitled, Dishwashing, (no date) reads in part: All items are air dried in racks before storing.The facility policy regarding steam tables (no date, no title), reads in part: Wash top of steam table with warm soapy water and cloth. Spray sanitizing solution.empty water.wash all covers after each meal. On 07/22/25 at 9:20 AM, Surveyor entered the kitchen to observe dish washing. Surveyor observed plastic containers stacked together in the clean area near the 3-compartment sink. Visible moisture inside of the outside container. On 07/22/25 at 9:23 AM, Surveyor observed [NAME] Q stack slotted plastic dinner plates together immediately upon them coming out of the dish machine. Several plates were still visibly wet. Surveyor observed [NAME] Q place a clean cover for a portable steam table onto the steam table which still contained the water from prior to breakfast and had not been cleaned. Surveyor observed no pan in steam table when clean cover was replaced.On 07/22/25 at 9:27 AM, Surveyor interviewed [NAME] P. [NAME] P stated the portable steam tables get cleaned once a day at the end of the day, and once per week with Lime. [NAME] P stated the same water remains in them throughout the whole day. On 07/23/25 at 11:34 AM, Surveyor entered kitchen for follow up. Surveyor observed plastic containers now on the clean dishes shelf, still stacked, moisture present. On 07/23/25 at 11:42 AM, Surveyor interviewed Dietary Manager (DM) N. DM N stated all dishes should air dry completely prior to them being put away. DM N stated steam tables should at least be wiped down if visibly dirty and there should be a pan inside if the lid is on. On 07/23/25 at 12:05 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated she agreed that dishes should be completely dry and the clean lids on the dirty steam tables could have the potential for bacteria concerns.

Based on observation, interview and record review, the facility did not ensure activities of daily living (ADLs) of toileting and incontinence cares were provided for 1 of 12 residents (R6) reviewed. This is evidenced by:R6 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease unspecified, dementia, type 2 diabetes mellitus, essential hypertension, major depressive disorder, and dysphagia.R6's minimum data set (MDS) assessment, completed on 07/05/25, confirmed R6 is incontinent of urine and frequently incontinent of bowels. R6 requires supervision assistance with eating. R6 is substantial or maximal assist on staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R6's care plan was initiated on 02/05/25, and included the following: BED MOBILITY:-2 assist EATING:-Set-up assistance DRESSING:-2 assist TOILET USE:-2 assist TRANSFER:-1 assist [NAME] steadyOn 07/22/2025 at 6:40 AM, Surveyor observed R6's room door closed. Surveyor knocked and no one answered so Surveyor entered and observed R6 lying in bed on back. On 07/22/2025 at 7:53 AM, Surveyor observed R6's room door closed. Certified Nurse Assistant (CNA) H walked into room and asked if R6 wanted to participate in men's breakfast. R6 shook head no. CNA H let R6 rest in bed. On 07/22/2025 at 12:08 PM, Surveyor observed R6's room door closed. Surveyor observed R6 in bed, moving covers around, leaning part way off bed. Surveyor observed fall mat in place. On 07/22/2025 at 12:44 PM, Surveyor observed R6's room door closed. Surveyor observed CNA H go into R6's room and ask if R6 was ready to get up. R6 shook head no to CNA H. CNA H indicated to R6 that CNA H will be back into room to get R6 up for the day but would let him rest a little longer. Surveyor observed CNA H exit R6's room.On 07/22/2025 at 12:47 PM, Surveyor interviewed CNA H and asked CNA H if R6 has been up yet for the day as Surveyor saw R6 lying in bed since Surveyor came into building at 6:40 AM and did not see R6 eat breakfast or lunch thus far. CNA H reported to Surveyor that R6 is a late owl and didn't go to bed till 6 AM this morning. R6 use to work night shifts in his younger years on the railroad. CNA H reported that R6's usual is getting up around 1pm-2pm. CNA H reported to Surveyor that CNA H will be getting R6 up soon. CNA H indicated that is when R6 will get up for the day and eat. On 07/22/25 at 2:20 PM, Surveyor observed new evening staff on for their evening shift and day shift leaving. Surveyor observed R6 still lying in bed awake fiddling with covers and hanging part way off bed. Fall mat was in place. Surveyor did not observe any staff go into R6's room during the continuous observation to provide incontinent care or offer toileting. Observation from second Surveyor:On 07/22/25 at 2:58 PM, Surveyor observed R6's room door closed. Surveyor knocked and no one answered so Surveyor entered room. Surveyor saw R6 leaning off bed which was in its lowest position and just above another mattress that is positioned on R6's right side. On 07/22/25 at 3:07 PM, CNA J and CNA I entered room and Surveyor followed CNAs and noted R6 lying with just an incontinent brief totally on top of the mattress that was positioned next to bed and fall alarm sounding. Surveyor observed CNA I go into bathroom and begin to gather supplies to conduct ADL care. CNA I knelt on floor next to R6 and proceeded to wash R6. Surveyor observed incontinent brief was urine soaked.R6 was assisted to toilet by CNAs and continuation of cares was conducted. Surveyor observed soiled incontinent product of urine only was removed and deterioration of product was visible with numerous flakes of inner lining/filling of incontinent product falling onto bathroom floor, sticking to resident's skin and noted numerous additional flakes near and on mattress next to bed. Bed mattress was noticeable urine soaked and confirmed by CNA J. CNA J stated that per 1st shift, R6 had been in bed all day as he was up all night until earlier this AM.On 07/23/2025 at 6:59 AM, Surveyor observed R6 sleeping in wheelchair in lounge area near nurse's station. On 07/23/2025 at 7:20 AM, Surveyor observed Director of Nursing (DON) B offer R6 to use bathroom, change shirt, and get ready for breakfast. DON B stated to R6, I know you have been up all night. Let's get a clean shirt, breakfast, and then you can lie down. DON B wheeled R6 to room and began changing R6's shirt. Surveyor interviewed DON B and asked how R6 does in the day. DON B reported to Surveyor that R6 use to work the railroad and was a night shifter. DON B reported that sometimes R6 sleeps all day. Surveyor asked DON B's expectation for checking on R6 and providing cares during the day when sleeping in room. DON B reported that staff should be checking on R6 and offering toileting or incontinent cares at least every 2-3 hours. DON B reported that staff should still be offering meals through the day. On 07/23/2025 at 7:23 AM, Surveyor observed CNA K enter R6's room and assist DON B with R6's transfer to toilet. CNA K took R6's pants down, placed wet brief in trash can, then placed R6 on toilet to use the bathroom. DON B and CNA K gave R6 a few minutes to use the bathroom.On 07/23/2025 at 7:27 AM, Surveyor interviewed CNA H and asked CNA H what time day shift laid R6 down on 07/22/25 since R6 had been up all night the previous night on 07/21/25. CNA H reported night shift laid R6 down right before day shift arrived around 5:30 AM or so. Surveyor asked CNA H what time CNA H went in yesterday on day shift of 07/22/25. CNA H reported that CNA H went into R6's room around 8:30 AM and provided incontinent cares. Surveyor asked CNA H if CNA H went in at any point further through the day to provide incontinent cares or offer toileting. CNA H reported that CNA H did not go in again to provide cares or toilet R6 and that usually depends on R6 and how he feels if we toilet or not. Surveyor asked CNA H if breakfast and lunch were offered to R6 throughout the day while R6 was in room. CNA H stated to Surveyor, Well you saw me go in around lunch time and ask if [R6] wanted to get up for lunch. He declined getting up for lunch. Surveyor asked CNA H what common practice is when offering toileting or providing incontinent cares to R6. CNA H reported to Surveyor that it just depends on how R6 is feeling, but CNA H should have gone in again to provide cares. On 07/23/2025 at 7:35 AM, Surveyor observed CNA L enter R6's room to assist CNA K with R6's transfer. CNA L asked CNA K if R6 is going to bed since he has been up all night. CNA K responded to CNA L and stated, [DON B] wants [R6] to stay up for breakfast and then we can lay [R6] down. Surveyor observed CNA K and CNA L lift R6 off toilet. CNA L noted smearing of bowel movement (BM) on R6's bottom so CNA L cleansed R6's bottom of BM. CNA L placed clean brief on R6 and then pulled shorts up. Surveyor did not observe peri cares completed on R6's groin area after incontinent episode of urine in R6's brief. Surveyor observed CNA K and CNA L transfer R6 back into wheelchair. CNA K wheeled R6 to dining room for breakfast. On 07/23/2025 at 11:36 AM, Surveyor interviewed CNA L and asked CNA L's process for performing peri cares. CNA L reported to Surveyor that CNA L performs peri care from front to back when changing an incontinent soiled brief. Surveyor asked CNA L if CNA L cleansed R6's genital area after changing R6's wet brief and toileting R6. CNA L reported that CNA did not wipe R6's front area when toileting R6. On 07/23/2025 at 2:03 PM, Surveyor interviewed DON B and asked expectation for performing peri cares on R6 after an incontinent episode. DON B reported to Surveyor the expectation is for CNAs to clean the whole peri care area front and back.

Based on staff interview and record review, the facility did not provide Advanced Beneficiary Notice (ABN) of non-coverage and/or Notice of Medicare of Non-Coverage (NOMNC) appropriately for residents (R) whose Medicare Part A coverage was discontinued with benefit days remaining for 2 of 3 residents (R) reviewed. (R55, R46) R55 had a skilled Medicare A Service Episode with a start date of 03/19/25 and last covered date of 04/19/25. The facility/provider initiated the discharge from Medicare A Services when benefit days were not exhausted. The facility checked the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Form CMS-10055 provided to the resident? The facility checked the box No with an explanation handwritten, Was given, however cannot find it in paper form or Electronic Medical Record (EMR). On the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Notice of Medicare of Non-Coverage (NOMNC) provided to the resident?, the box labeled No was checked with an explanation handwritten, Was given, however cannot find it in paper form or EMR. R46 had a skilled Medicare A Service Episode with a start date of 02/01/25 and last covered date of 03/19/25. The facility/provider initiated the discharge from Medicare A Services when benefit days were not exhausted. The facility checked the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN), Form CMS-10055 provided to the resident? The facility checked the box YES. On the box on the SNF Beneficiary Protection Notification Review form that asked the question Was a Notice of Medicare of Non-Coverage (NOMNC) provided to the resident? The box labeled YES. R46 received and dated the NOMNC on 03/18/25, which was only 1 day notice instead of the required 2-day notice. On 7/23/25 at 9:15 AM, Surveyor interviewed Social Worker (SW) G, regarding process of issuing and obtaining a NOMNC and ABN, SW G indicated that once a document is signed it is scanned into the system and SW G confirmed inability to locate the documents for R55. SW G stated the expectation of presenting a NOMNC to a resident for signature is a minimum of 2 days prior to last covered day. SW G was made aware of R46 signing the NOMNC the day prior to last covered day. SW G accessed computer system and confirmed document was signed 1 day prior and not 2 days prior to last covered day. On 07/23/2025 at 9:45 AM, Surveyor shared inability to find R55's NOMNC and ABN. Surveyor interviewed DON B and confirmed the facility was unable to locate the documents. Surveyor also shared observation of R46's NOMNC was not signed until 1 day prior to last covered day.

Based on observation, interview and record review, the facility did not notify the physician on call of R40's new break in skin on right great toe for 1 of 12 residents (R) reviewed for activities of daily living (ADL) (R40).Findings include:R40 was admitted to the facility on [DATE] with diagnoses including in part, acute respiratory failure with hypoxia, type 2 diabetes mellitus, obstructive sleep apnea, venous insufficiency, morbidly obese, bilateral osteoarthritis of hip, and prostatic hyperplasia. R40's care plan was initiated on 04/15/25 and included the following: DIABETIC:-Nursing to complete nail care on Tuesday evening. Surveyor reviewed R40's skin prevalence reports that did not note any skin issues. Surveyor reviewed diabetic foot checks weekly documentation:-On 07/07/25, R40's skin was intact.-On 07/14/25, R40's skin was intact.-On 07/15/25, R40's skin was intact.-On 07/21/25, R40's foot check was completed with right and left foot dry, not cracked, with slight edema which is not new to R40.-On 07/22/25, R40 had scant bleeding noted to right great toe, inflammation along line of toenail. Unable to determine exact open area for measurement due to placement of toenail/inflammation. No purulent drainage noted. Immediate action taken was cleansed right great toe with normal saline, applied band aid, gauze tube per R40's request. Added resident to weekly wound rounds, made appointment for R40 to be seen by provider due to resident being diabetic.Surveyor reviewed R40's progress notes and did not find any documentation that a staff member notified provider of new skin changes or assessed the new skin changes on R40's right great toe.Observations and interviewsOn 07/21/2025 at 10:36 AM, Surveyor interviewed R40. Surveyor asked if R40 had any sores or open areas on body. R40 reported to Surveyor that at this time R40 does not have any skin issues except R40's great right toe has a sore from podiatrist cutting toe nail off. Surveyor observed band aid and kerlix wrapped on great right toe.On 07/22/25 at 6:50 AM, Director of Nursing (DON) B asked if any Surveyor wants to observe wound dressing changes on any residents. Surveyor reported to DON B that Surveyor wanted to see what was going on with R40's band aid on great right toe. DON B reported to Surveyor that DON B would ask the Registered Nurse (RN) to bring Surveyor in once RN goes into R40's room.On 07/22/2025 at 7:23 AM, Surveyor observed Registered Nurse (RN) M walk out of R40's room. RN M reported to Surveyor that RN M was not aware of R40's right great toe and that the toe injury is new. Surveyor observed wound care supplies laid all over R40's bed when Surveyor entered. Surveyor asked RN M if RN M knew about the injury prior to today, 07/22/25. RN M reported that RN M did not know about it and that it is newly developed. RN M reported usually CNAs will let wound care nurse (RN M) know about it right away and no one has let RN M know yet. Surveyor asked RN M at what point did someone place a band aid on R40's right great toe. RN M stated, I am unsure. Surveyor asked RN M if there was any documentation in the chart to show the condition of R40's right great toe. RN M stated that RN M would look into it after dressing R40's wound. RN M stated to Surveyor that RN M would notify the on-call doctor to peek on R40 during virtual rounds. Surveyor asked RN M if RN M knew who placed the band aid on R40 and did not report it to RN M or provider. RN M reported to Surveyor that RN M is unsure but will call the shifts prior to day shift today. On 07/22/2025 at 7:45 AM, RN M reported to Surveyor that last skin checks documented for R40 were skin was intact. Surveyor asked where notes were that someone placed a band aid on R40. RN M reported that RN M would keep looking through the Electronic Health Record (EHR).On 07/22/2025 at 1:30 PM, Surveyor interviewed RN M and asked if RN M spoke with the staff who placed band aid on and why it was not reported to provider or another staff member. RN M reported to Surveyor that RN M has not heard back from staff yet. RN M reported to Surveyor that RN M contacted physician on call and will be completing a virtual visit to assess R40's diabetic toe. RN M reported that RN M will assess the skin issue, complete a Braden skin assessment, and update care plan as needed. On 07/23/25 at 8:01 AM, Surveyor interviewed RN M and asked if RN M spoke with the staff who placed band aid. RN M reported that no one has called back yet.On 07/23/2025 at 12:32 PM, Surveyor interviewed DON B and asked DON B's expectation of assessing R40's diabetic toe and then reporting it to physician. DON B reported to Surveyor that DON B's expectation is that whoever finds a new skin issue on any resident then it is reported immediately to next shift, physician on call, and DON B. Surveyor asked DON B's expectation for assessing and documenting new skin issues on R40. DON B reported to Surveyor that DON B expects staff to assess a new skin issue thoroughly, measure, cleanse, document, and notify on call provider. Surveyor asked DON B if DON B knew who placed the band aid on and who didn't report this upon finding the new skin issue on R40. DON B reported to Surveyor that RN M was reaching out to all previous shifts and had to leave messages. DON B reported so far there are no call backs.

Based on record review and interview, the facility did not ensure acceptable parameters of nutritional status to maintain usual body weight. This occurred for 1 of 3 residents reviewed for nutritional status, Resident (R) R6.R6 was not weighed weekly to assess if he was maintaining his usual body weight. R6 had significant weight loss that was not assessed appropriately. Based on record review and interview, the facility did not ensure acceptable parameters of nutritional status to maintain usual body weight. This occurred for 1 of 3 resident reviewed for nutritional status. Resident (R) R6.R6 was not weighed weekly to assess if he was maintaining his usual body weight. R6 had significant weight loss that were not assessed appropriately. This is evidenced by:R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease unspecified, dementia, type 2 diabetes mellitus, essential hypertension, major depressive disorder, and dysphagia.R6's minimum data set (MDS) assessment, completed on 07/05/25, confirmed R6 is incontinent of urine and frequently incontinent of bowels. R6 requires supervision assistance with eating. R6 is substantial or maximal assist on staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear.R6's care plan was initiated on 02/05/25, and included the following:EATING:-Set-up assistance DENTAL CARE initiated on 02/05/25,-Consult with RD and follow recommendations.-Keep physician and significant other/designated family member informed of significant weight loss (.4% of previously obtained weight).-Monitor for weight loss. POTENTIAL FOR ALTERED NUTRITIONAL initiated on 07/05/25,-Diet as ordered CCHO, mechanical soft diet texture, thin liquids.-Eating: Independent, with supervision/set up-Provide and serve supplements as ordered.-Weights as ordered. Update RD/MD with weight gain/loss per facility protocol. Weekly weight report printed and examined.Surveyor reviewed R6's physician orders:-On 01/28/25, Weekly weights ordered.Surveyor reviewed R6's weights from 01/02/25 to present 07/22/25. -On 01/11/25 211 lbs.Staff missed 3 weeks of weights for R6.-On 02/07/25 223.7 lbs.-On 02/14/25 223 lbs.Staff missed 2 weeks of weights for R6.-On 03/07/25 224.3 lbs.-On 03/10/25 205 lbs.-On 03/19/25 208.6 lbs.-On 03/26/25 207.2 lbs.-On 03/31/25 208.3 lbs.Staff missed 2 weeks of weights for R6.-On 04/15/25 205.2 lbs.-On 04/22/25 206.6 lbs.-On 05/02/25 204.7 lbs.-On 05/08/25 208.6 lbs.-On 05/14/25 204.6 lbs.Staff missed 1 week of weights for R6.-On 05/30/25 200.5 lbs.-On 06/04/25 200.6 lbs.-On 06/10/25 201.2 lbs.Staff missed 2 weeks of weights for R6.-On 07/03/25 192.1 lbs.Surveyor calculated weight loss in percentage as follows: - On 02/07/2025, the resident weighed 223.7 lbs. On 05/02/2025, the resident weighed 204.7 lbs. which is a -8.49% loss.- On 02/07/2025, the resident weighed 223.7 lbs. On 07/11/2025, the resident weighed 200 lbs. which is a -10.59% loss.Surveyor reviewed Nutritional At Risk (NAR) reports from 01/03/25 to 07/18/25 for dietary in assessing and intervening for residents at risk or with weight loss. Surveyor did not find R6 noted on Dietary Manager (DM) N's NAR reports that she prints and brings to weekly meetings to the interdisciplinary team. Surveyor reviewed R6's progress notes:-On 02/28/25, Nutritional note: Diet CCHO, regular texture, thin liquids.eating independently with supervision/ set up. Intakes are quite varied, 25-100% of meals. Fluids are 240-720cc per meal. No issues chewing/swallowing noted. Weight: 223#, BMI of 33- obese. Care plan has been reviewed/updated. No new recommendations, RD to f/u and monitor prn.-On 04/17/25, Dietary note, Nutritional note: ST trial of Mech soft texture through 4/21/25 breakfast, monitoring for better meal intakes, re-eval at that time.-On 07/06/25, Nutritional risk assessment completed and noted R6 will proceed with nutritional diagnosis. Nutritional risk related to, if applicable: dysphagia related to difficulty swallowing as evidenced by requires modified texture diet. Care plan has been reviewed/updated. recommend offering sugar free house supplement BID, RD to follow up and monitor prn.Surveyor found no documentation for follow up on the trial for mechanical soft from 04/17/25 until 07/06/25 after R6 lost significant amount of weight. Surveyor did not find any documentation addressing R6's weight loss and updated care plan with new interventions until 07/05/25. On 07/23/25 at 12:01 PM, Surveyor interviewed DM N and asked DM N to explain process for monitoring weight loss in residents. DM N reported to Surveyor that DM N goes into EHR and follows weights. DM N will track trends and see who is at risk for weight loss or is actively losing weight and then documents in reports called NAR reports. DM N reported that the NAR reports go to the Registered Dietician (RD) and then interventions are put into place once RD reviews. DM N then reported that a dietary profile, mini nutrition assessment, and nutritional check assessment is concluded quarterly and annually. Surveyor asked DM N if R6 was on DM N's NAR reports. DM N reviewed NAR reports and stated, No R6 is not on NAR reports from 01/03/25 to present. Surveyor asked how R6 was missed for having significant weight loss. DM N was not sure how the significant weight loss was missed. On 07/23/2025 at 12:13 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor informed DON B of review of R6's nutrition and significant weight loss and the interview with DM N who reported somehow R6 did not populate as weight loss to review and intervene for further weight loss. Surveyor asked DON B's expectation of staff addressing the weight concerns for R6. DON B reported to Surveyor that DON B's expectation is that staff communicate about weight changes. DON B reported that CNAs tell the nurse the weights and if nurse sees a significant change that dietary is notified right away. DON B reported that DM N has her own way of assessing weights and then reporting significant changes to residents on a consistent basis. DON B reported that DON B would review and address R6's daily living and adjust schedule to preferences of sleep, eating, etc. VP of Clinical Operations E reported to Surveyor that VP of Clinical Operations E completed education regarding NAR reports, weight loss, nutrition in a meeting with all staff on 05/23/25.

Based on observations, interviews and record reviews, the facility did not provide appropriate skin assessments and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 12 residents (R40) reviewed.Staff did not assess or document R40's new break in skin on great right toe or treat the skin injury appropriately.Findings include:R40 was admitted to the facility on [DATE] with diagnoses including in part, acute respiratory failure with hypoxia, Type 2 Diabetes Mellitus, obstructive sleep apnea, venous insufficiency, morbidly obese, bilateral osteoarthritis of hip, and prostatic hyperplasia.R40's care plan was initiated on 04/15/25, and included the following:DIABETIC:-Nursing to complete nail care on Tuesday evening. Surveyor reviewed R40's skin prevalence reports that did not note any skin issues. Surveyor reviewed Diabetic foot checks weekly documentation:-On 07/07/25, R40's skin was intact.-On 07/14/25, R40's skin was intact.-On 07/15/25, R40's skin was intact.-On 07/21/25, R40's foot check was completed with right and left foot dry, not cracked, with slight edema which is not new to R40.-On 07/22/25 R40 has scant bleeding noted to right great toe, inflammation along line of toenail. Unable to determine exact open area for measurement due to placement of toenail/inflammation. No purulent drainage noted. Immediate action taken was cleansed right great toe with normal saline, applied band aid, gauze tube per R40's request. Added resident to weekly wound rounds, made appointment for R40 to be seen by provider due to resident being diabetic.Surveyor reviewed R40's progress notes and did not find any documentation that a staff member assessed the new skin changes on R40's right great toe. Observations and interviewsOn 07/21/2025 at 10:36 AM, Surveyor interviewed R40. Surveyor asked if R40 had any sores or open areas on body. R40 reported to Surveyor that at this time R40 does not have any skin issues except R40's great right toe has a sore from podiatrist cutting toe nail off. Surveyor observed band aid and kerlix wrapped on great right toe.On 07/22/25 at 6:50 AM, Director of Nursing (DON) B asked if any Surveyor wants to observe wound dressing changes on any residents. Surveyor reported to DON B that Surveyor wanted to see what was going on with R40's band aid on great right toe. DON B reported to Surveyor that DON B would ask the Registered Nurse (RN) to bring Surveyor in once RN goes into R40's room.On 07/22/2025 at 7:23 AM, Surveyor observed Registered Nurse (RN) M walk out of R40's room. RN M reported to Surveyor that RN M was not aware of R40's right great toe and that the toe injury is new. Surveyor observed wound care supplies laid all over R40's bed when Surveyor entered. Surveyor asked RN M if RN M knew about the injury prior to today, 07/22/25. RN M reported that RN M did not know about it and that it is newly developed. RN M reported usually CNAs will let wound care nurse (RN M) know about it right away and no one has let RN M know yet. Surveyor asked RN M at what point did someone place a band aid on R40's right great toe. RN M stated, I am unsure. Surveyor asked RN M if there was any documentation of an assessment in the chart to show the condition of R40's right great toe. RN M stated that RN M would look into it after dressing R40's wound. Surveyor asked RN M if RN M knew who placed the band aid on R40 and did not report it to RN M or provider. RN M reported to Surveyor that RN M is unsure but will call the shifts prior to day shift today. On 07/22/2025 at 7:45 AM, RN M reported to Surveyor that last skin checks documented for R40 were skin was intact. Surveyor asked where notes were that someone placed a band aid on R40 or assessed the toe. RN M reported that RN M would keep looking through the Electronic Health Record (EHR). On 07/22/2025 at 1:30 PM, Surveyor interviewed RN M and asked if RN M spoke with the staff who placed band aid on and why it was not reported to provider or another staff member. RN M reported to Surveyor that RN M has not heard back from staff yet. RN M reported that RN M will assess the skin issue, complete a Braden skin assessment, and update care plan as needed. On 07/23/25 at 8:01 AM, Surveyor interviewed RN M and asked if RN M spoke with the staff who placed band aid. RN M reported that no one has called back yet.On 07/23/2025 at 12:32 PM, Surveyor interviewed DON B and asked DON B's expectation for assessing and documenting new skin issues on R40. DON B reported to Surveyor that DON B expects staff to assess a new skin issue thoroughly, measure, cleanse, document, and notify on call provider. Surveyor asked DON B if DON B knew who placed the band aid on and who didn't report this upon finding the new skin issue on R40. DON B reported to Surveyor that RN M was reaching out to all previous shifts and had to leave messages. DON B reported so far there are no call backs.

Based on interview and record review, the facility did not ensure 1 of 5 residents reviewed (R2) was free from unnecessary medications.-Facility did not ensure adequate indication for use of psychotropic medications.Findings include:R2 was admitted to the facility on [DATE] with diagnoses of dizziness and giddiness, and dementia (moderate) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.Most recent Minimum Data Set (MDS) shows a Brief Interview for Mental Status (BIMS) score of 13/15 indicating R2 is cognitively intact.Facility policy titled, Psychotropic Medication Evaluation and Utilization, last reviewed 12/2024, reads in part: Psychotropic medications and other medications with black box warnings are specifically identified as requiring additional monitoring.these medications require more in-depth review.due to the potential for limited effect and higher potential for significant side effects.all of these medications require individualized monitoring which may include.targeted behavior monitoring.Care Plan in part (prior to start of psychotropic medications):Focus: R2 is at risk for falls r/t syncopal episodes, medication use, and history of falling. (Last revised on 02/05/25) Interventions include 1:1 supervision provided related to fall and encourage R2 to use call light system for assistance (last reviewed on 02/05/2025)Record review indicated no targeted behavior monitoring in place prior to starting Lorazepam and Escitalopram. No previous diagnosis of anxiety or depression prior to beginning these medications.General behavior monitoring 30 days prior to start of medications indicated 4 episodes of anxiousness.Physician orders indicated R2 was on an antibiotic for a urinary tract infection (Nitrofurantoin Macro crystal) from 05/09/25-05/23/25.Progress note, from 05/21/25, indicates staff spoke with R2's daughter. R2's daughter requested a mood stabilizer. R2's daughter was not activated power of attorney (POA) at this time. Progress note, from 05/21/25, indicates R2 was sent to the emergency room for evaluation related to loss of consciousness/syncope. Progress note, from 05/22/25, indicated facility staff left message with clinic manager at hospital for R2's physician to address possible medication for mood stabilization. Progress note, from 05/22/25, indicated facility staff received a call from R2's physician for new orders for Escitalopram, Lorazepam, and a new diagnosis of depression with anxiety.Power of Attorney signed and activated on 05/22/25.Care plan initiated after new diagnosis/start of psychotropic medications on 05/22/25:SIDE EFFECT MONITORING: ANTIANXIETY-Monitor for side effects: Dizziness, Nausea, Drowsiness, Blurred Vision, Confusion, Weight Gain, Psychomotor Agitation, Panic AttacksSIDE EFFECT MONITORING: ANTIDEPRESSANT-Monitor for side effects: Nausea, Dizziness, Headache, Constipation, Weight gain, Drowsiness, Insomnia, fatigue, diarrhea, irritability, restlessnessSIDE EFFECT: ANTICOAGULANT-Monitor for side effects: Blood in urine/stool, black stool, severe bruising, prolonged nosebleeds, bleeding gums, vomiting/coughing up blood.Focus: I use antidepressant medication r/t mixed anxiety/depressive disorder with interventions including monitoring for change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal, decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyesProgress note, from 05/24/25, indicated R2 was feeling dizzy and nauseated and stayed in the nurse's station for 15 minutes to be observed. Progress note, from 05/28/25, indicated R2 reported feeling dizzy but did not have nausea, and declined supper.Progress note, from 06/11/25, indicated a pharmacy recommendation was made to discontinue the as needed Lorazepam. R2's provider discontinued as recommended and gave new orders for Lorazepam daily scheduled at night.Progress note, from 06/17/25, indicated R2 was experiencing hallucinations and confusion.Progress note, from 06/17/25, indicated staff spoke with R2's power of attorney regarding dose of Lorazepam. R2's POA agreed the current dose was working.Record review indicated 1 episode of confusion and repetition of questions on 06/18/25 with neutral facial expressions and limited eye contact.Progress note, from 06/18/25, indicated staff contacted R2's physician in relation to increased anxiety and behaviors. R2's physician gave verbal orders to increase Lorazepam to twice daily.Progress note, from 06/22/25, indicated R2 experienced confusion.R2 was sent to emergency room on [DATE], after an unwitnessed fall and complaints of right hip and elbow pain. R2 returned to facility with order for antibiotic for a urinary tract infection. Intervention added to care plan: Offer to assist R2 to lay down after lunch. (06/22/2025)Progress note, from 07/06/25, indicated R2 had an unwitnessed fall. Intervention added to care plan: Anti-roll back bars on wheelchair (07/06/2025)Progress note, from 07/12/25, indicated R2 experienced hallucinations and restlessness.Progress note, from 07/15/25, indicated R2 experienced confusion, was roaming around R2's room, and undressing.R2 sent to emergency room on [DATE], after an unwitnessed fall. R2 returned to facility same day with no new orders. Intervention added to care plan: 1:1 supervision provided related to fall (07/20/2025) Resident Posting/Sign: Call, don't fall sign in room. (07/20/2025) Pharmacy review of medications. (07/21/2025) On 07/23/25 at 10:12 AM Surveyor interviewed R2. R2 stated she was frustrated that she keeps falling but is glad she has no broken bones. R2 stated she gets infections in her urine, and she gets turned around at times. R2 could not recall dates of falls, number of falls, or names of the new medications but did say they make her stopped up. R2 said when that happens it upsets her stomach, and she doesn't feel like eating.On 07/23/2025 at 11:21 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O stated R2 has always been anxious since she has been at the facility. CNA O stated CNA O hasn't noticed any changes in general, better or worse. CNA stated R2 is hit or miss for sleep and will sometimes sleep in the bed and sometimes in the recliner. CNA O stated they use pressure alarms on the bed and in the recliner, and a string alarm while in the wheelchair. CNA O also stated R2 was moved closer to the nurse's station for safety as well. CNA O stated they carry a copy of the resident care plan while working and stated those get updated as needed when things change. On 07/23/2025 at 11:27 AM, Surveyor interviewed Registered Nurse (RN) M. RN M stated R2 is anxious at baseline but seems to be becoming more confused. RN M stated she believes the behaviors R2 has seem to ebb and flow. There isn't consistency. RN M also stated they have noticed behaviors are more often in the evening and are planning to discuss possible sundowning with the provider. RN M stated the number of falls prior to, and post psychotropic meds are about the same. RN M stated a lot of symptoms and falls have correlated with when R2 had UTIs. RN M stated some of the interventions in place for safety are alarms, offering activities, dycem in the wheelchair, and physical and occupational therapy assessments. On 07/23/2025 at 12:07 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated facility staff receive yearly and as needed education on the procedure/expectations for psychotropic medications. DON B stated they assess the resident, look at their history, implement non-pharmacological interventions, and discuss with physician before starting on psychotropic medications. DON B stated behavior monitoring should be completed prior to starting the medication. DON B stated R2 has had the same provider for a long time, and he knows her and her family well. DON B stated R2's physician is aware of her history and possibly that is why he prescribed the medications so quickly. Surveyor located no behavior monitoring prior to the medication or rationale prior to the use of the psychotropic medication.

Based on observation, interview and record review, the facility did not ensure that 1 of 4 residents (R1) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent potential skin breakdown and promote healing of existing PIs. R1 was on hospice and nearing end of life. R1 was at risk for PI; alternate support surfaces were not provided when skin issues were noted. Findings include: The facility policy, titled Pressure Injury Risk Assessment, revised [DATE], states: .#1. Pressure injury risk assessments will be conducted by a licensed nurse on admission, weekly times four weeks, then quarterly. Assessments will be conducted after a change in condition or after any newly identified pressure injury .#5. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care base don specific factors identified in the risk assessment . The facility policy, titled Documentation of Wound Treatments, revised [DATE], states: .#4. Additional documentation shall include, but is not limited to: D. Modifications of treatments or interventions. E. Notifications to physician and/or responsible party regarding wound or treatment changes . On [DATE], Surveyor reviewed R1's medical record. R1 was admitted on [DATE] with unspecified dementia with behavioral disturbance, congestive heart failure, and hypertension. R1's Minimum Data Set (MDS) assessment, dated [DATE], had a Brief Interview for Mental Status (BIMS) score of 03 out of 15 which indicated R1 had severe impaired cognition. R1's MDS section GG for functional ability indicated R1 is total dependent on staff for transfers, toileting, repositioning, and personal hygiene. MDS indicated that R1 was admitted with no skin issues, but at risk for skin breakdown. Surveyor reviewed R1's Potential for pressure/ulcer injury care plan dated [DATE]: -Conduct a full body skin inspection weekly. -Diet as ordered. Supplements per dietary recommendations. -Encourage physical mobility, activity, and range of motion to maximize potential. -Keep skin as clean and dry as possible. -Meds, labs, treatments as ordered. -Pressure reduction mattress, and wheelchair cushion. -Provide incontinence care after each incontinent episode. -Report areas of skin breakdown to nurse. Surveyor reviewed R1's assessments, progress notes, and weekly skin prevalence nursing assistant sheets: -On [DATE], admission observation noted R1 had no alterations in skin. -On [DATE], Braden skin assessment noted R1 had no ulcers, wounds, or skin problems. R1 scored 15 which indicated R1 was at risk for skin breakdown. -On [DATE], progress note indicated open area on left buttock. Placed exoderm satin on area, appears to have skin tear due to friction of sliding in wheelchair. -On [DATE], progress note indicated abrasion to left buttock resolved, d/c Hydrocolloid dressing. -On [DATE], Braden skin assessment noted R1 scored 11 which indicated R1 was at a high risk of skin breakdown. -On [DATE], weekly skin prevalence nursing assistant sheet indicated during shower CNA observed red excoriated area on left upper buttock. -On [DATE], progress note indicated R1 has open area to buttocks 1.0cm x 0.6cm superficial area to left buttock. Appears to be an abrasion due to shearing forces. Area cleansed; skin prep applied to entire wound area and covered with Hydrocolloid dressing. Will change every 5 days and as needed. -On [DATE], progress note indicated R1's dressing changed to abrasion of the left buttock. Area 100% epithelized, however tissue fragile, continue with Hydrocolloid dressing for protection at this time will observe again Monday. -On [DATE], progress note indicated . Cleansed area with normal saline and patted dry with gauze. Applied silicone sacral pad to coccyx area. -On [DATE], Braden skin assessment noted R1 scored 11 that indicated R1 was at a high risk of skin breakdown this is the same as the July braden assessment -On [DATE], progress note indicated R1's abrasion to left buttock healed. D/C Hydrocolloid dressing. Continue with alternating air overlay to mattress. Repositioning and barrier cream with cares. -On [DATE], weekly skin prevalence nursing assistant sheet indicates R1 had redness noted to coccyx area. -On [DATE], progress note indicates that R1 has redness and blanching to sacral area. Due to poor intakes and positioning in her Broda chair and recliner will add a protective Meplix to sacrum to be changed every 5 days. Of note, resident is on hospice and at end of life with poor fluid and food intake that is unavoidable. https://hospicefoundation.org/ When death is near, signs and symptoms: Although pressure wounds can develop at any stage of a terminal illness, open wounds may appear rapidly at the end of life as the skin, like other organs, begins to stop functioning. Surveyor did not find any new interventions put into place on R1's care plan for R1's high risk of skin breakdown such as a change in pressure relieving support surfaces for the broda chair and bed when redness noted on [DATE]. -On [DATE], progress note indicates that writer following up on sacral foam dressing that was applied for protection. Last week all skin was intact and pink. This week writer noted a foul odor in room. Upon observation there was shadowing to sacral foam dressing. Sacral dressing removed exposing an unstageable pressure injury to her sacrum that measures 0.8cm x 1.5cm. Wound bed with 100% black eschar. Moderate amount of seropurulent drainage. Edge of wound well defined. Peri wound red and blanchable. Writer cleansed area with wound wash, patted dry. Collagen AG applied to wound bed for bacterial control and drainage control. New sacral foam applied. Staff instructed that resident no longer to sit in recliner at this time. Side to side positioning only in bed. Continue with pressure reduction mattress. Dietary notified of new wound. R1 continues on hospice. Hospice notified. POA-HC updated. CP updated with interventions. Surveyor reviewed R1's pressure/ulcer injury care plan dated [DATE]: -R1 in Broda chair for meals only then position in bed. Position side to side. Change position every 1 hour while in bed. -Unstageable pressure injury to Sacrum: 1. Cleanse with wound wash. 2. Pat dry. 3. Apply skin prep to peri wound. 4. Cover wound bed with Aquacel AG or equivalent. 5. Cover with sacral foam dressing. Change daily. -On [DATE], progress note indicated that a call was placed to hospice to request order from provider for wound culture, Prosource 30ml three times a day with vanilla shakes, Roho cushion for recliner and wheelchair and to order wound care supplies. 4x4's, calcium alginate, small sacral foams, and wound wash. -On [DATE], progress note indicates preliminary wound culture results returned. Gram stain: no squamous epithelial cells. Moderate Gran stain positive cocci singly, in pairs and clusters. Rare gram-negative rods. Rare Gram-positive rods. POA-HC notified of preliminary results and will keep updated on final results and sensitives. -On [DATE], progress note indicates Many E-coli. Sent to provider for treatment. Of note, resident is incontinent and e. coli has high probability of getting into the sacral area. -On [DATE], progress note indicates provider orders Bactrim DS ,d+[DATE]mg oral twice a day for 7 days for wound infection. -On [DATE], progress note indicates unstageable pressure injury to R1's sacrum measures 2.0cm x 2.0cm, wound bed with 100% green/grey stringy slough. Large amount of purulent drainage to old dressing. Edge of wound macerated, no longer attached to base. Undermining around entire wound bed, greatest depth of undermining at 12'o clock at 1.5cm. No tunneling. Peri wound red and blanchable. Writer cleansed area with wound wash, patted dry, collagen AG tucked into undermining areas of wound and new sacral foam applied. Continue side to side positioning while in bed. Continue Prosource three times a day. Hospice and POA-HC updated on wound status. -On [DATE] at 3:38 PM, progress note indicates R1 had expired. Family at bedside. Resident expired 9 days after PI identified. Interviews: On [DATE] at 1:41 PM, Surveyor interviewed Power of Attorney (POA) D who indicated there was not a cushion in the Broda chair until facility requested Roho cushion for chair from hospice on [DATE]. POA D indicated there was a thin overlay mattress for pressure reduction on R1's bed before [DATE]. On [DATE] at 3:14 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C, wound nurse, and asked what LPN C process is for new wounds. LPN C indicated that LPN C places a note in the progress notes. Surveyor asked LPN C what mattress did R1 have upon admission. LPN C indicated that R1 started off with a basic overlay pressure reduction mattress. LPN C indicated that once R1 was found to have a PI in November then LPN C requested hospice bring an alternating air mattress for R1's bed. LPN C indicated that R1 had a basic cushion in R1's wheelchair until the Roho cushion was requested by hospice in November as well. LPN C indicated that at this point R1 needed to get off R1's bottom as it was painful and R1 became ,d+[DATE]-hour repositioning. Surveyor asked LPN C if LPN C knew why there were no new interventions put into place when R1 declined on hospice and had a noted red area on [DATE]. On [DATE] at 4:35 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked DON B if R1's PI could have been prevented. DON B indicated that DON B is unsure if the PI could be prevented as R1 was on hospice declining and nearing the end of life. Surveyor asked why R1 did not have an alternating air mattress or roho in place earlier than [DATE]. DON B indicated the previous areas were not PIs and were blanchable. All areas healed with the interventions provided. DON B thought hospice was taking care of the air mattress and did not realize that R1 only had an overlay pressure reduction mattress and not the high flow alternating air mattress and ideally should have had alternate support surface when redness was noted on [DATE], and R1's condition was declining.

Based on observation, interview and record review, the facility did not ensure that the steam heated hot water system is maintained in a safe operating condition resulting in the return hot water temperature at fixtures used by residents fluctuating in temperature, at times not adequate temperature for bathing/handwashing. This has the potential to affect all 46 residents (R) in the facility. Findings: Facility policy titled, Water Management Program Policy and Procedure, revision date May 29, 2024, states: Purpose: The purpose of this policy is to ensure the safety of our residents, staff, and guests. Through monitor, testing, and maintaining of our domestic water system under the guidelines and regulations by Centers for Medicare and Medicaid Services (CMS) and the Center for Disease control (CDC) recommendations. Implementation: 4. Weekly audits and water flushes completed on all high-risk areas for legionella to grow. Temps completed to all hot water holding tanks to be in compliant range of 140 degrees Fahrenheit (F) to 150 degrees F. Water Systems Flow 3. Cold water is heated to 140 degrees F by a closed loop steam heat exchanger which supplies a 250-gallon holding tank with a re-circulating loop. 4. Hot water is distributed to showers/spa, sinks, and hot water booster to the kitchen with a recirculating line designed to return to the holding tanks. Safe bathing water temperatures should be maintained at 100 degrees F. On 08/21/24, Surveyor's thermometer was calibrated (a procedure using ice water to ensure the thermometer is measuring correctly) before hot water temperature checks were obtained. The Surveyor's hot water temperature checks in resident rooms and showers beginning at 10:10 a.m. revealed the following. 10:10 a.m., resident room [ROOM NUMBER] was 100 degrees F. 10:15 a.m., resident room [ROOM NUMBER] was 100 degrees F. 10:25 a.m., resident room [ROOM NUMBER] was 90 degrees F. 10:40 a.m., 300-hall shower was 94 degrees F. 10:52 a.m., resident room [ROOM NUMBER] was 82 degrees F. 10:58 a.m., resident room [ROOM NUMBER] was 88 degrees F. 11:08 a.m., resident room [ROOM NUMBER] was 92 degrees F. 11:15 a.m., resident room [ROOM NUMBER] was 90 degrees F. 11:20 a.m., resident room [ROOM NUMBER] was 80 degrees F. 11:25 a.m., resident room [ROOM NUMBER] was 94 degrees F. 11:32 a.m., shower of 100-hall was 96 degrees F. 11:40 a.m., spa on 200 hall was 92 degrees F. 11:50 a.m., 400-hall shower was 94 degrees F. On 08/21/24 at 10:25 a.m., Surveyor interviewed R4 and asked if the hot water in the sink and in the shower is hot. R4 stated R4 takes mostly showers and the water is hot if it is run for a while first. R4 stated the hot water in the sink is fine. On 08/21/24 at 10:39 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) C and asked if the resident room sinks and showers have hot water. CNA C stated the resident room sinks the water is not hot enough. CNA C stated the resident room sinks must be run a long time to get warm and the showers must have the water run for at least 15 minutes before it is hot. On 08/21/24 at 10:58 a.m., Surveyor interviewed R5 asked if the hot water in the sink and in the shower is hot. R5 stated the water in the sink is just warm enough to wash your face. On 08/16/24 at 11:16 a.m., Surveyor interviewed CNA D asked if the resident room sinks and showers have hot water. CNA D stated sometimes the water is real hot and sometimes it is not hot enough. CNA D stated it varies a lot. On 08/21/24 at 11:25 a.m., Surveyor interviewed R9 and asked if the hot water in the sink and in the shower is hot. R9 stated the water was warm enough, but not always hot. On 08/21/24 at 12:00 p.m., Surveyor interviewed Director of Maintenance (DOM) G and asked if the facility has had any hot water issues. DOM G stated the facility has a steam heated hot water system and it is old. It was installed in the 1960s. DOM G stated there have been issues over the years with the system, which were reported to management. DOM G indicated there have been no attempts to repair the system. DOM G stated on 08/20/24, DOM G most recently worked on the hot water. DOM G stated the steam valve sticks. DOM G needed to tweak the mixing valve for the water temperature. (Note: In a steam-heated water system, a mixing valve uses a piston to open and close a steam valve. The cold-water supply lifts the piston, which opens the steam valve. When the cold-water supply stops, the piston falls and closes the steam valve. The piston needs to move freely to maintain the design). DOM G stated when DOM G left work on 08/20/24, the system was functioning, and the water temperature was fine. DOM G stated the water is heated and stored in the holding tank at 140 degrees F and the return temperature is 120 degrees F. DOM G stated the system was checked early morning and the water temperature was working fine. DOM G indicated that frequently the system needs to be readjusted. DOM G stated on 08/21/24 mid-morning, the system was checked, and the return temperature was 90 degrees F. The early morning temperatures did not stay consistent by mid morning. DOM G stated this was adjusted later on 8/21/24. On 08/21/24 at 12:38 p.m., Surveyor asked DOM G to re-check water temperatures. DOM G stated the temperature on the return was 120 degrees F in the basement on the gauge of heating system before DOM G came to re-check temperatures. DOM G used an electronic thermometer. Temperatures were as follows: room [ROOM NUMBER] 107.4 degrees F room [ROOM NUMBER] 115.0 degrees F 300-hall shower 105.2 degrees F. On 08/21/24 at 1:00 p.m., Surveyor reported findings to Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Surveyor asked if NHA A has been aware of the water temperature issues as maintenance has stated. NHA A stated Dove Healthcare has been working on many improvements in the facility and NHA A stated the water temperature issues will be reported to the Dove Healthcare corporate office, so it can be addressed.

Based on observation, record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 14 residents (R32) reviewed for medication errors. R32 has a type 1 diabetes mellitus diagnosis. Facility staff administered glucagon three times with no documentation and reasoning for giving glucagon outside of blood glucose parameters. Facility staff did not administer glucagon when R32's blood glucose levels were 30 to 54. Facility staff did not follow physician orders when insulin was held and administered insulin as R32 requested. The facility did not have a physician order to allow R32 direct the amount of insulin administered. Findings include: Surveyor reviewed the policy titled, Management of Hypoglycemia which stated in part, #2. For level 1 hypoglycemia (<70mg/dL but >54 mg/dL: e. Give resident an oral form of rapidly absorbed glucose (15-20grams); f. Notify the provider immediately. g. Remain with the resident; h. Recheck blood glucose in 15 minutes: (4) If blood glucose remains <70 mg/dL repeat oral glucose and notify physician for further orders. #3. For level 2 hypoglycemia (,54 mg/dL): g. Administer glucagon (intranasal, intramuscular, or as provided); h. Notify the provider immediately; i. Remain with the resident; j. Place the resident in a comfortable and safe place (bed or chair); k. Monitor vital signs; and l. Recheck blood glucose in 15 minutes as above. -Documentation #1. Document the resident blood glucose before intervention. #2. Note blood glucose after each administration of rapid-acting glucose and the follow-up blood glucose. #3. Record the resident's level of consciousness before and after intervention. #4. Document provider instructions . R32 was admitted to the facility on [DATE] with diagnoses including in part, type 1 diabetes mellitus with diabetic chronic kidney disease and ketoacidosis without coma, metabolic encephalopathy, chronic kidney disease stage 4, vascular dementia unspecified severity with agitation, paroxysmal atrial fibrillation, gastrostomy status, and dysphagia oropharyngeal phase following cerebral infarction. R32's minimum data set (MDS) assessment, completed on 01/29/24, confirmed R32 scored 11/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R32 has an activated power of attorney for healthcare decisions. R32 is dependent on staff for nutritional needs and R32 has gastrostomy (G)-tube placement. Review of R32's medical record identified the following physician orders stated in part, .Monitor blood glucose levels before tube feeding and at bedtime. 01/23/24 - 02/7/24: insulin Glargine 25 units 8 am. 01/23/24 - 01/29/24 Insulin Lispro 10 units give QID simultaneously with tube feeding boluses 8 AM, 12 PM, 4 PM, and 8 PM. 01/23/24 - 01/25/24 insulin Lispro sliding scale with meals 8 12 4. 01/23/24 - 01/29/24 insulin Lispro sliding scale 8 pm. 01/29/24- 02/7/24 insulin Lispro 8 units QID give only before tube feeding 8 12 4 8. 01/29/24 - 02/20/24 insulin Lispro sliding scale QID before tube feeding (Three times a day 12p, 4pm, 8pm) . Review of R32's medical record identified the following notes: On 02/04/24 at 4:41 AM, Medication Administration Record (MAR) indicated Glucagon 1mg given to R32 with no documentation of BG results and why Glucagon was administered. On 02/05/24 at 12:46 AM, MAR indicates that Glucagon 1mg was given for a BG of 77. No notes were observed reasoning giving glucagon outside the BG parameters. On 02/05/24 at 6:11 AM, progress note indicates, . BG dropped to 71 and glucagon administered at 4:40 AM. No notes were observed reasoning giving glucagon outside the BG parameters. On 02/06/24 at 4:22 AM, progress notes indicate: .0030 BG 66 OJ with 3 sugar packets given via GT. 0100 BG 60 gave bolus of Jevity. 0300 BG 217 . Review of R32's medical record identified the following physician orders stated in part, on 02/07/24 at 1:00 PM, .Change Lantus to 11 units twice daily due to hypoglycemia. If blood sugar below 100mg.dl prior to tube feeding inject 3 units Humalog, not full dose. Continue Humalog 8 units before tube feedings if blood sugar is above or equal to 100mg/dl . On 02/08/24 at 1:35 PM, progress notes indicate, .Resident was 102 per order and was ordered to give 8 units of Lispro but residents did not want 8 units of Lispro. Order is less than 100 give 3 units of Lispro, 100 or greater give 8 units of Lispro but the resident only wanted 3 units . Staff did not follow physician orders to administer 8 units. MAR documented staff gave insulin and did not document the number of units administered. On 02/10/24 at 10:54 PM, MAR indicated that an 8:00 PM dose of Glargine was held. BG 64. Staff did not follow physician orders to administer 11 units. On 02/12/24 at 9:07 PM, MAR indicated R32 refused Lispro. BG 89. On 02/12/24 at 9:18 PM, progress note indicated BG result 49. Insulin held. Staff did not follow the diabetic protocol for hypoglycemic episode and administer Glucagon for BG under 54. On 02/13/24 at 12:19 PM, MAR indicated BG flowsheet indicated BG 53. Staff did not follow the diabetic protocol for hypoglycemic episode and administer Glucagon for BG under 54. On 02/13/24 at 12:19 PM, MAR indicated BG flowsheet indicated rechecked BG with the result of 44. Staff did not follow the diabetic protocol for hypoglycemic episode and administer Glucagon for BG under 54. On 2/17/24 at 11:10 AM, BG flowsheet indicated BG 51. Staff did not follow the diabetic protocol for hypoglycemic episode and administer Glucagon for BG under 54. On 02/21/24 at 8:37 PM, MAR indicated resident refused Glargine insulin and Lispro. Surveyor did not observe any progress notes indicating any other interventions for R32's refusal of insulin. On 02/24/24 at 8:55 PM, progress note indicated BG 62 and insulin Lispro was given 3 units. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 02/29/24 at 5:57 AM, progress notes indicated BG 54, bolus of Jevity was given. Staff did not follow the diabetic protocol for hypoglycemic episode and administer Glucagon for BG under 54. On 03/01/24 at 8:00 PM, MAR indicated that nurse gave insulin Lispro and Glargine. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. At 8:51 PM, BG flowsheet indicated BG 61. On 03/02/24 at 1:28 AM, progress notes indicated BG 61 bolus of Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 03/03/24 at 2:16 AM, progress note indicated that on 03/02/24 at HS BG 30 and bolus Jevity given. Staff did not follow the diabetic protocol for hypoglycemic episode and did not administer Glucagon for BG under 54. On 03/08/24 at 5:00 AM, progress notes indicated BG 50. Staff did not follow the diabetic protocol for hypoglycemic episode and did not administer Glucagon for BG under 54. On 03/08/24 at 8:00 AM, MAR indicated all insulins Glargine and Lispro were given as order. At 8:39 AM, BG flowsheet indicates BG 66. On 03/10/24 at 10:29 AM, progress note indicated resident had BG 66, resident did not want interventions just wanted feeding to start. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. On 03/14/24 at 12:38 PM, progress notes indicated BG 57 bolus given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 03/16/24 at 11:20 AM, BG flowsheet indicated BG 62. On 03/16/24 at 1:22 PM, Progress notes indicated resident symptomatic with low blood sugars, clammy, skin cool. Gave bolus. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Staff did not follow the diabetic protocol for hypoglycemic episode. On 03/24/24 at 4:11 AM, progress notes indicated resident complaint of blood sugar low. BG was 66 and bolus Jevity started. On 03/24/24 at 4:50 PM, BG flowsheet indicated BG 63. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 3/25/24 at 4:37 PM, BG flowsheet indicated BG 60. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 3/29/24 at 3:43 PM, BG flowsheet indicated BG 57. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 4/8/24 at 5:12 PM, BG flowsheet indicated BG 62. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 4/9/24 at 3:38 PM, Blood Sugar flowsheet indicates BG 67. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 4/19/24 at 5:02 AM, BG flowsheet indicated BG 54. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. On 04/19/24 at 5:03 AM, progress note indicated the resident called the light on for a warning of low blood sugar. BG was 54. On 4/21/24 at 3:54 PM, BG flowsheet indicated BG 52. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Insulin was still administered with low BG. Staff did not follow the diabetic protocol for hypoglycemic episode. Surveyor reviewed physician orders on 04/22/24 stated in part, .Decrease Lantus insulin Glargine to 7 units BID 8 am and 8 pm. Increase Humalog with 8am tube feed to 11 units, other tube feeds remain at 8 units. If blood sugar <100 and tube feed is planned, give 5 units. Give insulin within 10 minutes of tube feed start . Surveyor reviewed physician orders on 04/23/24 stated in part, .Humalog Lispro give 11 units with 8 am if BG below 100 give 5 units. Insulin Lispro every 6 hours BG below 100 give 5 units, over 100 8 units . On 04/24/24 at 4:11 AM, progress notes indicated BG result 66. Gave bolus Jevity. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Provider was not notified. Re-check of blood glucose was not observed in progress notes. On 04/26/24 at 8:00 PM, BG flowsheet indicated BG 125. The MAR indicates that R32 requested Lispro 6 units. Staff administered Lispro 6 units to R32. Staff did not follow physician orders and the incorrect dose was given. On 04/27/24 at 4:00 PM, BG flowsheet indicated BG 107 and the MAR indicated R32 requested Lispro 6 units, staff administered Lispro 6 units. Staff did not follow physician orders and the incorrect dose was given. On 04/27/24 at 7:25 PM, BG flowsheet indicated BG 108. On 04/27/24 at 8:00 PM, MAR indicated R32 requested Lispro 3 units, staff administered Lispro 3 units. Staff did not follow physician orders and the incorrect dose was given. On 04/28/24 at 7:12 PM, blood sugar flowsheet BG 194. On 04/28/24 at 8:00 PM, MAR indicated Lispro was given 7 units. Staff did not follow physician orders and the incorrect dose was given. On 04/29/24 at 8:00 PM, MAR indicated resident requested Lispro 3 units, staff administered Lispro 3 units. At 8:44 PM, BG flowsheet indicated BG 76. Staff did not follow physician orders and the incorrect dose was given. On 05/04/24 at 8:44 PM, progress notes indicated R32 requested 3 units of Lispro and 5 units of Glargine for BG of 79. At 8:45 PM, the MAR indicated Lispro 3 units and Glargine 5 units was given. Staff did not follow physician orders and the incorrect dose was given. On 05/08/24 at 8:00 PM, MAR indicated Resident requested 6 units of Lispro. Staff administered 6 units of Lispro. Staff did not follow physician orders and the incorrect dose was given. On 05/08/24 at 9:07 PM, BG flowsheet indicated BG 142. On 05/13/24 at 10:03 PM, progress notes indicated R32 requested 3 units of Lispro and 5 units of Glargine for BG of 104. MAR indicated Lispro 3 units and Glargine 7 units given. Staff did not follow physician orders and the incorrect dose was given. On 05/15/24 at 11:04 PM, progress notes indicated R32 requested 4 units of Lispro and 5 units of Glargine for BG 125. MAR indicated Lispro 4 units and Glargine 5 units. Staff did not follow physician orders and the incorrect dose was given. On 05/18/24 at 11:58 PM, progress notes indicated R32 requested 3 units of Lispro and 5 units of Lantus for BS 100 at HS. MAR indicated Lispro 3 units and Glargine 5 units. Staff did not follow physician orders and the incorrect dose was given. On 05/19/24 at 8:00 PM, MAR indicated R32 requested 3 units of Lispro and was administered. At 8:43 PM, BG flowsheet indicates BG was 89. Staff did not follow physician orders and the incorrect dose was given. On 05/20/24 at 12:00 PM, MAR indicated 5 units of Lispro were given to R32. Staff did not follow physician orders and the incorrect dose was given. On 05/20/24 at 12:17 AM, progress notes indicated BG 89 and R32 requested 3 units of Lispro and 5 units of Glargine that was given by staff. Staff did not follow physician orders and the incorrect dose was given. On 05/21/24 at 10:14 PM, progress notes indicated BG 63, R32 requested 3 units of Lispro and 4 units of Glargine. Staff did not follow physician orders and the incorrect dose was given. Interviews: On 05/20/24 at 10:55 AM, Surveyor interviewed R32 and asked about insulin usage. R32 indicated that R32 is diabetic and sometimes staff give too much insulin at night and then R32 plummets in the night. R32 indicated that usually, the doctor will order insulin but always asks how R32 feels about the decision to change dosage or medication. R32 indicated, I am very aware of my blood sugars and how I feel when they are high or low. On 05/22/24 at 3:45 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for hypoglycemic episodes. DON B indicated that R32 is a brittle diabetic. DON B indicated all nurses are to follow the diabetic protocol and notify the physician of any changes or concerns with BGs. DON B indicated that nurses were educated on diabetic protocol back in September of 2023. DON B indicated that DON B has had verbal discussions with nursing staff regarding R32's BGs but nurses keep doing what nurses want to do. On 05/23/24 at 7:36 AM, Surveyor interviewed DON B and asked about the diabetic protocol and how it is applied to R32 when R32 is NPO. DON B indicated that nurses can still give the glucagon injection. Surveyor indicated to DON B that Surveyor reviewed MAR and MAR indicated that Glucagon was given several times with R32's BG 77, and 71 or over and Glucagon was given. DON B indicated that nurses are not following the diabetic protocol and the nurses should be. On 05/23/24 at 8:16 AM, Surveyor interviewed Licensed Practical Nurse (LPN) Q and asked what LPN Q's process is for checking blood sugars and deciding how much insulin is given to R32. LPN Q indicated that R32 has specific orders for set insulin but sometimes LPN Q steers more to how R32 feels. LPN Q asks R32 how R32 feels about insulin against BG result and if R32 doesn't feel comfortable with dosage then LPN Q gives as R32 requests. LPN Q just documents the result and the insulin given in R32's medical record. Surveyor asked LPN Q how LPN Q follows the diabetic protocol for when R32 is hypoglycemic. LPN Q indicated that R32 has never been hypoglycemic in LPN Q's care, but that LPN Q has had R32's BG be 63ish and LPN Q just observes how R32 feels at that time and bases the insulin usage with what R32 would like. On 05/23/24 at 10:07 AM, Surveyor interviewed RN AA and asked what RN AA's process is for checking blood glucose levels and deciding how much insulin is given to R32. RN AA indicated that after R32's medications were changed by the endocrinologist, RN AA gave insulin as the resident requested because RN AA felt R32 could make R32's own decisions. RN AA indicated that resident requests all the time to take less of Lispro or more depending on BG. RN AA indicates that RN AA administers insulin as resident feels that day. RN AA stated that R32 is a brittle diabetic and knows his BGs and how insulin affects R32. Surveyor asked if RN AA notifies the physician about low BGs or of the changes that resident is requesting. On 05/23/24 at 10:12 AM, Surveyor interviewed Endocrinologist BB and asked what expectations are for hypoglycemic or hyperglycemic episodes. Endocrinologist BB indicated that facility staff should be following the diabetic protocol within the facility. Surveyor asked Endocrinologist BB if Endocrinologist BB is ok with R32 making R32's own decisions about insulin usage and requesting other units to be given. Endocrinologist BB stated, Absolutely not as R32 is a brittle diabetic. Surveyor asked what the likelihood of outcome is to R32's organs or body with low blood glucose levels. Endocrinologist BB indicated that R32 has multiple health complications and that extreme fluctuations in blood glucose levels can cause worsening of complications and even death from low blood glucose levels.

Based on observations, interviews and record reviews, the facility did not provide diabetic care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being for 1 of 14 residents (R32) reviewed. Staff did not follow diabetic protocol to manage R32's type 1 diabetic hypoglycemia episodes by not providing glucagon when blood sugars were below 70 and re-checking low blood glucose (BG) levels within 15 minutes after intervention. Staff did not notify R32's physician when hypoglycemic and hyperglycemic episodes were occurring to change treatment. Staff did not monitor R32's vital signs, monitor and documenting signs and symptoms. Findings include: Surveyor reviewed the policy titled, Management of Hypoglycemia, which stated in part, .-Symptoms of Hypoglycemia #1. Signs of symptoms of hypoglycemia usually have a sudden onset and may include the following: Weakness, dizziness, fainting, pale, cool, moist skin, excessive perspiration, stupor, unconsciousness, and/or convulsions, and coma. -Management of Hypoglycemia #2. For level 1 hypoglycemia (<70mg/dL but >54 mg/dL): a. Give resident an oral form of rapidly absorbed glucose (15-20grams); b. Notify the provider immediately. c. Remain with the resident; d. Recheck blood glucose in 15 minutes: (3) If blood glucose remains <70 mg/dL repeat oral glucose and notify physician for further orders. #3. For level 2 hypoglycemia (<54 mg/dL): a. Administer glucagon (intranasal, intramuscular, or as provided); b. Notify the provider immediately; c. Remain with the resident; d. Place the resident in a comfortable and safe place (bed or chair); e. Monitor vital signs; and f. Recheck blood glucose in 15 minutes as above. -Documentation #1. Document the resident blood glucose before intervention. #2. Note blood glucose after each administration of rapid-acting glucose and the follow-up blood glucose. #3. Record the resident's level of consciousness before and after intervention. #4. Document provider instructions . R32 was admitted to the facility on [DATE] with diagnoses including in part, type 1 diabetes mellitus with diabetic chronic kidney disease and ketoacidosis without coma, metabolic encephalopathy, chronic kidney disease stage 4, vascular dementia unspecified severity with agitation, paroxysmal atrial fibrillation, gastrostomy status, and dysphagia oropharyngeal phase following cerebral infarction. R32's minimum data set (MDS) assessment, completed on 01/29/24, confirmed R32 scored 11/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. R32 has an activated power of attorney for healthcare decisions. R32 is dependent on staff for nutritional needs and R32 has gastrostomy (G)-tube placement. Review of R32's medical record identified the following physician orders stated in part, . -Monitor blood glucose levels before tube feeding and at bedtime . Review of R32's medical record identified the following notes: On 01/27/24 at 3:36 PM, BG flowsheet indicated that R32's BG was 50. Surveyor did not observe any progress notes indicating interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/01/24 at 7:07 PM, BG flowsheet indicated BG 67. Surveyor did not observe any progress notes indicating interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/04/24 at 4:41 AM, Medication Administration Record (MAR) indicated Glucagon 1mg given to R32. Surveyor did not observe any progress notes indicating the BG result and why R32 was treated with Glucagon. BG was not rechecked within 15 minutes after administration of Glucagon, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/05/24 at 12:46 AM, MAR indicates that Glucagon 1mg was given for a BG of 77. No progress notes were observed for reasoning giving glucagon outside the BG parameters with any re-check of BG within 15 minutes, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/05/24 at 6:11 AM, progress note indicated, . BG dropped to 71 and glucagon administered at 4:40 AM. Rechecked BG with result 332 at 6:30 AM. No progress notes were observed for reasoning giving glucagon outside the BG parameters. BG was not rechecked within 15 minutes after administration of Glucagon, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/06/24 at 4:22 AM, progress notes indicated: .0030-BG 66 OJ with 3 sugar packets given via GT. 0100 BG 60 gave bolus of Jevity. 0300 BG 217 . Surveyor did not observe any other progress notes indicating the re-checks of BG results within 15 minutes of giving Jevity, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/10/24 at 10:54 PM, MAR indicated that an 8:00 PM dose of Glargine was held. At this time BG was 64 and at 9:00 PM BG was 80. Surveyor did not observe any progress notes indicating interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/11/24 at 4:39 AM, progress note indicated, . BG result 64 at HS on 02/10/24, Glargine given . Surveyor did not observe any progress notes indicating interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/12/24 at 4:35 AM, progress note indicated, . BG result 56. Bolus of Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/12/24 at 9:18 PM, progress note indicated BG result 49. Insulin held. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/13/24 at 12:19 PM, MAR indicated BG flowsheet indicated BG 53. On 02/13/24 at 12:19 PM, MAR indicated BG flowsheet indicated rechecked BG with the result of 44. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 2/15/24 at 8:03 PM, BG flowsheet indicated BG 62. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 2/17/24 at 11:10 AM, BG flowsheet indicated BG 51. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 02/24/24 at 8:47 PM, BG flowsheet indicated BG 62. On 02/24/24 at 8:55 PM, progress note indicated BG 62 insulin Lispro was given 3 units. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Re-check of BG within 15 minutes was not observed in progress notes. Insulin was still administered with low BG, and signs and symptoms and vital signs were not monitored. Staff did not notify R32's physican of low blood glucose level. On 02/29/24 at 5:57 AM, progress notes indicated BG 54, bolus of Jevity was given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/01/24 at 8:00 PM, MAR indicated that nurse gave insulin Lispro and Glargine. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Re-check of blood glucose was not observed in progress notes. Insulin was still administered with low blood glucose level. At 8:51 PM, BG flowsheet indicated BG 61. Staff did not notify R32's physican of low blood glucose level. On 03/02/24 at 1:28 AM, progress notes indicated BG 61 bolus of Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/03/24 at 2:16 AM, Progress note indicated that on 03/02/24 at HS BG 30 and bolus Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/08/24 at 5:00 AM, progress notes indicated BG 50 and bolus given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/10/24 at 8:39 AM, BG flowsheet indicated BG 66. On 03/10/24 at 10:29 AM, progress note indicated resident had BG 66, resident did not want interventions just wanted feeding to start. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/14/24 at 12:38 PM, progress notes indicated BG 57 bolus Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/15/24 at 10:51 AM, progress notes indicated BG 67 bolus Jevity given. On 03/15/24 at 1:02 PM, progress notes indicated BG 67 bolus Jevity given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/16/24 at 11:20 AM, BG flowsheet indicated BG 62. On 03/16/24 at 1:22 PM, progress notes indicated blood sugar was very low, bolus was given, and monitored resident closely. Staff did not notify R32's physican of low blood glucose level. On 03/16/24 at 1:22 PM, progress notes indicated resident symptomatic with low blood sugars, clammy, skin cool. Gave bolus of Jevity. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/16/24 at 5:16 PM, BG flowsheet BG 388. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the elevated blood glucose level. On 03/16/24 at 9:30 PM, BG flowsheet BG 465. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the elevated blood glucose level. On 03/24/24 at 4:11 AM, progress notes indicated resident complaint of blood sugar low. BG was 66 and bolus Jevity started. At 8:00 AM, MAR indicates that the nurse administered insulin Lispro and Glargine. Staff did not notify R32's physican of low blood glucose level. On 03/24/24 at 4:50 PM, BG flowsheet indicated BG 63. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 03/24/24 at 8:12 PM, BG flowsheet indicated that BG HIGH. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the elevated blood glucose level. On 3/25/24 at 4:37 PM, BG flowsheet indicated BG 60. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 3/29/24 at 3:43 PM, BG flowsheet indicated BG 57 Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 04/3/24 at 10:16 PM, BG flowsheet indicated BG 423. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the eleveated blood glucose level. On 04/4/24 at 7:17 AM, BG flowsheet indicated BG 347. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the elevated blood glucose level. On 04/04/24 at 11:29 AM, BG flowsheet indicated BG 364. Surveyor did not observe any progress notes indicating any other interventions to treat the high blood glucose level. Re-check of blood glucose was not observed in progress notes, and no monitoring of signs and symptoms, and vital signs. Staff did not notify R32's physican of the elevated blood glucose level. On 4/8/24 at 5:12 PM, BG flowsheet indicated BG 62. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 4/9/24 at 3:38 PM, Blood Sugar flowsheet indicated BG 67. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 4/19/24 at 5:02 AM, BG flowsheet indicated BG 54. On 04/19/24 at 5:03 AM, Progress note indicated the resident called the light on for a warning of low blood sugar. BG was 54, and 60 ml bolus of Jevity was given. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 4/20/24 at 8:06 PM, BG flowsheet indicated BG 68. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 4/21/24 at 3:54 PM, BG flowsheet indicated BG 52. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. Glucagon was not administered for less than 54 BG levels. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 04/24/24 at 4:11 AM, progress notes indicated BG result 66. Gave bolus Jevity. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. On 04/30/24 at 10:04 PM, progress notes indicated at 4:00 PM BG was 67. Surveyor did not observe any progress notes indicating any other interventions to treat the low blood glucose level. BG was not rechecked within 15 minutes after initial low BG, and did not monitor signs and symptoms, and vital signs. Staff did not notify R32's physican of low blood glucose level. Interviews: On 05/20/24 at 10:55 AM, Surveyor interviewed R32 and asked about insulin usage. R32 indicated that R32 is diabetic and sometimes staff give too much insulin at night and then R32 plummets in the night. R32 indicated that usually, the doctor will order insulin but always asks how R32 feels about the decision to change dosage or medication. R32 indicated, I am very aware of my blood sugars and how I feel when they are high or low. Lately, I have been low a lot. This morning I rang for staff to come in as I was low, and it took them 30 minutes to come in. On 05/23/24 at 8:16 AM, Surveyor interviewed Licensed Practical Nurse (LPN) Q and asked what LPN Q's process is for checking blood sugars for R32. LPN Q just documents the result and the insulin given in R32's medical record. Surveyor asked LPN Q how LPN Q follows the diabetic protocol for when R32 is hypoglycemic. LPN Q indicated that R32 has never been hypoglycemic in LPN Q's care, but that LPN Q has had R32's BG be 63ish and LPN Q just observes how R32 feels at that time and bases the insulin usage with what R32 would like. On 05/22/24 at 3:45 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for hypoglycemic episodes. DON B indicated that R32 is a brittle diabetic. DON B indicated that nurses were educated on diabetic protocol back in September of 2023. DON B indicated that DON B has had verbal discussions with nursing staff regarding R32's BG's but nurses keep doing what nurses want to do. On 05/23/24 at 10:12 AM, Surveyor interviewed Endocrinologist BB and asked what expectations are for hypoglycemic or hyperglycemic episodes. Endocrinologist BB indicated that facility staff should be following the diabetic protocol within the facility. Surveyor asked Endocrinologist BB if he wanted to be contacted with BG lower than 70 and Endocrinologist BB indicated yes, Endocrinologist BB wants to be notified. Endocrinologist BB indicated that Endocrinologist BB is on call 24/7 and staff should be calling at all hours with BGs lower than 70. Surveyor asked Endocrinologist BB if Endocrinologist BB is ok with R32 making R32's own decisions about insulin usage and requesting other units to be given. Endocrinologist BB stated, Absolutely not as R32 is a brittle diabetic. Surveyor asked what the likelihood of outcome is to R32's organs or body with low blood glucose levels. Endocrinologist BB indicated that R32 has multiple health complications and that extreme fluctuations in blood glucose levels can cause worsening of complications and even death from low blood glucose levels.

Based on record review and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 50 residents who reside in the facility. This is evidenced by: On 05/22/24 at 9:30 AM, Surveyor completed a record review for the month of May related to daily staff postings and noticed there were certain weekends where RN coverage hours were less than 8 hours. The dates of 05/04/24, 05/05/24, 05/18/24, and 05/19/24 all showed less than 8 hours of RN coverage. On 05/22/24 at 9:45 AM, Surveyor completed a record review of the time punches for the days of 05/04/24, 05/05/24, 05/18/24, and 05/19/24 and confirmed there were less than eight hours of coverage on those days. -On 05/04/24, only 4.5 hours were covered by a Registered Nurse. -On 05/05/24, only 4.5 hours were covered by a Registered Nurse. -On 05/18/24, only 4.5 hours were covered by a Registered Nurse. -On 05/19/24, there was no coverage from a Registered Nurse. On 05/22/24 at 1:25 PM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding the lower hours of RN coverage. They said the procedure for coving RNs is to call down the list of available RNs and if there is no one else to cover DON B or the Infection Preventionist will come in and cover the hours. Surveyor asked about the specific dates that show less than eight hours of coverage. DON B said yes they did come in, but they must not have worked for the full eight hours. NHA A confirmed they had no coverage on the date of 05/19/24 and they did not have eight hours of RN coverage on the dates listed.

Based on observation, staff interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. This had the potential to affect 48 of 50 residents within the facility that took nourishment from the kitchen. Opened milk in the refrigerator not labeled with open date. Staff touching ready to eat foods with contaminated gloves during food service. Staff did not perform hand hygiene between glove changes during food service. Findings: Milk not labeled: Facility policy titled, Infection Control, Sanitation, Safety the most current revision, states in part: .E. Storage Refrigerators/Freezers .7. Food must be covered and dated when stored . 10. Commercial products must be labeled as to date of initial opening and will be discarded per manufacturer's expiration date. On 05/20/24 at 9:06 AM, during initial tour of the kitchen, Surveyor noted that a gallon of milk did not have a date opened written on the container. Surveyor interviewed Dietary Manager (DM) L and asked, What date was this opened? DM L took the opened gallon of milk and replied, Thank you. Surveyor found a second gallon of milk in the refrigerator opened without a date and asked DM L, What date was this opened? DM L took the second gallon of milk from Surveyor and replied, Thank you again. Hand Hygiene/Touching ready to eat foods: The Wisconsin Food Code states in part: .3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility policy titled, Handwashing/Hand Hygiene revised August 2019, states in part: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: .m. After removing gloves .Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. On 05/21/24 at 11:31 AM, Surveyor observed [NAME] M serving the hot food service. [NAME] M had single use gloves on and touching multiple surfaces including ladles, covers for hot food, toaster, plates, spoons to plate food and bowls. [NAME] M removed gloves and put on new gloves; no hand hygiene was performed. [NAME] M had taken bread out of the bread bag after opening the twist tie that was securing the closed bag. The bread was picked up by [NAME] M with contaminated gloves and placed into the toaster. The toast was removed from toaster with same gloved hands and buttered the toast, plated the toast, and gave the staff to serve to the resident. [NAME] M removed gloves, no hand hygiene performed, and put on new gloves. [NAME] M returned to plating hot food and serving the plates to staff to serve the residents. Cook M took burned toast out of the toaster and placed onto a four wheeled serving cart. [NAME] M took bread from the bread bag with the same gloves that were used while serving. [NAME] M took the bread, made a meatball sandwich with the same contaminated gloves, and cut the meatball sandwich into four pieces. [NAME] M plated the sandwich and served to resident. Cook M then popped up the toaster, grabbed the toast with same gloved hands, buttered it, cut in half and served to the resident. Surveyor observed [NAME] M change gloves two additional times without any hand hygiene before finishing serving hot food items to residents. On 05/21/24 at 12:20 PM, Surveyor interviewed [NAME] M and asked, What is the process when wearing gloves and touching multiple potentially contaminated surfaces in the hot service area and touching ready to eat food like bread? [NAME] M replied, When I took the twist tie off to get the bread out I should have changed my gloves. Surveyor asked [NAME] M, When should hand hygiene be performed in regard to changing gloves? [NAME] M replied, As long as I am just working in this area I can just change the gloves and I don't have to wash my hands. On 05/21/24 at 12:35 PM, Surveyor interviewed DM L regarding observations made during hot food service. Surveyor asked DM, What should [Cook M] have done if working with contaminated gloves? DM L replied, [Cook M] should have changed gloves after untwisting the tie on the bread bag to get the bread out. Surveyor asked DM L, With glove changes is it ok to change gloves without hand hygiene? DM L replied, If staff are just working the hot service area, it is ok to change gloves without performing any hand hygiene. On 05/22/24 at 9:56 AM, Surveyor interviewed Director of Nursing (DON) B and asked, When in the kitchen serving food what is the expectation for hand hygiene with glove use? DON B replied, When they change gloves they should perform hand hygiene between glove changes. On 05/22/24 at 4:03 PM, Surveyor informed DON B an observation was made of [NAME] M touching multiple potentially contaminated surfaces then touching ready to eat foods. Surveyor asked DON B what the expectation in this scenario is. DON B replied, You should remove gloves and perform hand hygiene and put on new gloves before touching the toast.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 49 residents (R). The facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. Staff provided high-contact care to residents on Enhanced Barrier Precautions (EBP) without wearing proper Personal Protective Equipment (PPE). (R32 and R17). The facility is not tracking the type of symptoms for all staff and resident infections. The facility is not providing alternative testing to rule out influenza or RSV cases when residents and staff become sick. Findings include: Facility policy and procedure entitled: Enhanced Barrier Precautions, dated 04/01/24, stated in part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .Gloves and gowns are applied prior to performing the high contact resident care activity .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing) . Example 1 On 05/21/24 at 8:57 AM, Surveyor interviewed Infection Preventionist (IP) X and asked about the facility's water management plan and policy for Legionella. IP X indicated that IP X keeps track of [NAME] water filter audits daily and has logs. IP X handed Surveyor a binder that had logs from April 2023- April 2024 that indicated [NAME] water filters maintenance was conducted every day and tracked on monthly sheets. IP X indicated that IP X would need to go get the water management plan/policy from Maintenance Director W. On 05/21/24 at 10:08 AM, Nursing Home Administrator (NHA) A gave Surveyor a water management policy. Surveyor reviewed policy and did not find detailed report on the flow system diagram for water management, audits, logs, or ways to decrease the transmission of Legionella. On 05/21/24 at 3:02 PM, Surveyor interviewed NHA A and Maintenance Director W and asked about hot spots, stagnation, and dead leg areas on the diagram. NHA A indicated the facility has not implemented hot spots, stagnation, and dead-leg areas on the detailed policy/plan or the flow system diagram. NHA A asked Maintenance Director W if audits and dead legs were being conducted in the facility's Intel software or anywhere else. Maintenance Director W indicated that Maintenance Director W is not documenting audits in Intel or paper for audits of dead legs, flushing and that auditing documentation needs to be done. Surveyor observed no documentation or plan to prevent the transmission of Legionella through the facility policy and flow system diagram. Example 2 On 05/21/24 at 7:50 AM, Surveyor observed Certified Nursing Assistant (CNA) D and CNA E enter R17's room to assist R17 get washed up and dressed and transferred to a wheelchair. Surveyor observed a sign outside R17's room that stated Enhanced Barrier Precautions with a PPE cart under the sign. CNA D and CNA E did not put on gowns or gloves to provide cares for R17. At 8:00 AM, Surveyor observed CNA E bring R17 to the dining room for breakfast. Surveyor observed CNA D making R17's bed. Surveyor asked CNA D which resident in this room was on EBPs. CNA D was not sure and went to the nurse's station to ask. CNA D came back and informed Surveyor R17 was on EBP for a gastrostomy tube. CNA D stated they should have put on a gown and gloves to care for R17 but forgot. On 05/21/24 at 8:24 AM, Surveyor interviewed Director of Nursing (DON) B and explained observation of CNAs D and E providing morning cares and a lift transfer for R17 without gown or gloves on. Surveyor informed DON B that CNA D was not sure which resident in R17's room required EBP when Surveyor asked. DON B stated they should have known that and should have put on a gown and gloves to provide personal cares for R17. Example 3 On 05/20/24 at 9:24 AM, Surveyor observed PPE located outside R32's room. Surveyor interviewed CNA Z and asked what precautions R32 was on. CNA Z indicated that R32 is on EBP for tube feeding and wound dressing change to foot. On 05/20/24 at 11:32 AM, Surveyor observed LPN Y enter R32's room without PPE on in EBP room. LPN Y sanitized hands, applied gloves, and checked R32's Blood Glucose. Surveyor observed LPN Y connect R32's priming tube to start the tube feeding infusion. Surveyor did not observe LPN Y wear proper PPE for R32's tube feeding. On 05/20/24 at 12:45 PM, Surveyor interviewed LPN Y and asked about the process for utilizing PPE with R32's EBP room. LPN Y indicated during tube feeding and dressing change LPN Y always wears full PPE. LPN Y indicated LPN Y realized that she did not wear PPE. LPN Y indicated it is not ok to not wear PPE in an EBP room unless LPN Y is providing minimal care that doesn't require touching R32. Example 4 On 05/21/24 at 11:01 AM, Surveyor received infection surveillance from the COVID-19 outbreak starting 08/28/23 to 12/26/23. Surveyor did not observe the type and time of symptoms that started for all positive staff and residents starting 08/28/23 to 12/26/23. Surveyor received infection surveillance from the COVID-19 outbreak starting 01/01/24 to 05/02/24. Surveyor did not observe the type and time of symptoms that started for all positive staff and residents between 01/01/24 to 05/02/24. Surveyor did not observe alternative testing when COVID-19 testing was negative to rule out influenza or RSV for staff and residents. On 05/21/24 at 11:35 AM, Surveyor interviewed IP X and asked about how IP X tracks the onset of symptoms and how IP X tracks when staff members are fever free, or when symptoms are decreasing so staff know when to be allowed back to work. IP X indicated that IP X is not tracking on surveillance logs the exact type of onset of symptoms or decrease in symptoms for when staff can return to work. IP X indicated that all staff call into charge nurse if IP X is not in building and IP X follows up with sick staff member once IP X is back in the building. IP X indicated that unfortunately since IP X is only at the facility 3 times a week there was a recent staff member, CNA T, who came to work the next day after vomiting. The charge nurse had not given good instructions for staff members to stay home. IP X indicated that once IP X got to the facility IP X tried touching base with CNA T who was already at the facility after vomiting the day before. CNA T did not communicate what occurred and how CNA T was feeling before returning to work. IP X indicated during the COVID-19 outbreak the charge nurse on duty would call IP X on off-hours. IP X also indicated that IP X is not testing for influenza or RSV when staff are sick with possible symptoms because IP X didn't feel like IP X needed to. Surveyor asked IP X how staff know when residents can come off precautions/quarantine since IP X is not tracking the onset of symptom type. IP X indicated the nurses just know this. Surveyor asked IP X how the staff knew this. IP X indicated that since IP X is only at the facility 3 times a week, IP X had set up a document labeled Appendix A from the CDC that describes all infections and quarantine status, and the staff follow the guidelines located near the isolation carts when they need it. On 05/21/24 at 12:41 PM, Surveyor interviewed CNA T and asked about CNA T's process for when CNA T becomes sick and has a shift to work. CNA T indicated that usually CNA T will call the charge nurse at work and let them know that CNA T is sick. CNA T indicated then after when CNA T feels better, then CNA T can come back to work. Surveyor asked CNA T about the recent day CNA T called off from work due to vomiting. CNA T indicated that she felt better the next day and hadn't vomited but only a couple of times the day before. CNA T indicated that CNA T had talked with IP X before returning to work, and IP X texted CNA T and she could come back to work. Surveyor did not observe any documentation that IP X had talked with CNA T about returning to work nor any education on symptoms and not coming to work infectious. 40181

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 5 of 8 staff reviewed. This had the potential to affect all residents. Findings include: Facility policy and procedure entitled, Abuse Prohibition, last revised 11/28/16, stated in part, .Once an offer of employment has been made, the facility will submit a request to obtain a criminal history from the Department of Justice (DOJ). An electronic search will be conducted by the Department of Health and Family Services (DHFS) to check on the prospective employee's status in the following areas: the Nurse Aide Directory, Caregiver Finding of Abuse or Neglect of a client; or Misappropriation of a Client's Property, Denials or Revocations of Operating Licenses for Adult Programs, and any Rehabilitation Review Findings. In addition the Department of Regulation and Licensing (DRL) will also conduct an electronic search as to the status of Professional Credential(s), License(s), or Certificate(s) .Background Information Disclosure forms must be completed, and background checks shall be repeated every four years for employees who have access to residents . The policy and procedure also stated in part, .If a prospective employee is not a resident of Wisconsin, or at any time within the last 3 years preceding the date of the search that person has not been a resident of Wisconsin, the facility will make a good faith effort to obtain information from the state the person resided in, search information that is equivalent to the criminal history information specified in par. (a) 1.A or HFS 12.21 . On 05/22/24, Surveyor reviewed the caregiver background check information for eight staff members and found the following information. Dietary Aide (DA) G was hired on 07/27/22 and completed a Background Information Disclosure (BID) on 07/15/22. The Department of Justice (DOJ) Response and Integrated Background Information System (IBIS) Letter were both dated 10/06/24. On 05/22/24 at 4:50 PM, Surveyor interviewed Human Resources (HR) N and asked why the Caregiver Background Check was not completed for DA G until over two months after date of hire. HR N stated that employee was hired before HR N started working in this position and HR N did not know the reason for the delay. Housekeeper (HK) H was hired on 12/12/22 and completed a BID on 11/18/22. The BID identified HK H resided in Minnesota. The DOJ Response and IBIS Letter were both from the state of Wisconsin. On 05/22/24 at 4:50 PM, Surveyor interviewed HR N and asked if a Minnesota background check was completed for HK H prior to starting employment. HR N reviewed HK H's personnel file and did not locate a Minnesota or Federal background check. HR N stated this employee was hired before HR N started working in this position and HR N was unsure why there was no Minnesota background check completed. Environmental Services Director (ESD) I was hired on 08/02/22 and completed a Background Information Disclosure (BID) on 07/21/22. The Department of Justice (DOJ) Response and Integrated Background Information System (IBIS) Letter were both dated 08/16/22. This was 14 days after ESD I began employment. On 05/22/24 at 4:50 PM, Surveyor interviewed HR N and asked why the Caregiver Background Check was not completed for ESD I until 14 days after date of hire. HR N stated that employee was hired before HR N started working in this position and HR N did not know the reason for the delay. Certified Nursing Assistant (CNA) J was hired on 08/05/19. The BID was completed on 05/18/24. The DOJ Response and the IBIS Letter were both dated 05/22/24, which was greater than four years since the date of hire. On 05/22/24 at 4:50 PM, Surveyor interviewed HR N and asked if CNA J had a caregiver background check completed at time of hire. HR N showed Surveyor CNA J's personnel file and confirmed a caregiver background check was done at time of hire in 2019. Surveyor asked if the current caregiver background check, dated 05/22/24, was overdue. HR N confirmed CNA J's caregiver background check was overdue and should have been done last August. CNA K was hired on 06/21/21. The BID was completed on 06/04/21. The DOJ Response and IBIS Letter were both dated 07/02/21, which was 11 days after CNA K began employment. On 05/22/24 at 4:50 PM, Surveyor interviewed HR N and asked why the caregiver background check was not completed until 11 days after CNA K started employment. HR N stated that employee was hired before HR N started working in this position and HR N did not know the reason for the delay. On 05/22/24 at 5:10 PM, Surveyor interviewed Nursing Home Administrator (NHA) A, who stated when HR N was hired last fall they identified the caregiver background checks were out of compliance and they have been working on getting them into 100% compliance since that time.

Based on observation, interview and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes his quality of life. Resident (R43) was not provided privacy when lying in bed not fully clothed and covered while being visible from the hallway. For 1 of 13 sampled residents (R43). Findings include: R43 was admitted to the facility on [DATE] following a stroke. R43 was not able to speak but was able to nod head to yes and no questions. R43 had hemiplegia (paralysis) and hemiparesis (weakness) on the right side of the body following the stroke and was dependent on staff for all cares. R43's most recent Minimum Data Set (MDS) assessment, dated 4/23/24, identified R43 showed signs of mild depression with a PHQ-9 (depression scale) score of 09. On 05/20/24 at 11:03 AM, Surveyor observed R43 lying in bed in resident room. R43 was completely uncovered and only wearing an incontinent brief. The door to the room was open with no privacy curtain pulled and R43 was visible to everyone walking in the hallway. Surveyor also observed a urine drainage bag hanging on the side of the bed and half full of urine. The bag was not covered with a dignity cover. At 11:14 AM, Surveyor observed Licensed Practical Nurse (LPN) C walk past R43's room and look in but did not enter the room to cover R43 or close the privacy curtain. From 11:14 AM until 1:00 PM, Surveyor observed multiple staff members walk past R43's room, but no one went in to cover R43 or pull the privacy curtain, and R43 remained visible to the hallway wearing just an incontinent brief. On 05/20/24 at 2:26 PM, Surveyor observed R43 lying uncovered in bed wearing just a brief. The door was open, the privacy curtain was not pulled, and R43 was visible to everyone walking past the room. Surveyor interviewed LPN C and asked if R43 was able to communicate. LPN C stated R43 could nod head to yes/no questions and the speech therapist made a speech tool with words on it for staff or R43 to point to aid in communication. Surveyor asked if R43 always laid in bed wearing just a brief and no cover. LPN C stated R43 was often hot and pulled off any covers that staff put over R43. Surveyor asked if they always left the door open or privacy curtain open so R43 was visible from the hall. LPN C said they always pulled the curtain when R43 was uncovered but did not know why it was not pulled at that time. LPN C walked away and did not go into R43's room to pull the privacy curtain. On 05/21/24 at 6:37 AM, Surveyor observed R43 lying in bed with just an incontinent brief on. The door to R43's room was open, and the privacy curtain was pulled back so R43 was visible from the doorway. Surveyor also observed a urine drainage bag hanging on the side of the bed, visible from the hall, with no dignity cover over it. Surveyor observed maintenance staff, Certified Nursing Assistant (CNA) E and LPN C outside R43's doorway in the hall. No staff entered R43's room to close the privacy curtain or cover R43. On 05/21/24 at 8:40 AM, Surveyor observed R43 lying in bed, uncovered wearing just an incontinent brief. The urine drainage bag was hanging uncovered on the side of bed. R43 was visible from the hallway. The privacy curtain was not pulled, and the room door was not closed. Surveyor observed multiple staff members walk past R43's room and no one went in to cover R43 or pull the privacy curtain. On 05/21/24 at 2:39 PM, Surveyor interviewed R43 and asked if R43 was okay with the staff leaving the privacy curtain opened or the door opened when R43 was lying in bed uncovered with just a brief on. R43 very clearly shook head back and forth indicating no. On 05/22/24 at 7:01 AM, Surveyor observed R43 asleep in bed with nothing on but an incontinent brief. The blanket on the bed was covering R43 from feet to knees with the rest of R43's body exposed. The door was open, and the privacy curtain was open and R43 was visible from the hallway. There was a urine drainage bag hanging on the side of the bed with urine in it and no dignity cover. All of this was visible from the hallway. Surveyor observed multiple staff members walk by R43's room and no one entered the room to pull the privacy curtain or close the door. On 05/22/24 at 9:43 AM, Surveyor interviewed Director of Nursing (DON) B and explained multiple observations over the past three days of R43 lying in bed completely uncovered except for an incontinent brief with the privacy curtain open and door open. R43 was visible from the hallway. Surveyor observed multiple staff walked by the room and did not go in to cover R43 or close the privacy curtain. Surveyor asked R43 if R43 was okay with being visible from the hallway while lying in bed with just a brief on. Surveyor explained to DON B that R43 shook head back and forth to indicate no. Surveyor asked DON B if that was a concern for R43's dignity. DON B stated yes, that was a dignity concern and staff should be more attentive to R43's privacy and dignity when lying in bed uncovered.

Based on record review, observation and interview, the facility did not implement a comprehensive individualized safety care plan to meet the needs of 1 of 14 residents (R). R34. This is evidenced by: R34 was admitted to the facility on [DATE] with diagnoses that included in part Alzheimer's disease, dementia, and cognitive communication deficit. On 03/24/24, a male resident was found in R34's room with his pants down urinating. One of the interventions from this incident was a stop sign barrier added to R34's entrance to her room to help prevent other residents from wandering into R34's room. R34's care plan, dated 03/24/24, with a target date of 05/29/24, states: .[R34] has a stop sign rope across doorway in room. Stop sign will prevent others from entering her room due to wondering behaviors. Intervention: Have stop sign on [R34]'s door if she is in her room at night while sleeping . R34's progress note on 03/30/24 stated, [R34] expressed concern about men going into her room. Nurse reassured resident that we would be monitoring and that we would try and avoid such an incident. She was understanding of this. When resident was in room stop sign was placed across doorway. R34's progress note on 03/31/24 stated, [R34] did not report any fears to nurse today. She has stop sign across doorway while in room to prevent entry into her room. R34's progress note on 04/01/24 stated, Stop sign to door remains in place. [R34] does not appear afraid. [R34] is in bed resting. Observations: On 05/20/24 at 11:16 AM, Surveyor observed no stop sign barrier to R34's door. R34 was lying in bed with eyes closed. No stop sign barrier found in R34's room. On 05/21/24 at 7:00 AM, Surveyor observed no stop sign barrier across R34's door. R34 was asleep in bed with door open, no staff in the room. No stop sign barrier found in R34's room. On 05/22/24 at 6:54 AM, Surveyor observed R34's room had a stop sign barrier that was hanging off to the side of the door, not across the doorway. R34 was asleep in bed, no staff in the room. R34's door was halfway open. On 05/23/24 at 6:57 AM, Surveyor observed R34's room had a stop sign barrier that was hanging off to the side of the door, not across doorway. R34's door was open. R34 was asleep lying in her bed, no staff in room. Based on the interventions set in place for R34, the stop sign barrier should have been utilized and hung across the doorway to prevent other residents from wandering into R34's room. Interviews: On 05/21/24 at 12:37 PM, Surveyor interviewed Certified Nursing Assistant (CNA) E and asked where the stop sign barrier was. CNA E said R34 had it on her door for the first few weeks of the incident, but not seen since. CNA E said she was not sure where it was. On 05/21/24 at 12:39 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C and asked about R34's stop sign barrier. LPN C said R34 had been known to take it down and stash in her room. LPN C said the sign had magnets that attached to the doorway and was easy to remove. Surveyor asked LPN C to show where the stop sign was. LPN C went to R34's room to look but could not find it. On 05/21/24 at 12:58 PM, Surveyor interviewed LPN O and asked if R34 needed a stop sign barrier. LPN O said yes. We use the stop sign to prevent other residents from wandering into a resident's room. Surveyor asked LPN O where R34's stop sign was. LPN O went to R34's room and looked for the stop sign. LPN O said she does not see the stop sign barrier in R34's room. LPN O said she will go to the Director of Nursing (DON) and ask if the care plan was changed or where the stop sign was. On 05/21/24 at 2:50 PM, Surveyor interviewed CNA R and asked if R34 has had the stop sign barrier across the doorway at night. CNA R said no, the stop sign barrier had not been up for a while since R34 has been moved to this hall (300 hall). On 05/22/24 at 3:22 PM, Surveyor asked DON B if R34's stop sign barrier intervention put into place since the incident on 03/24/24 was still active. DON B said yes it was. Surveyor asked DON B if R34 had the stop sign barrier up before Surveyor asked about it. DON B said no, not sure if the stop sign barrier was not moved over during the room change. DON B said R34 should have the stop sign barrier across the doorway.

Based on record review and interview, the facility did not review and revise the comprehensive toileting care plan for 1 of 14 sampled residents, Resident (R)7. This is evidenced by: The facility policy, entitled Incontinence, Catheters, & Urinary Tract Infections, last reviewed in January 2017, states in part: 7. The following items may be addressed in the care plan according to individualized resident needs: . interventions specific enough to guide the provision of services and treatment that are also dependent on resident choices and preference. R7 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified osteoarthritis, unspecified site, anxiety disorder, unspecified, pain in unspecified hip, and constipation, unspecified. R7's Minimum Data Set (MDS) assessment, dated 03/21/24, indicated that resident is always incontinent of bowel and bladder. On 05/20/24 at 10:42 AM, Surveyor observed the resident being transferred to bed using a Hoyer lift. After being transferred to bed Certified Nursing Assistant (CNA) T talked to the resident about having a bowel movement while in bed and that they would be back in 20 minutes to see if they had made one. R7 was expected to defecate in bed as a way to toilet the resident. On 05/20/24 at 11:00 AM, Surveyor completed record review of the care plan dated 03/27/24 indicated: approach . provide incontinence care after each incontinent episode . report any signs of skin breakdown . apply moisture barrier . The care plan was not updated to include R7's preferred method of toileting. On 05/21/24 at 9:36 AM, Surveyor interviewed CNA T as to why they don't use other modes of toileting. CNA T said they had tried other modes like the commode, toilet, and a bed pan, but those interventions were too painful for R7. They found that using the Depends brief and making sure to check and change as soon as possible has been the best for the resident. When they had tried to use the bed pan R7 would move and wiggle in pain and the bed pan was not working. Surveyor asked where the information was related to how R7 was to be toileted. CNA T said they just knew it from experience and working here. This has been the system for R7 for a while and they check often. On 05/21/24 at 12:54 PM, Surveyor interviewed R7 regarding the current toileting plan. R7 said they did not have any concerns. Surveyor asked if they had tried other methods of toileting like the commode or bedpan, R7 said yes, they did, but they were too painful for her back. R7 indicated the current procedure was the least painful and they have no concerns related to toileting. On 05/21/24 at 2:07 PM, Surveyor interviewed Director of Nursing (DON) B regarding R7's toileting procedure. DON B said that a while ago R7 came back from a hospital stay and started going downhill. Previously they were able to use other options for toileting but then they became too painful for the resident. R7 prefers to lay on their left side and use their Depends. Surveyor asked if the care plan should reflect the mode of toileting. DON B said yes, they would expect the care plan to reflect the way R7 prefers to be toileted, and they will change that right away. On 05/22/24, Surveyor verified with therapy services that R7 had attempted some therapy for the use of other toileting methods, but R7 chose to stop all therapies and elected for palliative care. Therapy notes revealed a progress note related to this decision to stop all therapy and pursue palliative care.

Based on observation, interview and record review, the facility did not ensure activities of daily living (ADLs) of meal set-up, repositioning, and incontinence cares were provided for 1 of 15 residents (R21) reviewed. This is evidenced by: R21 was admitted to the facility on [DATE], with diagnoses including alcohol induced persisting dementia, malignant neoplasm of esophagus, Wernicke's encephalopathy, aphasia following cerebral infarction, and depressive disorder. R21's minimum data set (MDS) assessment, completed on 04/04/24, confirmed R21 is incontinent of urine and frequently incontinent of bowels. R21 requires supervision assistance with eating. R21 is dependent on staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R21's care plan was initiated on 03/28/24, and included the following: BED MOBILITY: -The resident requires assist of one staff to turn and reposition in bed. -Turn/reposition as needed. EATING: -Supervision/Set-up. -Provide liquids/food as needed. PERSONAL HYGIENE: -The resident requires assistance of one with personal hygiene. DRESSING: -The resident requires assist of one with dressing upper and lower body dressing. TOILET USE -The resident requires assistance of one with utilizing bed pan/urinal for toileting. -Provide peri care as needed. TRANSFER -The resident requires is totally dependent on two staff for transferring. -The resident requires mechanical lift Hoyer lift with two staff assistance for transfers. INCONTINENT: -Provide incontinence care with each incontinence episode. POTENTIAL FOR NUTRITIONAL RISK: -Puree texture diet with thin liquids. -Elevate head of bed or position upright before feeding. -Observe closely for signs of choking and/or aspiration. -Provide adequate time for feeding self, assist as needed. On 05/20/24 at 9:12 AM, Surveyor observed Certified Nursing Assistant (CNA) Z deliver R21's breakfast tray to room. R21 tried grabbing a glass of milk and could not reach it. R21 was lying in bed unable to reach for items on bedside table. On 05/20/24 at 9:55 AM, Surveyor entered R21's room. Breakfast tray was sitting in front of R21. R21 only stated, Hi, when Surveyor introduced self. R21 could not speak clearly or offer any information to Surveyor. Surveyor observed R21 looked pale and fragile lying on back in bed. On 05/20/24 at 10:22 AM, Surveyor entered R21's room and observed breakfast tray sitting on bedside table not touched. R21 was still lying in bed on back, sheet over top, foot crossed, and fall mat in place. R21 was unable to reach for items on bedside table as bedside table crooked near bed. On 05/20/24 at 11:56 AM, Surveyor observed breakfast tray still on bedside and pushed away, R21 had kicked covers off, not positioned well in bed, and trying to say something but couldn't get anything out. Surveyor did not observe staff enter R21's room to assist R21. On 05/20/24 at 12:01 PM, Surveyor observed CNA Z enter R21's room. CNA Z did not check on R21 but went straight to roommate's bed and offered to assist ambulate down hall to lunch. Surveyor observed breakfast tray still in place at R21's bedside table. Surveyor observed CNA Z exit R21's room and did not check on R21. On 05/20/24 at 12:43 PM, Surveyor observed Licensed Practical Nurse (LPN) O enter R21's room to assist R21's roommate. Surveyor did not observe LPN O speak with R21 or check on R21. CNA Z stood at door and asked LPN O if R21 was a feeder. LPN O indicated R21 is an assist to feed but has not been eating good and that staff should be in room to assist R21. CNA Z stated, Ok, and walked down the hallway. On 05/20/24 at 12:58 PM, Surveyor observed CNA Z enter R21's room and asked R21 if R21 wanted lunch. R21 stated, Yes. CNA Z took breakfast tray out of room. Surveyor observed breakfast tray not touched with all food still on food tray. Surveyor observed CNA Z bring lunch tray in to R21's room and set the bedside table up closer to R21. CNA Z exited the room and walked down the hallway. Surveyor did not observe R21 try to eat anything. Surveyor did not see R21 move much at all. On 05/20/24 at 1:45 PM, Surveyor observed R21 lying in bed with lunch tray in front of R21 with no food eaten. Surveyor did not observe staff nearby or go into R21's room again. Surveyor did not observe meal assistance, repositioning, or incontinent care performed between 9:20 AM and 1:45 PM. On 05/21/24 at 1:50 PM, Surveyor interviewed CNA Z and asked about how often R21 is repositioned or provided incontinent care. CNA Z indicated that CNAs go in every so often and check on R21 but that R21 is on hospice. CNA Z indicated that CNA Z has been down the other halls and was just helping pass trays today so CNA Z was unsure when someone else checked on R21. On 05/22/24 at 8:54 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for providing R21 repositioning and incontinent cares. DON B indicated that expectation for staff to provide repositioning and incontinent care should occur every two hours and as needed. Surveyor indicated that Surveyor did not observe repositioning or incontinent care from 9:20 AM-1:45 PM. DON B indicated expectation is that R21 should have been repositioned and provided incontinent care every two hours and as needed. Surveyor asked DON B expectation of R21 receiving assistance with breakfast meal and lunch meal. DON B indicated sometimes R21 will say if he wants breakfast or lunch and most of the time staff starts the first bite of food and then staff will drop the tray off and leave to pass other trays. Surveyor indicated to DON B that according to record review R21 has an order for dysphagia diet and care plan indicates that R21 is supposed to have assistance/supervision during meals to prevent aspiration. DON B indicated that staff are supposed to stay with R21 the entire time for meals if eating in room. DON B indicated that usually R21 comes to dining room to eat but that the last few days R21 was having behaviors and staff were keeping R21 in room instead.

Based on interviews and record reviews, the facility did not update the care plan with nor provide new interventions to promote the healing of pressure injuries according to current standards of practice for 1 of 1 residents (R) reviewed for pressure injuries (R4.) On 08/12/22, R4 had a significant change in condition due to a broken arm resulting in needing additional assistance with cares and mobility. The facility did not implement new interventions for R4's decreased mobility. After discovering R4's pressure injury on 08/22/22, the facility did not implement new repositioning interventions to promote the healing of the pressure injury. This is evidenced by: R4 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Annual Minimum Data Set (MDS), dated [DATE], indicated R4 is not at risk for developing pressure injuries and has a pressure reducing device for chair. Brief Interview for Mental Status (BIMS) score of 02, indicating impaired cognition. R4 is independent with transfers and bed mobility. The quarterly MDS on 04/23/22 and 07/21/22 indicate R4 continues to be independent with bed mobility and transfers, and is not at risk for pressure injury. On 08/18/22, R4 had a Significant Change in Condition MDS completed, indicating R4's mobility status has changed and R4 now needs assistance of two or more persons for transfers, bed mobility, and toilet use. Most recent MDS dated [DATE] documents R4 is at risk to develop pressure injuries and has a stage 3 pressure injury. The MDS documents R4 has a pressure relieving device for her chair. R4 has a BIMS score of 3, indicating cognitive impairment. R4 requires assistance with assist of two persons for transfers, bed mobility, and toilet use. R4 is occasionally incontinent of urine and frequently incontinent of bowel. MDS rejection of care completed as behavior not exhibited. Care plan: All interventions or approaches were added to care plan on 05/05/2021. No new interventions were added after pressure injury was identified on 08/22/22. Interventions initiated on 05/05/21 include: -Conduct a systemic skin inspection weekly. Pay particular attention to my bony prominences. -Use pressure reduction mattress when I am in bed. -Use lift sheet to avoid shearing my skin during positioning, transferring and turning. -Report any signs of skin breakdown (sore, tender, red, or broken areas). -Reduce friction injuries by using lubricants, protective films, lift sheets prn as indicated. -Provide incontinence care after each incontinent episode. -Pressure reduction cushion to my chair. -Meds, labs, TX as ordered, nursing to monitor for effectiveness and side effects of medications as ordered. -Keep my skin as clean and dry as possible, minimize my skins exposure to moisture. -Keep my linen clean and dry. -Encourage physical activity, mobility, and range of motion to maximal potential. -Encourage fluids during and between meals and prn. -Diet as ordered, dietary supplements per dietary recommendations. -Assess me for the presence of risk factors, treat, reduce, eliminate risk factors as able. Care Plan Revision on 09/28/22 - Problem: R4 has an infected pressure ulcer to left buttocks and has the potential for further skin breakdown due to limited mobility. The interventions were not updated on 09/28/22. The nurses' notes contain in part: 8/12/22-Fall resulting in ulnar fx 8/13/22-Splint and sling in place to left arm. R4 requiring more help with cares. 8/16/22-Frequent reminders that R4 needs to wait for assistance before transferring, verbalizes understanding. 8/22/22-R4 found to have a pressure injury to left buttock. Measures: 2.5 x 2.9 x 0.2cm. Wound bed is pink with slough noted. Area cleansed with normal saline and covered with bordered foam. Primary Care Provider (PCP) faxed with update and request for treatment order. There is no staging of the wound on this date. 8/23/22-MD order: Buttocks open area: cleanse with normal saline, apply skin prep to peri wound cover with bordered foam. Change every three days and as needed. Surveyor reviewed treatment administration record (TAR) and confirmed treatment was administered as ordered. 8/24/22-Wound rounds: Pressure area to left buttocks 1.0 x 5.1 cm. Wound base 80% epithelial tissue, 20% slough. Peri-wound skin normal. Small amount serous drainage. R4 denies any pain to the area. The wound is described as a stage 3 pressure injury. 8/26/22-R4 is transferring herself to and from the toilet without asking for assistance. Reminders given. Dietary added Mighty Shake to meals. 8/30/22-Dressing change completed to coccyx with nightly cares. Area of slough remains. Maxsorb applied with cover. Surrounding tissue darker in color. Odor present. 8/31/22-Weekly wound note-2.6 x 4.2 cm. Moderate exudate, serous drainage, no odor, no undermining, no sinus tract present, Stage 3, epithelial tissue. 9/1/22-dressing to coccyx soiled, replaced. Moderate amount of slough present at center of wound. Surrounding tissue hard and deep pink in color. Encouraged to lay side to side in bed. 9/6/22-Order: Cleanse coccyx with normal saline, cut calcium alginate to size, and cover with [MEDICATION(S)]. Change every three days and as needed. Surveyor reviewed TAR and confirmed treatment was administered as ordered. 9/7/22-Weekly wound note-2.2 x6.6 cm. Light exudate, serosanguinous drainage, Stage 3, tissue slough, wound declining. 9/9/22-Per MD order-wound order modified to cleanse with normal saline then place collagen powder on wound base followed by calcium alginate ag and mepiplex - change every three days. Surveyor reviewed TAR and confirmed treatment was administered as ordered. 9/11/22-Dressing changed to buttocks as it was soiled. Moderate amount of brownish drainage with slight odor but she did have a bowel movement as well so unsure if it was the open area or stool smell. 9/14/22-Weekly wound note-2 x6.1 cm. Moderate exudate, seropurulent drainage, no odor, Stage 3, tissue slough. 9/15/22-Resident dressing to buttocks remains clean, dry and intact. R4 encouraged to change positions frequently to off load pressure. 9/17/22-Staff of three assisted R4 into shower chair as resident was foul in odor. Coccyx dressing changed. Area remains very red around perimeter. Breakdown 4 x3 cm with another compromised area below. 9/20/22-R4 continues to decline repositioning in bed. Referral request faxed to PCP for wound clinic. 9/21/22-Weekly wound note-3 x2 cm, moderate purulent drainage, odor present with deep tissue necrosis, unstageable, undermining and tunneling present. Necrotic tissue. 9/22/22-Order obtained for referral to wound clinic for necrotic wound on coccyx. 9/23/22-PCP called and updated on resident coccyx wound being painful and foul odor. McGeers criteria met for antibiotic (abx). Orders received to culture wound, wound clinic referral, and [MEDICATION(S)] twice daily x 10 days. 9/23/22-Received call from Lab that wound culture had to be cancelled as there was no swab in the specimen tube. Lab tech stated that wound culture will have to be redrawn. 9/25/22-R4 is on an abx for wound infection. It is very malodorous. Odor is present when R4 is dressed and in her room. 9/26/22-Note from wound clinic: wet to damp dressing changes four times per day. Moisten gauze with saline, place in wound avoiding outer skin layer. Cover with dry gauze and border foam dressing. Order for wound vac to be placed after devitalized tissue is removed from wound and infection is controlled. 9/26/22-R coccyx open with tunneling, no odor, cleaned area with saline, skin prep to surrounding area. packed inside of wound with sterile saline, moist gauze and covered with [MEDICATION(S)] dressing. R4 denied any feeling to the area. R4 remained in bed with encouragement. Wound clinic appointment scheduled on this date. 9/27/22-Wet to Dry dressing changes done. Edges are clean. No odor from wound at this time. Treatment Administration Record (TAR): -8/23/22-9/6/22, cleanse with normal saline, apply skin prep to peri wound cover with bordered foam. Change every three days and as needed. -9/6/22-9/9/22, cleanse coccyx with normal saline, cut calcium alginate to size, and cover with [MEDICATION(S)]. Change every three days and as needed. -9/9/22-9/26/22, cleanse with normal saline then place collagen powder on wound base followed by calcium alginate ag and mepiplex - change every three days. -9/26/22-current, wet to damp dressing changes four times per day. Moisten gauze with saline, place in wound avoiding outer skin layer. Cover with dry gauze and border foam dressing. Four Times A Day 05:00 AM, 11:00 AM, 03:00 PM, 12:00 AM. Special Instructions: Wound culture collected 9/26/22, will order wound VAC to be placed after devitalized tissue is removed from wound and infection is controlled. 09/28/22 at 11:45 AM, Surveyor interviewed R4 to ask if she had any skin issues. R4 denied any skin concerns. Surveyor noted no odor present. R4 has a pressure reducing cushion in her wheelchair. R4 does not have a specialty mattress. 09/28/22 at 1:04 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C who stated that R4 can be combative with cares at times. CNA C stated that R4 insists that she does not need help and refuses cares. CNA C confirmed that when R4 refuses cares they reapproach and try again, and it is reported to the nurse. 09/28/22 at 1:53 PM, Director of Nursing (DON) B reported that R4 often self-transfers to bed, wheelchair (w/c) or toilet. R4 does not wear a brief but will change herself when incontinent. DON B stated that she had a meeting with Dietary Manager on 09/22/22 and it was discussed to request [MEDICATION(S)] for wound healing. DON B confirmed that R4 has w/c cushion, and reports that the facility mattresses are pressure reducing. Culture was obtained on 09/26/22 when R4 attended wound clinic appointment. Reviewed shower documentation: 8/15-refused, 8/22-refused, 8/29-refused, 9/5-shower, 9/12-shower, 9/17-shower. Surveyor asked DON B how R4's skin is assessed when she refuses showers. DON B asked CNA E, and CNA E reported that skin is still assessed during cares. Staff provide wash-up or bed bath. If R4 refuses, staff continue attempts throughout the day to ensure that R4 is provided care daily. 09/28/22 at 2:32 PM, interview with CNA D. CNA D reported that when R4 refuses showers, aides attempt to give bed bath on the toilet. CNA D confirmed that R4 does refuse cares, and often self-transfers and the aides attempt to catch her when she is going into the bathroom, so they can assist with cares. CNA D reported that R4 will ask for assistance at times and will sit in the doorway of her room and ask staff in the hallway. CNA D stated that R4 does not want to be repositioned and prefers to lay on her back when in bed. R4 becomes combative when she is refusing cares. CNA D reported that R4 has been wearing a brief since wound began about a month ago, as R4 is having increased incontinence of bowel and bladder. R4 has had drainage from wound that has required more frequent hygiene assistance. Staff have been assisting more with dressing and re-dressing due to the soiling of R4's clothes. 09/26/22 Surveyor reviewed wound clinic documentation: Culture obtained. Stage 3 Coccyx: 2.1 x2.2 x2.3 cm, Stage 2 left buttock: 2 x2.5 x0.1 cm. Will order negative pressure wound therapy for when devitalized tissue and infection from wound are cleared up. The final culture results on 09/30/22 document many gram positive rods, few Streptococcus agalactiae, no further work up. Streptococcus agalactiae is a bacteria commonly found in the intestine and [CONDITION(S)] tract of healthy adults. The facility did not implement new repositioning interventions to promote the healing of the pressure injury discovered 08/22/22.

Based on interview and record review the facility failed to provide treatment and services to prevent a urinary tract infection by incorrectly placing an indwelling urinary catheter, by failing to assess the resident from 8:30 PM on [DATE] to 8:00 AM on [DATE], and by failing to provide appropriate treatment when the resident continued to have no urine output and bleeding complications from the catheter. This occurred for one of four residents (R) reviewed with urinary catheters (R1). As a result, this resident had a loss of approximately one liter of blood, became septic, was transferred to the emergency room , and then transferred to a larger hospital for treatment. R1 died three days later. The facility's failure to provide appropriate care and treatment of [REDACTED]. Surveyor notified Nursing Home Administrator (NHA) A of the IJ finding on [DATE] at 1:45 PM. The IJ was removed on [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: Facility policy entitled, Foley Catheter Insertion, Male Resident states, in part, Steps in the Procedure .22. Insert the catheter gently into the meatus (approximately ,[DATE] inches) until urine begins to flow from the bladder. When urine begins to flow, advance the catheter another 2 inches. Inflate balloon slowly with 5 ml (milliliters) normal saline. If resident complains of any pain or pressure while inflating the balloon, stop, deflate the balloon and advance the catheter another inch. Inflate the balloon slowly. If the resident complains of pain or pressure, stop, deflate the balloon and call for assistance. Remove the the syringe after successfully inflating the balloon. Pull gently on catheter to check placement. 23. If slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscles and overcome resistance to entry. If resistance continues, do not force the entry. Stop the procedure and notify your supervisor . Record review identified R1 as an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R1's medications included Xerelto (a blood thinner) 10 milligrams (mg) daily. R1 had long-term use of an indwelling urinary catheter due to [MEDICAL CONDITION]. A physician order [REDACTED]. Review of nursing progress notes from [DATE] through [DATE] identified R1 had experienced repeated complications with the urinary catheter, including urinary tract infections [MEDICAL CONDITION] requiring treatment with antibiotics, and hospitalization [MEDICAL CONDITION] due to a UTI. Review of nursing progress notes on R1's medical record identified a note dated [DATE] at 8:38 PM that stated: 14 french catheter changed per order. Old catheter removed without problem. c/o (complained of) pain upon insertion. No urine in bag 2 hours later. Balloon deflated and catheter inserted one more inch. Return of blood clot and small amount of urine. Pt (patient) encouraged to push fluids. No further documentation was noted on R1's nursing progress notes until [DATE] at 2:35 PM. On [DATE] Surveyor interviewed Registered Nurse (RN) C, who changed R1's catheter on the evening of [DATE]. RN C stated the catheter change was at approximately 6:30 PM. RN C stated there was no urine output from R1's catheter when it was placed. RN C stated typically RN C would confirm proper placement of the urinary catheter by observing for return of urine before inflating the balloon on the end of the catheter. RN C stated the catheter was inserted as far as it would go and the balloon was inflated even though there was no urine return, because the previous month the same thing happened when changing R1's catheter. RN C reported R1 did complain of pain during the procedure. RN C stated at approximately 8:30 PM, there was still no urine output from R1's catheter. RN C stated RN C deflated the balloon and attempted to advance the catheter a little farther into the bladder. RN C stated a blood clot and drips of urine came out of the catheter, and the balloon was re-inflated. When asked if this condition would warrant consulting with a physician, RN C stated no, the typical facility practice was to watch and wait. When asked how long RN C would watch and wait before assessing R1 for urine output from the catheter, RN C stated RN C did not assess R1's catheter condition or urine output for the remainder of the evening shift. RN C stated report of the catheter change and no urine output was given to the night nurse. Review of R1's medical record identified no documentation from the night nurse on [DATE] to [DATE], and no documentation of urine output on R1's medical record for that shift. On [DATE] Surveyor interviewed RN D who worked the night shift from [DATE] to [DATE]. RN D stated RN C reported at change of shift that R1 had little to no urine output from catheter following a catheter change earlier in the evening. RN D stated R1 had two small clots in the drainage tubing, but no additional urine output at approximately 11:50 PM. Surveyor asked RN D if RN D did an assessment of R1's comfort, or assessed for proper placement of R1's catheter since it had been over five hours since the catheter had been inserted. RN D stated R1 had a history of [REDACTED]. Surveyor asked RN D when RN D re-assessed R1's catheter condition or for the presence of any urine output. RN D stated R1 was not re-assessed during the rest of that shift, because R1 would get very upset if woken during the night. RN D reported R1 slept through the night and showed no signs of discomfort. RN D stated there continued to be no urine output in R1's catheter tubing or drainage bag through the night. RN D stated the physician was not consulted or notified of no urine output since the catheter was changed at 6:30 PM the previous evening, but it was reported to the day nurse. Review of R1's medical record identified the following nursing progress note dated [DATE] at 2:35 PM: Resident noted to have no urine output during the night hours. 14 fr. (french) catheter in place. Blood clots were noted in drainage tube - app (approximately) 60 mls (milliliters) blood in collection bag. Irrigation shows no return. Abdomen soft when palpated. App. 1 hour later - still no urine output. Upon exam - large amount of blood present coming from penis. App. ,[DATE] mls. Tena (brand of absorbent pad) pad in place. Area cleaned as able. Resident had history of split meatus. Catheter replaced at 11:30 - immediate flash of app 10mls urine, lighter in color - but blood present. Resident tolerated procedure well - and without c/o (complaint). Resident placed in chair so staff could cleanse bed. At 1300 (1:00 PM) staff relay that resident does not look good upon exam - resident pale in color, abdomen clammy to touch. Resident is alert and answers when spoken to, but not at normal level. Resident now has 600 mls of straight blood in urine collection bag. Vitals = bp (blood pressure) ,[DATE], p (pulse) 54 and irregular - resident is on Xerelto, t (temperature) 97.2 spo2 (oxygen saturation) 94% r (respirations) 18. Advance directives indicate resident is a full code and that (R1) does want hospital intervention. Call placed to (Medical Doctor)(MD) F - order given to transport to E.R. (emergency room ) for further workup. Daughter updated. Resident transported by local ambulance to Spooner E. R. On [DATE] Surveyor interviewed Licensed Practical Nurse (LPN) E who stated RN D reported R1 had no urine output through the urinary catheter since it was changed on the previous evening shift. LPN E stated R1 was first assessed by LPN E at approximately 8:00 AM. At that time LPN E noted some blood clots in the drainage tubing and approximately 60 mls of blood in the collection bag. LPN E stated no further assessment was completed at that time and LPN E did not consult with a supervisor or R1's physician. LPN E reported between 9:30 AM and 10:00 AM no urine output was noted from R1's catheter, so LPN E attempted to irrigate the catheter with sterile saline. LPN E reported there was still no urine output after the irrigation of the catheter, but R1 was not complaining of any discomfort, and R1's abdomen was soft. LPN E did not consult with a supervisor or physician at that time. LPN E stated at approximately 11:30 AM there was still no urine output from R1's catheter, and upon closer examination, LPN E noted a large amount of blood coming from R1's penis. LPN E stated R1 had a previous history of a split meatus, and LPN E was not sure if the bleeding was from this reopening or if it was coming from internally. LPN E stated the urinary catheter was removed and LPN E inserted a new 16 french urinary catheter into R1. LPN E stated there was some resistance during insertion of the catheter, indicating passage by the enlarged prostate. LPN E reported the catheter was inserted past the resistance and a flash of urine and blood was noted coming from the catheter. LPN E reported the balloon was then inflated with 10 ml of saline and R1 tolerated the procedure without complaint of discomfort. LPN E stated an attempt was made to consult with a nursing supervisor or Director of Nursing (DON) at this time, but neither was located in the facility. LPN E stated the physician was not consulted, as LPN E's plan was to watch for more urine output and notify the physician later if still no urine output. LPN E did not assess R1 for bleeding or urine output until approximately 1:00 PM when Certified Nursing Assistant staff informed LPN E that R1 did not look good. LPN E stated R1 was found to be pale, and clammy with a low blood pressure and pulse. LPN E also noted that approximately 600 mls of straight blood was noted in R1's urine drainage bag at that time. LPN E then summoned the RN charge nurse and called R1's physician for consult. LPN E stated R1 was sent to the local ER per physician's orders [REDACTED]. On [DATE] Surveyor interviewed DON B who stated the facility had a bladder scanner, but it was not part of the current policy and procedure for catheter placement. DON B stated in hind-sight it would have been a good idea for nursing staff to use the bladder scanner to check for [MEDICAL CONDITION] after R1 had no urine output for several hours following the change of the urinary catheter. DON B stated the expectation would be that nursing staff would frequently assess a resident's condition/comfort, urine output for amount, color, and presence of blood following a catheter change. DON B further stated the facility expectation would be that nursing staff would consult with a supervisor or physician immediately if any complications were noted such as the ones that R1 experienced on [DATE] through [DATE]. The note from the local ER indicated R1 had an estimated one liter of blood loss following a catheter change prior to arrival in the ER. R1 was noted to have a low blood pressure and rapid heart rate in the ER. Blood cultures and a urine culture were obtained. R1 was transferred to a larger hospital after stabilization. The urology note from the ER stated, in part, .Suspect bleeding started due to malpositioned foley catheter exacerbated by Xerelto . Review of the discharge summary from the larger hospital indicated R1's blood cultures [MEDICAL CONDITION] related to pseudomonas (bacteria), and urine culture showed a UTI also related to pseudomonas. The hospital discharge summary indicated R1 died on [DATE] following a cardiac event as a complication of [MEDICAL CONDITION]. A misplaced urinary catheter multiplies the already inherent risk for infection associated with catheter usage. Additionally, a misplaced catheter can create trauma that can lead to bleeding. A catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes, comprising 405 of all institutionally acquired infections. CAUTIs are considered complicated UTIs and are the most common complication associated with long-term catheter use .They are associated with increased urosepsis, [MEDICAL CONDITION], and mortality. Catheters are a good medium for bacterial growth because bacterial biofilms (layers of organisms) adhere to the many surfaces of the catheter system. https://www.urotoday.com/urinary-catheters-home/indwelling-catheters/complications/problems.html#:~:text=Hematuria%20occurs%20in%20patients%20who,a%20urologist%20may%20be%20indicated. Sepsis occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life-threatening condition that can cause organ failure.[MEDICAL CONDITION] is the leading cause of death in hospitals in the United States, [MEDICAL CONDITION] is associated with an estimated in-hospital mortality risk between 25 and 30 percent. In the U.S. alone, more than 500,000 adult patients are admitted to hospitals every year with evidence [MEDICAL CONDITION] and organ dysfunction. Each year in the U.S. there are approximately 750,000 cases of [MEDICAL CONDITION], which result in 215,000 deaths. https://www.[MEDICATION NAME].com/health/archive/,[DATE]/sepsis-to-shock-what-happens-when-bacteria-invade-the-body/ 2/ Blood found in the catheter showed this resident was bleeding, a complication that could be magnified by the fact that this resident was on a blood thinner and may be prone to bleeding more easily. The average person has 5 liters of blood; 20% blood loss (1 liter) can lead to hypovolemic shock. Failure to ensure that bleeding is stopped or controlled can lead to hypovolemic shock and death. According to http://www.healthline.com/health/hypovolemic-shock#Causes2, Hypovolemic shock, also called hemorrhagic shock, is a life-threatening condition that results when you lose more than 20 percent (one-fifth) of your body's blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump sufficient blood to your body. Hypovolemic shock can cause many of your organs to fail. The condition requires immediate emergency medical attention in order to survive. Hypovolemic shock results from significant blood and/or fluid losses in your body. Blood loss of this magnitude can occur because of .internal bleeding from the gastrointestinal tract . Untreated hypovolemic shock will lead to death. A lack of blood and fluid in your body can lead to the following complications: damage to organs such as your kidney or brain; gangrene of the arms or legs; [MEDICAL CONDITION]. The facility's failure to provide appropriate care and treatment of [REDACTED]. The facility removed the jeopardy on [DATE], when it had completed the following: On [DATE] the facility updated the Foley Catheter Insertion policy to include use of bladder scanning as a consideration, and reinforced immediate notification to MD for any abnormalities. The facility developed a new policy titled Physician Notification, to simplify the expectation that nurses are to notify the physician for incidents, significant change, deteriorations in health, and /or life-threatening conditions, or clinical complications. On [DATE] all nursing staff was educated to complete a treatment administration record order that will state: check output of urine after catheter insertion every 2 hours for the first 12 hours after insertion of a catheter to ensure urine flow is occurring, and if not, notify the MD to determine next steps. All nursing staff was also educated on a new policy and procedure called Notification of Physician, which included procedure for notification and use of situation-background-assessment-recommendation (SBAR) form. The deficient practice continues at a scope/severity level of D as the facility continues to implement the removal plan.

Based on interview and record review, the facility did not immediately consult with a physician following complications with insertion of an indwelling urinary catheter. Facility staff waited 18 hours before consulting a physician, despite noting bleeding and no urine output. This occurred for one of four residents (R) reviewed with urinary catheters. (R1) This resulted in loss of approximately one liter of blood, transfer to the emergency room , and then transfer to a larger hospital for treatment. R1 died three days later. The facility's failure to consult with a physician in a timely manner following complications with insertion of an indwelling urinary catheter created a finding of Immediate Jeopardy (IJ) that began on [DATE]. Surveyor notified Nursing Home Administrator (NHA) A of the finding of the IJ finding on [DATE] at 1:45 PM. The IJ was removed on [DATE]; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement it's removal plan. Findings include: The facility policy entitled, Foley Catheter Insertion, Male Resident, last revised [DATE], states the following, in part, Reporting .2. Notify the physician of any abnormalities (i.e. bleeding, obstruction, etc.) Review of R1's medical record identified a nursing progress note dated [DATE] at 8:38 PM that stated: 14 french catheter changed per order. Old catheter removed without problem. c/o (complained of) pain upon insertion. No urine in bag 2 hours later. Balloon deflated and catheter inserted one more inch. Return of blood clot and small amount of urine. Pt (patient) encouraged to push fluids. The next nursing progress note dated [DATE] at 2:35 PM stated: Resident noted to have no urine output during the night hours. 14 fr. (french) catheter in place. Blood clots were noted in drainage tube - app (approximately) 60 mls (milliliters) blood in collection bag. Irrigation shows no return. Abdomen soft when palpated. App. 1 hour later - still no urine output. Upon exam - large amount of blood present coming from penis. App. ,[DATE] mls. Tena (brand of absorbent pad) pad in place. Area cleaned as able. Resident had history of split meatus. Catheter replaced at 11:30 - immediate flash of app 10mls urine, lighter in color - but blood present. Resident tolerated procedure well - and without c/o (complaint). Resident placed in chair so staff could cleanse bed. At 1300 (1:00 PM) staff relay that resident does not look good upon exam - resident pale in color, abdomen clammy to touch. Resident is alert and answers when spoken to, but not at normal level. Resident now has 600 mls of straight blood in urine collection bag. Vitals = bp (blood pressure) ,[DATE], p (pulse) 54 and irregular - resident is on Xerelto, t (temperature) 97.2 spo2 (oxygen saturation) 94% r (respirations) 18. Advance directives indicate resident is a full code and that (R1) does want hospital intervention. Call placed to (Medical Doctor)(MD) F - order given to transport to E.R. (emergency room ) for further workup. Daughter updated. Resident transported by local ambulance to Spooner E. R. Review of ER note indicated R1 had approximately one liter of blood loss following a catheter change prior to arrival in the ER. R1 was noted to have a low blood pressure and rapid heart rate in the ER. Blood cultures and a urine culture were obtained. R1 was transferred to a larger hospital after stabilization. Review of the discharge summary from the larger hospital indicated R1's blood cultures [MEDICAL CONDITION] related to pseudomonas (bacteria), and urine culture showed a UTI also related to pseudomonas. The hospital discharge summary indicated R1 died on [DATE] following a cardiac event as a complication of [MEDICAL CONDITION]. On [DATE] Surveyor interviewed Registered Nurse (RN) C, who changed R1's catheter on the evening of [DATE]. RN C stated the catheter change was at approximately 6:30 PM. RN C stated RN C was not alarmed to initially have no urine output after the catheter change, as this had happened during R1's catheter change the previous month. RN C stated at approximately 8:30 PM, there was still no urine output from R1's catheter. RN C stated RN C attempted to advance the catheter a little farther into the bladder and got a blood clot and drips of urine out of the catheter. When asked if this condition would warrant consulting with a physician, RN C stated no the typical facility practice was to watch and wait. RN C did not assess R1's catheter condition or urine output for the remainder of the evening shift. On [DATE] Surveyor interviewed RN D, who worked the night shift on [DATE]. RN D stated RN C reported at change of shift that R1 had little to no urine output from catheter following a catheter change earlier in the evening. RN D stated R1 had two small clots in the drainage tubing, but no additional urine output at approximately 11:30 PM. RN D stated this was not alarming to RN D because it took several hours for R1 to have urine output after a catheter change the previous month. RN D stated R1 did not have any urine output for the rest of the night shift. RN D stated a physician was not consulted after R1 had no urine output for approximately twelve hours following a change of the urinary catheter. On [DATE] Surveyor interviewed Licensed Practical Nurse (LPN) E who worked the day shift on [DATE]. LPN E stated RN D reported R1 had no urine output through the urinary catheter since it was changed on the previous evening shift. LPN E stated R1 was first assessed by LPN E at approximately 8:00 AM. At that time LPN E noted some blood clots in the drainage tubing and approximately 60 mls of blood in the collection bag. LPN E stated no further assessment was completed at that time and LPN E did not consult with a supervisor or R1's physician. LPN E reported between 9:30 AM and 10:00 AM no urine output was noted from R1's catheter, so LPN E attempted to irrigate the catheter with sterile saline. LPN E reported there was still no urine output after the irrigation of the catheter, but R1 was not complaining of any discomfort, and R1's abdomen was soft. LPN E did not consult with a supervisor or physician at that time. LPN E stated at approximately 11:30 AM there was still no urine output from R1's catheter, and upon closer examination, LPN E noted a large amount of blood coming from R1's penis. LPN E stated R1 had a previous history of a split meatus, and LPN E was not sure if the bleeding was from this reopening or if it was coming from internally. LPN E stated the urinary catheter was removed and LPN E inserted a new 16 french urinary catheter into R1. LPN E stated there was some resistance during insertion of the catheter, indicating passage by the enlarged prostate. LPN E reported the catheter was inserted past the resistance and a flash of urine and blood was noted coming from the catheter. LPN E reported the balloon was then inflated with 10 ml of saline and R1 tolerated the procedure without complaint of discomfort. LPN E stated an attempt was made to consult with a nursing supervisor or Director of Nursing (DON) at this time, but neither was located in the facility. LPN E stated the physician was not consulted, as LPN E's plan was to watch for more urine output and notify the physician later if still no urine output. LPN E did not assess R1 for bleeding or urine output until approximately 1:00 PM when Certified Nursing Assistant staff informed LPN E that R1 did not look good. LPN E stated R1 was found to be pale, and clammy with a low blood pressure and pulse. LPN E also noted that approximately 600 mls of straight blood was noted in R1's urine drainage bag at that time. LPN E then summoned the RN charge nurse and called R1's physician for consult. LPN E stated R1 was sent to the local ER per physician's orders [REDACTED]. On [DATE] Surveyor interviewed DON B about the incident with R1's urinary catheter change and bleeding on [DATE] through [DATE]. When asked if DON B would have expected nursing staff to consult with a physician about the situation sooner in the timeline, DON B stated in hindsight, DON B would have preferred the nursing staff to consult with a physician after there was no urine output for two hours following a catheter change. DON B stated nursing staff should have consulted with a physician after it was noted R1 had no urine output through the entire next shift, and also as soon as the large quantity of bleeding was noted from R1's penis. On [DATE] Surveyor interviewed R1's attending physician, MD F. After reviewing the timeline of events from the insertion of R1's catheter on the evening of [DATE] through R1's transfer to the ER, MD F stated the first time the nursing staff consulted with MD F about R1's condition was sometime after 1:00 PM on [DATE]. MD F stated MD F's expectation would be that the facility staff should have consulted much sooner during the timeline of events. When asked if this situation could have in anyway contributed to R1's death, MD F stated R1 died as a result [MEDICAL CONDITION]. MD F stated the prolonged [MEDICAL CONDITION] from a misplaced catheter, and repeated manipulation of the catheter could have caused [MEDICAL CONDITION], thus contributing to R1's death. The failure to immediately consult with a physician following complications with insertion of an indwelling urinary catheter created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it had completed the following: On [DATE] the facility updated the Foley Catheter Insertion policy to include use of bladder scanning as a consideration, and reinforced immediate notification to MD for any abnormalities. The facility developed a new policy titled Physician Notification, to simplify the expectation that nurses are to notify the physician for incidents, significant change, deteriorations in health, and /or life-threatening conditions, or clinical complications. On [DATE] all nursing staff was educated to complete a treatment administration record order that will state: check output of urine after catheter insertion every 2 hours for the first 12 hours after insertion of a catheter to ensure urine flow is occurring, and if not, notify the MD to determine next steps. All nursing staff was also educated on a new policy and procedure called Notification of Physician, which included procedure for notification and use of situation-background-assessment-recommendation (SBAR) form. The deficient practice continues at a scope/severity level of D as the facility continues to implement the removal plan.

Based on observations, interviews and record reviews, the facility did not provide the necessary interventions to promote the healing of pressure injuries according to current standards of practice for 3 of 4 residents reviewed for pressure injuries. (R31, R36 and R56). R31 developed a unstageable pressure injury (PI) on 1/30/19. R31 was to be evaluated for appropriate wheelchair seating as well as a pressure reducing cushion and this was not done. According to R31's current care plan she was to be repositioned every hour when in her chair and was observed to not be repositioned for 2 hours and 34 minutes. During this time R31 was observed in a wheelchair without a pressure relieving cushion. R36 developed a PI over her coccyx that has since healed. There was little to no documentation and assessment of the wound over the course of it's healing as would be expected according to current standards of practice. It is expected that the condition of a wound of this type would be recorded to include at the very least it's location, the size, the condition of the wound bed, and the condition of the skin surrounding the wound. R56 developed a Deep Tissue Injury (DTI) to his right lateral heel, which opened and developed eschar. In reviewing the progress of the wound, it was noted missing weekly documentation of the wound. The wound has since healed. This is evidenced by: Example 1: R31's MDS (Minimum Data Set Assessment) dated 01/03/19 indicates R31 is at risk for PIs, does not have any current PIs, requires extensive assistance for bed mobility and transfers and does not walk. R31's care plan dated 01/10/19 included the following goal and approach on page 9: I will be clean dry and appropriately dressed. Positioning device: assist of 1 staff member to reposition every 1 hour in w/c (wheelchair) and every 2 hours when in bed. On 1/30/19, the facility documented Unstageable pressure ulcer to sacrum. No other information is noted in this note. The facility did not have the description of the pressure injury or the measurement of the pressure injury. Documentation of the PI includes the following: 02/04/19 Reddened area on coccyx has 2 open area with encompassing redness app 10 cm in diameter (approximately centimeters). Area cleansed and treatment initiated, after speaking with former wound nurse as current wound nurse u/a (unavailable). Resident placed in recliner after noon meal and rolled to side to off-load pressure. Resident using pummel cushion for safety-will explore other options to aid in pressure relief. 02/08/19 Wound Observation: . asked to observe wound to sacrum. Presents as a unstageable pressure ulcer. Wound measures 4.5 cm x 6.0 cm. There are 2 open areas across the sacrum. Wound at 3 o'clock position is superficial, wound bed in bright red granulation tissue. At 9 o'clock the wound is covered with 100% adherent white/green/purple colored slough, there is an area of [MEDICATION NAME] tissue between both open areas that measures 1.0 cm. Edges of wound appears intact at this time. Periwound: There is 1.0 . circumferentially and is [MEDICAL CONDITION]. The open area at 9 o'clock is firm with palpation .Therapy eval (evaluation) for different wheelchair for pressure reduction to sacrum or different wheelchair cushion This was the first measurement of the sacral wound/pressure injury. The pressure injury was observed to have 2 open areas and swelling. The pressure injury was first observed on 01/30/19. There is no evidence R31 was evaluated for a different wheelchair or a pressure relief cushion. 02/13/19 length 3.5 cm Width 7.5 cm [MEDICAL CONDITION] Unstageable Slough and/or Eschar Necrotic Tissue with well defined wound edges. Wound Status: Declining. Comments: Wound is covered with 100% necrotic adherent slough that is dark purple to the center and tan in color to the perimeter . The pressure injury is declining and becoming larger. There were no further measurements of the pressure injury until 02/22/19. 02/22/19 length 3 cm Width 6.3 cm The note indicates there is heavy purulent exudate and the wound is unstageable. 02/28/19 length 5.5 cm Width 6.5 cm .sinus tract/tunneling measurement cm: 1 Sinus tract/tunneling direction: 9 o'clock. 100 % of wound covered by slough tissue. Wound healing status: declining. 03/03/19 Old Coccyx dressing had come off. Pressure injuries are getting bigger and now sloughing off the top layers, exposing deep tissue. Wound have a very strong odor with purulent drainage. Surrounding skin cleansed, skin prep and new dressing applied. T 98.0 oral. (temperature). The odor noted with the pressure injury is a possible sign of infection. On 03/03/19 11:49 AM surveyor observed staff transfer R31 from her wheelchair to bed with a hoyer lift. CNA L indicated to surveyor that R31 has had a pressure ulcer for a couple of weeks. Surveyor observed R31 was seated on a pommel cushion covered with sheepskin. There was no pressure relieving device in the chair. On 3/4/19, R31's care plan was updated and included, Approach start date 03/04/19: Positioning device: assist of 1 staff member to reposition every 1 hour in w/c and every 2 hours when in bed. I have a low air loss, alternating air mattress to my bed .Assist of 2 staff members with all toileting tasks. I am incontinent of bowel and bladder. Check and change incontinent product every 2 hours and during noc rounds. On 03/04/19 10:24 AM Surveyor observed R31 seated in Broda wheelchair with pommel cushion and sheepskin over the pommel seated on sheepskin and hoyer sling underneath her. The pommel cushion with the sheepskin and hoyer sling over the cushion are not pressure relieving devices. On 03/05/19 Surveyor completed a continuous observation of R31 from 7:00 AM to 9:34 AM, R31 was seated in the Broda wheelchair on a pommel cushion with sheepskin over the cushion and the hoyer sling over both of them. During the 2 hour and 34 minute time frame, several staff interacted with R31, but none offered or assisted with repositioning. At 9:34 AM on 03/05/19 CNA K and CNA L told surveyor that they got resident up at 630 AM. CNA K and CNA L said R31 was incontinent of both bowel and bladder. R31 went for 3 hours from 6:30 AM. until 9:34 AM. without repositioning or checking for incontinence. This did not promote the healing of R31's existing pressure injury. On 03/05/19 12:35 PM surveyor spoke with CNA [MI] CNA L indicated the she usually works with R31. CNA L said that they have care plans in rooms and showed R31's care plan located in her closet. The care plan was dated 3/4/19 and indicated R31 was to be reposition every 1 hour in w/c and every 2 hours in bed. On 03/05/19 10:22 AM surveyor spoke with LPN G (Licensed Practical Nurse/ Wound Nurse). LPN G said she does the wounds and does weekly wound rounds every Thursday or Friday. LPN G said she learns of pressure injuries from staff or by reading the progress notes where the nurses document the condition of the pressure injury. LPN G said R31's pressure ulcer to sacrum was discovered on 01/30/19 and it was unstageable. LPN G said R31 should be repositioned every hour when in her wheelchair. LPN G said the care plans are in each resident room. LPN G said R31 is at high risk for development of ulcers due to incontinence and [DIAGNOSES REDACTED]. On 03/05/19 at 2:41 PM Surveyor interviewed COTA M (Certified Occupational Therapy Assistant/Rehab Director). COTA M said the DON (Director of Nursing) and ADON (Assistant Director of Nursing) came to her as R31 was sliding down in the Broda chair. COTA M said that they tried the shorter Broda chair, with pommel cushion to keep R31's hips back. COTA M told Surveyor the pommel cushion is not a pressure relieving cushion, that it is just a standard kind. COTA M said they would have to order a special cushion. Surveyor asked COTA M if R31 is being evaluated for a different wheelchair and cushion. Surveyor showed COTA M the note from 02/08/19 that references a therapy evaluation. COTA M said she never received a referral. On 03/06/19 at 8:11 AM, Surveyor spoke again with LPN G. LPN G was asked about a referral to therapy for a wheelchair and wheelchair cushion for R31. LPN G said she thought she verbally told COTA M. LPN G said she did not send anything to her. At the time of exit on 03/06/19 at 2:00 PM, nothing was received from LPN G or COTA M regarding an evaluation of R31's wheelchair and wheelchair cushion. Example 2: R36 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 3/4/19 Surveyor interviewed RN-B (Registered Nurse). RN-B stated R36 had an open slit on her coccyx with a little depth that was treated with a covering of a gel impregnated gauze and covered with [MEDICATION NAME] brand adhesive foam dressing. RN-B stated R36 was at one point not expected to live past Christmas and has since bounced back. RN-B stated the documentation of the wound would be in the progress notes. Review of the progress notes found that the wound was first documented by the facility on 1/9/19 the day after her admission. There is the one Wound Management assessment dated [DATE] at 1:26 p.m. that indicated the wound was not present upon admission and was just discovered. The wound remained open until 2/13/19 when a notation stated, Coccyx pressure ulcer healed, event closed. MASD (Moisture-Associated Skin Damage) under breasts and groin healing well, continuing with ordered (treatment). The progress notes found frequent notations that stated the dressing was intact over her coccyx. The only notation beyond this was about the size and treatment of [REDACTED]. The notation by RN-B states, Changed dressing to coccyx this AM (morning). Open area almost gone, 0.1 cm (centimeter) by 0.1 cm. Nursing Cleansed well, applied hydrogel gauze the new [MEDICATION NAME] that was supplied by hospice . On 3/5/19 at approximately 3:00 p.m. Surveyor interviewed LPN-G as she is in charge of the wound treatments in the facility. LPN-G stated she is aware of the standard of practice for wound assessment and documentation and does the wound documentation once a week and indicated the missing documentation was when she was put on work restrictions on 12/29/18. DPS: Example 3: R56 has medical [DIAGNOSES REDACTED]. Standards of practice dictate that pressure injuries should be assessed at least weekly. This is done to evaluate whether the current treatment is effective or should be changed, as well as to determine if other care plan approaches should be added to assist in the healing process. The weekly assessment should include the following information: - the stage of the wound, if applicable and its location; - the measurement of the wound; - the presence of tunneling and/or undermining, if applicable; - the presence of drainage and it's type, color, amount or whether there is an odor; - the presence of pain, nature and frequency; - the wound bed, if visible should describe the tissue color and type, as well as the presence of granulation, slough or eschar; and finally, - a description of the wound edges and it's surrounding appearance. This is critical information for the nursing team to determine if a change in treatment or a change in the plan of care for the resident is warranted. In review of R56's medical record, the surveyor noted that R56 developed a DTI to his right lateral heel 10/11/18. The original documentation regarding this wound noted the area to be 3.0 cm length x 2.0 cm wide, describing it as a dark purple and boggy area. This would classify the wound as unstageable, as one cannot visualize the actual wound and what was occurring under the surface of the skin. There was no assessment from 10/12/18 - 11/1/18. The next entry was dated 11/2/18. This is 3 weeks later. The assessment dated [DATE] indicates that the wound had opened and measured 1.5 cm length x 1.0 cm width by 0.1 cm deep, and was 100% granulation tissue, indicating the healing process. However, it was noted that the next three weeks of assessments were missing. They were: - 12/28/18 - 1/4/19 - 1/11/19 The next assessment was dated 1/17/19 and now noted a decline in the wound to 100% eschar covered. Note: Eschar is dead tissue that is typically tan, brown, or black, and may be crusty. Wounds are classified into stages based on how deep they are and how much skin tissue is affected. When a wound has eschar on top of it, the wound can ' t be classified. This is because eschar is dead, dark tissue that makes it difficult to see the wound underneath. Oftentimes, this eschar needs to be removed in order for healing to take place. The assessment dated [DATE] noted the wound continued to be unstageable as it was 100% covered with eschar. Further review also noted a missing assessment that should have been dated at or around 2/8/19. On 3/5/19 at 4:35 p.m., the Surveyor interviewed LPN-G (Licensed Practical Nurse) regarding wound care. LPN-G is the facility wound nurse. LPN-G stated that wounds are to be documented on weekly. She stated this is done so that declines in progress are noted. She further stated that she had shattered her elbow and during the healing process, the staff nurses were responsible to assess and conduct wound care. She stated that she reviewed R56's wound notes and found no real assessment of his wound and these assessments of his wound are missing. Note: On 3/6/19 the Surveyor observed wound care to R56's toe and noted the heel wound was covered with scab tissue and nearly healed.

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 four of fifteen residents (Resident #10, 8, 9 and 5) reviewed for quality of care. 1. Resident #10 experienced left leg pain, which was a result of a femur fracture. The facility did not thoroughly assess for pain, change the pain medication or interventions when the resident experienced continued and increasing pain. The facility did not update the care plan related to the pain. 2. Resident #8, with known stage III pressure ulcer and who is at high risk for developing further open areas, did not have an appropriate mattress. 3. The facility did not assess each resident's foot condition daily, according to current standards of practice, for Resident #8 and Resident #9. 4. Resident #5 developed open areas to the 1st, 2nd and 3rd toes of the right foot and 2nd and 4th toes on the left foot that were not inspected daily. This is evidenced by: On 06/07/16 at 12:37 p.m., Surveyor received and reviewed a facility policy entitled, Pain Assessment and Management. The policy, revised March 2015, states the following, in part: .'Pain management' is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals .conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain .Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain . Assessing Pain .Assess pain using a consistent approach and standardized pain assessment instrument appropriate to the resident's cognitive level .Discuss with the resident .his or her goals for pain management and satisfaction with the current level of pain control . Identifying the Causes of Pain .Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including .[MEDICAL CONDITION] .Fractures .[MEDICAL CONDITION] . Pain management interventions shall reflect the sources, type and severity of pain .For those situations where the cause of the resident's pain has not been or cannot be determined, follow current standards of practice for managing pain to help determine appropriate options . Monitoring and Modifying Approaches .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated . Examples 1. On 06/07/16, Surveyor reviewed Resident #10's medical record. Resident #10 has [DIAGNOSES REDACTED]. As of 05/01/16, Resident #10 was receiving the following medications for pain management: -Tylenol 650 milligrams (mg), 8:00 a.m., noon, and 6:00 p.m. -Tylenol 500 mg at 8:00 p.m. (bedtime) -[MEDICATION NAME] 50 mg, 8:00 a.m., noon, and 8:00 p.m. -[MEDICATION NAME] (for neuropathic/nerve pain) 300 mg, with each meal at 8:00 a.m., noon and 5:00 p.m. -[MEDICATION NAME] 600 mg, 8:00 p.m. -Tylenol 500 mg, every six hours as needed (PRN) -[MEDICATION NAME] 5 mg (0.5 Milliliter (mL)) subcutaneous, every two hours PRN -Aspercreme lotion 10%, one topical application, every six hours PRN Resident #10's most recent Brief Interview for Mental Status (BIMS) score, dated 04/26/16, was a 13 out of 15 possible points, indicating intact cognition. The Minimum Data Set (MDS), dated [DATE], identifies Resident #10 does not have any pain. Resident #10's MDS, dated [DATE], indicates Resident #10 experiences occasional pain, which makes it difficult to sleep. This MDS identifies Resident #10 is not able to walk, and uses a Hoyer lift with the assistance of two staff members for transfers. Resident #10 requires total staff assistance for dressing, bed mobility, bathing and personal hygiene. Resident #10's pain assessment, dated 04/25/16, states the following, in part: .Quarterly Pain Observation .At any time in the last 5 days, has the resident received non-medication intervention for pain? Yes .Repositioning .Location of Pain: Legs .Frequency (of pain) .Occasionally .Pain Presence .Late Evening, Night .What brings pain on or increases pain? Other-post stroke .Duration of Pain: Pain Comes and Goes .Over the past 5 days, has pain made it hard for you to sleep at night .Yes .Manner of Expressing Pain: Other-verbal .Numeric Rating Scale (00-10): 00 .Indicate Plan of Care action taken: Continue Current Plan of Care . Resident #10's comprehensive care plan, dated 04/27/16, states, in part: .Problem .ADL (Activities of Daily Living) Functional .Approach Start Date 04/27/2016. Mobility .I am in a Broda (brand name of wheelchair) chair. Assist of one staff member needed to navigate Broda through out the facility .Repositioning: Assist of one staff member to turn and reposition me every 2 hours while in bed .I am incontinent of bowel and bladder . Problem .Pain .I have a potential for pain r/t (related to) previous [MEDICAL CONDITION]'s ([MEDICAL CONDITION] or stroke) .immobility .Goal .My pain will be a 3 or less on a 1-10 scale and I will show no non-verbal signs of pain within 40 minutes of prn [MEDICATION NAME] (pain medication) being given . Approach .Administer pain relief measures: distraction, relaxation, back massages, turning and repositioning .Monitor and record effectiveness .Assess the effects my pain has on me in regards to potential (sleep disturbance, activity disturbance, grimacing .withdrawal .) .Clarify misconceptions regarding addition to pain medications .Encourage me to ask for pain medication before my pain becomes intolerable .Evaluate the effectiveness of pain management interventions .Meds, labs, TX (Treatment) as ordered, nursing to monitor for effectiveness and side effects of medications as ordered .Monitor and record any complaints of pain: location, duration, quantity, quality, alleviating factors .Monitor and record any non-verbal signs of pain .Position for comfort with physical support as necessary . Problem .Restorative Nursing .Approach .AROM (Active Range of Motion): 6x/wk (six times per week) (M/W/F strength, T/Th/Sat/Sun stretch) Bilateral (Both) UE & LE (Upper Extremity and Lower Extremity) using up to 1-2 # dumbbells and 2-3 # ankle wts. (weights) per protocol. Each exercise 12-15 reps/set (repetitions per set). as tolerated .Encourage me to move full ROM and to exhale holding UE/LE stretching .10-15 sec (seconds) . Resident #10's nurses' notes, dated 04/01/16 to 06/08/16, were reviewed. The nurses' notes for April 2016 state the following, in part: -04/13/16: .has been having pain in legs at night lately requesting extra pain medicine. -04/19/16: SLEEP CHARTING: Resident sleeps well most nights between cares. Occasionally c/o (complains of) LE pain overnight; PRN medication and/or repositioning usually effective .is able to verbalize needs . Surveyor reviewed Resident #10's Medication Administration Record [REDACTED]. The April 2016 MAR indicated [REDACTED] -04/05/16 at 10:40 p.m.: Tylenol 500 mg for left leg and foot pain -04/07/16 at 4:15 a.m.: Tylenol 500 mg for left leg pain -04/11/16 at 3:30 a.m.: Tylenol 500 mg, left leg hurts -04/14/16 at 2:30 a.m.: Tylenol 500 mg, left leg hurts -04/22/16 at 2:20 a.m.: Tylenol 500 mg for left leg pain The nurses' notes for May 2016 state the following, in part: -05/05/16: No acute concerns at this time. Residents (sic) blood pressures elevated-but reviewed by MD (Medical Doctor) and no new orders .Prn pain meds effective for occasional c/o pain . -05/11/16: Resident continues on scheduled pain medications continues to c/o lt. (left) leg pain Muscle rub applied states 'it helps'. -05/12/16 at 11:02 a.m.: Resident continues to have pain with movement. Fax to MD at this time. The note does not identify where the pain is located. -7:01 p.m.: (MD O's name) ordered [MEDICATION NAME] (a muscle relaxant) 2mg .q6hr (every six hours). for a muscle relaxer for resident. -9:33 p.m.: Continues on scheduled [MEDICATION NAME] .and Tylenol 975 (mg) at HS (Hour of Sleep) and muscle rub for c/o pain lt. leg. states 'better' when asked if it helps. -05/13/16 at 10:23 p.m.: Resident given pain medication as ordered, she had pain through out shift. complaints of pain to left knee with swelling noted, ice pack applied to knee and elevated. -10:28 p.m.: .BP (Blood Pressure) 168/106 .States having pain in left leg just above the knee for 'a month, well, a long time'. States pain when moving knee, not while at rest. Left leg just above the knee, in particular, is swollen, and the left leg is also slightly swollen. No redness or bruising. Skin color is same as right leg .Left LE and foot is warm to the touch, pedal pulse palpated .States ice pack is really helpful. Fax sent to (MD O), and passed along in shift report. Surveyor reviewed the fax, sent to MD O on 05/13/16 at 11:04 p.m. The fax states the following, in part: .(Resident #10's name) has swelling of the left leg at the knee and just above, in particular. The left leg is also slightly swollen. BPs have been elevated. See notes (and) VS (Vital Signs) report. Would you assess when you can .Any new orders? MD O did not respond to this fax until 05/16/16 at 12:34 p.m., three days later. The physician indicated Resident #10 would be assessed in-person, at the facility on 05/17/16. Resident #10's May nurses' notes, continue, in part: -05/14/16 at 10:24 p.m.: .Resident did c/o pain during cares and repositioning during shift. Resident also stated to nurse, shortly after receiving scheduled pain meds, that pain persisted, resident was then given [MEDICATION NAME] 2 mg at (8:00 p.m.), muscle relaxer, is helping. Left leg remains swollen at this time and is elevated when laying in bed. -05/15/16 at 10:55 p.m.: Resident states, that pain is better. Observed that resident is still not at a 100 percent coverage for pain. The left leg is swollen from above the knee to the inner aspect and behind the knee, is visibly in pain upon repositioning resident . -05/17/16 at 12:56 p.m.: Md in house for rounds. Recent concerns with pain control addressed. MD spoke also with resident. Md increased Neurontiin to 600 mg tid (three times a day) .and 900 mg at HS . -3:09 p.m.: .Resident c/o pain lt. leg Prn meds, Scheduled meds, given for pain with some relief also Ice pack applied Prn. -10:23 p.m.: Resident continues to c/o lt. leg pain ice pack and muscle rub applied took scheduled meds without difficulty. A progress note, signed by MD O on 05/20/16, states the following in part: Chief Complaint: Left leg and arm pain. History of Present Illness .complains about persistent right leg and arm pain on her stroke side. She currently takes [MEDICATION NAME] (Neurontiin) 300 mg with each meals and 600 mg at bedtime. I tried some [MEDICATION NAME] and increased [MEDICATION NAME] without any improvement . Vitals: (Blood Pressure) 168/106 .Physical Exam .General appearance: Abnormal. (lying on left side with dense left hemiparalysis) .Discussion/Summary: I think her pain is neuropathic in origin . Resident #10's May nurses' notes continue, in part: -05/18/16 at 3:06 p.m.: Resident continues to offer c/o pain. Resident given scheduled meds, muscle rub and repositioned throughout shift. Resident still offering c/o discomfort. Resident reassured and is aware of new med orders . -10:41 p.m.: Resident c/o pain at start of shift, was given new medication dose per orders, and ice applied for comfort, was helpful. Resident was repositioned q2h (every two hours) and prn. Resident still c/o discomfort at HS and was given scheduled medications and prn [MEDICATION NAME] 2 mg at (8:00 p.m.), muscle relaxer. Resident reassured and is aware of new med orders. Resident is resting comfortably . -05/19/16: Resident stating discomfort this am-notably in left knee area. Area observed by charge nurse, no redness noted .Area is less is (sic) size with a small area of swelling right above knee cap-presents as a tight muscle. Prn muscle rub and scheduled meds given-with stated effectiveness. -05/20/16 at 10:38 p.m.: Resident continues to c/o lt hand, leg, and foot, pain. Muscle rub applied at HS for c/o discomfort. When given medication asks for 'something for pain' when reassured pain medication being given states 'good I sure need it'. -05/21/16 at 2:17 a.m.: [MEDICATION NAME] and Tylenol given at (1:10 a.m.) for c/o left leg and knee pain. Swelling of left knee continues; ice pack applied. CNA (Certified Nursing Assistant) reported abnormal clicking felt near left knee with manipulation. Resident repositioned onto side and reported being comfortable. The note does not identify which side of the body Resident #10 was repositioned. -10:15 p.m.: Resident continues to have tenderness to left knee area. Knee is swelled. Resident has old scarring at site from prior surgery. Scheduled medication regime helpful with pain control. If pain persists next days will contact Md for further instructions . -05/22/16 at 10:50 a.m.: Left knee continues to be more swollen then (sic) the right. Is somewhat warm but not pink or discolored. Her pain today has been controlled with new meds . -05/23/16 at 11:34 a.m.: Resident had some swelling noted over left knee. Resident said it was tender when touched. AM meds given and resident laid down in bed with leg elevated and relief was obtained with this. -3:00 p.m.: When resident was asked if she had pain in her left knee, she stated yes. States it is there with and without movement. States pain level 10/10, and that the increased pain medication isn't working. Resident sitting in Broda at the time. No restlessness, moaning, facial grimacing, or vocal complaints of pain observed at the time of assessment. -8:32 p.m.: Helped resident be Hoyer lifted into bed. When asked pain number, resident states 100 (out of 10) . -9:06 p.m.: Progress notes regarding resident's pain in LEFT leg/knee faxed to (MD O) for his review. -05/24/16 at 10:15 a.m.: Follow up fax to primary MD in regards to on-going pain-left knee. Surveyor reviewed the follow-up fax, sent to MD O, on 05/24/16. The fax states the following, in part: (Resident #10) continues to have A LOT of pain in the (Left) knee area. She has a large scar on that knee-and wondering if she had a knee replacement that may have shifted? Would you consider an xray there . MD O responded to the fax at 1:26 p.m., on 05/24/16, and ordered an x-ray of the left knee. Resident #10's May nurses' notes continue, in part: -05/24/16 at 3:00 p.m.: Left leg noticeably more swollen than before. (MD O) responded to fax regarding continued pain. Resident is scheduled to have an X-Ray of the leg tomorrow at (10:30 a.m.). -10:19 p.m.: Continues to c/o lt. hand and knee pain .Continues on scheduled pain meds with little relief reported by resident. -05/25/16 at 1:25 a.m.: [MEDICATION NAME] 2mg given at (11:10 p.m. on 05/24/16) per request for c/o L leg/knee pain. Muscle rub applied to right hip and an ice pack was applied to left knee per resident . -1:50 p.m.: Resident returned from xray. Resident repositioned and resting in bed at this time. Resident continues to have much pain in left knee area, swelling present. Left, top of foot noted to be domed when she returned from app't (appointment). Teds ([MEDICAL CONDITION]-Deterrent hose or compression stockings) worn. Prn Tinazidine with scheduled (Noon) meds effective at this time for pain control. Will away xray results . It is noted, Resident #10 did not have an order to wear Ted stockings to the legs. -05/26/16 at 2:07 p.m.: Scheduled and prn [MEDICATION NAME] given this am for c/o left knee pain. Medication effective for pain control. Left knee and foot remain [MEDICAL CONDITION]. Results pending from knee xray. -2:30 p.m.: .This writer placed a phone call to Shell Lake Clinic to see if results back from knee x-ray performed .on 5/25/16 .The nurse at first stated that sometimes it takes 'a while' to get results, but when she looked-the results were already in the residents (sic) chart. Shell Lake nurse then stated 'Oh, she has a fracture. I should have the on-call Dr. look at this.' This writer then notified charge nurse and D. O. N. (Director of Nursing) of findings . The x-ray identified Resident #10 has a left femur fracture with slight displacement and angulation of major fracture fragments and osteopenia. Resident #10 had a new order to wear an immobilizer on the left leg. Resident #10's nurses' notes, for 05/31/16, state in part: -11:21 a.m., Social Services documentation: .Wrier followed up regarding injury by interviewing resident .Writer asked resident about fracture in leg. Writer asked resident if she knew how it happened. Resident said, 'Deep pain in left leg' .Resident then said, 'My left arm and left leg hurt' . -9:43 p.m.: Blister rt. (right) heel intact quilted heel protector worn this shift . There are no measurements identified in the medical record of the blister. Resident #10's May 2016 MAR indicated [REDACTED] -05/09/16 at 12:25 a.m.: Tylenol 500 mg, left leg hurts -05/14/16 at 4:00 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/14/16 at 10:49 a.m.: [MEDICATION NAME] 2 mg -05/14/16 at 8:00 p.m.: [MEDICATION NAME] 2 mg -05/15/16 at 6:00 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/15/16 at 8:10 p.m.: [MEDICATION NAME] 2 mg -05/16/16 at 2:40 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/16/16 at 1:41 p.m.: [MEDICATION NAME] 2 mg -05/17/16 at 3:10 a.m.: [MEDICATION NAME] 2 mg -05/19/16 at 3:35 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/20/16 at 5:10 a.m.: Tylenol 500 mg -05/21/16 at 1:10 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/23/16 at 3:00 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg were given for c/o right foot and leg pain. There were no other as needed pain medications given on this date, when Resident #10 experienced pain rated at 10 out of 10, and later 100 out of 10. -05/24/16 at 5:40 a.m.: Tylenol 500 mg and [MEDICATION NAME] 2 mg -05/24/16 at 10:10 p.m.: [MEDICATION NAME] 2 mg -05/25/16 at 12:00 p.m.: [MEDICATION NAME] 2 mg given for pain control -05/26/16 at 7:30 a.m.: [MEDICATION NAME] 2 mg given for muscle/pain relief -05/28/16 at 2:00 a.m.: Tylenol 500 mg -05/28/16 at 6:00 a.m.: [MEDICATION NAME] 2 mg -05/28/16 at 4:30 p.m.: [MEDICATION NAME] 0.5 mL, pain rated a 10 out of 10. This is the first time the as needed [MEDICATION NAME] was given to Resident #10 for pain management. -05/29/16 at 2:20 a.m.: Tylenol 500 mg -05/29/16 at 4:15 a.m.: [MEDICATION NAME] 2 mg -05/30/16 at 4:35 a.m.: [MEDICATION NAME] 2 mg Resident #10 used as needed pain medication five times in the month of April, and 23 times during the month of May. There are no resident pain rating scales on the MAR, or in the nurses' notes, except for 05/23/16 and 05/28/16. There are no pain assessments in May, in response to Resident #10's significant increase in pain. Surveyor reviewed Resident #10's restorative/range of motion documentation for May 2016. The documentation indicates Resident #10 did not receive range of motion exercises on the following dates, 05/10/16, 05/11/16, 05/18/16, 05/20/16, and 05/27/16. Resident #10 did not participate in passive range of motion on 05/19/16 and 05/24/16. Resident #10 did not participate in active range of motion on 05/12/16, 05/14/16, 05/15/16, 05/17/16, 05/25/16 and 05/26/16. There was no documentation to indicate why Resident #10 did not receive restorative exercises for the above eleven days. Resident #10's pain assessment, dated 06/02/16, states the following, in part: .DESCRIPTION: significant change .At any time in the last 5 days, has the resident received non-medication intervention for pain? Yes .splint, rest, reposition, offer ice pack Location of Pain: left knee .How much of the time have you experienced pain or hurting over the last 5 days .Frequently .Pain Presence .Early Morning, Mid Morning, Afternoon, Evening .What brings pain on or increases pain? Movement .Duration of Pain: Pain Comes and Goes .Manner of Expressing Pain: Other-verbalizes .Numeric Rating Scale (00-10): (Did not provide rating) .Comments: Much better with splint on .Indicate Plan of Care action taken: Continue Current Plan of Care . Resident #10's most recent MDS, dated [DATE], indicates frequent and severe pain within the last five days. Resident #10 did not rate her pain, on a scale of 0 to 10. Surveyor reviewed Resident #10's comprehensive care plan, updated on 06/06/16. The care plan states the following, in part: .Problem .ADL Functional .Approach Start Date 06/06/2016. Mobility .I am in a Broda chair. Assist of one staff member needed to navigate Broda through out the facility .Repositioning: Assist of one staff member to turn and reposition me every 2 hours while in bed . Problem .Pain .I have a potential for pain r/t previous [MEDICAL CONDITION]'s .immobility and my recent left pathological femur fracture at the end of May 2016 .Goal .My pain will be a 3 or less on a 1-10 scale and I will show no non-verbal signs of pain within 40 minutes of prn [MEDICATION NAME] being given . This comprehensive care plan has the same approaches and restorative/range of motion exercise program as the care plan, dated 04/27/16. The facility did not update Resident #10's care plan with individualized and updated interventions and care techniques for pain management. The care plan has not been updated to reflect if Resident #10 is currently receiving a restorative/range of motion exercise program to the lower extremities. Resident #10's nurses' notes for June 2016, state the following, in part: -06/01/16 at 4:43 a.m.: [MEDICATION NAME] 2mg given at (4:40 a.m.) per request for c/o left leg pain. Repositioning tried first but pain persisted per resident. -06/03/16 at 2:05 a.m.: Tylenol 500mg was given at (1:50 a.m.) per request for c/o left arm and leg pain. Staff have repositioned multiple times so far this shift. -9:13 a.m.: .Resident continues to c/o pain after scheduled meds given .Resident unable to move foot when asked. Resident rated pain at a 9 on a scale from 1-10. Blister continues to be intact. -10:36 p.m.: Resident continues to c/o break thru pain rated 9/10, scheduled meds given with some relief . -06/04/16 at 11:06 a.m.: Resident c/o pain this a.m. level 9, was given scheduled pain medication and was effective . -06/05/16: Resident continues to have breakthrough pain and prn medications are helpful, but not giving complete coverage . -06/07/16: Tylenol 500mg was given at (1:30 a.m.) per request for c/o left leg pain. Repositioning was tried prior to administration but c/o pain persisted. Splint (immobilizer) intact . -3:02 p.m.: .Prn [MEDICATION NAME] 0.5mg given in am for stated pain, resident states mixed results 'It helped some.' Scheduled [MEDICATION NAME] 50mg given. At (11:00 a.m.)-resident stating discomfort. Prn [MEDICATION NAME] given at that time. Resident states it 'helped' .Resident continues to refuse offer of ice pak . -06/08/16 10:26 a.m.: Signed request by (MD O) for .continuance of therapy prescription for [MEDICATION NAME] sulfate conc (concentration) 20mg/ml . -11:24 a.m.: .At (10:00 a.m.), resident stated she was having pain, prn [MEDICATION NAME] 10 mg given at that time. Resident resting comfortably at this time. Resident #10's June 2016 MAR indicated [REDACTED] -06/01/16 at 2:10 a.m.: Tylenol 500 mg -06/01/16 at 4:40 a.m.: [MEDICATION NAME] 2 mg -06/02/16 at 1:45 a.m.: Tylenol 500 mg -06/03/16 at 1:50 a.m.: Tylenol 500 mg -06/04/16 at 4:15 p.m.: [MEDICATION NAME] 2 mg -06/05/16 at 10:00 a.m.: Tylenol 500 mg -06/05/16 at 9:37 p.m.: [MEDICATION NAME] 2 mg -06/06/16 at 12:45 a.m.: Tylenol 500 mg -06/07/16 at 1:30 a.m.: Tylenol 500 mg -06/07/16 8:30 a.m.: [MEDICATION NAME] 5 mg given for pain control. -06/07/16 at 11:40 a.m.: [MEDICATION NAME] 2 mg given for general pain and pain in the hand Resident #10 has received as needed pain medication daily, for the first seven days of June 2016. There are no pain rating scales on the MAR indicated [REDACTED]. On 06/07/16 at 7:00 a.m., Surveyor interviewed Resident #10. Resident #10 was wearing the immobilizer on the left leg. Resident #10 stated the left leg hurts all the time and is worse when staff move her. Resident #10 states sometimes the pain medications help alleviate the pain. Resident #10 described the pain as bad. Surveyor asked if Resident #10 experienced excruciating pain, prior to the use of the immobilizer on 05/26/16, to which Resident #10 replied, Yes. Resident #10 stated she was experiencing pain currently. Surveyor asked Resident #10 a question regarding pain with movement, to which Resident #10 replied, I'm having pain right now. Resident #10 remained seated in the wheelchair and was not moving or repositioning. Surveyor asked if Resident #10's pain is worse in the morning, and Resident #10 replied, I'm having pain right now. At this time, Resident #10 confirmed the current pain was located in the left leg. On 06/08/16 at approximately 10:06 a.m., Surveyor interviewed Resident #10 who was sitting in a Broda chair. Resident #10 stated she experienced difficulty sleeping, prior to 05/26/16, due to the pain in the left leg. Resident #10 stated there were times in which the pain affected the resident's activity attendance, as well. Surveyor asked if Resident #10 had pain during repositioning, prior to 05/26/16. Resident #10 replied staff would bend her left knee when rolling from side-to-side in bed. Resident #10 stated, It really hurt. Resident #10 indicated bed mobility while wearing the immobilizer is difficult, but it helps with the pain. On 06/08/16 at 7:30 a.m. and at 10:00 a.m., Surveyor interviewed CNA A who provides range of motion and restorative exercises to residents. CNA A indicated a few weeks prior to Resident #10's x-ray on 05/25/16, Resident #10 was having more pain and swelling in the left leg, which was abnormal. CNA A stated Resident #10 was less active and not able to move the left leg as much. CNA A stated she informed the charge nurse when these issues were identified. During the continued interview, CNA A indicated Resident #10 had pain daily with cares, transfers and repositioning a few weeks before the fracture was identified. CNA A stated Resident #10 has had daily pain since an immobilizer was placed on the left knee, on 05/26/16, but the pain is better now. Surveyor discussed the restorative/range of motion documentation for April and May 2016 with CNA A. CNA A states she writes in a restorative notebook whenever residents refuse or if the resident is unavailable. CNA A indicated the blanks on Resident #10's restorative documentation could have resulted from Resident #10 refusing to participate or being unavailable. CNA A stated Resident #10 normally would participate in range of motion exercises. On 06/08/16 at 2:10 p.m., Surveyor interviewed MD N, who is the facility's medical director and visits the facility a few times per week. MD N stated he reviewed the facility self-report investigation, regarding Resident #10's fracture. On 06/08/16 at 4:12 p.m., Surveyor interviewed the DON and Nursing Home Administrator (NHA). Surveyor was present at this time. The DON indicated Resident #10 is capable of informing staff when the resident is experiencing pain. The DON stated the resident has had chronic right-sided pain in the past.The DON indicated Resident #10's pain is assessed by pain scales and the resident-reported ratings should be documented on the resident's MARs. Surveyor indicated no other pain ratings were identified on the MARs or in the medical record, except those indicated above. Surveyor requested any other pain assessments or pain rating scales, documented for Resident #10. No further information was provided to the surveyor. 2. Resident #8's [DIAGNOSES REDACTED]. Resident #8 has a stage III pressure injury originating from a deep tissue injury secondary to diabetic [MEDICAL CONDITION]. On 06/08/16, Surveyor observed Resident #8's durable medical equipment. Resident #8's bed had a standard facility issued mattress. At 9:15 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) E, who functions as the facility's wound nurse. LPN E indicated that Resident #8 had not agreed to sleep in bed until December of 2015, and at that time the facility did not offer a mattress appropriate for a stage III pressure ulcer. Surveyor reviewed the manufacturer's recommendations for Resident #8's current mattress. The recommendations stated, in part, .used to treat low to moderate risk levels . LPN E agreed that Resident #8 qualified for high risk mattress interventions due to Resident #8's current wound and diagnosis. LPN E stated that she would talk to Resident #8 regarding the use of a mattress that would provide a higher grade of pressure relief. 3. Resident #8 On 06/08/16, Surveyor interviewed Resident #8. Resident #8 stated that the facility checks his intact foot once a week, after a shower, for any open areas or abnormalities. The CNAs are responsible for this, and inform the charge nurse if there are any findings. Resident #8 stated, They check my foot once a week after my bath. The bath girls do it. Then they let the nurse know if they find anything. No observations of daily foot assessments were noticed during the survey. Resident #9 Resident #9's [DIAGNOSES REDACTED]. Resident #9's BIMS score was 15, indicating no cognitive defect. On 06/07/16 at 7:00 a.m., Surveyor interviewed Resident #9. Resident #9 stated, They check my foot often, but not daily. No observations of daily foot assessments were noticed during the survey. On 06/08/16 at 9:30 a.m., Surveyor interviewed LPN E, who is responsible for the wound management in the facility. LPN E indicated diabetic foot checks are performed upon admission and weekly. Resident #8 has assessments every third day, since that is when Resident #8's wound care is due. Resident #9 receives weekly assessments. LPN E told Surveyor that weekly skin assessments are the practice of the facility, regardless of the resident's diagnosis (i.e., high risk for breakdown). The American Diabetes Association recommends .check your feet daily .look at your feet daily. If you can't see the bottoms of your feet, ask someone to help you . (*ADA 10/10/14). 4. Resident #5's [DIAGNOSES REDACTED]. Review of Resident #5's medical record identified the physician orders did not contain treatment orders for the toes of the right and left foot. Review of the nurses' wound documentation notes, read in part: 05/16/16 4:04 p.m., Initial Wound Observation: Unavoidable pressure injurie

Based on interview and record review, the facility did not consult with a physician in a timely manner for two of fifteen residents reviewed, when a significant change in condition occurred. 1. The facility did not promptly consult with a physician when Resident #10 was having an increase in left leg/knee pain, swelling, and when staff heard an abnormal clicking by the resident's knee. Resident #10 was later found to have a left femur fracture. 2. Resident #14 had one episode of a significantly high blood pressure, and two episodes of significantly low blood pressures. The facility did not consult with a physician regarding the significant changes in the blood pressure readings. This is evidenced by: On 06/07/16 at 12:37 p.m., Surveyor received and reviewed a facility policy, entitled, New Process for calling Doctors 1/19/16. The policy states the following, in part: Step 1: Call the Primary Doctor First. If the primary MD (Medical Doctor) does not answer, do not leave a message, proceed to step 2. Step 2: Call the on Call Doctor listed on the On Call List at the nurse's station. There will be a month to month on call list provided to the NH (Nursing Home) from the hospital. If the On call person does not respond in an appropriate time frame for the condition that arises, move to step 3. Step 3: Call (MD N's name, who is the facility's Medical Director) if step 1 and step 2 are unsuccessful, and he will address the situation. Remember To: If it is a true emergency, do not wait, for the Doctor to return your call, work through the steps rapidly .Try to call during waking hours when able .Remember to document your attempts to reach the doctors in your documentation . Surveyor received and reviewed a facility policy entitled, Pain Assessment and Management. The policy, revised March 2015, states the following, in part: .Identifying the Causes of Pain .Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including .[MEDICAL CONDITION] .Fractures .[MEDICAL CONDITION] . Monitoring and Modifying Approaches .If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated . Reporting. Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain .3. Prolonged, unrelieved pain despite care plan interventions . On 06/07/16, Surveyor reviewed Resident #10's medical record. Resident #10 has [DIAGNOSES REDACTED]. Resident #10's Brief Interview for Mental Status (BIMS) score, dated 04/26/16, was a 13 out of 15 possible points, indicating intact cognitive status. The Minimum Data Set (MDS), dated [DATE], indicates Resident #10 is not able to walk, and uses a Hoyer lift (a mechanical lift which uses a body sling) with the assistance of two staff members for transfers. Resident #10 requires total staff assistance for dressing, bed mobility, bathing and personal hygiene. The care plan identifies Resident #10 is to be repositioned by staff every two hours. The care plan indicates Resident #10 receives upper and lower body active and passive range of motion/restorative exercises for strength and stretching, six days a week. Surveyor reviewed Resident #10's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Resident #10 received as needed pain medication for left leg pain, on 04/05/16, 04/07/16, 04/11/16, 04/14/16 and 04/22/16. Resident #14's nurses' notes, dated 04/01/16 to 06/08/16, were reviewed. The nurses' notes state the following, in part: -04/13/16: .has been having pain in legs at night lately requesting extra pain medicine. The note does not identify which leg the pain is located. -05/11/16: Resident continues on scheduled pain medications continues to c/o (complain of) lt. (left) leg pain Muscle rub applied states 'it helps'. -05/12/16 at 11:02 a.m.: Resident continues to have pain with movement. Fax to MD (Medical Doctor) at this time. The note does not identify where the pain is located. -7:01 p.m.: (MD O's name) ordered [MEDICATION NAME] 2mg (milligrams) .q6hr (every six hours). for a muscle relaxer for resident. -9:33 p.m.: Continues on scheduled [MEDICATION NAME] for and Tylenol 975 (mg) at HS (Hour of Sleep) and muscle rub for c/o pain lt. leg. states 'better' when asked if it helps. -05/13/16 at 10:23 p.m.: Resident given pain medication as ordered, she had pain through out shift. complaints of pain to left knee with swelling noted, ice pack applied to knee and elevated -10:28 p.m.: .BP (Blood Pressure) 168/106 .States having pain in left leg just above the knee for 'a month, well, a long time'. States pain when moving knee, not while at rest. Left leg just above the knee, in particular, is swollen, and the left leg is also slightly swollen. No redness or bruising. Skin color is same as right leg .Left LE (Lower Extremity) and foot is warm to the touch, pedal pulse palpated .Fax sent to (MD O), and passed along in shift report. Surveyor reviewed the fax, sent to MD O on Friday 05/13/16 at 11:04 p.m. The fax states the following, in part: .(Resident #10's name) has swelling of the left leg at the knee and just above, in particular. The left leg is also slightly swollen. BPs have been elevated. See notes (and) VS (Vital Signs) report. Would you assess when you can .Any new orders? The notes and vital reports were not attached to this fax. The fax did not identify Resident #10 had been having this pain for approximately one month, or pain with movement. MD O did not respond to this fax until Monday 05/16/16 at 12:34 p.m., three days later. The physician indicated Resident #10 would be assessed in-person, at the facility on 05/17/16. There is no documentation in Resident #10's medical record another physician was notified and consulted when the increased pain and swelling, between 05/13/16 and 05/16/16. Resident #10's nurses' notes identify the resident was having continued pain, from 05/16/16 to 05/20/16. The nurses' notes continue, in part: -05/21/16 at 2:17 a.m.: [MEDICATION NAME] and Tylenol given at (1:10 a.m.) for c/o left leg and knee pain. Swelling of left knee continues; ice pack applied. CNA (Certified Nursing Assistant) reported abnormal clicking felt near left knee with manipulation . There is no documentation a physician was notified and consulted, regarding the abnormal clicking in Resident #10's left leg. The nurses' notes, continue, in part: -05/23/16 at 3:00 p.m.: When resident was asked if she had pain in her left knee, she stated yes. States it is there with and without movement. States pain level 10/10, and that the increased pain medication isn't working. Resident sitting in Broda (wheelchair) at the time. No restlessness, moaning, facial grimacing, or vocal complaints of pain observed at the time of assessment. -8:32 p.m.: Helped resident be Hoyer lifted into bed. When asked pain number, resident states 100 (out of 10) . -9:06 p.m.: Progress notes regarding resident's pain in LEFT leg/knee faxed to (MD O) for his review. -05/24/16 at 10:15 a.m.: Follow up fax to primary MD in regards to on-going pain-left knee. There is no documentation in Resident #10's medical record a physician was promptly notified and consulted regarding the increase in pain, and Resident #10's reported pain scale of 100. Surveyor reviewed the follow-up fax, sent to MD O on 05/24/16. The fax states the following, in part: (Resident #10) continues to have A LOT of pain in the (Left) knee area. She has a large scar on that knee-an wondering if she had a knee replacement that may have shifted? Would you consider an xray there . MD O responded to the fax at 1:26 p.m. on 05/24/16 and ordered an x-ray of the left knee. On 05/26/16, an x-ray (completed on 05/25/16) identified Resident #10 has a left femur fracture with slight displacement and angulation of major fracture fragments. The x-ray identified Resident #10 has osteopenia. On 06/07/16 at approximately 3:30 p.m., Surveyors and interviewed the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The DON indicated the facility follows the American Medical Director's Association (AMDA) standards of practice, for notifying a physician of a resident's change of condition. According to AMDA guidelines, the facility should immediately notify a physician when there is new severe pain, or marked increase in chronic pain. AMDA guidelines identifies immediate physician notification is classified as Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and A Marked Change (i.e. more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed . On 06/08/16 at 7:30 a.m. and at 10:00 a.m., Surveyor interviewed CNA A. CNA A provides range of motion and restorative exercises to residents, including Resident #10. CNA A indicated a few weeks prior to Resident #10's x-ray on 05/25/16, CNA A noticed Resident #10 was having more pain and swelling in the left leg, which was abnormal. CNA A stated she also noticed Resident #10 was more inactive and not able to move the left leg as much. CNA A stated she informed the charge nurse when these issues were identified. On 06/08/16 at 2:10 p.m., Surveyor interviewed MD N, who visits the facility a few times per week. MD N stated he reviewed the facility self-report investigation, regarding Resident #10's fracture of unknown origin. MD N stated he had concerns regarding the timeliness of physician notification, appropriate MD response, and why an x-ray was not obtained at an earlier time. MD N reported speaking with MD O, regarding the above concerns. According to MD N, MD O believed Resident #10 was experiencing neuropathic pain in the left leg and knee. According to MD N, MD O's clinic has preferred the facility to fax the physicians with any resident updates. MD N stated this isn't the best way to notify a physician. MD N stated the facility could have called and notified him of Resident #10's significant changes. On 06/09/16 at approximately 10:35 a.m., Surveyor interviewed the DON. Surveyor asked how the facility contacts a physician during non-working hours. The DON replied the facility can fax the clinic, unless it is something that needs to be handled immediately. If something emergent arises, the DON indicated the facility would call the Shell Lake on-call physician, which has MDs on-call 24-hours per day. The DON stated the facility should have notified and consulted with a physician when Resident #10 was experiencing pain on a scale of 100 and when abnormal clicking was heard on 05/21/16. 2. On 06/08/16, Surveyor reviewed Resident #14's medical record. Resident #14 had [DIAGNOSES REDACTED]. Resident #14 was admitted to the facility on [DATE]. The hospital documentation identifies Resident #14 had the following blood pressure readings: -2/27/16: 117/62 -02/28/16: 146/78 -02/29/16: 151/66 Resident #14 had the following medications, used to manage high blood pressure, ordered upon Resident #14's admission to the facility: -[MEDICATION NAME] 12.5 mg, daily at 8:00 a.m. -[MEDICATION NAME] 5 mg, daily at 8:00 a.m. There are no physician ordered blood pressure parameters located in Resident #14's medical record. Surveyor reviewed Resident #14's nurses' notes, and vitals report, from 02/29/16 to 03/21/16. The documentation states the following, in part: -03/02/16: High blood pressure reading of 168/99. -03/07/16: 99/56 -03/14/16: Low blood pressure reading of 81/50 -03/15/16: 122/66 -03/21/16: Low blood pressure reading of 83/52 at 1:09 p.m. Low reading of 90/63 at 2:00 p.m. According to the facility's documentation on the vitals report, an acceptable range for a resident's blood pressure is 90-160 /50-100. A nurse's note, dated 03/21/16 at 2:00 p.m., states in part, Noted lower b/p (blood pressure) in am--recheck at this time is 90/63. Resident states that she did not feel dizzy or weak this am when first blood pressure was taken with am shower. There is no documentation regarding what time Resident #14 had a shower. Surveyor reviewed Resident #14's March 2016 MAR. The MAR indicated [REDACTED]. There is no documentation of Resident #14's blood pressures, from 03/16/16 to 03/20/16. There is no documentation in Resident #14's medical record a physician was notified and consulted regarding Resident #14's significantly high blood pressure, on 03/02/16, or low readings on 03/14/16 and 03/21/16. On 06/08/16 at 4:12 p.m., Surveyor interviewed the DON. Surveyor and the NHA were present at this time. The DON confirmed Resident #14's MAR indicated [REDACTED]. The DON was not aware of Resident #14's low blood pressure readings, on 03/14/16 and 03/21/16. Surveyor asked for any documentation in which a physician was notified of Resident #14's significant changes in blood pressures. On 06/09/16 at 10:15 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) M. LPN M indicated the CNAs obtain the resident's blood pressures on the days residents receive showers. LPN M confirmed she rechecked Resident #14's blood pressure at 2:00 p.m. on 03/21/16. LPN M is not able to remember if an earlier blood pressure recheck was completed on 03/21/16, but stated it would have been documented. LPN M does not remember if a physician was notified and consulted with, on the days of the significant changes in Resident #14's blood pressure (03/02/16, 03/14/16 and 03/21/16). At 10:33 a.m., Surveyor interviewed CNA S, who provided Resident #14 with weekly showers. CNA S indicated Resident #14 was not a morning person, and usually received a shower between 7:30 a.m. and 8:15 a.m. CNA S did not remember if Resident #14 received morning medications before, or after a shower. CNA S stated she will immediately notify the charge nurse, with any significant changes in a resident's blood pressures, such as anything in the 80's, or anything less than 54. At 12:20 p.m., Surveyor interviewed the DON. Surveyor was present. The DON stated a physician was not notified regarding Resident #14's significant changes in blood pressure readings. The DON stated Resident #14 did not have any blood pressure parameters, ordered by a physician. The acceptable parameters, identified in the vital reports, are parameters for everyone in the facility. The DON indicated Resident #14 had not been taking the high blood pressure medications for very long so the facility should have been routinely documenting on the resident's condition and vitals as an event. The DON indicated she discussed the above issues with LPN M. According to the DON, LPN M said the blood pressure medications would never have been given after Resident #14's low blood pressure readings, and rechecks.

Based on observation, interview and record review, the facility did not provide the necessary treatment and services to promote healing, prevent infection and prevent new open areas from developing for 2 of 2 residents (Residents #4 and #8) reviewed with pressure ulcers and 2 of 3 residents (Residents #10 and #5) at risk for developing pressure ulcers. Resident #4 has a history of pressure ulcers. The facility did not complete a skin assessment such as a tissue tolerance test to determine a specific repositioning schedule. The resident's care plan did not include a repositioning schedule. Staff did not inspect resident's skin daily. Staff did not follow aseptic technique when changing a dressing. The facility did not document that the ulcers were unavoidable. Resident #8 has a history of pressure ulcers. The facility did not complete a skin assessment such as a tissue tolerance test to determine a specific repositioning schedule. Staff did not inspect resident's skin daily. The facility did not document that the ulcers were unavoidable. The facility did not initiate a repositioning schedule for Resident #10, who was at high risk for the development of a pressure ulcer. The facility did not provide evidence that the resident was being repositioned per facility policy. Resident #5 was identified at high risk for the development of a pressure ulcer. The facility did not provide a repositioning schedule to reflect current standards of practice for Resident #5. The facility did not provide evidence that the resident was being repositioned per facility policy. This is evidenced by: According to the standards of practice outlined by the NPUAP (National Pressure Ulcer Advisory Panel). a pressure ulcer is skin and tissue damage, as the result of friction and shearing (rubbing) and/or pressure (pressing in) over a bony prominence. The NPUAP states skin should be inspected at least daily and document assessment results. Bed bound persons should be repositioned at least every 2 hours and chair bound residents should be repositioned every hour. The facility's policy, "Pressure Ulcer Risk Assessment" dated October 2010 states, "1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. 2. The most common site of a pressure ulcer is where the bond is near the surface of the body including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, ankles and toes...1. Risk Assessment. A pressure ulcer risk assessment will be completed upon admission, with each additional assessment, quarterly, annually and significant changes. 2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a "skin alert" performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. " 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per admission skin risk assessment completed on 10/16/12, the resident had no open areas and was not identified as being at high risk for development of pressure ulcers with a Braden scale of 22 (19 or higher not at risk). A diabetic foot screen completed on 10/17/12 identified Resident #4 had an area of dead skin on the bottom of the right foot at the base of the large toe. The Minimum (MDS) data set [DATE] stated the resident required extensive assistance of two staff with bed mobility and transfers. The resident had impairment of range of motion on both lower extremities. The assessment stated the resident was at high risk for developing pressure ulcers and had no current pressure ulcers. The Care Area assessment dated [DATE] stated the resident was at risk for skin problems as he spends most of the day either in his w/c or bed. -History of Heel ulcer Per Nurses note dated 10/30/12 stated, "Assessed resident's right outer heel this a.m. Resident has suspected deep tissue injury, measures 3.5 x 2.5 x 0 cm (centimeters) at this time. Area is not open at this time, color purple." On 10/24/12 a Braden Scale assessment was completed and rated the resident at 17 at risk of developing pressure ulcers. The resident was coded as: having very moist skin, chairfast with ability to walk severely limited or nonexistent. Can't bear own weight and/or must be assisted into chair or wheelchair. Resident's ability to change and control body position was slightly limited making frequent, though slight, changes in body or extremity position independently. The Braden scale assessment completed on 11/01/12 and 11/08/12 was scored at 18. The Braden scale assessment completed on 11/16/12 was scored at 17. The assessment stated the resident was readmitted to the facility from the hospital. The assessment stated the resident continued to have a 3.5 x 3.5 cm black, suspected deep tissue injury to outer right heel. Noted increase in size since resident discharged from the hospital. Per nurses note dated 01/23/13 at 1:08 p.m. evaluation note stated area is resolved. -New ulcers The Wound Evaluation Flow Sheet dated 01/16/13 stated the resident had a 0.8 cm x 0.5 cm diabetic ulcer on the left great toe. The area is intact and reddened. The area continued to decrease in size and measured 0.4 x 0.3 cm on 02/20/13. The Wound Evaluation Flow Sheet dated 02/06/13 stated the resident had a stage 2 pressure ulcer measuring 0.8 x 0.8 x 0.1 cm on the right sacrum with another stage 2 pressure ulcer measuring 0.6 x 0.6 x 0.1 cm on the left sacrum. The skin measurement dated 02/21/13 stated the ulcer on the right sacrum measured 0.6 x 0.5 x .05 cm. and the left sacrum ulcer measured 0.4 x 0.3 x .05 cm. On 02/06/13 the MDS stated the resident required extensive assistance of two staff with bed mobility, transfers, locomotion on and off the unit and toileting. The resident continued with impairment in range of motion on both lower extremities. The resident was at risk for developing pressure ulcers and had two stage 2 ulcers present. The Wound Evaluation Flow Sheet dated 02/09/13 stated the resident had a stage 2 pressure ulcer on the right gluteal fold measuring 0.5 x 0.5 x 0.1 cm. The resident's current care plan dated 01/31/13 and current Certified Nursing Assistant (CNA) care plan do not include a repositioning schedule for the resident. Surveyor reviewed the resident's chart on 03/04/13 and found no skin assessment such as a tissue tolerance test to determine a specific repositioning schedule and no documentation that the resident's skin was inspected daily. The surveyor could not find documentation stating the resident's ulcers were unavoidable. On 02/24/13 Surveyor observed Resident #4 seated in a wheelchair from 3:35 p.m. to 5:40 p.m. with no change in positioning. On 03/04/13 at 10:05 a.m. Surveyor questioned the Director of Nursing related to their pressure ulcer protocol. The DON stated the facility does not complete tissue tolerance tests as all their beds are pressure reducing. The DON stated the Certified Nursing Assistants inspect skin daily and weekly with showers. No documentation of daily skin inspections was provided. The surveyor asked for documentation of a turning schedule for Resident #4. No information was provided. The DON stated the resident is independent with repositioning in bed and is able to shift his weight in a chair. The DON stated the resident acquired the ulcers on the heel and sacrum at the facility. The DON stated the resident refused cares in a 24 hours period and laid in a soaked bed prior to the skin breakdown on his sacrum. Surveyor requested that documentation. No documentation was provided. -Dressing Change The physician orders [REDACTED]. Change q (every) 72 hrs (hours) and PRN (as necessary) and [MEDICATION NAME] to upper right thigh. Special instructions: change q 72 hrs and PRN." On 02/27/13 at 12:15 p.m., Surveyor observed Licensed Practical Nurse (LPN) Z change a dressing on Resident #4. LPN Z removed the soiled dressing on the sacrum and cleansed the ulcers and applied a new [MEDICATION NAME] dressing without changing her gloves. On 02/28/13 at 1:00 p.m., Surveyor observed Registered Nurse (RN) E change a dressing on the resident's sacrum and right gluteal area. RN E gloved and opened a package of [MEDICATION NAME]. RN E did not change her gloves prior to cleansing the ulcers and applying new [MEDICATION NAME] dressings. RN E did not change her gloves between cleansing and applying new [MEDICATION NAME] to three different ulcers (the right gluteal ulcer and two sacrum ulcers). The Director of Nursing measured the ulcer on the right gluteal area as 0.5 cm x 0.3 x 0.25 cm and stated the ulcer was a stage 2 healed ulcer. Surveyor requested the facility obtain a flash light to better view the ulcer. Upon using a flash light the DON then stated the ulcer was an stage 2 opened ulcer. The facility's procedure,"Dressings, Dry/Clean" dated August 2011 states, The purpose of this procedure is to provide guidelines for the application of dry, clean dressings...7. Wash and dry your hands thoroughly. 8. Put on clean gloves. Loosen tape and remove soiled dressings. 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open dry, clean dressing (s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 12. Using clean technique, open other products. 13. Pour prescribed cleansing solution over the dry, clean gauze into clean basin section of tray. 14. Put on clean gloves...16. Cleanse the wound. 17. Use dry gauze to pat the wound dry. 18. Apply the ordered dressing and secure with tape." On 03/04/13 at 10:45 a.m. Surveyor discussed the dressing observations with the DON. The DON stated RN E should have changed her gloves. 2. Resident # 8 was admitted on [DATE]. Per the admission record Resident #8 was admitted with [DIAGNOSES REDACTED]. Skin Integrity Event form dated 12/16/11 stated the resident had a burn like lesion on the right gluteal fold 0.6 cm wide by 5.1 cm long with an open area 0.3 x 0.2 cm proximal to the scrotum. The progress notes dated 01/15/12 stated the resident had several open areas on top of toes bilaterally. Also the resident had an open area on lateral side of left foot and outer left ankle. Right ankle also had an open area. Per Minimum (MDS) data set [DATE] stated Resident #8 required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. Resident #8 has functional limitation of range of motion to upper extremity on one side. Resident #8 was identified as being at high risk for developing pressure ulcers. At the time of the assessment the resident did not have any current pressure ulcers. Interventions in place were pressure reducing devices in bed and chair, the resident was on a turning schedule. The Care Area Assessment (CAA) for falls stated,"His braden indicates not at risk." The CAA's for Pressure Ulcers stated the resident is at risk for skin problems due to his immobility, dependency for transfers, incontinence of stool and need to be repositioned by staff when in bed. The CAA's further stated the resident had a stroke and wears a splint on his left forearm/hand. He is unable to walk. He can propel the w/c short distances. His skin is free of breakdown." The quarterly MDS dated [DATE] stated Resident #8 required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toilet use. Resident #8 has functional limitation of range of motion to upper extremity on one side. Resident #8 is at risk for developing pressure ulcers, has no unhealed pressure ulcers at stage 1 or higher. The residents has a pressure reducing device for chair and bed and is on a turning/ repositioning program. The Braden Skin Assessment completed on 01/09/13 stated the resident requires extensive assistance with bed mobility and is very limited with making occasional slight changes in body or extremity position, but unable to to make frequent or significant changes independently and has a potential problem with friction and shearing. The Braden score was 15 for high risk for developing pressure ulcer. The assessment stated the resident is at risk for breakdown due to incontinence of stool, immobility, dependency upon staff for transfers and has a contracture of the left hand. The resident is dependent on staff for skin care and repositioning. On 01/24/13 per the Wound Evaluation Flow Sheet, Resident #8 developed a right inner heel blister that measured 3 x 3 cm. On 02/24/13 per the Wound Evaluation Flow Sheet, Resident #8 developed a stage 2 ulcer on his left upper gluteal fold measuring 1.7 x 0.4 x 0.1 cm. On 02/27/13 at 7:15 a.m., Surveyor observed LPN Z and the DON perform a dressing change on Resident #8. The DON measured the right heel ulcer as 2.8 x 2.8 x 0.2 cm. The left upper gluteal ulcer measured at 0.8 x 0.5 x 0.1 cm. On 02/26/13 Surveyor observed Resident #8 seated in his wheelchair from 7:20 a.m. to 9:08 a.m. with no repositioning. Surveyor reviewed the Resident #8's chart on 03/04/13 and found no skin assessment such as a tissue tolerance test to determine a specific repositioning schedule and no documentation that the resident's skin was inspected daily. The surveyor could not find documentation stating the resident's ulcers were unavoidable. On 03/03/13 at 10:00 a.m., Surveyor interviewed the DON related to Resident #8. The resident's ulcers were acquired at the facility. The DON stated the facility does not complete tissue tolerance tests. The DON stated the Certified Nursing Assistants inspect skin daily and weekly with showers. No documentation of daily skin inspections was provided. 3. Resident #10 [DIAGNOSES REDACTED]. On 02/27/13 Surveyor observed hygiene cares and wound cares provided for Resident #10. Resident #10 required assistance with turning and repositioning. The resident had a pressure reducing mattress on his bed. Surveyor reviewed Resident #10's clinical record. The MDS (Minimum Data Set) dated 12/19/12, stated that Resident #10 required one person extensive assistance with bed mobility. The Nursing Care plan, dated 01/03/13, stated "Bed Mobility: Assist of one. Use lift sheet. Heel protectors in bed. Arm protectors when up. ROHO cushion in w/c(wheelchair)." Turning and repositioning to prevent the development of pressure area(s) was not addressed on the nursing care plan or on the nursing care cards (Nursing Assistant Assignment Sheets). On 02/28/13, Surveyor reviewed a document entitled "Skin and Wound Management" provided by the DON. The document states, in part, that "......Extrinsic risk factors for pressure ulcers include.....pressure--the resident is not capable of moving without assistance, is confined to bed, and/or requires a regular schedule of turning." On 03/3/13 at 10:05 a.m., Surveyor interviewed the DON. The DON told Surveyor that residents at risk for or who have pressure ulcers are routinely repositioned every 2 hours. Surveyor asked to see documentation which reflects staff compliance with a reposition schedule. The DON told Surveyor that the Nursing Assistants document the times that they assist the residents with repositioning on the back of their care cards (Nursing Assistant Assignment Sheets). Surveyor asked for evidence for compliance with the stated turning and repositioning schedule. The facility did not produce this documentation for Surveyor . 4. Resident #5 [DIAGNOSES REDACTED]. On 02/25/13, Surveyor observed personal hygiene cares provided to Resident #5. Resident #5 had a pressure reduction mattress on her bed, and a pressure relief cushion was noted in place in her chair. The resident did not to get out of bed. The resident was at high risk for developing a pressure area due to weight (93#), and immobility. Surveyor interviewed CNAs (Certified Nursing Assistants). CNA Y and EE told Surveyor that they assisted Resident #5 to turn from side to side every 2 hours. On the care card (CNA Assignment Sheet) it is noted "turn q (every) 2 hours." The nursing care plan stated "turn q (every) 2 hours and prn (as needed)". On 03/3/13 at 10:05 a.m., Surveyor interviewed the DON. The DON told Surveyor that residents at risk for or who have pressure ulcers are routinely repositioned every 2 hours. Surveyor asked to see documentation which reflects staff compliance with a reposition schedule. The DON told Surveyor that the Nursing Assistants document times that they assist the residents with repositioning on the back of their care cards (Nursing Assistant Assignment Sheets). Surveyor asked for evidence for compliance with the stated turning and repositioning schedule. The facility did not produce this documentation for Surveyor .

Based on observations, record review and staff interviews, the facility did not always ensure they provided the necessary care and services for 2 of 17 residents (#1 and #14) who were reviewed for bowel continence. One (1) of 17 residents (#9) was not served breakfast when she slept later in the morning on 1 of 3 days of survey. Residents #1 and #14 had a decline in bowel continence which was not comprehensively assessed in order to establish an individualized plan of care with interventions implemented so each resident is able to attain or maintain their highest practicable well-being in regards to bowel continence. The facility did not have a policy in place which directed staff on when and how to compressively assess those residents who were incontinent of bowel. Resident #9 was not gotten up for breakfast and did not get to eat breakfast on 1/24/12. This is evidenced by: 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 1/24/12 at 6:55 a.m., Surveyor reviewed the medical record of Resident #1. Surveyor reviewed the Nurse's Care Plan with last date of review of 5/17/11. Under potential for skin problems due to occasional incontinence, it documented, "wears a liner; needs to be taken to the bathroom regularly; liner due to urge type of incontinence and functional as needs assist due to cognitive loss and assistance with transfer/toileting." Surveyor reviewed the certified nursing assistant's (CNA's) plan of care (no date on this form) and under toileting it stated, "Inc. (incontinent) bladder, Inc. bowel, Product: Brief Purple M/R." Resident #1's most recent annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 is always continent of bowel. Resident #1's most recent quarterly MDS dated [DATE] indicated Resident #1 is frequently incontinent of bowel. During the record review, Surveyor was not able to find or locate a bowel assessment due to a bowel decline, with patterning, in the copies of the record requested. On 1/24/12 at 11:55 a.m., Surveyor interviewed RN/MDS Coordinator-A and asked if she had a bowel assessment due to Resident #1's decline in bowel continence from always continent of bowel to frequently incontinent of bowel. RN/MDS Coordinator-A stated, "Probably not, but I will check." RN/MDS Coordinator-A returned and stated Resident #1 did not have a bowel assessment after her decline as indicated on the MDS. On 1/25/12 at 10:30 a.m., Surveyor interviewed RN/MDS Coordinator-A who stated there was no bowel or bladder assessment found. RN/MDS Coordinator-A stated it would have been she that was to catch this on the MDS's, but she didn't do an assessment regarding this decline in bowel continence. RN/MDS Coordinator-A stated she had no excuse; she just didn't do one. Surveyor interviewed RN/MDS Coordinator-A regarding when and how often bowel assessments are to be done. RN/MDS Coordinator-A stated, "They should be done upon admission. A 3-day bowel and bladder is compiled and then the assessment is completed by the nurse manager when all information is gathered. Bowel assessments should be done on admission and reviewed quarterly for any changes. This is done by the bowel and bladder status the certified nursing assistant put in the Matrix. When a change is noted, they are expected to do a bowel/bladder assessment all over again. If there is a decline in bowel, then a bowel assessment should be done. If there are no changes, then attach a note to the previous assessment stating no changes." RN/MDS Coordinator-A stated the facility did not have a bowel/bladder protocol in place prior to this new corporation taking over. They had only an admission interview with the admitting nurse. 2. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/25/12 at 1:50 p.m., Surveyor reviewed the medical record of Resident #14. A review of the Nurses' Care Plan with a problem start date of 9/26/11 identified an alteration in elimination with potential for skin breakdown/infection related to dementia, type 2 diabetes. Under approach it stated, "Encourage/assist this resident to use the bathroom with am (morning) and hs (evening) cares, prior to meals, activities and prn (as needed). Monitor bowel and bladder patterns, note, record and report changes. Monitor for black tarry stools, bleeding rectally as this resident with hx (history) of GI bleed." Surveyor reviewed the Physician order [REDACTED]. On this report (due to the new Matrix system) the CNA plan of care was listed under ADL (Activities of Daily Living) flow sheet. General Nursing, start date 12/27/11, End date - Open ended. Under Description it noted, "ADL: Toileting, Special instructions: Extensive assist of one. Continent of bladder. Incontinent of bowel. Wears briefs." Surveyor reviewed the most recent admission MDS dated [DATE]. Under "Bowel Continence" it is coded with a 0, which means Resident #14 was always continent of bowel on admit. The most recent quarterly MDS dated [DATE] indicated a 3 under "Bowel Continence" which means Resident #14 is always incontinent of bowel. During the record review, Surveyor was not able to find or locate a bowel assessment due to a decline in bowel continence. On 1/25/12 at 3:25 p.m., Surveyor interviewed Unit Manager (UM)/RN-L regarding Resident #14's decline in bowel as indicated on to the MDS assessments. UM/RN-L stated she thought the admit MDS was still accurate because she thought Resident #14 was still continent of bowel. On 1/25/12 at 3:30 p.m., Surveyor interviewed RN/MDS Coordinator-A regarding her coding of the MDS indicating Resident #14 was continent on the admission MDS however, the most recent quarterly MDS dated [DATE] now indicated Resident #14 was always incontinent of bowel. RN/MDS-A stated she gets this information from the Kiosk/Matrix the certified nursing assistants put in regarding bowel and bladder. RN/MDS Coordinator-A printed off the Matrix and Resident #14 is marked to be incontinent of bowel most times. Surveyor asked if a bowel assessment was completed due to the decline in bowel continence, and RN/MDS Coordinator-A stated no bowel assessment was completed for Resident #14 due to a decline in bowel continence. On 1/25/12 at 3:35 p.m., Surveyor interviewed CNA-Y regarding Resident #14's continence. CNA-Y stated she is very familiar with Resident #14 due to being her caregiver on the second shift. CNA-Y stated Resident #14 is 50% or more incontinent of bowel. CNA-Y stated she indicates this by putting the information into the Kiosk/Matrix system. CNA-Y stated she tries to toilet Resident #14 as often as she can and there are times she is continent, but most times she is incontinent of bowel. Surveyor noted Resident #14 was continent of bowel on admission but then became incontinent of bowel over a couple of months. It was noted in the Kiosk/Matrix and noted as a decline on the MDS. No bowel assessment was completed on Resident #14 with this decline. This information was shared with the facility and the facility was asked if there were any assessments for Resident #1's and #14's bowel continence decline and they stated, no. No further information was provided. 2. Resident #9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #9's medical record identified she utilized a wander guard and propelled herself throughout the facility in her wheelchair. Resident #9's medical record identified she had [MEDICAL CONDITION] and was up during the night. On 11/11/11, the RD (registered dietitian) progress note identified Resident #9 had a slow gradual weight loss of 9 pounds over the past four months. Resident #9's meal intake was poor and her intake of fluids varied greatly. She received a regular diet. Whole and chocolate milk had been added to help avoid excessive weight loss and increase fluid intake. After her meal was set up, Resident #9 fed herself with cues and supervision. On 12/20/11, the RD progress notes identified Resident #9 had experienced a significant weight loss of 8 pounds from 11/11/11 though 12/11/11. Intake records revealed Resident #9's intake was poor and her intake was stable as compared to the last month. Resident #9's activity level had increased which was likely due to medication changes. Resident #9 had more agitation which likely increased k-calorie expenditure. Intake of fluids at mealtime had increased and was very good. Additional approaches were put into place to provide increased k-calories, fluid and Vitamin C to maintain weight. Resident #9 requires assistance at mealtime. On 01/03/12, the RD progress note identified a positive weight gain of 3 pounds from 12/06/11 to 12/22/11. On 01/24/12 Surveyor observed Resident #9 from 7:45 a.m. to 11:12 a.m. asleep in her bed in the same position. At 11:47 a.m., Surveyor observed Resident #9 seated in her wheelchair in the hallway outside the dining room. At 12:14 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) C related to the time Resident #9 was gotten up that morning. CNA C stated Resident #9 was gotten up between 11:00 a.m. to 11:10 a.m. CNA C stated she had not provided Resident #9 anything to eat or drink since that time as Resident #9 "was going right in to eat." CNA C made the decision to not feed Resident #9 without input or guidance from nursing staff. The facility had no policy and procedure for serving breakfast to residents who sleep in. Resident #9 remained in the hallway until 12:22 p.m. when a CNA took Resident #9 to the dining room table. Resident #9 was not offered any fluids or food. Resident #9's tablemate was brought to the table at 12:43 p.m. and was provided a glass of water at 12:52 p.m. Staff did not offer or provide Resident #9 with a glass of water. Resident #9's tablemate was served her dinner at 12:54 p.m. A CNA sat down to assist the tablemate with her meal. At 1:02 p.m., Registered Nurse (RN) D brought Resident #9's medications to the dining room table with 4 ounces of Mighty Shake. Resident #9 was observed to take her medications and drink the Mighty Shake from a straw by 1:05 p.m. Surveyor interviewed RN D who stated she had administered medications to Resident #9 about 10:00 a.m. that morning with a Mighty Shake and a little pudding. Surveyor asked the amount of pudding served and RN D stated it was approximately an ounce. RN D stated Resident #9 sleeps in as she is up a lot at night. RN D stated staff do not want to feed Resident #9 anything in bed to eat. No reason was given for this. RN D stated Resident #9 had received two Mighty Shakes that morning (with medications). RN D exited the dining room without obtaining Resident #9's meal tray or providing additional fluids. At 1:09 p.m., Surveyor observed CNA E serve Resident #9 her dinner. Surveyor observed Resident #9 made no attempt to pick up her utensils or drinking glasses on her tray. CNA E provided total assistance with the noon meal. When CNA E asked Resident #9 if she was hungry Resident #9 stated, "Yes." CNA E stated Resident #9 had not eaten by herself the past three weeks. CNA E stated Resident #9 sleeps in until she wakes up by herself. When Resident #9 is up, staff are to provide her with her breakfast. CNA E stated staff are not to make residents wait until the next meal before eating. Resident #9 went 1? hours before being served a meal on 1/24/12. At 1:20 p.m., Surveyor interviewed RN D who stated Resident #9 should have been provided with something to eat/drink when she was gotten up that morning. RN D stated staff are not to wait until the next meal to provide food or fluids to residents who sleep later in the morning. On 01/24/12 at the meeting with facility management beginning at approximately 4:00 p.m., a request was made for the facility policy regarding residents who sleep in receiving meals upon awakening. No policy was provided.

Based on record review, observations, interviews and policy review facility staff did not ensure 2 of 2 residents who smoke were provided adequate supervision to prevent accidents while smoking, Residents #8 and #13. Resident #8 had a history of [REDACTED]. On 09/29/10 Resident #8 returned to the facility from the hospital with continuous oxygen (02) in use. On 10/12/10 Resident #8 smoked three times while oxygen was in use, with the charge nurse being aware of this fact. The Licensed Practical Nurse (LPN) charge nurse: * Did not consult with the Registered Nurse or management staff on-call for assistance or direction when Resident #8 insisted on smoking with the oxygen on, even though the LPN was aware of the risks and had provided education of the risks to Resident #8. * Did not prevent Resident #8 from smoking with his oxygen running. Because an oxygen-enriched environment makes the air highly combustible and makes burning more efficient, allowing Resident #8 to smoke could have caused serious burns to the resident. The findings created an immediate jeopardy situation beginning 10/12/10 when Resident #8 smoked while using continuous oxygen. The immediate jeopardy was removed on 10/12/10. Facility management staff were notified of the Immediate Jeopardy on 10/13/10. The deficient practice continues at a D level (potential for harm that is not immediate jeopardy/isolated) due to the following example. Resident #13, who smokes routinely outside the facility while on outings displayed questionable smoking at the facility documented 07/08/10. An 08/13/10 plan directed the team leader to check Resident #13's person and belongings after returning from being out on pass. On 10/18/10 after Resident #13 returned from an outing with a family member, staff did not check to see if the resident had cigarettes and a lighter. This is evidenced by: 1. Resident #8 was originally admitted to the facility 10/23/03. Resident #8 was hospitalized ,[DATE]-[DATE]. The 09/29/10 hospital discharge summary documented Resident #8 had "chronic arthritic pain and is narcotic dependent." A history of cigarette use was documented. Resident #8 was oxygen dependent during the hospitalization . Discharge [DIAGNOSES REDACTED]. Discharge orders included oxygen 2-5 liters as needed for oxygen saturations below 89%. Oxygen saturations were monitored and oxygen use continued at 2 liters (L) per minute by nasal cannula (N/C) 09/29 through 10/12/10. Nasal cannula delivery of oxygen is achieved by use of tubing running from the oxygen source extending into each naris by approximately 1 cm prongs. Resident #8's most recent quarterly Minimum Data Set completed 08/11/10 identified Resident #8 had short-term memory problems and that his cognitive skills for daily decision making were moderately impaired-decisions poor; cues supervision required. The resident had no problems understanding or making self understood. Resident #8 was his own decision maker. The care plan updated 10/11/10 identified Resident #8 was on oxygen continuously now with a portable oxygen tank on his wheelchair. Approaches included: "has not been smoking since most recent hospitalization ; says he is going to quit." During the 10/12/10 10 a.m. entrance conference the Nursing Home Administrator (NHA) joined by Social Worker (SW) E and the Director of Nursing (DON) told Surveyor that Resident #8 has resided in the facility for approximately eight years and did not smoke. Then after the death of a family member the resident began smoking. The campus was non-smoking when Resident #8 began smoking, so a plan was developed that allowed the resident to go off campus to smoke. Eventually the resident was allowed to smoke outside on a small section of the campus. Facility staff educated Resident #8 about the campus non-smoking status and the need to have nursing staff store smoking materials. Staff also educated those they felt were providing smoking materials to Resident #8 that they should not do so for safety reasons. Other interventions included team meetings with the resident and family, interdisciplinary team and medical director; a smoking safety plan; involvement of outside agencies including the Veteran's Administration and Ombudsman; and consideration of alternate placement to a facility that would allow smoking. Resident #8 was hospitalized recently and returned on 9/29/10 utilizing oxygen. During a 10/12/10 3:05 p.m. interview, SW E told Surveyor when Resident #8 was readmitted [DATE] from the hospital with oxygen and a nicotine patch, the resident told staff he was not going to smoke anymore. The 09/29/10 through 10/11/10 interdisciplinary team notes documented oxygen use and no requests to or smoking by Resident #8. During 10/12/10 3:35 p.m. and 3:50 p.m. interviews, LPN J told Surveyor she had been working the night shift, 10:30 p.m. to 7:00 a.m., as the charge nurse, which is a newer position for her. The past two weeks she had worked approximately four to five nights per week. LPN J is the only nurse in the facility on the night shift, with a Registered Nurse (RN) available to her in the attached hospital or facility RNs on the call list. LPN J was the night charge nurse 10/11/10 10:30 p.m. through 7:00 a.m. 10/12/10, with three Certified Nursing Assistants on duty. Resident #8 got up that night and told LPN J that he wanted to go out to smoke. LPN J stated she tried to deter him from doing so by telling him it was cold out. Resident #8 had oxygen on and running through a nasal cannula, however she did not remember what the liter flow was. Resident #8 insisted on going to smoke and she educated him on the dangers of smoking with oxygen on, that it was dangerous to be so close to an open flame with oxygen on and he could cause harm to himself or others. LPN J told Resident #8 they should remove the oxygen if he was going to smoke and he refused stating he knew about the dangers, did not want to remove his oxygen to smoke as he would not be able to breathe without it and he was going. LPN J watched Resident #8 from the nurses' station camera screen as he smoked outside the nursing home parking lot entry door, two separate times. Resident #8 had cigarettes and a lighter with him. He smoked one cigarette each time, which took approximately 10 minutes. LPN J did not ask the resident for the smoking materials when he returned inside. Although LPN J knew the risks of smoking with oxygen on and running, she did not consult with the RN or call facility management staff because she stated she knew Resident #8 was his own person and made his own decisions. The distance between the nurses' station camera screen area to the parking lot exit door was 120 feet. During a 10/13/10 7:00 a.m. interview, LPN J told Surveyor prior to 10/12/10 and most recent hospitalization Resident #8 would go out to smoke one to two times during the night when he felt well, but was not using oxygen at that time. On 10/12/10, LPN J was aware Resident #8 went outside to smoke with his oxygen on at approximately 2:30-3 a.m. and 4:30 a.m. At approximately 6:30 a.m. LPN J stated she went out to her car and saw Resident #8 outside smoking with his oxygen on and "assumed it was running" but did not check. She did not say anything to the resident at that time about smoking with oxygen. She did pass it along in report to the day shift. LPN J stated the only thing she was thinking was resident rights, as there had been big resident rights inservices shortly after she started employment, about five months ago. A 10/12/10 11:05 a.m. nursing progress note by the day nurse, Licensed Practical Nurse (LPN) K, documented: "Resident is outside smoking about ? way to the road about 0620-0625 (6:20-6:30 a.m.). When writer comes in the door resident is sitting in his w/c (wheelchair) by the library. He has is (sic) 02 on and NC intact. He is reminded about the danger of 02 and smoking that it can explode. He put his head down and said, "I know." He also had a 21 mg nicotine patch on and that is removed. Writer explained to him that nicotine is being delivered to his blood stream by that patch and when you go out to smoke you are loading up on nicotine in your body. Adverse SE (side effects) are explained and patch is removed. AM patch is held. 02 is off today. SPO2 on RA (room air) is 96-93%. He had therapy with no 02 and pt (patient) stated he did well with no SOB (shortness of breath) noted. RR (respiratory rates) are 16-18 even and non labored today." (SPO2 is the saturation of arterial blood with oxygen as measured by a pulse oximeter, expressed as a percentage. Taber's Cyclopedic Medical Dictionary, Volume 19.) A 10/12/10 1:32 p.m. note by Registered Nurse (RN) H documented the physician was updated on Resident #8 going out to smoke during the night and early a.m. shift. When team leader saw resident smoking she removed his nicotine patch. Updated on oxygen saturations on room air 95%. The physician gave an order to apply a new nicotine patch and discontinue oxygen (10:30 a.m.). During a 10/12/10 2:35 p.m. interview, LPN K verified she came to work 10/12/10 at approximately 6:20-6:25 a.m. observing Resident #8 outside with his oxygen on by nasal cannula, which was running at 2 liters per minute. As she approached Resident #8, he threw his cigarette on the ground and admitted to LPN K he had been smoking. LPN K stated she checked the resident's oxygen saturation which was 95-97%. She removed the nicotine patch, educated him on the risk of smoking with oxygen on and that he may get sick smoking with the patch on. Resident #8 replied he knew. LPN K stated LPN J told her during report Resident #8 had been out smoking twice during the night. LPN K told Charge Nurse H about the episode, management staff were notified, the physician was called, the oxygen was discontinued and the resident was monitored. The NHA, SW E and DON were informed 10/12/10 at 4:28 p.m. of the above findings. The DON stated they interviewed nursing staff during the 10/12/10 day shift and this was the first time Resident #8 wanted to smoke with 02 on, as he had been too ill since return from hospital. Prior to hospitalization he'd sign out to smoke. During a 10/18/10 3:05 p.m. interview facility Certified Respiratory Therapist (CRT) L told Surveyor the portable oxygen cylinders utilized by the facility contained enough oxygen to run approximately four hours at 2 Liters per minute (L/min). As to the dangers of smoking cigarettes with oxygen running by nasal cannula, CRT L stated when persons smoke when oxygen is on the oxygen supports combustion and a spark from a cigarette can ignite the oxygen, with a nasal cannula it would more likely be the plastic cannula itself. This could cause severe burns if the cannula catches fire and the plastic melts to the skin. It could also cause tracheal burns if the fire follows the oxygen. CRT L stated nursing home staff are routinely scheduled for departmental orientation given by her and oxygen use, including the dangers of smoking with oxygen, is reviewed. The facility policy #045-027 titled Oxygen Usage current revision date 07/23/08 directives included: "NO SMOKING: Smoking is not allowed in the hospital. Staff responsibility is to educate patients concerning the hazards of oxygen and open flame." During a 10/13/10 8:15 a.m. interview, the DON told Surveyor this was also the policy utilized by the nursing home. Allowing Resident #8 to smoke three times on 10/12/10 created a finding of immediate jeopardy. The immediate jeopardy was removed on 10/12/10 by the following actions: LPN K intervened to stop Resident #8 from smoking with oxygen on 10/12/10 at approximately 6:20-6:25 a.m., provided education to Resident #8 regarding the risk of smoking with oxygen on, completed an assessment and reported this to Charge Nurse RN H. Monitoring began immediately to ensure the resident would not smoke with oxygen on. Management staff including the DON, NHA and SW E were notified and an investigation and education to staff began related to Resident #8 smoking with oxygen, the danger associated with the practice and need to prevent this from recurring. The physician was called and discontinued the order for oxygen for Resident #8. Staff inservicing began 10/12/10 including: * A memo dated 10/12/10 updating the care plan changes for Resident #8, including but not limited to: Resident #8's desire to continue to smoke despite the risks presented to him; agreement by the resident to participate in the Wanderguard program to ensure he does not go outside and smoke with the nicotine patch in place; 100 hall team leader to continue to request Resident #8 give his cigarettes and lighter to staff whenever he receives from visitors to be stored in med room cubby; visitors to be told they cannot provide cigarettes; and staff not to provide cigarettes. When Resident #8 wishes to go out to smoke off campus, to ensure his safety staff must accompany him off campus, off curb. Any staff witnessing Resident #8 smoking on property should approach him and remind him of tobacco free policy, notify the charge nurse, social worker and NHA regardless of the time. * F323 Accidents and Supervision Pathway Health Services Inc. training tool. * DDES-BQA (Division of Disability and Elder Services-Bureau of Quality Assurance) Memo 06-012, page 4 outlining immediate jeopardy situations including citations involving residents who were allowed to smoke while their oxygen tank was running or while the tank was attached to their wheelchair. * A wanderguard transmitter was placed on Resident #8 with his permission to remind him to notify staff if he was going outside to smoke in which case one-to-one staff supervision would be provided. * By 10/18/10 at 11:30 a.m. 63 of 81 staff members had received the education. Those left were planned to be educated prior to working their next shift. Observations throughout days of survey 10/13, 10/14 and 10/18/10 revealed no oxygen use or respiratory difficulty for Resident #8. The resident had no concerns related to the care at the facility. The deficient practice at F323 continues at a scope/severity level of D (potential for harm that is not immediate jeopardy/isolated) based on the following example: 2. Resident #13 was admitted to the facility 11/09/09. [DIAGNOSES REDACTED]. Resident #13 had an activated POAHC, with guardianship now being put in place. Surveyor observed Resident #13 at the desk with a visitor on 10/18/10 day shift. Resident #13 stated she was going out with the visitor. The resident was alert, well groomed, independently ambulatory and communicated well. Resident #13 returned to the facility on the day shift. A 07/04/10 3:06 p.m. nursing progress note by RN H documented a Certified Nursing Assistant told her "(Resident #13) is smoking in her room...This writer and a a.m. LPN entered room which had the smell of smoke in hallway and room. A "doused butt" was found on the sink...Res also had curling iron on her bed. This writer took pack of cigarettes and placed in res cubby in med room." Resident #13 was placed on 15-minute checks and follow up monitoring was documented. A 08/13/10 note by SW E documented receiving notification from nursing staff that "housekeeping staff had found a used cigarette butt in her room while cleaning her room. No immediate danger noted." NHA and DON were updated. Resident #13 was able to recall and "described it as her having "cleaning out my purse several weeks ago and out it fell on the floor...(Resident #13) has a hx (history) of confusion and forgetfulness, of confabulating stories." HCPOA (health care power of attorney) is activated. "Writer explained to (Resident #13) that this is the third incident of potential fire hazard and despite education and reminders from staff, she does not appear able or willing to follow the tobacco free policy..." The care plan was updated as the following: The "Problem Activity" care plan located in the computer identified a 08/13/10 problem "Safety Check of Person and Belongings." Approaches directed: ~Staff will assist (Resident #13) in searching her person and belongings upon return from any OOP (out on pass) for cigarettes, lighters, matches, curling iron or any other safety hazards due to her forgetfulness and confusion. ~Staff will store any concerning items in med room for AHCPOA (activated health care power of attorney) retrieval. Staff will notify AHCPOA of any incidents of concern. The hard copy activities of daily living care plan utilized by CNAs and nursing staff also contained the above directive to search upon return from OOP. Surveyor met with RNs G and H and LPN K on 10/18/10 at 3:20 p.m. while interviewing related to the 07/04/10 documentation, to determine if Resident #13 was smoking in the facility. All three were on duty 07/04/10. RN H and LPN K stated the room smelled of smoke but no one actually saw Resident #13 smoking. A cigarette butt, wet on the end was found on the sink. SW E and responsible family members were notified and monitoring was ongoing. RN H directed Surveyor to the "Problem Activity" problem in the computer, stating nursing staff are to look at and know what is documented. The documentation here was as described in the preceding paragraph. RN G and LPN K were unaware of the directives. LPN K, team leader on Resident #13's unit 10/18/10 day shift, stated she did not check her on return to the facility today as she was unaware of the need to do so. LPN K immediately checked Resident #13 and found no safety risks. At 3:35 and 3:45 p.m. respectively full time p.m. shift LPN N and day shift LPN M told Surveyor they were aware of the need to check Resident #13's person and belongings for cigarettes and lighters upon return from outings. During a 10/18/10 4:00 p.m. interview RN A and SW E told Surveyor Resident #13 was never observed smoking in the facility. She would smoke when family members took her out. The three "incidents" were from staff finding cigarette butts. The 08/13/10 safety plan was put in the computer for nursing staff to be aware of, directing checking Resident #13's person and belongings for cigarettes, lighters and other potential hazardous items. The plan was put in place as family members did not seem to understand the associated risks of providing these items, even though they had been educated. SW E stated the former DON was notified on 07/04/10 of the incident in the absence of SW E. Fifteen minute checks were started at that time.