Every finding on record at Dove Healthcare - St Croix Falls

Based on interview and record review, the facility has not established 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 has the potential to affect all 47 residents (R) in the facility. The facility failed to test staff who displayed COVID-19 and norovirus symptoms. The facility failed to ensure staff wore appropriate PPE (personal protective equipment) while handling soiled linens and laundry. This is evidenced by: The facility policy, titled, Covid-19 Prevention, Response and Reporting, dated 1/2025, includes in part: Policy: 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. Policy Explanation and Compliance Guidelines: . 2. Staff will be alert to signs of Covid-19. a. Fever or chills, b. Cough, c. Shortness of breath or difficulty breathing, 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. 4. The facility will establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2 infection to include: . b. Establishing a process to make everyone entering the facility aware of the recommended actions to prevent transmission to others if they have any of the following. criteria: . ii. Symptoms of Covid-19. 5. The facility will instruct Healthcare Personnel (HCP) to report any of the above criteria to the Infection Preventionist or designee for proper management. 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. The facility policy, titled, Infection Prevention and Control Program, dated 1/2025, includes in part: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions) . who provide care and services to residents on behalf of the facility. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious disease. staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. 2. All staff are responsible for following policies and procedures related to the program. 9. Covid-19 Testing: a. Anyone with even mild symptoms of Covid-19. should receive a viral test for SARS-CoV-2 as soon as possible. The facility policy, titled Personal Protective Equipment, dated 12/2024, states, in part: Policy: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. Definitions: Personal Protective Equipment or PPE, refers to a variety of barriers used alone or in combination to protect. skin and clothing from contact with infectious agents. It includes gloves, gowns. Policy Explanation and Compliance Guidelines: 1. All staff who have contact with residents and/or their environment must wear personal protective equipment as appropriate. in which exposure to blood, bodily fluids, or potentially infectious material is likely. 2. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. 4. Indications/considerations for PPE use: a. Gloves: i. Wear gloves when direct contact with blood, body fluids. is anticipated. b. Gowns: i. Wear gowns to protect arms, exposed body areas, and clothing from contamination with blood, body fluids, and other potentially infectious material. Example 1 On 9/18/25, Surveyor reviewed the Infection Control line list for the facility, which indicated, in part, the following for SM X (staff member): -Last date worked of 4/5/25. -Symptom onset date 4/6/25. -Symptoms including headache, sore throat, cold symptoms. -Comment section: blank (No indication that a Covid-19 test was performed). -Return to work date of 4/7/25. Example 2 On 9/18/25, Surveyor reviewed the Infection Control line list for the facility, which indicated, in part, the following for SM W: -Last date worked of 4/9/25. -Symptom onset date 4/14/25. -Symptoms including vomiting. -Comment section: blank (No indication that a Covid-19 or norovirus test was performed). -Return to work date of 4/15/25. Example 3 On 9/18/25, Surveyor reviewed the Infection Control line list for the facility, which indicated, in part, the following for SM U: -Last date worked of 4/13/25. -Symptom onset date 4/15/25. -Symptoms including vomiting, diarrhea. -Comment section: blank (No indication that a Covid-19 or norovirus test was performed). -Return to work date of 4/17/25. Example 4 On 9/18/25, Surveyor reviewed the Infection Control line list for the facility, which indicated, in part, the following for SM V: -Last date worked of 5/26/25. -Symptom onset date 5/26/25. -Symptoms including vomiting, diarrhea. -Comment section: CM (case manager) sent home. (No indication that a Covid-19 or norovirus test was performed). -Return to work date of 6/2/25. Example 5 On 9/18/25, Surveyor reviewed the Infection Control line list for the facility, which indicated, in part, the following for HI T (Health Information): -Last date worked of 6/2/25. -Symptom onset date 6/3/25. -Symptoms including nausea, vomiting. -Comment section: blank (No indication that a Covid-19 or norovirus test was performed). -Return to work date of 6/5/25. On 9/18/25 at 11:30 AM, Surveyor reviewed the facility Infection Control line list with IP AA (Infection Preventionist) and asked if nausea, vomiting, diarrhea, sore throat, headache were possible symptoms of both Covid-19 and norovirus. IP AA stated that they were. Surveyor asked IP AA if these staff members should have been tested for Covid-19 and norovirus. IP AA stated yes, these staff members should have been tested to confirm or rule out infectious disease such as Covid-19 and norovirus. Example 6 On 9/17/25 at 9:02 AM, Surveyor observed the facility laundry service. Surveyor observed EVS S wearing gloves but not a gown while handling the facility dirty laundry. Surveyor asked EVS S what personal protective equipment (PPE) was used while handling the dirty laundry. EVS S stated that she wears gloves whenever handling the dirty laundry and that she wears a gown if the resident has Covid. On 9/17/25 at 10:27 AM, Surveyor interviewed IP AA (Infection Preventionist) and shared the observation of laundry service. Surveyor asked IP AA what PPE the staff should be wearing when handling dirty linens and laundry. IP AA stated that the laundry staff should be wearing appropriate PPE, including gloves and gown, whenever handling the dirty laundry. The facility failed to monitor and evaluate for clusters or outbreaks of illness among staff and ensure the appropriate testing was completed. The facility failed to ensure that staff handled soiled linens and laundry with accepted national standards of practice in order to prevent the spread of infection.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 47 residents who reside in the facility. Surveyor observed staff in the food preparation area without donning hair restraints. Surveyor observed frozen drips on the ceiling inside of the facility's freezer and on and inside of boxes of food that were no longer sealed by the manufacturer. Surveyor observed a stored mixer to be stored unclean. Surveyor observed [NAME] Y with his personal beverage on the food preparation counter. Surveyor observed opened boxes of juice without an open date. Evidenced by: Example 1 Facility policy, titled Dietary Employee Personal Hygiene, effective 4/2025, includes: Hair Restraints: All dietary staff must wear hair restraints, hairnet, hat, and/or beard restraint to prevent hair from contacting food. Head coverings must be clean. On 9/16/25 at 11:50 AM Surveyor observed [NAME] R in the kitchen, in the food preparation area, without a beard restraint and with a baseball cap. Surveyor also observed [NAME] Q serving lunch with a stocking cap on. During an interview [NAME] Q indicated he wears the stocking cap everywhere as he is a snowboarder and a skateboarder. Surveyor asked [NAME] Q if he has a hat that is designated just to the facility's kitchen. [NAME] Q indicated he doesn't, but he would get one. On 9/16/25 at 12:13 PM Dietary Manager P indicated NHA A (Nursing Home Administrator) told her that the men did not need beard restraints, and she was not sure which food code the facility uses as a standard of practice. Dietary Manager P indicated both [NAME] R and [NAME] Q wear their hats to the facility and to home when they leave. Dietary Manager P indicated she was unsure how often the hats are laundered or where exactly [NAME] Q and [NAME] R are wearing the hats outside of the facility. On 9/16/25 at 12:15 PM NHA A (Nursing Home Administrator) indicated staff with facial hair need hair covered and there are beard restraints available for their use. NHA A indicated the facility should designate hats for [NAME] R and [NAME] Q to keep in the facility's kitchen. Then they can wear their personal hat to the kitchen and their designated hat in the kitchen while working. Example 2 On 9/15/25 at 1:12 PM Surveyor observed the facility's mixer to be stored with all of the pieces inside the bowl. When Surveyor looked up inside of the undercarriage, Surveyor observed splatters of orange and white food substance. During an interview, Dietary Manager P indicated the mixer is unclean and she would clean it right away. On 9/15/25 at 1:40 PM NHA A indicated kitchen equipment should be stored clean. Example 3 Facility policy, titled Dietary Employee Personal Hygiene, effective 4/2025, includes: Eating and drinking is not permitted in food service or preparation areas. On 9/15/25 at 1:12 PM Surveyor observed [NAME] Y ‘s half drank can of diet Pepsi on the food preparation table along with food items that would be used to prepare resident meals. During an interview [NAME] Y and Dietary Manager P indicated staff food and beverages should be kept separate from resident food and beverages. On 9/15/25 at 1:40 PM NHA A indicated staff should keep resident food or beverages and personal food or beverages separated. Example 4 On 9/15/25 at 1:12 PM during initial tour of the facility's kitchen, Surveyor observed frozen drips on the ceiling inside of the facility's walk-in freezer. Surveyor also observed opened, unsealed boxes of vegetables underneath the frozen drips. Surveyor observed the boxes to have ice buildup on and inside of the box flaps. During an interview, Dietary Manager P indicated there is potential for the food inside of the boxes to be contaminated due to the dripping. On 9/15/25 at 1:40 PM NHA A indicated there is potential for food to become contaminated if there is dripping condensation in and on the boxes and ice built up on and in the boxes. Example 5 On 9/15/25 at 1:12 PM Surveyor observed two containers of juice in the facility's juice machine to be opened and undated. Surveyor asked Dietary Manager P when the juices were opened, and she indicated she was unsure. During an interview Dietary Manager P indicated all food and beverages that are opened should be labeled and dated with an open date or a use by date. On 9/15/25 at 1:40 PM NHA A indicated all food, and drinks should be labeled with an open date or used by date when it is opened.

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistive devices to prevent accidents in 2 of 2 (R6 and R17) residents reviewed for falls. R17 was assessed and care planned for 2-person assist with an EZ stand to meet her needs for transfers. CNA E (Certified Nursing Assistant) did not follow manufacturer’s recommendations for the EZ stand lift and did not fasten the harness’ safety strap around R17’s waist. R17 had a change in plane when she was lowered to the floor. R6 has diagnoses repeated falls, has been assessed by the facility to be at risk for falling, and has experienced multiple falls since admission. Surveyor observed R6 without his care planned intervention in place related to fall prevention. This is evidenced by: Facility policy, titled Safe Resident Handling/Transfers, revised 1/2025, states in part…the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Compliance Guidelines, states in part…14. Resident lifting and transferring will be performed according to the residents’ individual plan of care. 15. Staff will perform mechanical lifts/transfers according to the manufacturer’s instructions for use of the device. EZ way Smart Stand Operator’s Instructions with a revision date of 5/9/2025, states, in part; …Safety Notes …Do not modify harness design in any way. …Transferring the patient: …1) Position the harness around the upper body of the patient so the sides of the harness are between the patient’s torso and arm, resting 2-3 inches below the underarm. 2) For the safety of the patient, securely fasten the safety strap around the patient’s torso. 3) Secure the buckle and pull the strap to tighten. Facility policy, titled Fall Prevention Program, reviewed on 8/24, includes: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls… Some interventions may include, but not limited to encourage resident to wear shoes or slippers with nonslip soles when ambulating… Each resident’s risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. Interventions will be monitored for effectiveness. The care plan will be revised as needed. When a resident experiences a fall, the facility will: assess the resident, complete post fall assessment, complete an incident report, notify the provider and resident/resident representative, review care plan and update as needed, document all assessments/observations and actions, obtain witness statements in the case of injury, neuro checks will be completed for any unwitnessed fall or witnessed fall where resident hit their head… staff to alert provider of any abnormal findings from the neuro checks… Review each fall/fall investigation during the next morning meeting/clinical meeting with the interdisciplinary team. Actions may include review investigation and determination of potential root cause of fall, review of fall risk care plan and update, additional revisions to the care plan, education of staff to as any care plan revisions as needed, scheduling care conferences, verification of timely notification of provider and responsible party. Example 1 R17 admitted to the facility on [DATE]. Her diagnoses include arthropathy (any kind of disease or disorder affecting a joint), morbid obesity, polyneuropathy (a condition where multiple peripheral nerves throughout the body become damaged or diseased), unilateral primary osteoarthritis right knee (joint condition that causes pain, stiffness and loss of movement), edema (swelling), and history of right humerus (upper arm) fracture. R17’s MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/21/25 indicates R17 was cognitively intact with a BIMS (Brief Interview for Mental Status) of 15 out of 15. R17’s Comprehensive Care Plan date initiated 4/2/24, target date 10/23/25, indicates R17 requires two assist, with mechanical sit to stand, and XL harness for transfers. R17’s Facility Fall Report, dated 9/12/25, includes the following: Date and Time occurred-9/12/25 9:00 PM. Incident Location: Activity Room (it should be noted that the fall occurred in R17’s room.) Initial Report: Fall was reported to RN D (Registered Nurse) that R17 had fall in evening of 9/12/25 from lift. Writer was notified and investigation initiated. Incident was witnessed. Immediate action taken: Description: Investigation completed. RN D completed skin assessment and initiated clinical follow up forms. DON, admin, on call provider updated. Resident not taken to hospital. Other information: Resident was unwilling to allow staff to reposition her properly. She would not have been lowered to the floor if she would have let us touch her legs. Power was out, backup generator functioning to red outlets. Bed was stuck in raised position and staff were unable to transfer her back to bed from commode. Statements: CNA E (Certified Nursing Assistant): …in part, CNA E states that resident had requested to go on the commode, she transferred very well and safely. R17 began saying she was tired and “get me to the bed.” At this point CNA E walkied (Walkie Talkie) for second staff member. R17 began saying “no, no, no put me back on the commode”, and started to let go of the lift. Resident was beginning to slide through the straps and CNA E stated she got behind her and assisted her slowly to the ground sliding to the floor with her legs and body. Resident did not fall out of the Hoyer but did remark in having R (right) shoulder pain. CNA G: Called for fall, resident was reportedly standing in EZ stand. Reports resident did not fall from Hoyer sling. Was positioned on her back onto sling. Resident was out of it, received pain meds and within 30 min (minutes) back to normal. May have pinched her arm in the sling as she was asked to give herself a hug but was out of it and staff had to watch arm and body positioning. CNA F: …in part, [CNA E] called for help with getting resident off commode. When she went into help [CNA E] started moving her and asked her to put the bed down. Was unable to as power was out. [CNA E] told her to get the w/c (wheelchair) or commode to put under her. Resident was squatting too much and fell. On 9/17/25 at10:41 AM, CNA E indicated R17 was moved to her commode with EZ stand. She was ready to go back. Once standing she wanted to go back to the commode, but she was too low and couldn’t get her back on the commode. R17 was screaming take me back to the commode. CNA E reported the sling on her arm had come off. Surveyor asked if the sling had come off the machine, CNA E stated no; the clip was off. She stood behind R17, and she slid her down onto the floor. Called the nurse and any help we could get. Now use the Hoyer to transfer. We put her back to bed from the ground with the Hoyer. On 9/17/25 at 11:02 AM Surveyor interviewed CNA F. Surveyor asked CNA F what happened during fall with R17. CNA F reported that she told CNA E that she had to go to the bathroom and then she could help transfer R17. CNA E asked me to help but started before me. When CNA F returned CNA E was pulling her away from the commode and was stuck on the wheel of her electric wheelchair. R17 was yelling to go back to the commode. R17 started to squat down, and she tried to get the commode underneath her, but she was slowly going down. Surveyor asked CNA F how R17 could be sitting on the floor with the sling still on. CNA F reported that she didn’t think that CNA E had the harness clipped. R17 was holding onto the sides of the lift until she couldn’t hold anymore and then she let go and lowered to the floor. Surveyor asked CNA F what the policy is for lifting with the EZ stand. CNA F stated that R17 was a 2 assist for transfers. The information is on a board in the back of the staff office, or a Kardex on her door. On 9/17/25 at 2:10 PM Surveyor interviewed CNA G. CNA G reported that she had put R17 on the commode with another staff member earlier. She was called into the room for a fall R17 was sitting on the floor and her back was resting on CNA E’s legs. EZ stand was in the highest position and not lowered down. Surveyor asked CNA G how the EZ stand could be at its highest position and the patient is on the floor. “R17 doesn’t like to be strapped into the belt.” Surveyor asked how the harness was used without it being clipped shut. CNA G responded that R17 doesn’t like the sling to be buckled. The loops are hooked to the actual machine. She has it hanging there (the buckle) with her arms over the straps. CNA G reports she has been doing this for 2 years. CNA G stated R17 is very particular. On 9/18/25 at 7:32 AM Surveyor interviewed CNA H. Surveyor asked if you are transferring with an EZ stand how many staff do you have. CNA H stated EZ stand is 1 unless care planned for 2. On 9/18/25 at 7:47 AM Surveyor interviewed CNA I. Surveyor asked if you are transferring with an EZ stand how many staff do you have. CNA, I reported usually 1 unless care planned, then 2. On 9/18/25 at 9:46 AM Surveyor interviewed RN D (Registered Nurse). Surveyor asked should the buckle on the EZ stand harness be clipped during the transfer. RN D responded absolutely. On 9/18/25 Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she would expect her staff to follow the care plan for each resident. DON B replied yes. Surveyor asked if R17 should have had two staff with her transfer. DON B replied yes. Surveyor asked DON B if the belt on the harness should have been clipped. DON B stated yes. DON B provided fall and sling sizing education that was completed on 9/16/25. (Education was started after the survey team entered the building.) Example 2 R6 admitted to the facility on [DATE] with the following diagnoses: Parkinsonism (clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability), peripheral vascular disease (narrowed or blocked blood vessels in the limbs), unspecified dementia, repeated falls, hemiplegia (the complete paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body), and cerebral infarction (stroke). R6’s fall risk assessment, dated 4/17/25, indicates he is at risk for falls with a score of 16. R6’s Comprehensive Care Plan, effective 11/20/23, includes: 4/29/25 Wear grippers without shoes, as my current ones are rubbing on my toe. 6/16/25 Wear grippers without shoe, as my current ones are rubbing on my toe. R6’s Nurse Notes, dated 6/12/25, include: Nurse was called to the … restroom for an unwitnessed fall. Resident was found sitting on his buttocks in front of the sink, with back against the wall. He states that he needed to use the bathroom, and his common bathroom was locked. So, he transferred himself to this bathroom and fell. He denied hitting his head. Denies any pain. States his neighbor had the bathroom door locked and he needed to go so he transferred himself. States he lost his balance and fell. Assessed body alignment and for pain. Vitals assessed and WNL (within normal limits). Assisted resident into his wheelchair and back to room. Assisted with toileting and ensured his bathroom door was unlocked. Educated him on the importance of calling before transferring to prevent falls in the future. Nurse Practitioner at facility and aware of fall. Nurse Manager alerted of incident. Neurological checks initiated. Interventions discussed and put in place. R6’s Nurse Note, dated 7/30/25, includes: … was called to resident's room by CNA (Certified Nursing Assistant) via walkie (Walkie Talkie). Writer walked into resident's room and found resident on his back near his wheelchair. Resident was holding his head up and writer assessed resident and found no injury. Resident states, I slid out of my chair. R6’s Comprehensive Care Plan, effective 11/20/23, includes: 8/28/25 Wear gripper socks at all times, no shoes . R6’s Kardex, reviewed and updated 9/15/25, includes: wear gripper socks at all times. No shoes. On 9/17/25 at 8:00 AM Surveyor observed R6 in the dining room with regular socks on. R6 indicated in an interview that a staff member assisted him in getting ready for the day. On 9/17/25 at 9:00 AM during an interview R6 indicated he has fallen a couple times, and he has a wound on his toe that was caused by his shoes. R6 showed Surveyor the shoes he said cause the wound on his toe. On 9/17/25 at 10:14 AM during an interview CNA O (Certified Nursing Assistant) indicated she was unsure if R6 was a fall risk. CNA O and Surveyor reviewed R6’s Kardex that hung in his bathroom. On 9/17/25 at 10:15 AM Surveyor asked CNA O if R6 should have nonskid footwear on? CNA O stated, “I tried to put your shoes on this morning, and you refused.” R6 indicated his shoes hurt his feet. Surveyor and CNA O reviewed R6’s Kardex noting it states “wear gripper socks at all times. No shoes. Surveyor observed CNA O exchange R6’s socks for gripper socks/nonskid footwear. CNA O indicated the gripper socks are for fall prevention, and he can’t have the shoes due to his wound. On 9/17/25 at 2:09 PM NHA A (Nursing Home Administrator) and Surveyor reviewed R6’s Comprehensive Care Plan, 2 falls, and Kardex. NHA A indicated R6 is a fall risk and has a pressure injury on his toe caused by his shoes. Surveyor shared observation with NHA A of R6 having on regular socks. NHA A stated, “He should have gripper socks on.” On 9/18/25 at 9:22 AM [NAME] President of Clinical Operations N indicated R6 should have gripper socks on at all times.

Based on interview and record review the facility failed to ensure they followed standards of practice for an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 (R44) of 5 residents reviewed for antibiotic stewardship.R44 was diagnosed with an acute urinary tract infection. The physician ordered the antibiotic ciprofloxacin (Cipro) 500 milligram (mg) tablet. There was no susceptibility testing done to ensure that R44's antibiotic treatment would be effective.Evidenced by:The facility's Antimicrobial Stewardship Procedure policy, dated March 2012, with last revision date of March 2024, states, in part: Policy: To ensure judicious use of antibiotics, optimize clinical outcomes while minimizing unintended consequences of antimicrobial use including toxicity, to prevent the development of pathogenic organisms. and the emergence of resistance. Procedure: 1. Antibiotic Decision Making. c. The medical provider utilizing their medical judgment and the clinical picture determines the correct treatment plan for the individual resident condition. 2. Basic Premises for all Common Infections in Long Term Care. a. Antibiotic treatment will be determined by the medical provider based on individual resident condition and clinical practice standards. These standards require the practitioner to evaluate symptoms and using their medical judgement. 3. Antimicrobial/Antibiotic orders: . e. The infection Preventionist or designee reviews any antibiotic orders entered in the electronic medical record. This review will include but not be limited to: i. Obtaining further documentation for the necessity of the treatment plan will be obtained from the medical provider as necessary. The facility's Infection Prevention and Control Program policy, dated 1/2025, states, in part: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines . 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious disease. 6. Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program.R44 was admitted to the facility on [DATE] with diagnoses that include chronic kidney disease, Type 2 diabetes mellitus, and urge incontinence. On 8/8/25 the facility Infection Surveillance Monthly Report indicates that R44 was experiencing pain, itching or burning in the vagina. On 8/10/25 R44 was seen in the Emergency Department (ED). R44's hospital encounter summary indicates, in part: . urinary tract infection presenting with concern for urinary tract infection with dysuria and discomfort in the area of the perineum. Patient notes that she was recently treated for urinary tract infection while she was on the antibiotics did seem as if the symptoms improved but noted that they seem to return shortly after she completed the antibiotics. R44's urinalysis results indicate, in part: . occult blood in the urine 1+. [NAME] Blood Cells (WBC) > 100. Bacteria moderate. R44 was diagnosed with an Acute urinary tract infection and ordered a 5-day course of the antibiotic ciprofloxacin (Cipro) 500 mg tablet to be taken twice daily. On 9/18/25 at 10:00 AM, Surveyor interviewed VPCO N (Vice President of Clinical Operations) about antibiotic stewardship. Surveyor asked VPCO N if there was a culture and sensitivity test completed for R44. VPCO N stated that she was looking for a culture and sensitivity in R44's electronic health record but was unable to find one. VPCO N stated of course there should have been a culture and sensitivity completed to ensure R44 was prescribed the correct antibiotic.

Based on interview and record review, the facility did not ensure the resident's right to request, refuse, and/or discontinue treatment and to formulate an advanced directive for 2 of 12 residents (R27 and R32) R27 and R32's charts did not contain current copies of their advanced directive and/or did not contain evidence of advanced care planning, other than code status, for a time when they are not able to make their own healthcare decisions. Evidenced by: The facility policy titled, Advance Directives, revision date 7/10/24, indicates, in part: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directive. Definitions: Advanced directive is a written instruction, such as a living will or durable power of attorney for health care.relating to the provision of health care when the individual is incapacitated. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information.about the right to refuse medical or surgical treatment and formulate an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives. Example 1 R27 was admitted to the facility on [DATE]. On 9/16/25 at 9:19AM during the record review portion of the initial pool process, surveyor was unable to locate a copy of R27's advanced directive/POAHC (Power of Attorney for HealthCare) in his electronic medical record. On 9/16/25 at 3:15PM Surveyor interviewed Social Services Director C (SSD) and requested information regarding advanced directive/living will documentation for R27. SSD C indicated R27 did not have one on file. Surveyor asked SSD C if a copy of the HCPOA should be on file at the facility, or if they do not have one, should it be documented that the resident was offered assistance in completing one and their preference. SSD C indicated, yes. SSD C indicated she would look for any documentation about offering assistance, if they refused, and if anyone reapproached if they wanted more time to decide. On 9/16/25 3:52PM Surveyor interviewed SSD C who indicated she was unable to find anything for R27 related to his HCPOA/living will. Surveyor asked SSD C if someone should have ensured a HCPOA/living will was on file for R27 or documented discussions/assistance offered to R27 regarding completing a HCPOA/living will. SSD C indicated, yes. Example 2 R32 was admitted to the facility on [DATE]. On 9/16/25 at 8:18AM during the record review portion of the initial pool process, surveyor was unable to locate a copy of R32's advanced directive/POAHC (Power of Attorney for HealthCare) in his electronic medical record. On 9/16/25 at 3:15PM Surveyor interviewed Social Services Director C (SSD) and requested information regarding advanced directive/living will documentation for R32. SSD C indicated R32 did not have one on file. Surveyor asked SSD C if a copy of the HCPOA should be on file at the facility, or if they do not have one, should it be documented that the resident was offered assistance in completing one and their preference. SSD C indicated, yes. SSD C indicated she would look for any documentation about offering assistance, if they refused, and if anyone reapproached if they wanted more time to decide. On 9/16/25 at 3:56PM SSD C brought in documentation regarding HCPOA/living will for R32. The document dated 4/25/25 and titled, Social Service Evaluation (Q) Care Conference Progress Note . indicates, in part: Section G. Advance Care Planning.2.No POA (Power of Attorney) paperwork on file, resident is interested in completing the documents. On 9/17/25 at 8:47AM Surveyor interviewed SSD C, reviewed the information from the document dated 4/25/25 and titled, Social Service Evaluation (Q) Care Conference Progress Note ., Section G. Advance Care Planning.above. Surveyor asked SSD C, with the note stating R32 was interested in completing the documents, should assistance have been given and documented. SSD C indicated, absolutely.

Based on interview and record review the facility did not document a thorough investigation and did not resolve grievances as outlined in the facility policy for 2 of 12 Residents (R32 and R20) reviewed for grievances. R32 voiced a concern to a staff member and the facility failed to follow their grievance policy by thoroughly investigating, following up, and documenting the concern. R20 voiced a grievance regarding wound care and the facility did not follow the grievance process. Evidenced by: The facility policy, “Grievance Policy,” revision date 11/2019, indicates, in part: Policy Statement: …grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their long-term care facility stay. The facility will ensure prompt resolution to all grievances, keeping the Resident and Resident Representative informed throughout the investigation and resolution process. The Facility grievance process will be overseen by a designated Grievance Official who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations…communicate with residents throughout the process to resolution…Objective of Grievance Policy: The objective of the grievance policy is to ensure the Facility makes prompt efforts to resolve grievances a resident may have. The facility policy, “Grievance Procedure,” revised date 11/2023, indicates, in part: Purpose: To ensure that each Resident or Resident Representative has the right to voice grievances regarding treatment, care, management of funds, lost clothing or violation of rights and to ensure that the Facility makes prompt efforts to resolve these grievances. Procedure: …5. The facility has identified a grievance official who is responsible for: a) Overseeing the grievance process b) Receiving and tracking grievances through their conclusion c) Leading any necessary investigations by the facility…e) Issuing written grievance decisions to the Resident or Resident Representative as requested…7. As necessary, the Facility will take immediate action to prevent further potential violation of Resident rights while the alleged violation is being investigated…9. Facility will immediately initiate an investigation by acknowledging receipt of the grievance. Assurance will be given that the incident or series of incidents will be investigated. 10. The investigation report should include, as each may apply: a. The date and time the incident took place; [sic] b. The date and time the grievance was received; c. A summary statement of the Resident’s grievance; d. The steps taken to investigate the grievance…e. A statement as to whether the grievance was confirmed or not confirmed f. Any corrective action taken or to be taken by the Facility as a result of the grievance will be in accordance with Facility policies and Federal and State regulations. g. The date written decision was determined…12. The investigation should be completed within fifteen (15) working days of the receipt of the grievance unless otherwise directed and/or approved by administration. 13. The Resident or Resident Representative will be informed of the conclusion of the investigation and will be given a written summary upon request… Example 1 R32 was admitted to the facility on [DATE] with diagnoses that include, in part: Acute and Chronic Respiratory Failure with Hypoxia; Difficulty in Walking; Muscle Weakness; Pain in Left Hip; Trochanteric Bursitis, Right Hip (an inflammation of the bursa, a fluid-filled sac, located on the outer side of the hip) … R32’s most recent Minimum Data Set (MDS), 8/8/25, indicates R32 has a Brief Interview for Mental Status (BIMS) score of 12, indicating R32 has a moderate cognitive impairment. R32’s Kardex indicates, in part: Mobility/Transfer/Bed Mobility: …Transfer: 2 assist full mechanical lift… R32’s Kardex does not address Locomotion on the unit. R32’s Comprehensive Care Plan includes, in part: .Focus: I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) activity intolerance, fatigue, pain. Date initiated: 7/13/23. Revision on: 1/31/24…Interventions: Transfer: 2 assist full mechanical lift. Date Initiated: 1/12/24. Revision on: 9/16/25. Surveyors were unable to find information regarding locomotion on the unit noted on the comprehensive care plan. 9/15/2025 3:58PM Surveyor interviewed R32 as part of the initial screening process. R32 indicated sometimes when he goes to the dining room, he requests help, and he is told he can do it himself. R32 states sometimes he can but doesn’t always feel up to it and sometimes when he carries his cup with him, he can’t do it himself. R32’s progress notes, include, in part: 9/14/25 1:22PM…Behavior: Resident was yelling out while rolling himself down the (hallway number) hallway. Nurse was going to resident to assist him with a ride in his wheelchair to his room. Resident began to cry i can’t wait until Monday to report not being helped. Resident was upset he couldn't find a ride from the dining room to his room. Resident had a cup in his hand making it hard to roll himself back to his room with 1 hand. Nurse explained to resident that during lunch, people have to pass trays and assist others with feeding. Resident was not understanding. Interventions Attempted: Nurse gave resident a ride back to his room…Resident greatly appreciative. Effectiveness of Interventions: effective. Author: Registered Nurse (RN) D On 9/17/25 at approximately 10:39AM, Surveyor interviewed Certified Nursing Assistant L (CNA) and asked how she knows how the residents she cares for move on the unit. CNA L indicated they have a Kardex in their room and it is updated on Monday, Wednesday, Friday, and as needed. Surveyor asked CNA L how R32 moves on the unit. CNA L indicated she knows he is dependent in the hall. Surveyor asked CNA L if R32 has ever told her he isn’t being helped. CNA L indicated he’s asked me if he is being ignored, and she tells him no and explains if she was helping another person. CNA L indicated if you explain it to him, he is usually pretty understanding. CNA L indicated he has never told her “Flat out” that people haven’t helped him. Surveyor requested CNA L review the Kardex in R32’s room with her. Surveyor asked CNA L if she could locate information on how R32 moves around in the hall. CNA L indicated she could not locate the information and that the Kardex is what she uses to know how to care for her residents. Surveyor asked CNA L how she knows that R32 needs assistance moving in his wheelchair on the unit. CNA L indicated from the nurses, other aides, and from doing a lot of her training on the hall. On 9/17/25 at approximately 10:00AM Surveyor interviewed RN D (Registered Nurse) and asked what the expectation is if a resident voices a concern. RN D indicated, typically they will make note of it and report it to the case managers. We now have a policy where we have to reach out to the Nursing Home Administrator (NHA) or Director of Nursing (DON), but I know that the case manager also reaches out to them. RN D indicated, depending on the concern we will go talk to the resident, get their side, and see what is going on. Surveyor reviewed with RN D the note above from 9/14/25 1:22PM (authored by RN D) for R32 regarding him stating he doesn't get help and couldn’t wait until Monday to report it. Surveyor asked RN D if R32 had told her if he had asked for help that day. RN D indicated, he just made the comment that he can’t ever get any help, which is typical of him if he can’t get it right away. Surveyor asked RN D if she reported to anyone R32’s concern with not getting help. RN D indicated she did not, she just did the behavior note since he was on behavior charting. Surveyor asked RN D if she feels this should have been reported as a grievance. RN D indicated, now that I’m thinking about it yes. In the moment, it is such a common thing for him to say he doesn’t get help, that it didn’t register to file one. Surveyor asked RN D if this is something R32 says all the time at what point would she say it should be looked into given he continues to say he isn’t receiving help. RN D indicated, I don’t really have an answer, sooner rather than later. On 9/17/25 at 10:55AM Surveyor interviewed Nursing Home Administrator A (NHA) and asked if he was the grievance officer. NHA A indicated he was. Surveyor reviewed the note from 9/14/25 regarding R32 reporting to RN D that he is not getting help and the interview with RN D indicating he states this frequently. Surveyor asked NHA A if there should have been a grievance completed given R32’s concern. NHA A indicated, yes. Example 2 R20 was admitted to the facility 3/2/23 with diagnosis of Diabetes Mellitus Type II with foot ulcer, and personal history of diabetic foot ulcer. On 9/18/25 at 7:34 AM During an interview R20 indicated she did not want NP Z (Nurse Practitioner) debriding her foot wound, stating “It’s worse, and then it starts to make my leg start to hurt.” R20 indicated she reported to the NHA A and one of the nurses her concern about her wound. R20 told NP Z that she didn’t like her and didn’t want her to touch her foot anymore. 0n 9/18/25 at 9:49 AM AA K (Administrative Assistant) indicated that R20 had voiced a concern about not wanting to see NP Z anymore. AA K indicated R20’s concern is a grievance, and it should be investigated. AA K stated that she reported R20’s voiced concern to NHA A. On 9/18/25 at 10:01 AM NHA A indicated he was aware of R20’s voiced concern. NHA A (Nursing Home Administrator) indicated when a resident voices a concern. Staff should follow the facility grievance policy. (It is important to note that R20 voiced a grievance to facility staff, and they did not fill out a grievance form and follow up on the concern per facility policy.)

Based on interview and record review, the facility did not ensure 1 (R13) of 12 resident's right to be informed of, and participate in, his or her treatment was honored. The facility offered R13 the Respiratory Syncytial Virus (RSV) Vaccine but did not administer the vaccine when R13 indicated her preference for receiving it. Findings include: The facility policy, titled Resident Rights - Self Determination dated 4/20/20 with a revision date of January 2025, indicates, in part: Purpose: To ensure that each resident has the opportunity to exercise their autonomy regarding those things that are important in their life which includes interests and preferences. Procedure: Residents have the right to actively participate in planning their care, making informed decisions about their treatment, and being fully aware of their care options. Residents will be informed of available services and care options and will have the right to select those services that best meet their needs. The facility will accommodate to the extent possible, resident preferences. The facility policy, titled Resident Rights, dated June 2002 with a revision date of January 2025, indicates, in part: Purpose: . The facility is committed to. each resident by honoring their individual goals, preferences, and choices. and their right to make decisions regarding their care and well-being. Procedure: Resident rights include: . Planning and Implementing Care. Self-Determination. The facility will support residents in exercising their rights to autonomy and choice, allowing them to decide, to the fullest extent possible, how they wish to. receive care. The facility policy, titled Management of RSV, dated 12/2024, indicates, in part: Policy: It is the policy of this facility to ensure that proper and appropriate infection control principles are utilized to help decrease the risk of transmission and respiratory syncytial virus (RSV). Definition: Respiratory syncytial virus (RSV) refers to a common respiratory virus that usually causes mild, cold-like symptoms. It can be dangerous for adults 65 years and older. those with weakened immune systems. Policy Explanation: Respiratory syncytial virus (RSV) is a highly contagious respiratory virus that can affect any age but is a greater risk for children and older adults. It is easily spread through the air on infected respiratory droplets or through direct contact. For older adults, serious complication like pneumonia. can occur. Compliance Guidelines: . 6. The facility may offer the RSV vaccine to residents aged 75 and older and residents 60-74 at increased risk of severe RSV. R13 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis, pneumonitis (inflammation of the lungs) due to inhalation of other solids and liquids, and personal history of Covid-19. R13's Acknowledgement of Receipt of Vaccine Information Sheet indicates the following, in part: I understand that Dove Health Care - St. Croix Falls recommends that I receive the vaccines to protect myself, other residents, and others in the facility and surrounding community. Dove has provided information on the risks and benefits of each vaccine listed. I have checked YES or NO to identify which vaccines I would like to receive. R13 placed a check mark in the box for Yes I want this for the Respiratory Syncytial Virus Vaccine. R13 signed and dated this form on 10/8/24. Surveyor reviewed R13's electronic health record (EHR) and could find no evidence that R13 received the RSV vaccine per her preference. On 9/17/25 at 10:23 AM, Surveyor interviewed IP AA (Infection Preventionist) and asked her if R13 received the RSV vaccine per her preference. IP AA stated that R13 did not receive the RSV vaccine, and that the facility would have to call the pharmacy in order to obtain it because they don't have that vaccine in house. Surveyor asked IP AA if R13 should have received the RSV vaccine if she wanted it. IP AA stated yes, R13 should have received the RSV vaccine if she wanted it. The facility failed to ensure that R13 was provided the RSV vaccine per her preference.

Based on interview and record review, the facility did not ensure that all alleged violations involving injuries of unknown origin are reported immediately to the administrator of the facility and to other officials, including to the State Agency, in accordance with State law for 1 of 12 residents (R1) reviewed for abuse.R1 was noted to have an area of swelling to right hip and dark purple bruising to right shoulder and arm. The origin of this injury was unknown and was not reported to the Nursing Home Administrator (NHA) or the State Agency (SA).Evidenced by:The facility's Resident Abuse, Neglect, Misappropriation of Property, and Exploitation Prevention Program policy, dated 10/2023, states, in part: .Definitions: . Injuries of unknown source an injury should be classified as an injury of unknown source when all of the following are met: the source of the injury was not observed by any person; and the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.7. Reporting/Response: .All staff/covered individuals are required to immediately report all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property to the administrator, State Survey Agency, and local law enforcement, without fear of retaliation or reprisal. In addition, facility must report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the State Survey Agency, and other proper officials (e.g. local law enforcement and adult protective services) within the prescribed time frame. This required reporting is the responsibility of the Administrator or designee.R1 was admitted to the facility on [DATE] and has diagnoses that include Cerebral infarction due to thrombosis of left middle cerebral artery (a stroke caused by blockage in a major blood vessel in the brain); Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (paralysis or weakness on the right side of the body following stroke); difficulty in walking; unsteadiness on feet.R1's Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment.R1's progress notes include:*3/8/25: This nurse called into resident's room for assessment by CNA (Certified Nursing Assistant) because resident was complaining of increased pain, difficulty ambulating, an area of swelling noted on right hip and dark purple bruising on the front of right shoulder and arm.*3/8/25: Resident is at hospital.has a hematoma (a localized collection of blood outside the blood vessels that causes swelling and bruising) and a pneumothorax (a condition where air enters the space between the lung and chest wall, causing the lung to collapse; may occur without obvious cause or may be result of chest injury) with a chest tube (a tube inserted into the space between the lung and chest wall to drain fluid, air, or pus).On 9/16/25 at 3:46 PM, Surveyor interviewed RNNM J (Registered Nurse / Nurse Manager) and asked about the procedure when a resident is noted to have swelling and bruising. RNNM J stated an assessment would be done and if the facility does not know how it occurred there will be an investigation and documentation on a risk management. Surveyor reviewed R1's progress note from 3/8/25. RNNM J stated there should be risk management, but did not see any in R1's chart.On 9/16/25 at 4:21 PM, Surveyor interviewed DON B (Director of Nursing) about the procedure when a resident is noted to have swelling and bruising. DON B stated complete an assessment, notify the provider, investigate the root cause. DON B stated this would be documented in risk management. Surveyor asked if there was risk management for R1 for the bruising and swelling noted on 3/8/25. DON B stated no and would have expected there to be an investigation; this would be an injury of unknown source that would need to be reported to NHA and SA, but it was not reported.On 9/17/25 at 4:05 PM, Surveyor interviewed NHA A (Nursing Home Administrator) who stated that R1's swelling and bruising would be considered an injury of unknown origin and should have been reported.

Based on record review, interview, and policy review, the facility failed to thoroughly investigate an allegation of staff to resident abuse for 2 of 3 residents (R3 and R2) reviewed for abuse out of five sampled residents.Findings include:Review of the facility's policy titled, Resident Abuse, Neglect, Misappropriation of Property, and Exploitation, Prevention Program revised October 2023, revealed Investigation, all the following are promptly investigated per facility policies and practices. If at any time during the investigation, caregiver misconduct is suspected, the resident(s) will be protected and the Administrator notified.All investigations will be thorough, well-documented, and immediate to determine if mistreatment occurred and, if so, to what extent. A thorough investigation may include identifying staff responsible for the investigation; o Collecting and preserving physical and documentary evidence that could be used in a criminal investigation; o interviewing alleged victim(s) and witness(es); interviewing accused individual(s) (including staff, visitors, resident's relatives, etc.) allegedly responsible for mistreatment, or suspected of causing an injury of unknown source; interviewing other residents to determine if they have been abused or mistreated; interviewing staff who worked on the same shift as the accused to determine if they ever witnessed any mistreatment by the accused; interviewing staff who worked previous shifts to determine if they were aware of an injury or incident; o Observation of resident and staff behaviors during the investigation; o Environmental considerations; and involving other regulatory authorities who may assist, (e.9., local law enforcement, elder abuse agency).1. Review of R3's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD). Review of Facility Initial Report, dated 07/18/25 at 9:36 PM and provided by the facility, revealed on 07/12/25, was notified of an allegation that the agency Certified Nurse Aide (CNA) on R3's floor was rough when helping R3 to bed. R3 reported sitting on the bed and the staff member throwing her legs up on the bed aggressively. Review of the investigation revealed no interview with R3, or the alleged CNA. Further review of the investigation revealed no staff interviews and none of the residents were asked about the care they received by CNA1.2. Review of R2's Face Sheet located in the EMR under the Profile tab revealed the resident was re-admitted to the facility on [DATE] with diagnoses which included chronic kidney disease.Review of Facility Initial Report, dated 07/18/25 at 8:38 PM and provided by the facility, revealed on 07/12/25, was notified that R2 reported to nursing staff about an agency staff member on the overnight shift. The staff member had told R2 in the early morning that she could hold it instead of assisting R2 to the restroom. Review of the investigation revealed no interview with R2, or the alleged CNA. Further review of the investigation revealed no staff interviews and none of the residents were asked about the care they received by CNA1.During an interview on 08/13/25 at 12:35 PM The Administrator stated he was new to the position and had only been the administrator for about two months. He stated that the former Director of Operations did the investigation and that he wrote up the summary that was submitted to the state. He agreed there should have been staff interviews along with the resident who made the allegations and that the other resident interviews should have been more specific concerning the allegations and the staff identified. He stated they did try to interview the alleged CNA (CNA1) but there was no documentation of that.

Based on observation, interview and record review, the facility did not ensure 1 of 3 residents (R) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs (R1). R1 was admitted to the facility without a PI and was assessed to be at risk for PI development. R1 developed one PI a deep tissue injury (DTI) on 01/22/25. The facility did not have preventive measures of heel boots in place prior to the development of the DTI. The facility did not complete a comprehensive assessment with staging of the PI upon discovery and did not care plan new interventions timely to promote healing. This is evidenced by: Facility's policy titled Pressure Injury Prevention and Management with last reviewed date of 09/24, read in part, 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .C. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Weekly Wound Tracker. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. 4. Interventions for Prevention and to Promote Healing. A. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Guidelines from the National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guide 2019 indicate in part: 2.1 Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the health care service .5.1 Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated .5.5 Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved . NPIAP Classification deep tissue injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear . R1 was admitted on [DATE]. Current diagnoses of Alzheimer's disease, type 2 diabetes mellitus, dementia with behavioral disturbance, weakness, depression, and reduced mobility. R1's Minimum Data Set (MDS) dated [DATE] a quarterly assessment: documented brief interview status (BIMS) score of 12 out of 15 meaning R1 has moderate cognitive impairment. R1 has no impairment to upper or lower extremities. R1 requires moderate staff assistance for oral care, toilet hygiene, dressing, personal hygiene, and transfers. R1 is dependent on staff assistance for bed mobility and showers. R1 had no behaviors of rejections of cares provided by staff. R1 was assessed to be at risk for PI, no current open PI, and has moisture associated skin damage (MASD). R1's MDS dated [DATE] a significant change assessment: documented BIMS 8 out of 15 meaning R1 has moderate cognitive impairment. R1 has no impairment to upper or lower extremities. R1 is dependent on staff assistance for all Activities of Daily Living (ADLs), including bed mobility and transfers. R1 had no behaviors of rejections of cares provided by staff. R1 is at risk for PI and no current open PI. Physician orders: 03/28/23 Elevate legs as able every shift for edema Care plans read in part, I have potential for impairment to my skin r/t fragile skin Date Initiated: 04/15/2022. Interventions included, Provide me with pressure relieving devices pressure relieving/reducing mattress, cushion, pillows, sheepskin padding, wheelchair cushion. Date Initiated: 04/15/2022 Revision on: 07/11/2024. Care plan read in part, I have the potential for pressure ulcer development r/t Immobility. Date Initiated: 04/25/2024. Interventions included, Air mattress on bed. Date Initiated: 02/10/2025. If resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 04/25/2024. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 04/25/2024. Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: 04/25/2024. R1 was admitted to the hospital on 12/20/24 and was readmitted to the facility on [DATE]. The facility staff did not complete a readmission skin assessment upon R1's return to the facility. Two days later the facility completed a skin observation note on 12/25/24 at 1:47 p.m., which read, Skin Observation Note Text: Skin reviewed on this day and remains intact. On 01/15/25, R1 enrolled in hospice care. On 01/17/25, Hospice delivered an air overlay for the mattress. Of note, the air overlay manufacturer's product sheet did not describe the stage of wounds the mattress prevents or promotes healing. The manufacturer's product sheet did not describe or recommend positioning schedules. On 01/22/25, the facility completed a Braden pressure injury risk assessment with R1 scoring an 8, meaning high risk for PI. Facility documented in R1's progress notes, which read in part, on 01/22/25 at 2:27 p.m., Nurses Notes, Note Text: Hospice RN and HHA (Home Health Aide) visit was conducted today, 01/22/25. Noted new pressure injury to left heel related to terminal status and skin failure. Intervention to float heels as tolerated. Incident report completed. Of note, the facility did not complete a comprehensive PI assessment or add additional interventions to promote healing to the care plan. Facility documentation in R1's progress note, read in part, 01/26/25 at 10:33 a.m., Nurses Notes, Note Text: Writer in room doing coccyx dressing, noted to have area to left heel. Purple in color measuring 7 cm by 5 1/2 cm. intact at this time. Hospice notified of new skin issue. Placed posey boots on at all times and then elevate when in bed. 01/26/25 Physician order: Elevate heels at all times, posey boots in place with pillow under. Every shift. Of note, the heel boots were added on 01/26/25, after the DTI developed on 1/22/25. R1 was noted to be at risk to develop a PI on the 1/10/25 MDS. R1 was noted to be at high risk for developing a PI on the braden assessment completed on 1/22/25. Facility's weekly wound tracker, dated 01/31/25, read in part, Wound Information: Left heel - Pressure: Length = 4.56, Width = 2.91, - Stage Suspected Deep Tissue Injury. This is the first time writer has observed the wound. The skin/wound is showing no s/s infection at this time. There is currently no wound exudate present. There is no wound odor present. Wound Bed reviewed and as follows: Skin %: 100, Wound edges appear as: Epithelializing, Peri wound tissue area is: Intact/Uninvolved tissues Current Treatment includes: OTA, float heels Current interventions include, Supplements, Pressure Relieving Wheelchair Cushion, Pressure relief/reduction mattress, Toileting Program, Refer to wound eval tracker for further details. Will continue the current plan of care for resident. Wound clinic nurse practitioner (NP) C documentation on 02/07/25, read in part, Left heel, facility acquired, deep tissue injury, measurements 4.51 cm by 4.23 cm, wound bed with epithelial and eschar, goal of care slow to heal, progress of PI improving. Dietician notified, practitioner notified, POA notified. Physician order: 02/11/25 Meals for low intake magic cup served with dinner meal. NP C documentation on 02/14 /25, read in part, Left heel, facility acquired, deep tissue injury, measurements 4.57 cm by 4.29 cm, wound bed with epithelial and eschar, goal of care slow to heal, progress of PI improving. Dietician notified, practitioner notified, POA notified. Facility's weekly wound tracker dated 02/14/25, read in part, Wound Information: Left heel - Pressure: Length = 4.57, Width = 4.29, - Stage Suspected Deep Tissue Injury. There is currently no wound exudate present. There is no wound odor present. Wound Bed reviewed and as follows: Skin %: 100, Wound edges appear as: Epithelializing, Peri wound tissue area is: Intact/Uninvolved tissues Current Treatment includes: OTA, float heels. Current interventions include, Supplements, Pressure Relieving Wheelchair Cushion, Pressure relief/reduction mattress, Toileting Program, Refer to wound eval tracker for further details. Will continue the current plan of care for resident. On 02/18/25 at 1:00 p.m., Surveyor interviewed Director of Nursing (DON) B about the facility assessing pressure injuries and staging. DON B indicated NP C gave the diagnoses of the type of wound and is the expert of the wounds to stage. On 02/18/25 at 3:59 p.m., Surveyor interviewed Nurse Practitioner (NP) C about R1's wound and staging. It is expected for the wounds to decline with the resident's overall decline. NP C indicated the wounds are unavoidable and not surprised this happened. R1 was in bed for the month, moving very little as of January. NP C believes R1 had an air mattress in bed. R1 before was always in his recliner so when seen in bed NP C knew R1 was declining as R1 did not use his bed. It would be beneficial to offload to promote healing. NP C indicated she did not order for repositioning as R1 was on an air mattress and expected the facility to follow manufacturer's guidelines. On 02/19/25 at 10:45 a.m., Surveyor interviewed Registered Nurse (RN) D and asked about R1's wound assessments and interventions. RN D indicated NP C does the staging of the wounds. RN D indicated there was no full skin assessment upon R1's return from hospital on 12/23/24. Surveyor asked when pressure relief devices were in place prior and after heel PI development. RN D indicated floating heels was noted on 1/22/25, and the protective boots were on the care plan 01/26/25.

Based on interview and record review, the facility did not complete comprehensive weekly wound assessments for 1 of 3 residents (R)1 to ensure that residents receive treatment and care in accordance with professional standards of practice. R1 did not receive comprehensive assessment of a skin injury upon discovery and did not initiate timely interventions to promote healing. This is evidenced by: Facility's policy titled Documentation of Wound Treatments with the last reviewed date of 09/24, read in part, 1. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound .b .if non-pressure (partial or full thickness) c. measurements; height, width, depth, undermining, tunneling d. Description of wound characteristics . R1 was admitted on [DATE]. Current diagnoses of Alzheimer's disease, type 2 diabetes mellitus, dementia with behavioral disturbance, weakness, depression, and reduced mobility. Minimum Data Set (MDS) dated [DATE] a quarterly assessment: documented brief interview status (BIMS) score of 12 out of 15 meaning R1 has moderate cognitive impairment. R1 has no impairment to upper or lower extremities. R1 requires moderate staff assistance for oral care, toilet hygiene, dressing, personal hygiene, and transfers. R1 is dependent on staff assistance for bed mobility and showers. R1 had no behaviors of rejections of cares provided by staff. R1 was assessed to be at risk for PI, no current open PI, and has moisture associated skin damage (MASD). MDS dated [DATE] a significant change assessment: documented BIMS 8 out of 15 meaning R1 has moderate cognitive impairment. R1 has no impairment to upper or lower extremities. R1 is dependent on staff assistance for all Activities of Daily Living (ADLs), including bed mobility and transfers. R1 had no behaviors of rejections of cares provided by staff. R1 is at risk for PI, no current open PI, and has MASD. Physician orders: 02/11/25 Meals for low intake magic cup served with dinner meal. 12/30/24: Wound coccyx 1) Cleanse with warm soapy water, 2) Rinse with plain warm water 3) Pat Dry 4) Apply Medihoney 5) Lay ABD pad over top Change daily and PRN one time a day for wound care. Care plans read in part, I have potential for impairment to my skin r/t fragile skin Date Initiated: 04/15/2022. Interventions included, Provide me with pressure relieving devices pressure relieving/reducing mattress, cushion, pillows, sheepskin padding, wheelchair cushion. Date Initiated: 04/15/2022 Revision on: 07/11/2024 Care plan read in part, I have the potential for pressure ulcer development r/t Immobility. Date Initiated: 04/25/2024. Interventions included, Air mattress on bed. Date Initiated: 02/10/2025, If resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 04/25/2024 Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date Initiated: 04/25/2024, Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date Initiated: 04/25/2024 Care plan read in part, I have bladder incontinence r/t Dementia . date initiated on 04/25/23. Intervention to toilet 1 assist approximately every 2 hrs. while awake and every 4 hrs. at night, assist to change pull-up if required. Resident voids in large amounts and doesn't realize his pants are wet. May use an additional liner if resident allows, initiated on 11/07/24. R1 was admitted to the hospital and was readmitted to the facility on [DATE]. The facility staff did not complete a readmission skin assessment upon R1's return to the facility. Two days later the facility completed a skin observation note on 12/25/24 at 1:47 p.m., which read, Skin Observation Note Text: Skin reviewed on this day and remains intact. On 12/29/24 at 8:39 p.m., Nurses Notes Note Text: Notified [Name], daughter, of open area noted over coccyx via detailed VM. Of note, on 12/29/24 upon initial discovery of the wound, the facility did not complete a comprehensive wound assessment. On 12/30/2024 at 7:31 p.m., Communication/Visit with Provider Note Text: New orders received from NP: 1. Wound on coccyx: cleanse with warm, soapy water; Rinse; Pat Dry; Apply MediHoney; Lay on ABD pad. Change daily and PRN 2. Tylenol 325mg take 2 orally every 12 hours x7 days 3. Cough syrup 10mL give per S.O. for cough up to QiD x7 days. R1 aware. Pharmacy notified. Wound clinic nurse practitioner documentation on 01/02/25, read in part, Sacrococcygeal, facility acquired, MASD, measurements 7.45 cm by 4.15 cm, Multiple comorbidities affecting wound healing and wound progression, as well as risk for wounds including: reduced mobility, difficulty in walking, muscle weakness. Wound clinic nurse practitioner documentation on 01/09/25, read in part, Sacrococcygeal, facility acquired, MASD, measurements 4.11 cm by 2.78 cm, wound bed has epithelial, granulation, slough, islands of epithelium, goal of care is healable, progress is improving. Practitioner notified. R1's progress notes documented on 01/10/2025 at 3:08 p.m., Nurses Notes Note Text: Received orders from NP for hospice consult and mech soft diet downgrade as needed. Faxed to hospice. Wound clinic nurse practitioner documentation on 01/16/25 read in part, Sacrococcygeal, facility acquired, MASD, measurements 8.68 cm by 4.24 cm, wound bed 100% slough, islands of epithelium, moderate serosanguineous drainage, goal of care healable, progress is stable. Practitioner notified. Of note, MASD area is larger. On 01/15/25, R1 enrolled in hospice care. On 01/17/25, Hospice delivered an air overlay for the mattress. Of note, this mattress was delivered 19 days after the MASD area developed. Facility's weekly wound tracker on 1/20/25 at 2:50 p.m., read in part, Wound/Skin Healing Note, Wound Information: Coccyx - Other (specify): MASD: Width = , . Overall impression of wound is that it is improving. There is a small amount of wound exudate present. The wound exudate consistency is serosanguineous (thin, watery, pale, red/pink drainage. Wound Bed reviewed and as follows: Slough %:100 Wound bed Full Thickness. Periwound tissue area is: Macerated Excoriated/Denuded. Resident is exhibiting pain with the wound. Refer to wound form for further details. Current interventions include, Supplements, Pressure Relieving Wheelchair Cushion, Pressure relief/reduction mattress, Toileting Program. R1's progress notes documented on 01/23/25 at 12:43, read in part, Wound/Skin Healing Note, Note Text: Weekly wound tracker completed for resident. Wound Information: Coccyx - Other (specify): MASD: Length = 8.77, Width = 5.21, Overall impression of wound is that it is improving. The wound exudate consistency is serosanguineous (thin, watery, pale, red/pink drainage. There is no wound odor present. Wound Bed reviewed and as follows: Slough %: 100 . Periwound tissue area is: Macerated Excoriated/Denuded. Resident is exhibiting pain with the wound. Refer to wound form for further details. Of note, the MASD is larger on 1/23/25. Wound clinic nurse practitioner documentation on 01/23/25, read in part, Sacrococcygeal, facility acquired, MASD, measurements 8.75 cm by 5.21 cm, wound bed 40% granulation . goal of care healable, progress is deteriorating. Facility's weekly wound tracker on 01/31/25 documented in part, Wound Information: Coccyx - Other (specify): MASD: Length = 8.8, Width = 5.2. Overall impression of wound is that it is improving. There is a moderate amount of wound exudate present. The wound exudate consistency is serosanguineous (thin, watery, pale, red/pink drainage. Wound Bed reviewed and as follows: Periwound tissue area is: Macerated Excoriated/Denuded. Resident is exhibiting pain with the wound. Refer to wound form for further details. Wound clinic nurse practitioner documentation on 02/07/25 read in part, Sacrococcygeal, facility acquired, MASD, measurements 8.19 cm by 5.66 cm, wound bed has epithelial, granulation, slough, bleeding and islands of epithelium, moderate serosanguineous drainage, goal of care healable, progress is deteriorating, limited mobility, decreased nutrition, and receiving hospice benefits, dietician notified, practitioner notified and POA notified. Wound clinic nurse practitioner documentation on 02/14/25 read in part, Sacrococcygeal, facility acquired, MASD, measurements 8.9 cm by 4.42 cm, wound bed has epithelial, granulation, slough, bleeding and islands of epithelium, moderate serosanguineous drainage, goal of care healable, progress is stable, dietician notified, practitioner notified and POA notified. On 02/18/25 at 1:00 p.m., Surveyor interviewed Director of Nursing (DON) B about the facility assessing this MASD. DON B indicated that it was not staged as it was considered MASD. On 02/18/25 at 3:59 p.m., Surveyor interviewed Wound Clinic (NP) C about R1's wound and staging. NP C indicated the area on the coccyx started out as MASD. Nutrition, mobility, and general failing contributed to the skin breakdown. The wound started out as a butterfly shape from coccyx to cheeks of buttocks, wound had a dark purple effect. It is expected for the wounds to decline with the resident's overall decline. NP C indicated the wounds are unavoidable and not surprised this happened. R1 was in bed for the month of January and believes R1 had an air mattress in bed. R1 before was always in his recliner so when seen in bed NP C knew R1 was declining as R1 did not use his bed. It would be beneficial to offload to promote healing. NP C indicated she did not order for repositioning as R1 was on an air mattress and expected the facility to follow manufacturer's guidelines. R1 would help to roll and has some mobility in bed when asked. On 02/19/25 at 10:45 a.m., Surveyor interviewed Registered Nurse (RN) D and asked about R1's wound assessments and interventions. R1's coccyx was MASD. RN D indicated there was no full skin assessment upon R1's return from hospital on 12/23/24 and no assessment of the wound on 12/29/24. Surveyor asked when pressure relief devices were in place prior and after wound development. RN D indicated the cushion to the recliner was a foam cushion that was started in November 2024. On 02/19/25 at 1:44 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) E about R1 urinary habits and positioning. CNA E indicated prior to R1's decline he was able to go to bathroom on his own and R1 would be incontinent of urine. Staff now are to check R1's brief every two hours and reposition every two hours. Of note, Surveyor noted no new interventions for the urinary incontinence to promote healing of the MASD.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (R) (R1) observed when cares were provided. Facility staff did not conduct appropriate hand hygiene when providing personal cares. Facility staff did not wear personal protective equipment (PPE) for R2 who is on Enhanced Barrier Precautions (EBP). This is evidenced by: Facility's policy titled Hand Hygiene dated 12/24, read in part, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table: .Between resident contacts. After handling contaminated objects, before applying and after removing personal protective equipment (PPE), including gloves. Before and after handling clean or soiled dressings, liens, etc. Before performing resident care procedures. Before and after providing care to residents in isolation. When, during resident care, moving from a contaminated body site to a clean body site. After assistance with personal body functions. Facility's policy titled Enhanced Barrier Precautions, with last revision date of 01/2025, read in part, EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high contact resident care activities .4. High-contact resident care activities include: .h. Wound care: any skin opening requiring a dressing . Example 1 On 02/18/25 at 9:36 a.m., Surveyor observed Certified Nursing Assistant (CNA) F and CNA G provide personal cares for R1. R1 is on EBP for open wounds. CNA F and CNA G, without conducting hand hygiene, applied gown and gloves and entered R1's room to transfer R1 to bed using a mechanical lift. CNA G assisted to roll R1 to each side for CNA F to lower R1's pants and removed brief. CNA F using wipes cleansed R1's bowel movement. CNA F removed gloves, did not perform hand hygiene and applied clean gloves. CNA G called for Registered Nurse (RN) to clean R1's wound as it was soiled with stool. RN H entered room wearing gown and gloves. RN H went to R1's bathroom and turned the faucet on with gloved hands to wet a washcloth. RN H turned the faucet off with the same gloved hands and proceeded to provide wound care to R1. RN H removed gown and gloves, washed hands, turned the faucet off with clean hands and left R1's room. CNA F and CNA G then dressed R1 and positioned R1 on back with pillows slightly under R1's left side. CNA F and CNA G removed gloves and gown. CNA G sanitized hands and left R1's room. CNA F brought the garbage to the soiled utility room and sanitized hands. CNA F returned to sanitize the mechanical lift with sanitizing wipes. After completing cleaning, CNA F disposed of the wipes and did not perform hand hygiene. CNA G returned to R1's room to place a garbage bag in R1's trash can. CNA G exited room and did not perform hand hygiene. CNA F and CNA G entered R4's room to assist with personal cares and did not perform hand hygiene prior to entering. Example 2 On 02/18/25 at 11:27 a.m., Surveyor observed RN I and RN J provide wound care for R3. R3 is on EBP for multiple open wounds to both feet. During R3's wound care RN I or RN J did not wear PPE of a gown. Upon completion of wound care Surveyor interviewed RN I and RN J asked about R5 having EBP sign on door and if a gown should have been worn during wound care. RN I indicated R3's wounds are not infected, and a gown would not be needed during dressing change. On 02/18/25 at 1:00 p.m., Surveyor interviewed Director of Nursing (DON) B about hand hygiene and proper PPE to be worn during wound care for R3 who is on EBP. DON B indicated hand hygiene should be completed after glove changes. DON B indicated education to staff had been started for proper hand hygiene during personal cares. DON B indicated gowns are to be worn when a resident is on EBP and for any type of wound. DON B indicated education to staff had been started.

Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was a significant change in a resident's clinical condition when blood sugar levels exceeded the threshold. This occurred for 1 of 3 residents (R) R4, reviewed for insulin use. This is evidenced by: The facility's STANDING ORDERS for SKILLED NURSING FACILITIES with the revised date of 2024, read in part, Diabetic Management .If DMII (diabetic mellitus type 2): Notify provider if two BG (blood glucose) results are <(less than) 70 or > (greater than) 400 in a 24-hour timeframe and/or change in condition; if no condition change, notify provider on the next business day . R4 was admitted to the facility on [DATE]. R4's current diagnoses include chronic kidney disease stage 3, congestive heart failure, type 2 diabetes mellitus, diabetic neuropathy, and diabetic retinopathy. Minimum Data Set (MDS) quarterly assessment, dated 10/04/24, documents R4's Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R4 is cognitively intact and receives insulin injections. R4's physician orders include in part, carbohydrate controlled diet, 09/06/24 insulin glargine 65 units two times a day, 09/06/24 Novolog injection 18 units before meals and hold if BS (blood sugar) under 120, 01/04/25 empagliflozin (Jardiance) 10 mg, and 11/24/24 Ozempic 2mg. Review of the medication administration record (MAR) documented blood sugar (BS) results not within parameters. 01/06/25 BS results of 500 at 4:00 p.m. 01/07/25 BS results of 466 at 11:00 a.m. and 474 at 4:00 p.m. 01/08/25 BS results of 498 at 4:00 p.m. 01/09/25 BS results of 413 at 8:00 a.m. and 467 at 4:00 p.m. 01/10/25 BS results of 498 at 8:00 a.m. 01/11/25 BS results of 409 at 4:00 p.m. 01/12/25 BS results of 423 at 8:00 a.m. and 413 at 11:00 a.m. 01/13/25 BS results of 505 at 8:00 a.m., 505 at 11:00 a.m., and 501 at 4:00 p.m. 01/14/25 BS results of 413 at 11:00 a.m. 01/18/25 BS results of 452 at 8:00 a.m. and 435 at 11:00 a.m. Surveyor's review of R4's progress notes and medical record did not identify the facility notified R4's physician of BS being elevated. The progress notes did not document R4's condition when BS was elevated. On 01/22/25 at 3:48 p.m., Surveyor interviewed [NAME] President of Clinical Operations (VP) C about R4's elevated BS and physician notification. VP C indicated staff should follow the facility's standing orders for BS over 400 and to call the physician. VP C indicated no documentation was found for physician notification in January and the physician should have been notified. We will be changing the MAR to direct nursing staff when BS are not within parameters.

Based on interview and record review, the facility did not ensure that a resident who is unable to carry out daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Residents were not receiving regular weekly showers. This affects two of five residents reviewed, R1 and R7. Findings include: Example 1 The facility policy titled, Shower, reviewed in January 2025, states, It is the policy if this facility to assist resident with bathing to maintain proper hygiene, simulate circulation and help prevent skin issues as per current standards of practice . Residents will be provide showers as per request or as per facility scheduled protocols and based upon resident safety. R1 was admitted to the facility on [DATE] with the diagnoses of hypertension, diabetes mellitus, hyperlipidemia, arthritis, anxiety, and depression. R1's most recent Minimum Data Set (MDS), dated [DATE], indicated that R1 required substantial/maximal assistance - Helper does MORE THAN HALF the effort when showering/bathing. On 01/22/25 at 12:50 PM, Surveyor interviewed R1 and Family Member (FM) E simultaneously. R1 stated they are not receiving weekly showers, and it was their understanding that showers would be weekly. FM E confirmed that to their knowledge they did not believe that R1 had received a shower in at least two weeks if not longer. They were not sure why this happens, but they believed that if the facility did not have a shower aide that day, R1 would not get the showers they desired. Record review of R1's shower log revealed a blank space where an initial and time of shower should be recorded for the date of 01/14/25 was blank. Other PRN showers listed were labeled as DO-Did Not Occur. There was no indication of refusals. Record review of R1's progress notes revealed no notes regarding refusals of showers, and nothing listed on 01/14/25 that would indicate that R1 refused a shower. Example 2 R7 was admitted to the facility on [DATE] with medically complex conditions including diagnoses of anemia, hypertension, hyperlipidemia, malnutrition, and depression. R7's most recent MDS indicated that R7 has a Brief Interview for Mental Status (BIMS) evaluation that scored a 12 out of 15, indicating mild cognitive concerns, and that R7 required substantial/maximal assistance to shower or bathe self. Record review of R7's shower task indicated that R7 last received a shower on 01/06/25 which was over two weeks ago. The last two opportunities for a shower were not recorded, and there was no indication of a refusal from R7 in any progress notes. On 01/22/25 at 1:30 PM, Surveyor interviewed Registered Nurse (RN) D regarding the missing showers for R1 and R7. RN D indicated the facility expects residents to receive weekly showers and that is why they hired people specifically to perform showers. There are times that those showers would need to be moved around a day depending on availability, but they still expect those showers to happen every week. They have been having trouble with their shower aides recording the showers properly so RN D had no way of knowing if those showers had been completed or missed. RN D would expect shower aides to indicate on the shower sheet if they had refused or had a shower. RN D indicated there should be a progress note entered if a resident refused a shower.

Based on interview and record review, the facility failed to have a system in place to ensure the code status of residents (R), as indicated in their advance directives, was followed. This affected 1 of 1 resident reviewed (R1) whose Cardiopulmonary Resuscitation (CPR) wishes were not followed. R1's Critical Care Plan indicated R1 wanted CPR. On [DATE], R1 was found not breathing and without a pulse. Staff did not promptly begin CPR per resident's wishes. When CPR was initiated, it was not performed according to current standards resulting in ineffective procedure. The facility's failure to ensure R1 received basic life support, including CPR, in accordance with preferences on signed Critical Care Plan, created a finding of Immediate Jeopardy (IJ) beginning on [DATE]. Director of Nursing (DON) B was notified of the immediate jeopardy on [DATE] at 1:30 p.m. The facility began steps on [DATE] to correct the deficient practice and to ensure compliance. The immediate jeopardy was removed and corrected on [DATE]. Based on this determination, this citation is being cited as past noncompliance. Findings include: The facility's policy and procedure titled CPR-Cardiopulmonary Resuscitation Protocol, last reviewed on ,d+[DATE], states in part, It is the policy of this facility to provide basic life support, including CPR-Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice in the resident's advanced directives. Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place Resident presents with obvious signs of clinical death (e.g. rigor mortis, dependent lividity, decapitation, transection or decomposition) are present Initiating CPR could cause injury or peril to the rescuer . Under the section of the policy titled Procedure, the policy includes the following statement, .If no pulse, begin CPR (please note: if AED is immediately available, use defibrillator as soon as possible when device is ready for use): 1. Place backboard under resident in bed or assist resident to a firm surface if possible . Review of R1's medical record identified R1 was admitted to the facility on [DATE] with diagnoses including in part, traumatic subarachnoid hemorrhage without loss of consciousness, other nontraumatic intracerebral hemorrhage, and chronic kidney disease stage 4. R1's Brief Interview for Mental Status Score at the time of admission was 11 which indicated R1 had moderate cognitive impairment. The medical record identified R1 was own health care decision-maker and did not have an activated health care power of attorney directive in place. The critical care plan, signed by R1 and R1's physician on [DATE], indicated R1 wished to have CPR. Nurses' notes, dated [DATE] at 8:16 AM, stated: Resident found unresponsive in bed by Med Tech at 6:15 AM, Pulse check performed with no pulse found. Full code was called, CPR was initiated immediately EMS contacted. CPR continued until EMS arrived and took over. Resident transported to hospital via EMS Family and DON. An additional nurse's note, dated [DATE] at 3:47 PM, identified R1 expired at the hospital. On [DATE], Surveyor conducted a telephone interview with Certified Nursing Assistant (CNA) I who stated they were present and responded when Medication Aide (MA) C called for help when R1 was found unresponsive on the morning of [DATE]. CNA I stated it was approximately between 6:05 AM and 6:10 AM. CNA I stated there were multiple staff members present in R1's room and no one was doing anything. CNA I stated someone said R1 was a full code and CPR should be started. Licensed Practical Nurse (LPN) D refused to start CPR, stating they would not do CPR on an [AGE] year-old person. When MA C insisted they start CPR, LPN D gave about 8 to 10 half-hearted chest compressions and stopped. Then MA C took over chest compressions but R1 was on the bed, and they did not put a back board under R1 or move R1 to the floor. CNA I stated CNA I was CPR certified and had participated in codes in the past. CNA I stated neither LPN D nor MA C appeared to know how to perform CPR. CNA I stated it was approximately 6:15 AM when LPN D started the ineffective chest compressions and LPN D and MA C continued to take turns doing the half-hearted chest compressions for about 10 minutes until the ambulance arrived. CNA I stated no other nursing staff intervened and no one put the defibrillator on R1. On [DATE], Surveyor conducted a telephone interview with CNA H, who stated they had been in R1's room to reposition in bed and provide incontinent cares at approximately 5:45 AM. R1 was restless and complaining of shortness of breath. Shortly after 6:00 AM, MA C called for help over the radio that R1 was not breathing. CNA H stated when they responded to the room there were multiple staff members present including MA C, LPN D, LPN J and LPN G. No one was doing anything for R1 until LPN G stated that R1 was a full code and someone should start CPR. LPN G ran to the desk to call EMS. LPN J quickly left the room. LPN D refused to do CPR, stating the resident was [AGE] years old and already dead. MA C stated they had to do something because R1 was a full code and requested someone get the crash cart. LPN D did a few chest compressions but did not appear to know how to do CPR. R1 was still on the bed, and they did not put a back board under R1 or move R1 to the floor. CNA H stated MA C and LPN D sort of took turns doing chest compressions while R1 was in the bed until the ambulance arrived. CNA H did not know for sure how long the delay was from when MA C called for help and someone started CPR, but estimated it was maybe between 10 to 15 minutes. CNA H estimated it was approximately 10 minutes later that the ambulance crew arrived and moved R1 to the floor and took over CPR. On [DATE], Surveyor interviewed CNA F who stated they were with MA C when they found R1 not breathing on the morning of [DATE]. CNA F stated it was approximately 6:05 AM. CNA F stated MA C called for help right away over the radio and multiple staff responded but no one seemed to know what to do, and no one started CPR until someone stated R1 was a full code. Initially LPN D refused to do CPR stating they would not do CPR on an [AGE] year-old person. CNA F stated eventually LPN D did a few chest compressions after MA C insisted, but LPN D did not appear to know how to do CPR. CNA F said someone got the crash cart and someone called 911, but no one put a back board under R1 or moved R1 to the floor to do CPR until the ambulance arrived. CNA F estimated it was 10 to 15 minutes before anyone started CPR and maybe another 10 minutes until the ambulance arrived. On [DATE], Surveyor interviewed CNA E who stated they responded to R1's room on the morning of [DATE] when MA C called for help. CNA E did not remember exactly what time it was, but right at the beginning of the shift. CNA E stated there were a lot of staff in R1's room and there was a lot of confusion. CNA E stated eventually LPN D started doing chest compressions on R1 when someone said R1 was a full code. CNA E stated R1 was in the bed and did not think there was a back board under R1 when LPN D started compressions. CNA E did not know how long it was between the time MA C called for help and someone started CPR but thought maybe 10 minutes. CNA E did not stay in R1's room, so did not know if staff continued to provide CPR until the ambulance arrived. On [DATE], Surveyor conducted a telephone interview with LPN G. LPN G stated they had worked the overnight shift on [DATE] and R1 was restless and complaining of shortness of breath off and on all night. LPN G and CNA H had just been in R1's room providing cares around 5:45 AM. LPN G gave short report to MA C and went to count the narcotics on the other medication cart with LPN J. Shortly after 6:00 AM, they heard MA C call over the radio for help in R1's room as she was not breathing. LPN G went to nurse's station to check on R1's code status and LPN J went to R1's room. When LPN G arrived at R1's room, R1 was unresponsive in bed, and everyone was just standing around doing nothing. LPN G informed them to start CPR as R1 requested a full code. LPN G heard LPN D state they would not do CPR on an [AGE] year-old. LPN G then went back to the nurse's station to call 911 and get transfer paperwork ready because LPN G felt there were enough staff in the room to handle the situation. LPN G did not go back to the room and did not know who started CPR or what time it was started. On [DATE], Surveyor interviewed MA C who reported they were outside R1's room around 6:00 AM preparing R1's AM medications. LPN G and a CNA were in the room providing cares. LPN G said R1 not doing well when leaving the room. A few minutes later MA C entered room with AM medications and found R1 lying on right side facing the wall and unresponsive. MA C found R1 was without a pulse and not breathing and called for help over the radio. Multiple staff responded to MA C's call. MA C did not start CPR immediately because was waiting for direction from the nurses who arrived to help. LPN G entered and informed them R1 was a full code and instructed them to start CPR. LPN D refused to start CPR stating it was an [AGE] year old and they were already gone, there was nothing they could do. MA C insisted LPN D start CPR because it was R1's wish. LPN D then did about 10 chest compressions, quit and said, There are you happy? MA C said they couldn't do nothing and told someone to get the crash cart. MA C started chest compressions, but in the panic of the moment forgot to put a back board under R1 or move R1 to the floor. MA C did not know how long it was between finding R1 unresponsive and the start of CPR. MA C said the ambulance crew arrived around 6:30 AM and moved R1 to the floor to continue CPR. MA C stated they got a pulse back before transporting R1 to the hospital. On [DATE], Surveyor interviewed Registered Nurse (RN) K who was the nurse manager on call on [DATE] when R1 was found unresponsive. RN K received a phone call at 6:19 AM from LPN D who informed RN K that R1 was found not breathing and without a pulse and wanted to clarify if they should do CPR. RN K informed LPN D they should have already started CPR as R1 was a full code and they should call 911 right away. Review of the ambulance report identified they received the call at 6:22 AM on [DATE] and arrived on scene at 6:27 AM. They found R1 lying supine in bed with staff performing CPR. They moved R1 to the floor and resumed CPR. They inserted an airway, attached pads to R1's chest and noted an initial rhythm of asystole. They inserted an IV and administered three doses of epinephrine. Faint pulses were present at 7:02 AM and they transported R1 to the hospital. Review of the emergency room (ER) report identified R1 arrived at the ER at 7:26 AM. R1 was found to have a faint pulse, in bradycardia, with pupils fixed and dilated. Chest compressions were resumed. R1 was placed on a mechanical ventilator and provided emergency medical care until family arrived and requested to change code status to Do Not Resuscitate to stop the mechanical ventilation. R1 expired in the hospital. On [DATE], Surveyor interviewed Director of Nursing (DON) B and asked about the events involving R1 on the morning of [DATE]. DON B stated they began an investigation into the events on the morning of [DATE] and quickly identified there was a delay in the initiation of CPR for R1 due to staff refusal to perform CPR and staff confusion about responsibilities. Staff delay in initiating CPR for R1 after determining R1 was without a pulse was possibly as long as ten minutes. The website http://www.AED.com notes that there, is a 5-minute survival window for a victim of sudden cardiac arrest with the survival depending upon early CPR and having access to an AED within that 5-minute timeframe .The Chain of Survival steps must all occur within 5 minutes: 1. Early Access to get help: Call 911 2. Early CPR to buy time: Begin CPR Compressions Immediately 3. Early Defibrillation to restart heart: Use AED as soon as possible on victim 4. Early ACLS to stabilize: Ambulance arrival time Failure to immediately begin CPR reduced the chances that this resident could recover and survive. Brain death can occur within ,d+[DATE] minutes of the brain being deprived of oxygen. Further, the chance for a successful outcome decreases 7% with each minute that CPR is delayed. The facility's failure to follow the code status identified in the advance directives and promptly begin cardiopulmonary resuscitation resulted in serious harm, thus leading to a finding of immediate jeopardy that began on [DATE]. On [DATE], the facility identified the deficient practice that occurred when the facility staff did not perform CPR when R1 was found without respirations and a pulse. The facility began steps to correct the deficient practice on [DATE]. The immediate jeopardy was removed and corrected on [DATE] when the facility completed the following: All staff education of CPR policy, emergency medical services activation, and code status, crash cart location, delegation of duties, crash cart audits, code status audits, and mock code competency. On [DATE], Surveyor reviewed the following documentation: Education provided to all staff on CPR policy and Code Blue drills. Emergency Documentation form created and placed on both crash carts. Audits and restocking of both crash carts. Audits of all resident code status. Initiation of Code Blue drills to be completed periodically for all shifts. Based on this determination, the citation is issued as past noncompliance.

Based on observations and interviews, the facility did not distribute and serve food with professional standards for food service safety. This has the potential to affect all 43 residents in the facility. Observations of handling ready to eat foods with contaminated gloves. Observed dirty air conditioner blowing on clean dishes. Dirty, unsanitary condition in dish room. Findings include: On 07/16/24 at 11:05 AM, Surveyor observed the dish room; there was a window air conditioner blowing on the clean dishes. Surveyor observed the blades of the air conditioner and there was a light gray colored dust on them. Surveyor also observed the exhaust fan above the dishwasher; there was a black colored fuzzy substance on the fan. Surveyor also observed a fan attached to the wall across from the dish machine with fuzzy, black in color substance on it. Also on the wall all around the fan were black fuzzy spots. On 07/16/24 at about 3:28 PM, Surveyor toured the dish room with Nutritional Services Director (NSD) K and asked NSD K if they thought the air conditioner was clean. NSD K indicated nope. Surveyor pointed out the fan and the wall around it and asked if it was clean. NSD K indicated it looks yucky. Surveyor then pointed out the exhaust fan above the dish machine, and NSD K indicated it looks like it needs cleaning. On 07/16/24 at 12:08 PM, Surveyor observed [NAME] J wearing gloves and grabbed 2 spatulas to put sandwiches on the plates. With same gloves [NAME] J went into the cooler and brought out a tray of deviled eggs. With the same contaminated gloves on [NAME] J's hands, [NAME] J put 2 halves of sandwiches on a plate then removed half of the sandwich using the same contaminated gloved hand and a spatula. [NAME] J continued serving lunch then used their same contaminated gloved hand to help with dishing up a sandwich with a spatula on the plate. On 07/16/24 at about 3:28 PM, Surveyor interviewed NSD K sharing the observations of [NAME] J serving the sandwiches during lunch. Surveyor asked what the process should be. NSD K indicated that [NAME] J should have used tongs instead.

Based on interview and record review, the facility did not establish an Infection Control Program under which it investigates, controls, and prevents infections in the facility, and a system for recording incidents identified under the facility's Infection Control Program, including corrective action in a timely manner, for both residents and staff. This has the potential to affect all 43 residents in the facility. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to effect 43 of 43 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 during an outbreak. -Observations were made of the facility not implementing Enhanced Barrier Precautions (EBP) for 2 of 5 sampled residents on EBP. This is evidenced by: Example 1: The facility policy entitled, Water Management Program, which is not dated, states in part: Infection Control - . #3. Risk Assessment - will be conducted by water management team annually to identify where legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. #5. Based on risk assessment, control points will be identified and kept in the water management program binder: . #6. The measures shall be specified in the water management program action plan. #7. Testing protocols and control limits will be established, and adequate records of infection control measures documented then corrective actions be taken and documented . #9. Effectiveness of the water management program shall be evaluated with routine infection surveillance data, water quality data, and rounding data to validate effectiveness. The Center for Disease Control and Prevention (CDC) guidelines entitled, Controlling Legionella in potable water systems, last reviewed March 15, 2024, states in part: Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. On 07/17/24 at 9:15 AM, Surveyor reviewed the facility's Water Management Plan (WMP) and did not find a record of maintenance, inspections, or flushing of areas of concerns that required flushing. Surveyor did not observe the updated version of water management plan being utilized. Surveyor did not observe the flow diagram or WMP updated with locations of hot spots/stagnation areas deemed high risk areas of Legionella growth. Surveyor observed an annual risk assessment was completed on 07/07/23 and brief review of plan was conducted on 06/19/24 with no documented revisions or documentation on audit logs, surveillance data, or effectiveness of the last year's plan in place. On 07/17/24 at 10:11 AM, Surveyor interviewed Nursing Home Administrator (NHA) A who indicated that NHA A and Environmental Service (EVS) Director M are responsible for the water management plan in the facility. Surveyor interviewed NHA A and asked to walk Surveyor through the WMP. NHA A admitted to following the WMP tool kit from the CDC that was not updated from 2017. NHA A indicated the current WMP that the facility is using does not show distinct quality measures on the flow diagram or where stagnation/hot spots are located throughout the facility. NHA A indicated that nothing has specified locations and the flow diagram shows just description such as water heater, fountain, etc. but not where these items are located through the building and what is being assessed. NHA A indicated that there were no audit logs being completed by the facility until 06/27/24. Example 2: The facility policy entitled, Infection Surveillance, which is dated 08/2022, states in part: #6: The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. The infection site, pathogen, signs and symptoms, and residents' location, including summary and analysis of the number of residents and staff who developed infections . Surveyor reviewed Infection Control (IC) surveillance logs and found the facility identified the facility had an outbreak of COVID-19 starting in December of 2023 and ending in February 2024, which affected 19 of 43 residents. Surveyor observed data logs to be inconsistent and missing residents' last names, identifiers, and room numbers. Surveillance logs were observed missing information identifying onset of symptoms, when precautions were implemented, any testing, last well date, when symptoms ended, when precautions ended, and if provider was notified. Surveyor reviewed IC 2023 data line lists for residents and staff. Surveyor noted that all line lists from January 2023-December 2023 were inconsistent and missing data. Surveyor reviewed and noted line lists were missing the infection site, pathogen, signs and symptoms, residents' or staff's location, last well date, any summary and analysis of the number of residents and staff who developed infections. Line lists had incomplete data. On 07/16/24 at 9:33 AM, Surveyor interviewed Registered Nurse (RN) D who was the Infection Preventionist (IP) until 06/08/24 when the Director of Nursing (DON) B took over as IP. Surveyor asked RN D about the process for tracking surveillance of resident infections and sicknesses. RN D indicated that line lists were incomplete throughout the whole year last year in 2023 and into June of 2024. RND D indicated that RN D was doing the best that RN D could but that RN D was not fully trained in IP and had lots going on in RN D's role as DON and IP. Surveyor asked RN D about the process for tracking surveillance of resident infections during the identified COVID-19 outbreak that started on unknown day in December 2023. RN D indicated that RN D was supposed to track the date of onset of symptoms, testing parameters, when precautions such as quarantine start, and end based on the CDC recommendations for the COVID-19 virus. RN D indicated that RN D did the best that RN D could but that there was no other information documented pertaining to the COVID-19 outbreak. RN D indicated that RN D did not have a surveillance log tracking the 19 residents who became infected with COVID-19 sometime in December of 2023 and ending sometime in February 2024. Surveyor asked RN D if any staff members were identified as positive with COVID-19 virus in the COVID-19 outbreak. RN D indicated there were several staff members who became sick with COVID-19, but that RN D did not keep any records of the sick staff members and what actions were taken. Surveyor asked RN D if there was any other information that RN D could provide Surveyor with pertaining to the documentation of the COVID-19 outbreak. RN D indicated that RN D had no other information as the COVID-19 outbreak was not surveilled as it should have been. On 07/16/24 at 9:41 AM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for surveillance of infections throughout the building and what criteria is being utilized to determine antibiotic usage compliance. DON B indicated that DON B started as DON/IP on 06/10/24. DON B indicated the process for tracking infections and mitigating the spread of infections has not been in effect, and DON B is currently working on a correct process going forward. DON B indicated that last night on 07/15/24, DON B started formulating a nice spreadsheet line list to implement going forward. On 07/17/24 at 10:02 AM, DON B indicated that until today on 07/17/24 DON B has been pulling all residents who are on antibiotics and running a report at the end of the month and filling out the McGeers criteria sheet individually for them. DON B indicated that DON B started back tracking and reviewing antibiotic use from January 2024 to present and is gathering data to make into spreadsheets. DON B indicated then DON B places it in the correct set month and using the tracking list to verify what antibiotic residents were on and calculating the infection rate off that data. DON B indicated that DON B would start the McGeer's criteria right away once resident is deemed to have an infection to make sure that resident meets the criteria to be on antibiotic, but DON B indicated this was not being implemented with current residents who have infections and are on antibiotics. Surveyor asked DON B if DON B or RN D had any staff infection control line lists for January 2024 to present. DON B and RN D indicated that no staff line lists for January 2024 to present could be found. 40181 Example 3: According to CDC guidance entitled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), last updated 07/12/22, .EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Infection or colonization with an MDRO .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization . On 07/15/24 at 10:40 AM, Surveyor noted the Resident Matrix (CMS-802) identified R30 was on Transmission-Based Precautions (TBP). Surveyor observed there was no sign on R30's door identifying TBP, and there were no PPE supplies by R30's door or in the room. Surveyor asked Certified Nursing Assistant (CNA) L if R30 was on TBP and if Surveyor needed to put on PPE to enter R30's room. CNA L did not know if R30 was supposed to be on TBP. CNA L stated usually there should be a sign indicating what type of TBP on the resident's door, and a PPE cart outside the door for residents on TBP. On 07/15/24 at 10:45 AM, Registered Nurse (RN) C stated R30 should be on EBP due to an open wound on the foot. RN C stated there should be a sign on the door and PPE cart set up, and they would get that set up. At 11:05 AM, RN C came back and informed Surveyor R30 was no longer on EBP because their corporate consultant told them it was no longer required. On 07/16/24 at 8:14 AM, Surveyor observed RN D and CNA F provide incontinence cares for R30. RN D and CNA F were not wearing gowns during this high-contact care. On 07/16/24 at 1:31 PM, Surveyor observed RN D perform wound care on R30's left lateral ankle pressure injury. RN D did not wear a gown during this high-contact care. RN D stated the left ankle wound had been present for several months. On 07/17/24 at 8:38 AM, Surveyor interviewed Director of Nursing (DON) B and asked what criteria the facility used for putting residents on EBP. DON B stated they follow CDC guidance for EBP. Surveyor asked why R30 was taken off EBP since R30 still has a chronic wound open on the left outer ankle and CDC guidance recommends EBP for residents with chronic wounds. DON B stated their corporate nurse told them the corporation has a different policy and procedure related to criteria for EBP and R30 did not need to be on EBP, so they removed it. DON will get the policy and procedure for Surveyor to review. On 07/17/24 at 10:13 AM, DON B provided facility policy and procedure entitled Enhanced Barrier Precautions, last reviewed 4/2024. The policy and procedure stated in part, .EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Enhanced Barrier Precautions may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Infection or colonization with a targeted MDRO. Infection or colonization with other epidemiologically important MDROs, or Chronic wounds or indwelling medical devices, regardless of their MDRO colonization status . Surveyor asked DON B if R30's left ankle wound, which had been present since February of 2024, would be considered a chronic wound. DON B stated yes, it would be considered a chronic wound. Surveyor asked DON B if R30 should be on EBP due to having a chronic wound which was still open and getting daily wound care. DON B stated R30 should be on EBP and they would implement that today. 43352 Example 4: R21 was listed on the roster matrix as being on transmission based precautions (TBP) and was not observed to be on TBP. Facility policy titled Enhanced Barrier Precautions with an effective date of March 2023 read in part, Additional MDROS that can be considered for enhanced barrier precautions may include, ESBL - producing Enterobacterales may be considered per Director of Nursing directions. R21 was admitted to the facility on [DATE] and has diagnoses that include acute pain of right knee, neuropathy, osteoarthritis of right knee, kidney disease stage 3, ESBL producing bacteria infection in urine, and an open wound on vagina area. R21 also receives daily wound care on right and left ankles. On 07/17/24 at about 8:45 AM, Surveyor interviewed RN I, who is also the case manager and asked if R21 was supposed to be on any type of precautions. RN I looked at their bulletin board and indicated yes. Surveyor asked how someone would know if a resident is on any sort of precautions. RN I indicated there is supposed to be a bin inside the resident's room and a sign on the door. Surveyor told RN I that neither of those items were present. RN I said, Let's go check. When we got to R21's door, RN I indicated there should be a sign on the door and there is not. RN I knocked on the door and when R21 said come in, RN I and Surveyor entered the room. RN I asked R21 if there was ever a bin in R21's room. R21 indicated they never had one. On 07/17/24 at 9:00 AM, Surveyor interviewed DON B and asked if R21 should be on precautions with a history of ESBL. DON B indicated if ESBL they should be on EBP.

Based on interview, the facility failed to ensure the Infection Preventionist (IP) is trained in special education and training in infection prevention and control. This has the potential to affect all 43 residents. This is evidenced by: Registered Nurse (RN) D was the facility's Infection Preventionist (IP) until 06/08/24. On 07/17/24 at 9:30 AM, Surveyor asked RN D if RN D had specialized training in Infection Control (IC) and prevention. RN D stated, No, I never did finish the infection control instructional class to become certified but that there was a corporation person for IC who oversaw the infection control program sometimes. Surveyor asked what that role consisted of for the corporation IC and RN indicated that corporation IC would come into facility sometimes and oversee some of the significant IC data but that it was inconsistent, and RN D would conduct surveillance as best as RN D could. Surveyor asked RN D how long has RN D been the IP at the facility. RN D stated, I started this role sometime in April/May of 2023 and continued in the IC/Director of Nursing (DON) role until the interim DON B took over in June of 2024, but I was not proficient in IC surveillance and implementing the IC program. I did my best with the little experience and resources I had but IC was not being completed as IC needed to be. Surveyor reviewed documentation and only found that there was a corporation person overseeing the infection control program from Jan-July 2023 and then RN D was on RN D's own thereafter from July 2023- June 2024. Surveyor found significant errors and lack of documentation during infection surveillance from January 2023 - 07/17/24. Last known documentation that was signed from a trained infection preventionsit was a line list dated 07/2023 that had been reviewed and signed. DON B began the IC role around March of 2024. The facility has an inadequate water management program to prevent the spread of infection. Deficiencies were noted in Covid immunizations and influenza and pneumococcal vaccinations not being offered or given to prevent the spread of infection. See F880, F883, F887. The facility failed to ensure the IP has specialized training in infection prevention and control.

Based on staff interview and record review, the facility did not ensure 8 residents (R) of 13 sampled were offered a COVID-19 vaccine as indicated. (R40, R24, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC COVID-19 vaccine Timing for Adults reads, in part: One dose of COVID-19 vaccination booster is recommended for adults every 6 months unless immunocompromised . Surveyor requested a list of current residents and their COVID-19 immunization dates. R40 was admitted on [DATE]. R40's immunization record stated that COVID-19 vaccinations were recommended. Facility did not have documentation that the facility offered or educated R40 of the COVID-19 vaccination recommendation. The facility did not have a declination form in R40's record of the COVID-19 vaccination being declined. R24 was readmitted on [DATE]. R24's immunization record stated COVID-19 vaccination recommended. Facility did not have documentation that the facility offered or educated R24 of the COVID-19 vaccination. The facility did not have a declination form in R24's record of the COVID-19 vaccination being declined. R1 was admitted on [DATE]. R1's immunization record stated COVID-19 vaccination recommended. Facility did not have documentation that the facility offered or educated R1 of the COVID-19 vaccination. Surveyor reviewed a consent form signed on 11/23/23 titled, COVID-19 vaccine consent form, signed by R1's Power of Attorney (POA) which indicated the consent to receive the COVID-19 vaccine from the facility. The consent form does not specify that education was given, and the form does not have the screening questions answered to receive the vaccination appropriately. The immunization record does not indicate that R1 received the COVID-19 vaccination as requested. R2 was admitted on [DATE]. R2's immunization record stated that COVID-19 vaccination was recommended. Facility did not have documentation that the facility offered or educated R2 of the COVID-19 vaccination. Surveyor reviewed a consent form signed on 11/14/23 titled, COVID-19 vaccine consent form, signed by R2 which indicated the declination of the COVID-19 vaccination from the facility. The declination form does not specify that education was given. Surveyor reviewed R21, R42, R37, and R31's immunization record which indicated COVID-19 vaccinations were not offered and/or kept up to date, and/or education was not given to residents or POAs regarding the vaccinations. On 07/17/24 at 11:17 AM, Surveyor interviewed R40 and asked if R40 was offered or educated on COVID-19 vaccinations. R40 indicated that no one has spoken to R40 about vaccinations. R40 indicated that R40 was not offered an COVID-19 vaccination while being admitted to the facility. On 07/17/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B, Registered Nurse (RN) D, and VP of Clinical Operations Q and asked about the process for admission and up to date on current immunizations. DON B and RN D indicated the process for following up with vaccinations after residents are admitted is a working process at this time. RN D indicated the facility has recognized the process for updating immunizations, offering, and educating on vaccinations was not being completed throughout the whole facility. RN D indicated this task had fallen through the cracks. RN D indicated the staff did not administer or educate on COVID-19 vaccinations appropriately to R40, R24, R1, R2, R21, R42, R37, and R31.

Based on interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received influenza and/or pneumococcal immunizations, for 9 of 13 sampled residents, (R). (R40, R24, R11, R1, R2, R21, R42, R37, and R31) This is evidenced by: The CDC Influenza Vaccine Timing for Adults reads, in part: One dose of Influenza vaccine is recommended for adults each flu season . The CDC Pneumococcal Vaccine Timing for Adults reads, in part: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 . Surveyor requested a list of current residents and their influenza and pneumococcal immunization dates. R40 was admitted on [DATE]. R40's immunization record stated that influenza and pneumococcal vaccinations were recommended. Facility did not have documentation that the facility offered or educated R40 of the influenza and pneumococcal vaccinations recommended. The facility did not have a declination form in R40's record of the influenza and pneumococcal being declined. R24 was readmitted on [DATE]. R24's immunization record stated influenza immunization recommended. Facility did not have documentation that the facility offered or educated R24 of the influenza vaccination. The facility did not have a declination form in R24's record of the influenza vaccination being declined. R11 was admitted on [DATE]. R11's immunization record stated that influenza and pneumococcal were recommended. Facility did not have documentation that the facility offered or educated R24 of the influenza vaccination or pneumococcal immunization. The facility did not have a declination form in R24's record of the influenza vaccination or pneumococcal being declined. R1 was admitted on [DATE]. R1's immunization record stated influenza immunization and pneumococcal recommended. Facility did not have documentation that the facility offered or educated R1 of the influenza vaccination. Surveyor reviewed a consent form signed on 11/23/23 titled, Influenza vaccine consent form, signed by R1's Power of Attorney (POA) which indicated the consent to receive the influenza vaccination from the facility. The consent form does not specify that education was given, and the form does not have the screening questions answered to receive the vaccination appropriately. Surveyor also reviewed a consent form signed on 11/23/23 titled, Pneumococcal Vaccine consent form, signed by R1's Power of Attorney (POA) which indicated the consent to receive the pneumococcal vaccination from the facility. The consent form does not specify that education was given, and the form does not have the screening questions answered to receive the vaccination appropriately. R2 was admitted on [DATE]. R2's immunization record stated influenza vaccination was recommended. Facility did not have documentation that the facility offered or educated R2 of the influenza vaccination. Surveyor reviewed a consent form signed on 11/14/23 titled, Influenza vaccine consent form, signed by R2 which indicated the declination of the influenza vaccination from the facility. The declination form does not specify that education was given. Surveyor reviewed R21, R42, R37, and R31's immunization record which indicated influenza and pneumococcal vaccinations were not offered and/or kept up to date, and/or education was not given to residents or POAs regarding the vaccinations. On 07/17/24 at 11:17 AM, Surveyor interviewed R40 and asked if R40 was offered or educated on influenza, pneumococcal, and COVID-19 vaccinations. R40 indicated that no one has spoken to R40 about vaccinations. R40 indicated that R40 was not offered an influenza vaccination or anything else while being admitted to the facility. On 07/17/24 at 11:45 AM, Surveyor interviewed Director of Nursing (DON) B, Registered Nurse (RN) D, and VP of Clinical Operations Q and asked about the process for admission and up to date on current immunizations. DON B and RN D indicated the process for following up with vaccinations after residents are admitted is a working process at this time. RN D indicated the facility has recognized the process for updating immunizations, offering, and educating on vaccinations was not being completed throughout the whole facility. RN D indicated this task had fallen through the cracks. RN D indicated the staff did not administer or educate on influenza and/or pneumococcal vaccinations appropriately to R40, R24, R11, R1, R2, R21, R42, R37, and R31.

Based on observation, interview and record review, the facility did not ensure food was prepared in a form designed to meet individual needs for 1 of 10 residents (R) on mechanically altered diets. (R3) R3 had a choking episode in October 2022 and had orders for a mechanically altered diet. R3 was repeatedly served incorrect foods which resulted in two additional choking episodes that required intervention by nursing staff to clear R3's airway. On 05/30/23, observation showed R3 was served foods that did not meet standards for the current diet order of pureed. Failure to ensure foods were served to residents in the appropriate texture created a finding of Immediate Jeopardy (IJ), which began on 04/06/23. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on 05/31/23 at 11:39 AM. The immediate jeopardy was removed on 06/02/2023; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its removal plan. Findings include: According to data from the National Safety Council, choking is the 4th most common cause of death. https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/deaths-by-age/data-details/ Dietitians, speech language pathologists, and dietary managers all have codes of practice to follow within their professions. The definition of professional standard of care: Ethical or legal duty of a professional to exercise the level of care, diligences, and skill prescribed in the code of practice of his or her profession, or as other professionals in the same discipline would in the same or similar circumstances. https://www.businessdictionary.com/definition/professional-standard-of-care.html As of October 2021, the Academy of Nutrition and Dietetics announced International Dysphagia Diet Standardization Initiative (IDDSI) is the only professionally recognized standard of care for texture modified diets in the Nutrition Care Manual of the Academy of Nutrition & Dietetics for the United States. On 05/31/23, Dietary Manager (DM) G provided Guide To Diets-Therapeutic Diets as the current standard of practice the facility was using for texture modified diets. DM G stated the facility was currently in the process of implementing IDDSI as their standard of practice, but it was not fully implemented yet. Facility dietary standard of practice entitled Guide to Diets states in part: .Pureed Food must be blended to a smooth pudding like consistency. No lumps or chunks . Facility policy entitled, Therapeutic Diet Orders, dated 08/22/22, stated in part: .Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed . R3 was admitted to the facility on [DATE], with diagnoses including in part, Alzheimer's disease and pain. R3's most recent Minimum Data Set (MDS) assessment, dated 03/27/23, indicated R3 had severe cognitive impairment; R3 would not have been able to recognize foods that posed a choking risk. The MDS assessment further identified R3 required extensive assistance of one person for eating. R3's care plan stated, in part: .EATING: The resident requires limited assistance by one staff to eat. Last revised on 09/15/21 . Surveyor noted R3's care plan was not updated to R3's current eating assistance need per most recent MDS assessment. R3's diet orders dated 04/20/23 stated Level-1 Puree texture, Regular/thin fluid consistency. Review of R3's medical record identified R3 had a choking episode on 10/25/22. The resident was on a regular texture diet at the time. During the lunch meal R3 was found to be choking with no sound or breath heard. The nurse responding was able to dislodge three large boluses of food with a swipe of R3's mouth and back of throat. As a result of that incident, R3 was moved to the assisted dining table and diet texture was changed to pureed until Speech Therapy (ST) could evaluate R3's swallowing. ST discharged R3 from services with the following discharge instructions: Mech soft diet. Special Instructions: cut up food for patient . On 05/30/23, Surveyor interviewed ST D, who reported R3 had another choking episode on 01/26/23. ST D stated the choking incident occurred on 1/26/23 due to R3 being served lettuce that was not shredded and carrots that were not soft enough and not cut up. ST D stated those foods were not following the Mech Soft Diet orders. ST D stated they determined through ongoing ST treatments at that time, R3 was still able to safely manage a Mech Soft Diet without choking risk. ST D did not modify R3's diet orders at that time. ST D stated they provided education to dietary staff on appropriate foods for a Mech Soft Diet. According to facility standard of practice, Guide to Diets .Top foods to avoid on Mech Soft Diet .Lettuce is tricky-shredded is best. Iceberg mix not recommended d/t [due to] pieces of radish, carrot, cabbage. More difficult to chew/breakdown lettuce. Food should be soft enough to be cut with a fork. ST D provided documentation of therapy starting on 01/26/23. The ST evaluation and plan of treatment documentation stated resident was referred due to aspiration episode today resulting in patient's face turning red. Nursing reports patient choked on lettuce and carrots. Patient is currently on a mech soft diet with thin liquids . The ST Discharge Summary, dated 03/06/23 stated in part: .Supervision: How often does patient require supervision/assistance at mealtime d/t swallow safety? = 91-100% of the time (Patient sits at the max-assist table in the dining room. Patient sometimes requires assistance with feeding tasks d/t increased fatigue.) Surveyor was unable to identify any documentation in R3's medical record, such as nursing progress notes or incident notes related to the choking incident on 01/26/23. Surveyor was provided education from Speech Therapy with specific instructions on correct food consistency for diet types, to return a wrong diet immediately as it can be dangerous, to verify the meal slip for correct texture, if unsure ask a supervisor. Review of R3's medical record identified a third choking incident that occurred on 04/06/23. R3's diet orders on 04/06/23 were Mech Soft Diet. The nursing progress note indicated R3 choked on a corn dog and required nursing staff to perform the Heimlich maneuver. Staff had served the wrong form of diet to R3 again. On 05/30/23 at 12:25 PM, Surveyor observed a dietary aide place a lipped plate with ground meat and mashed potatoes in front of R3. R3 was also served a small bowl of creamed corn with visible corn kernels. R3 immediately began to eat the food independently. There was a blue meal ticket placed on the table beside R3's food. The ticket had R3's name and said Texture: Puree Surveyor asked Certified Nursing Assistant (CNA) I, who was feeding another resident at the same table, if the food on R3's plate was pureed. CNA I shrugged her shoulders and raised her eyebrows, but did not answer. Then a hospice nurse who was seated by a resident at the same table said the food appeared ground, not pureed. CNA I then stated R3's food appeared ground, but did not intervene with R3 eating, and continued to feed the other resident. Surveyor went to the kitchen service window to determine if R3 had the correct food and was informed the kitchen staff was currently consulting with ST D because another resident's pureed food was not the correct texture. Surveyor was informed kitchen staff was re-making the pureed food per ST D's instructions. Surveyor returned to R3's table and identified R3 had already consumed all of the ground meat on the plate, which was not prepared in the correct texture for a pureed diet. On 05/30/23 at 1:54 PM, Surveyor interviewed ST D about the pureed food served to R3 at the noon meal that day. ST D stated they were in the kitchen area consulting about another resident when asked to inspect the pureed food served to R8. ST D stated the food served was not correct puree consistency and instructed dietary staff to re-make the pureed food. ST D stated they were called away and did not inspect the final product that was served to residents receiving puree food. ST D was not aware that R3 was served ground meat during the lunch meal that day. ST D stated the creamed corn served to R3 during lunch should not have had any visible kernels if appropriately prepared to puree standards. ST D stated they had concerns about dietary staff continuing to serve incorrect diets to residents, including R3. ST D stated they had provided education to dietary manager after each of R3's choking episodes, but felt the kitchen staff was still serving incorrect foods which resulted in R3's choking episode on 04/06/23. ST D stated due to ongoing concerns about dietary staff serving incorrect foods for mechanically altered diets, they were working with dietary staff to implement IDDSI diets in the facility. On 05/30/23 at 2:30 PM, Surveyor interviewed Registered Nurse (RN) F who stated they were present when R3 choked on a corn dog in April. RN F stated R3 was supposed to be on a mechanically altered diet at that time, and should not have been served a whole corn dog. On 05/30/23, Surveyor asked Director of Nursing (DON) B for any documentation related to R3's choking incidents on 10/26/22, 01/26/23, and 04/06/23. DON B provided one nursing progress note for the incident on 10/26/23, Education and sign in sheets for the incident on 1/26/23, and provided nursing progress notes and an incident investigation and Quality Assurance and Performance Improvement (QAPI) corrective action packet for the incident on 04/06/23. Review of the QAPI packet identified investigation and root cause analysis of the 04/06/23 incident by the Interdisciplinary Team (IDT.) Education was provided to nursing and dietary staff. Dietary audits were done to verify correct diets were served. The dietary audit forms identified the following: 04/17/23 Supper, Diet Ordered: mech soft, Diet Served: mech soft, Education/Comments: lettuce? orange 04/26/23 Lunch, Diet Ordered: Pureed, Diet Served: Pureed, ground meats, Education/Comments: educated spoke with Dietary manager, replaced diet. 05/03/23 Supper, Diet Ordered: mech soft, Diet Served: mech soft, Education/Comments: Bread? orange 05/10/23 Supper, Diet Ordered: Regular, ground meat, Diet Served: Regular, Education/Comments: orange, Label Ticket? Surveyor noted as of 05/10/23, the dietary audits showed dietary staff was still serving incorrect diets. Surveyor found no evidence of what actions were taken when the audits revealed food was served to residents in the incorrect form and texture. Review of ST Discharge Summary, signed by ST D on 03/06/23, stated in part: .Short-Term Goals .Discharge (02/24/23) Kitchen/staff demonstrate the ability to provide patient with mech soft diet/textures with an average of 67% accuracy with no cues across 2 consecutive sessions. Comments: Patient discharged d/t positive for COVID. Kitchen continues to provide patient with textures that would be harder to masticate (i.e., bread crusts, tough desserts, vegetables with skins) .Assessment and Summary of Skilled Services: .Provided kitchen staff with extensive education re: appropriate preparation of mech soft textures to reduce the risk of aspiration and discomfort at mealtimes . It is noted at time of discharge from ST services on 02/24/23, dietary was providing accurate foods for mech soft diet only 67% of the time. On 05/30/23 at 4:14 PM, Surveyor interviewed DM G, who reported they had started working as DM in the facility in February 2023. DM G reported they were not a Certified Dietary Manager, but had taken the ServSafe training as part of orientation to job as DM. DM G did not have previous experience as a dietary manager in long term care or any other setting. When asked how they verify or know correct diets/textures for residents, DM G stated they followed each resident's diet orders and had recipes and meal plan guides to follow for altered diets. DM G stated they were in the process of switching to IDDSI, but were still using their previous system and recipes, as noted above. When asked if any audits or monitoring was done to ensure residents were served correct mechanically altered diets, DM G stated intermittent spot checks were done using IDDSI audit tools. DM G stated no records were kept to verify those spot checks were done. DM G stated they had three levels of verifying correct food/diet served, but somehow in April, R3 was served the wrong food for a mech soft diet. DM G stated after R3's choking episode in April they implemented color-coded diet guides and meal tickets. DM G stated they provided 1:1 training on correct diets and the new process to kitchen staff, so there should not be any mistakes made with diets served. Surveyor reported observation of R3 served what appeared to be ground meat and creamed corn with visible corn kernels at lunch that day. DM G stated they were aware of a problem with the consistency of the pureed food served during lunch that day. DM G stated they consulted ST D and re-made the pureed food for R8 and R9 according to ST D's recommendation, but DM G was not aware that R3 was served the incorrect consistency food. DM G did not know how that mistake happened, or why it was not identified by nursing staff and brought back to the kitchen. On 05/30/23 at 4:30 PM, Surveyor interviewed Dietary Aide (DA) H, who reported they deliver the food from the kitchen to residents at the tables in the dining room. Surveyor asked DA H if they had any training on diets, textures, and appropriate foods for altered diets. DA H reported they had recently had training on new color-coded meal tickets that were to be delivered to the table with the resident's food. Surveyor asked what the color-coded meal tickets meant and DA H stated the different colors were different types of diets, and they were supposed to verify if the food matched what the diet ticket said. DA H could not read what each color ticket said and did not remember what diet each color stood for. Surveyor asked how DA H verified if a resident was getting the correct foods, and DA H stated they could tell by what the cook served on the plate. Surveyor asked how DA H knew the cook served the correct food, and DA H stated they knew by watching what the cook served. Surveyor asked DA H if they had any training on what foods were appropriate to serve for a mech soft diet or pureed diet, and DA H did not remember any recent training on diets and appropriate foods for each type of diet. On 05/31/23 at 8:30 AM, Surveyor interviewed Regional Consultant Director (RCD) C about R3's choking episodes and facility response. RCD C reported they were aware of R3's choking episodes and reported R3 was switched to a mech soft diet after ST evaluation and moved to the assisted feeding table after the October incident. RCD C stated they were still looking for information about what happened in January. RCD C stated he was directly involved in the staff education and audits of meals following R3's choking episode in April. RCD C stated based on their education of staff and audits of meals served, they felt the problem was corrected. Surveyor reviewed dietary audit sheets from QAPI packet with RCD C. RCD C stated, per the audits, kitchen staff was still making mistakes with foods served for residents with mechanically altered diets. RCD C stated those mistakes were brought back to the kitchen and corrected. Surveyor reported observation of R3 served food that did not appear pureed at the noon meal on 5/30/23 and CNA I did not intervene and/or return R3's food to the kitchen. RCD C stated that was concerning and it appeared they still had a problem and would look into it. On 05/31/23 at 9:30 AM, Surveyor interviewed Cook K who was serving lunch on 05/30/23. Cook K stated they had received training on diets and recipes and how to prepare mechanically altered diets, while working at this facility and while working at a previous long term care facility. Cook K stated they did not know how R3 received the wrong food for a pureed diet for lunch yesterday. Cook K stated it was a hectic day in the kitchen and they must have made a mistake. R3 experienced two choking incidents, on 01/26/23 and 04/06/23, requiring staff intervention to open R3's airway. These choking incidents were a direct result of R3 being served the incorrect food texture for the diet prescribed. On 05/30/23, Surveyor observed R3 served incorrect food texture and staff did not stop R3 from eating the food. Dietary staff needed direction from ST to prepare pureed foods to the correct consistency. The failure to provide R3 with correct diet texture for prescribed diet created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on 06/02/2023, when it had completed the following: Education provided to all staff on duty and not on duty prior to the start of their next shift, provided to licensed and unlicensed nursing staff and dietary staff. Diet textures Preparing meals for residents with altered diets Reviewing meal ticket for diet order to compare meal texture before serving. Education on diet types, verbal validation of what to do for incorrect diets, supervising the dining room. Checking meal tickets with diet on trays. Demonstrated with dietary staff on meal trays 1:1 with dietary, validated food textures and immediately intervening if wrong meal served. How corrective action will be monitored: The DON/designee will audit 10 residents receiving altered texture meals during random meal times weekly x 6 weeks to ensure patients are receiving appropriate diet textures. The DON/designees will audit 5 frontline staff weekly x 6 weeks for serving meal trays with verbal validation on 1. Diet slip 2. Explain diet texture 3. What would you do if you noticed the wrong diet? This is to ensure safety and understanding of compliance. A quality assurance performance improvement (QAPI) performance improvement project PIP was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. The deficient practice continues at a scope/severity of D, while the facility continues to implement their removal plan.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents with dining for 1 of 3 residents (R3) who required altered diets. R3 had three previous choking episodes and had orders for puree texture diet. R3 was served ground meat and creamed corn with visible corn kernels. Staff did not intervene and send food back to kitchen for replacement with correct texture food to ensure R3's safety and prevent choking. Failure to intervene when resident was served food in the inappropriate texture created a finding of Immediate Jeopardy (IJ), which started on [DATE]. Surveyor notified Nursing Home Administrator A (NHA) of the immediate jeopardy on [DATE] at 11:39 AM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its removal plan. Findings include: According to data from the National Safety Council, choking is the 4th most common cause of death. https://injuryfacts.nsc.org/all-injuries/deaths-by-demographics/deaths-by-age/data-details/ Facility dietary standard of practice entitled Guide to Diets states in part: .Pureed Food must be blended to a smooth pudding like consistency. No lumps or chunks . R3 was admitted to the facility on [DATE], with diagnoses including in part, Alzheimer's disease and pain. R3's most recent Minimum Data Set (MDS) assessment, dated [DATE], indicated R3 had severe cognitive impairment, R3 would not have been able to recognize foods that posed a choking risk. The MDS assessment further identified R3 required extensive assistance of one person for eating. R3's care plan stated, in part: .EATING: The resident requires limited assistance by one staff to eat. Last revised on [DATE] . Surveyor noted R3's care plan was not updated to R3's current eating assistance need per most recent MDS assessment. R3's diet orders dated [DATE] stated Level-1 Puree texture, Regular/thin fluid consistency. Review of R3's medical record identified R3 had a choking episode on [DATE]. The resident was on a regular texture diet at the time. During the lunch meal R3 was found to be choking with no sound or breath heard. The nurse responding was able to dislodge three large boluses of food with a swipe of R3's mouth and back of throat. As a result of that incident, R3 was moved to the assisted dining table and diet texture was changed to puree until Speech Therapy (ST) could evaluate R3's swallowing. ST discharged R3 from services with the following discharge instructions: Mech soft diet. Special Instructions: cut up food for patient . On [DATE], Surveyor interviewed ST D, who reported R3 had another choking episode on [DATE]. ST D stated the choking incident occurred on [DATE] due to R3 being served lettuce that was not shredded and carrots that were not soft enough and not cut up. ST D stated those foods were not following the Mech Soft Diet orders. ST D stated they determined through ongoing ST treatments at that time, R3 was still able to safely manage a Mech Soft Diet without choking risk. ST D did not modify R3's diet orders at that time. ST D stated they provided education to dietary staff on appropriate foods for a Mech Soft Diet. According to facility standard of practice, Guide to Diets .Top foods to avoid on Mech Soft Diet .Lettuce is tricky-shredded is best. Iceberg mix not recommended d/t [due to] pieces of radish, carrot, cabbage. More difficult to chew/breakdown lettuce. Food should be soft enough to be cut with a fork. ST D provided documentation of therapy starting on [DATE]. The ST evaluation and plan of treatment documentation stated resident was referred due to aspiration episode today resulting in patient's face turning red. Nursing reports patient choked on lettuce and carrots. Patient is currently on a mech soft diet with thin liquids . The ST Discharge Summary, dated [DATE], stated in part: .Supervision: How often does patient require supervision/assistance at mealtime d/t swallow safety? = ,d+[DATE]% of the time (Patient sits at the max-assist table in the dining room. Patient sometimes requires assistance with feeding tasks d/t increased fatigue.) Surveyor was unable to identify any documentation in R3's medical record, such as nursing progress notes or incident notes related to the choking incident on [DATE]. Surveyor was provided education and sign in sheets completed on [DATE] with education provided by speech therapy on diet textures. Review of R3's medical record identified a third choking incident that occurred on [DATE]. R3's diet orders on [DATE] were Mech Soft Diet. The nursing progress note indicated R3 choked on a corn dog and required nursing staff to perform the Heimlich maneuver. CNAs and nurses did not identify the wrong diet was served or supervise R3 to prevent this choking episode. On [DATE] at 12:25 PM, Surveyor observed a dietary aide place a lipped plate with ground meat and mashed potatoes in front of R3. R3 was also served a small bowl of creamed corn with visible corn kernels. R3 immediately began to eat the food independently. There was a blue meal ticket placed on the table beside R3's food. The ticket had R3's name and said Texture: Puree. Surveyor asked Certified Nursing Assistant (CNA) I, who was feeding another resident at the same table, if the food on R3's plate was pureed. CNA I shrugged her shoulders and raised her eyebrows but did not answer. Then a hospice nurse who was seated by a resident at the same table said the food appeared ground, not pureed. CNA I then stated R3's food appeared ground, but did not intervene with R3 eating, and continued to feed the other resident. CNA I did not ensure R3 was supervised and assisted with the meal to prevent a potential choking incident. Surveyor went to the kitchen service window to determine if R3 had the correct food and was informed the kitchen staff was currently consulting with ST D because another resident's pureed food was not the correct texture. Surveyor was informed kitchen staff was re-making the pureed food per ST D's instructions. Surveyor returned to R3's table and identified R3 had already consumed all of the ground meat on the plate. On [DATE] at 1:54 PM, Surveyor interviewed ST D about the pureed food served at the noon meal that day. ST D stated they were in the kitchen area consulting about another resident when asked to inspect the pureed food served to R8. ST D stated the food was not correct puree consistency and instructed dietary staff to re-make the pureed food. ST D stated they were called away and did not inspect the final product that was served to residents receiving puree food. ST D was not aware that R3 was served what appeared to be ground meat. ST D stated the creamed corn should not have had any visible kernels if appropriately prepared to puree standards. ST D stated based on the education provided to staff, the staff should have intervened and brought R3's lunch meal back to the kitchen when they observed it was not properly pureed. On [DATE] at 2:21 PM, Surveyor interviewed CNA E, who stated they were present when R3 had the choking episode on [DATE]. CNA E stated R3 was served a corn dog and choked on it. CNA E stated R3 was on a regular diet at the time of the incident, so it was okay for R3 to be served a whole corn dog. Surveyor noted R3's medical record showed R3 was on a mech soft diet with special instructions to cut up food for R3 on [DATE]. Surveyor asked CNA E if they received any education following the choking incident. CNA E stated they were taught kitchen staff would put the meal ticket on the table with the resident's food and nursing or CNAs were supposed to verify if the food matched what the meal ticket said. CNA E said they did not remember any training on diet types or what food is okay with each diet type. CNA E stated they did not remember any training about diets or appropriate foods and textures prior to R3's April choking episode. On [DATE] at 2:30 PM, Surveyor interviewed Registered Nurse (RN) F who stated they were present when R3 choked on a corn dog in April. RN F stated R3 was supposed to be on a mechanically altered diet at that time and should not have been served a whole corn dog. RN F stated they did receive training after that incident in April about proper CPR techniques and providing the Heimlich maneuver for choking instead of finger sweep. RN F stated they were also informed they needed to verify resident's food with the diet order on the meal ticket when it was served but did not recall any specific training on diet types or appropriate foods or textures at that time. On [DATE] at 6:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN) J who stated they did receive training after R3's choking episode in April. LPN J stated the training consisted of training about only nurses to do the Heimlich maneuver and a nurse needed to be present at all times when R3 was in the dining room due to choking risk. LPN J stated they also were taught they needed to verify each resident's food with the color-coded meal ticket when served to verify accuracy and if not accurate send it back to the kitchen. LPN J did not recall any training on diet types or appropriate foods and textures or supervision at meals. On [DATE] at 7:30 AM, Surveyor interviewed CNA I and asked if they received any education following R3's choking incident in April. CNA I stated they received a piece of paper that they were to read and sign. It told them they needed to verify the resident's meal ticket with the food served and let the kitchen staff know if it is not correct. CNA I stated they did not receive any education on diet types and specific foods that were okay with the different diet types, so many of the staff were uncertain about verifying correct food when it was served to the residents. There was no mention of having correct care plans for meal supervision and assistance, to ensure R3's safety during meals. Surveyors observed breakfast meal on [DATE]. R3, R9, and R8 were all served pureed food for breakfast. On [DATE] at 8:30 AM, Surveyor interviewed Regional Consultant Director (RCD) C about R3's choking episodes and facility response. RCD C reported they were aware of R3's choking episodes and reported R3 was switched to a mech soft diet after ST evaluation and moved to the assisted feeding table after the October incident. RCD C stated he was directly involved in the staff education and audits of meals following R3's choking episode in April. RCD C stated based on their education of staff and audits of meals served, they felt the problem was corrected. Surveyor reported observation of R3 being served food that did not appear pureed at the noon meal on [DATE] and CNA I did not intervene and return R3's food to the kitchen. RCD C stated that was concerning and it appeared they still had a problem and would look into it. R3 experienced two choking incidents, on [DATE] and [DATE], requiring staff intervention to open R3's airway. These choking incidents were a direct result of R3 being served the incorrect food texture for the diet prescribed. On [DATE], Surveyor observed R3 served incorrect food texture and staff did not stop R3 from eating the food. Staff did not return it to the kitchen to get the correct texture food, allowing R3 to have another meal that was a choking hazard. The failure to supervise R3 to ensure the diet was served in the correct diet texture for prescribed diet, created a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on [DATE], when it had completed the following: Education provided prior to start of next shift to licensed and unlicensed staff and dietary staff on the following: Meal supervision policy Diet textures: Check the tray before serving to be sure that it is the correct diet ordered and the food consistency is appropriate. If wrong diet texture is served immediately remove tray and return to kitchen to be corrected and notify your supervisor and/or nursing. Education provided to MDS nurse on inputting correct data into the nutrition section for the MDS. Education provided to DON and MDS nurse and licensed personnel on reviewing, revising the plan of care on admission, quarterly and with any significant change of condition to accurately reflect current condition and supervision needed with meals. The DON and or designee will audit 10 residents receiving altered texture meals during random meal times weekly x 6 weeks to ensure patients are receiving appropriate diet textures The DON/designee will audit 6 employees weekly x 6 weeks for supervising the dining room with delivering and overseeing residents receiving altered diet texture in the dining room confirming correct diet with diet order and nutrition plan of care. The DON/designee will audit 3 residents' plan of care per week for accuracy for meal assistance x 6 weeks. The DON/designee will audit 3 residents' MDS per week for accuracy for meal assistance x 6 weeks. A quality assurance performance improvement (QAPI) performance improvement project PIP was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until a pattern of compliance is maintained. The deficient practice continues at a scope/severity of D while the facility continues to implement their removal plan.

Based on interview and record review, the facility failed to ensure a system was in place to check wander guard placement or functionality on residents with wander guards, and wander guard posting with photos was not updated with current list of wandering residents to help staff know who to supervise more closely to prevent elopement for 6 of 6 residents (R) who are at risk for wandering/elopement (R1, R2, R3, R4, R5, R6). Failure to ensure a system was in place to check wander guard placement and functionality and monitoring of residents at risk for wandering/elopement resulted in R1 eloping from the facility. This created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Nursing Home Administrator on [DATE] at 4:00 p.m. The immediate jeopardy was removed on [DATE]. The deficiency continues at a level E while the facility implements its corrective actions. This is evidenced by: The facility policy titled, Elopement and Wandering Residents, dated [DATE] states: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. On [DATE], Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to disorder of kidney & ureter-unspecified, heart failure, history of falling, unspecified dementia-unspecified severity-without behavioral disturbance, psychotic disturbance, mood disturbance, & anxiety, major depressive disorder, anxiety disorder, [CONDITION(S)], obstructive sleep apnea, and claustrophobia. R1's Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicates intact cognition. MDS documented R1 requires supervision with 1 assist for bed mobility, transfers, dressing, and personal hygiene. R1 is independent with set up on walking, locomotion on and off unit, eating, and toileting. Surveyor reviewed R1's progress notes with the following noted: On [DATE] at 4:45 p.m., the therapy director notified nursing staff R1 was seen attempting exit at rear of building. Nursing placed wander-guard on R1's right ankle for monitoring. A few hours later alarms sounded at rear of building (next to R1's room) and R1 was again found to be attempting exit. On [DATE] at 6:53 a.m., stated R1 was up at the beginning of the night noted in the hallway with her husband attempting to exit facility. R1 very confused. Attempts made to redirect, .R1's co-tag secure tag remained in place to right lower leg. On [DATE] at 10:00 a.m., R1 was confused and wandering the halls of the facility. R1's progress notes documented R1 spent much time in room with husband doting on him and stating that he is all she has. R1's documentation in the progress notes stated R1 forgets where she is at and needs to be reminded. R1's progress notes documented R1's husband expired on [DATE]. On [DATE] at 4:30 p.m., R1 was screaming hello and help, paranoid about staff trying to hurt her, writer was unable to calm R1 down. R1 was threatening to call the police on staff, running up and down the hall screaming help. hallucinating about items her room that weren't there. On [DATE] R1 fell and complained of pain in head and back. R1 was sent to hospital for evaluation and returned the same day. Upon return to the facility, R1's progress notes stated R1 was increasingly agitated. R1 was wandering the halls and yelling for help. On [DATE] the interdisciplinary team met and discussed R1's loss of husband, fall, and behaviors. Results of meeting stated R1 and behaviors to be monitored as well as redirect and reapproach as best practices. On [DATE], R1 got out of the facility and was brought back to the facility by a police officer. Documentation stated R1 had cut off the wander guard bracelet. After the elopement incident and return to facility documentation stated R1 was wandering in and out of other resident rooms and would become angry if asked to leave and aggressive with raising her cane to staff. R1 continued to walk up and down halls and interrupt TV sitting area where other residents were watching TV. Other residents told R1 to shut up and R1 raised her cane and staff had to escort R1 out of the area. On [DATE], NHA documented on the elopement incident involving R1. The note states the following: Writer received a call from the nurse that resident was found across the street by the police department and officer walked resident back. Nurse immediately looked for wander bracelet, resident admitted that she cut if off. Writer came to the building to initiate a self-report and spoke with resident about situation. Resident said she was not found by the police and that was hogwash .Frequency checks in place at this time. Documentation in R1's medical record stated continued agitation and aggressive behavior. Facility documented R1 wants to leave facility and facility is looking for alternate placement. Surveyor reviewed R1's care plan. Care plan for elopement risk/wanderer not initiated until [DATE], the day R1 eloped, despite documentation in medical record of wandering and exit seeking starting on [DATE], the day after R1 was admitted . The only intervention is white wander bracelet on right ankle. Care plan states R1 is 1:1, but documentation does not verify constant supervision. During survey on [DATE], Surveyor observed R1 on multiple occasions ambulating with walker independently without supervision in the hallways and common areas of the facilities. R1's whereabouts only documented during 15-minute checks following the incident of elopement on [DATE] at 10:24 a.m. until 5:45 a.m. on [DATE]. Documentation in R1's medical record as to R1's whereabouts occurs if yelling is heard by staff or other commotion. Record does not indicate routine monitoring of R1's whereabouts. Surveyor reviewed R1, R2, R3, R4, R5, and R6's medical records and no documentation provided for monitoring of resident and/or wander guard functionality or checking for placement of the wander guard. Surveyor visualized each exit door, and each exit door has an alarm when set off the door locks but when pushed it will open and a resident could get out of the building. Surveyor visualized outside of the front door of the facility. R1 walked across the parking lot of the facility stepped off a curb, crossed a street, stepped up onto another curb before coming to the telephone pole she was found leaning against. The street is busy with traffic as there is a school directly across the street from the facility. Surveyor checked the outside temperature via www.timeanddate.com/weather and noted the outside temperature at 10:24 a.m. on [DATE] was 59 degrees Fahrenheit. On [DATE] at 1:30 p.m., the front door alarm sounded and Surveyor observed R5, who got too close to the door and her wander guard caused the alarm to sound. Surveyor observed staff responding to the alarm immediately and redirecting R5 without incident. On [DATE] at 10:00 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) E via telephone. Surveyor asked about the incident involving R1 on [DATE]. LPN E stated R1 got out of the facility and went across the street. R1 was leaning on a telephone pole when a police officer stopped and brought her back to the facility. LPN E stated R1 was in the common area of the facility prior to the incident. LPN E could not indicate what time R1 was last seen. LPN E stated R1 was walking with her cane. LPN E stated wanderers and wander guards are checked on all the time but could not tell me what the policy is for checking or frequency, or whose responsibility it is. LPN E stated R1 had cut her wander guard bracelet off and the bracelet was found in her room along with multiple pairs of scissors from a box of items her family brought in. LPN E stated the sharps were returned to the family. LPN E stated an in-service was done showing how the alarms work and how to turn them off and staff was shown how to look for a missing resident. The facility had no system in place to check for placement of wander guards for R1, therefore they do not know when R1 had removed her wander guard. On [DATE] at 10:10 a.m., Surveyor interviewed Director of Nursing, (DON) B. Surveyor asked DON B where the list of residents who are at risk for wandering/elopement is located. DON B stated the list is in the charting room and the supervisor's offices. Surveyor asked what the facility policy and procedure is for checking on at risk residents and the actual wander guard functionality. DON B stated the wanderers are checked on every shift and the wander guards are checked at the beginning of each shift, and it is documented in the resident's treatment record. Surveyor asked DON B about the incident on [DATE] involving R1. DON B stated she was not working that day. Surveyor asked DON B about facility education for staff. DON B stated in-services were done with each shift on alarms, wander guard use and checks. On [DATE] at 10:18 a.m., Surveyor interviewed Certified Nursing Assistant, (CNA) C. Surveyor asked CNA C how staff is informed as to what residents are at risk for wandering/elopement. CNA C stated she has been at the facility about a month and when she started the staff told her who were wanderers and showed her the pictures of the wanderers, which are in the charting room. Surveyor asked how often the wandering residents are monitored. CNA C stated when she is taking care of any wanderers for her assignment, she keeps track of them constantly during her shift. CNA C stated she does not know of a particular schedule or time to check on them. Surveyor asked how often the wander guard is checked to ensure it is functioning. CNA C stated she did not know. Surveyor asked about the incident on [DATE], involving R1. CNA C stated she did not know of incident. (Nursing schedule shows CNA C worked that date). Surveyor asked if the facility has offered any education/in-services on wandering/elopement. CNA C stated the facility has had in-services on how wander guards work and how the alarms work. On [DATE] at 10:34 a.m., Surveyor interviewed CNA D. Surveyor asked CNA D about the incident on [DATE] involving R1. CNA D stated she did not know anything about the incident. (Nursing schedule shows CNA worked that date). Surveyor asked about the facility policy & procedure for monitoring residents who are at risk for wandering/elopement and their wander guards. CNA D stated she watched her own residents that she takes care if they are wanderers and doesn't know about a policy or procedure because she is agency staff and does not work their all the time. Surveyor asked if the facility provided staff with education wandering/elopements/wander guards. CNA D stated the facility did have an in-service. On [DATE] at 11:15 a.m., Surveyor interviewed Nursing Home Administrator, (NHA) A. Surveyor asked if facility conducted any in-service for staff following the incident involving R1 on [DATE]. NHA A stated she came to the facility and in-services were done with each shift on wandering residents and alarms. Surveyor asked for documentation regarding those in-services. NHA A stated she did not document the in-services. Surveyor asked about the list of residents who are at risk for wandering/elopement. NHA A stated the list with pictures of the residents are in the supervisor's offices and the charting room. Surveyor told the NHA A that the list and pictures in the charting room was dated ,d+[DATE] and R1 was not on that list. NHA A stated a new list was implemented following the [DATE] incident and should be posted. Surveyor stated that list was not posted. NHA A gave Surveyor new list of residents at risk for wandering/elopement and posted new list in offices and charting room. Surveyor asked who checks the door alarms and the wander guards. NHA A stated maintenance checks the door alarms, and the nurses check the wander guards, and it is documented in the resident's treatment record. On [DATE] at 11:30 a.m., Surveyor interviewed CNA F. Surveyor asked about the incident on [DATE] involving R1. CNA F stated she did not know about incident. (Nursing schedule shows CNA worked that date). Surveyor asked when wander guards are checked. CNA F stated wander guards are checked in the morning but does not know who checks them. Surveyor asked how often the residents who are at risk for wandering/elopement are checked on. CNA F stated she checks on her own residents when she works if there are any wanderers. Surveyor asked if the facility has provided any education on wandering/elopement/wander guards. CNA F stated the facility has provided education. On [DATE] at 2:21 p.m., Surveyor interviewed Police Officer, (PO) G. Surveyor asked PO G about incident involving R1. PO G stated he was driving past the nursing home and noticed a woman leaning on a telephone pole. PO G stated he stopped and R1 was confused and stated she needed to get home. PO G stated R1 was not in the right state of mind. PO G stated he brought R1 back to the facility and staff was surprised R1 got out of the building because they did not hear the alarm. PO G stated staff looked for R1's wander guard, but R1 admitted to cutting it off with a pair of scissors. PO G stated staff informed him it was not the first time R1 attempted to leave the facility. PO G stated R1 somewhat recognized the facility once inside but remained quite confused. Surveyor asked what clothing R1 was wearing. PO G stated according to the dash camera R1 was wearing jeans, a gown-type shirt and did have shoes on. On [DATE] at 2:15 p.m., NHA A came to Surveyor and admitted the wander guard checks are not on the resident treatment records. Shift checks should be on the treatment records of the residents for the wander guards. NHA A stated the task was placed on the treatment records for the 6 residents at risk for wandering/elopement today, [DATE]. Facility did not have a system in place for routine monitoring of wander guards for placement or function, or on the day R1 got out of facility. On [DATE] at 2:49 p.m., Surveyor interviewed Maintenance Director, (MD) H. Surveyor asked if MD H checked the alarms on the doors of the building. MD H stated he checks the doors and the wander guards weekly. MD H showed Surveyor the weekly logs kept for the door and wander guard monitoring. The facility doors and all 6 wander guards of the residents at risk for wandering/elopement was checked on [DATE]. The immediate jeopardy was removed on [DATE] when the facility completed the following -TAR orders in place for daily check for placement and functionality by nursing. Staff to alert nursing of any identified residents with concerns of wander device immediately and nursing staff to alert leadership and chart concerns and action plan for ensuring resident safety -DON educated all staff regarding TAR orders for daily check of placement and functionality of wanderguard -On [DATE] all staff received education on wandering, elopement, wander guard bracelet placement and resident safety. Any staff on leave will receive education on their next scheduled work day or via phone education -SSD ensured all posted wander risk resident photos were accurate in in designated areas -SSD ensured both wander risk elopement binders were accurate in in designated areas -Residents directly involved in this deficient practice had their care plans updated to reflect current wandering and elopement risk -Task in PPC POC task module for direct care staff has been updated per shift to include verification of placement, correct fitting and if concerns to address with nursing staff -The DON, designee and or MDS coordinator re-evaluated residents at risk for wandering/elopement using an elopement risk assessment tool -Elopement and wandering resident's policy was reviewed at QAPI meeting with IDT team. -DON and /or NHA educated the clinical team regarding completion of wandering/elopement screening intake form on all admissions in PCC

Based on observation, interview, and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury for one of two Residents (R) reviewed for pressure injuries (R1). R1 developed a Suspected Deep Tissue Injury (SDTI) to the left heel. As of 07/06/22, the wound has deteriorated to a stage 3 Pressure Injury (PI). There was no communication with physician and no physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Weekly wound assessments and measurements were not consistently documented. There was no care plan for prevention or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor observed staff provide wound care without proper hand hygiene and infection control procedures. Findings include: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's annual Minimum Data Set (MDS) assessment, dated 06/12/22, identified R1 as severely cognitively impaired. The MDS assessment also identified R1 was at risk for developing a pressure injury, and R1 had one stage 2 pressure injury. The previous MDS assessment, dated 03/13/22, identified R1 at risk for developing a pressure injury, but had no current unhealed pressure injuries or deep tissue injuries. On 07/05/22, at 2:03 PM, Surveyor conducted a telephone interview with R1's Power of Attorney for Health Care (POA HC). POA HC reported R1 developed a new sore on the left heel as R1 had become less mobile since being ill and hospitalized a few months ago. POA HC felt the wound developed due to staff not properly caring for R1 or assisting R1 with repositioning as needed. On 07/05/22, at 2:42 PM, Surveyor observed R1 lying supine in bed with a pillow under lower legs and blue boots on both feet. On 07/06/22, at 05:33 AM, Surveyor observed R1 lying supine in bed. R1's lower legs were elevated with a pillow or pad and blue boots were on both feet. On 07/06/22, at 11:53 AM, Surveyor interviewed Director of Nursing (DON) B about facility wound care. DON B stated they do not have a certified wound nurse on staff. DON B stated she was the facility wound nurse. DON B stated Registered Nurse (RN) C had been doing the weekly wound assessments and measurements for residents with wounds. Surveyor requested all wound documentation for R1's wounds, including wound descriptions, measurements, and communication with hospice and/or physician about wound condition. Surveyor also requested wound care orders for R1's left heel pressure injury and the pressure injury care care plan. Review of R1's medical record and documents provided by DON B identified the following: Skin observation tool, dated 02/10/22, stated skin intact. Skin observation tool, dated 02/24/22, listed stage 1 PI on the left inner ankle, no measurements on the document. *No evidence of communication with a provider about the new PI. R1 was hospitalized with [CONDITION(S)] and was COVID-19 positive from 02/24/22 through 03/05/22. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .partial-thickness ulcer medial left ankle with a pink base extending into dermal tissue with mild slough present and no signs of infection; no probing to bone undermining or tracking; no bone exposed; no signs of acute infection; ulceration appears improved since last visit; bogginess noted at last visit has improved as well bilateral heels .Plan: .Continue heel cushions at all times in bed to offload the heels/float heels decrease pressure. Continue [MEDICATION(S)] border dressings every other day or as needed. Skin observation tool, dated 03/06/22, after return from the hospital, noted: Risk factors for impaired skin integrity: Decreased mobility r/t disease process .Interventions in place to preserve skin integrity: Monitor skin daily with cares .Skin intact: yes Braden Scale for Predicting Pressure Sore Risk, dated 03/09/22, score 9, Very High Risk. Review of R1's care plan identified no problem or interventions related to risk for PI added at that time. RN Weekly Wound Assessment, dated 03/09/22, described left foot former venous stasis areas reopened at the hospital. Orders for wound care of left foot former venous stasis areas noted on the document. No mention of left heel pressure injury on the document. Skin observation tool, dated 03/13/22, noted, .Resident has SDTI to right elbow, left heel, and left second toe. -Skin prep BID [twice per day] Resident ulcer on left foot reopened while in hospital. -Continue to dressing changes three time per week. *Surveyor found no evidence of communication with a provider, physician orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] RN Weekly Wound Assessment, dated 03/16/22, noted left foot stasis ulcer. There was no mention of SDTI or PI to right elbow, left heel, or left second toe. Wound Data Collection, dated 03/18/22, noted, LLE [left lower extremity] Venous SDTI to right elbow, left heel, and left second toe. *The document did not have measurements or description of wound condition for any of the wounds listed. Skin Observation Tool, dated 03/20/22, the Site section of the document noted, Right elbow, Left elbow, Left heel, Left toe(s). The document further noted, Risk factors for impaired skin integrity: immobility. Interventions in place to preserve skin integrity: skin prep, dressing changes. *There was no measurement or description of any of the wounds listed. Wound Data Collection, dated 03/25/22, noted LLE ulcer. *There was no measurement or description of the wound, or mention of the previously mentioned SDTIs. Wound Data Collection, dated 03/27/22, noted, Right buttock rash, Right heel vascular, left heel vascular. *There were no measurements or descriptions of the wounds and no mention of the previously noted SDTIs. Wound Data Collection, dated 03/28/22, noted, LLE Venous SDTI to right elbow, left heel, and left second toe. *There were no measurements or descriptions of the wound conditions. RN Weekly Wound Assessment, dated 03/30/22, noted a provider was notified/updated on 03/30/22. Under the Special Equipment/Preventative Measures section, Air mattress was noted. The Observation section of the document noted, left foot, stasis. There was no mention of previously documented SDTIs. The Comments section of the document noted the previously mentioned orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *There was no update to R1's care plan to note the addition of an air mattress. Skin Observation Tool, dated 04/03/22, noted, Right elbow, Type other (specify) scab, length 1.5 cm, width 1 cm, depth UTA [unable to assess]; Right iliac crest (rear), Type Rash, no measurements; Left ankle (inner), Type Vascular, length 2.2 cm, width 4 cm, depth UTA; Left heel, Type Pressure, length 6.6 cm, width 2.8 cm, depth UTA . *No staging of the pressure injury was noted on the document. The document also listed three other vascular wounds on the left foot. Under Interventions in place to preserve skin integrity: skin prep, float heels, heelx boots, special mattress, dressings. *There was no update to R1's care plan to note the added interventions. Skin Observation Tool, dated 04/10/22, had no documentation of any wounds, measurements, or descriptions of the previously mentioned wounds. The Interventions section of the document noted, tx in place. Skin intact No. Wound Data Collection, dated 04/12/22, listed no wounds or site location. The document listed a dressing was in place and intact with drainage present on the dressing. There was no drainage leaking around the dressing. The tissue surrounding the dressing was described as macerated and denuded. Wound Data Collection, dated 04/13/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as macerated, denuded, and erythematous-reddedned. *No measurements or descriptions of the wounds were noted. No communication with physician or hospice about change in condition of tissue surrounding the wound. Wound Data Collection, dated 04/15/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as intact-pink. *No measurements or descriptions of the wounds were noted. Skin Observation Tool, dated 04/17/22, did not have any wounds listed on the observations section of the document. Under Risk factors section, Decreased mobility r/t disease process. Increase in skin exposure to moisture due to incontinency. Resident has open area on left foot and DTIs [Deep Tissue Injuries] to left heel/toes and right elbow. Under Interventions section, Monitor skin daily with cares. Wound treatment as ordered. Wound Data Collection, dated 04/19/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as erythematous-reddened. *No measurements or descriptions of the wounds were noted. Skin Observation Tool, dated 04/24/22, did not have any wounds listed on the observations section of the document. Under Risk factors section, Decreased mobility r/t disease process. Increase in skin exposure to moisture due to incontinency. Resident has open area on left foot and DTIs to left heel/toes and right elbow. Under Interventions section, Monitor skin daily with cares. Wound treatment as ordered. Wound Data Collection, dated 04/27/22, listed, LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as erythematous-reddened. The document also noted resident voiced complaints of pain related to the wound. Interventions listed: PRN analgesics or rest and elevate. *No measurements or descriptions of the wounds were noted. No documentation found to show communication with physician or hospice about pain related to wounds. Wound Data Collection, dated 04/29/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as macerated and erythematous-reddened. The document also noted resident voiced complaints of pain related to the wound. Interventions listed: PRN analgesics or rest and elevate. *No measurements or descriptions of the wounds were noted. No documentation found to show communication with physician or hospice about pain related to wounds. A copy of a hand-written document entitled, [NAME] of St. Croix Wound Grid, dated 05/05/22, noted the following: Name: L 2nd toe, Type: Vascular, Size: 0.8w 0.6L, Treatment: skin prep, Intervention, In-House, Date Acquired, and Misc. sections all blank. Name: L 3rd toe, Type: Vascular, Size: blank, Treatment: skin prep The remaining sections: Intervention, In-House, Date Acquired, and Misc. were all blank. Name: L [MEDICATION(S)] Foot, Type: Vascular, Size: 0.4 w, 0.6 L, Treatment: Cleanse with NS, xeroform, kerlix. Intervention, In-House, Date Acquired, and Misc. all blank. Name: L Medial ankle, Type: Vascular: Size: 2.4 w, 2.5 L, Treatment: Cleanse with NS, xeroform, kerlix. Intervention, In-House, Date Acquired, and Misc. all blank. Name: L Heel, Type: Pressure, Size: 4.5 w, 1.5 L, Treatment: Cleanse with NS, xeroform, kerlix. Intervention, In-House, Date Acquired, and Misc. all blank. Name: R Elbow, Type: Pressure, Treatment: Healed. *It was noted none of the wounds had a description of the condition of the wound bed, and the pressure injury was not staged on the document. Wound Data Collection, dated 05/09/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as pink-intact. The document also noted resident voiced complaints of pain related to the wound. Interventions listed: PRN analgesics or rest and elevate. *No measurements or descriptions of the wounds were noted. No documentation found to show communication with physician or hospice about pain related to wounds. Wound Data Collection, dated 05/11/22, listed LLE Venous SDTI to right elbow, left heel, and left second toe. Description of tissue surrounding the dressing was described as pink-intact. The document also noted resident voiced complaints of pain related to the wound. Description of pain and interventions listed: Resident moans and grimaces when foot is moved. PRN analgesics or rest and elevate with pressure relieving devices. *No measurements or descriptions of the wounds were noted. No documentation found to show a provider or hospice was notified of increased pain with the wound. A copy of a handwritten document entitled, [NAME] of St. Croix Wound Grid, dated 05/18/22, noted the following the previously mentioned Vascular wounds with measurements and treatment listed, but no description of the wound, or the other areas completed. The final wound mentioned on the document listed: Name: L Heel, Type: pressure, Size: 1.5 cm x 2 cm, Treatment: Cleanse with NS, Xeroform, kerlix. *There was no description of the wound bed, drainage, presence of slough, or staging of the pressure injury on the document. St. Croix Hospice Residential Communication form noted in part, Visit date: 5/23/22. Type of visit: HHA [Home Health Aide] .Comments: .wound dressing showed drainage and increased break down in heel. LPN [Licensed Practical Nurse] changed bandages. *No documentation of wound care provided or description of wound by LPN J found on the medical record. A copy of a handwritten document entitled, [NAME] of St. Croix Wound Grid, dated 06/01/22, noted the following the previously mentioned Vascular wounds with measurements and treatment listed, but no description of the wound, or the other areas completed. The final wound mentioned on the document listed: Name: L Heel, Type: pressure, Size: 4 cm w x 1.9 cm L, Treatment: Dressing tx in place. Intervention: Cleanse with NS, Xeroform, kerlix. *There is no description of the wound bed, drainage, presence of slough, or staging of the pressure injury on the document. No documentation found to show a provider or hospice was contacted about the increased size of the wound. Braden Scale for Predicting Pressure Sore Risk, completed on 06/09/22. Score 15, At Risk. *No care plan or interventions related to risk for pressure injury were added to R1's care plan. Copy of typed document, dated 06/15/22, RN Wound Assessments: Heel 2 cm x 2 cm x 2 cm/Side of foot 1.5 cm x 0.1 cm/Left Ear stage 2 0.5 cm x 0.5 cm. *No description or staging of wounds noted on the document. Copy of handwritten document: [NAME] at St. Croix Weekly Wound Log Week Ending: 06/18/22 .Date of onset: 3/16/22; Date of last wound assessment: 06/15/22; Location: Left Heel; Size: (LxWxD) 2 x 2 x 0.2; PI stage: lll; Pressure; Progress: I-improved; Treatment order: Cleanse NS cover xeroform kerlix. *No documentation found to show physician or hospice were contacted about deteriorating wound condition from a Suspected Deep Tissue Injury to a Stage 3 Pressure Injury. Copy of handwritten document: [NAME] of St. Croix Wound Grid week ending 06/25/22 .Type: Pressure Left Heel; Size: 2 cm x 5 cm x 0.1 cm; Treatment: Cleanse, skin prep periwound, xeroform, ABD, Kerlix; Intervention: Heel Protector. *No staging of the wound or description of wound bed, or presence of slough. Copy of handwritten document: [NAME] of St. Croix Wound Grid week ending 07/02/22 .Type: Pressure Left Heel; Size: 1.5 cm x 4 cm x 0.2 cm; Treatment: Cleanse, skin prep periwound, xeroform, ABD/Kerlix; Intervention: Heel Protector. *No staging of the wound or description of wound bed, or presence of slough. RN Weekly Wound Assessment, dated 07/05/22. The document is blank. Wound Data Collection, dated 07/06/22. Left Foot Heel Pressure. No measurements, description of wound bed, presence of slough, or staging of the wound. Skin Observation Tool, dated 07/06/22. No wounds are documented on the observation section. Under the question on the second page Skin intact: yes is marked. On 07/06/22, at 2:07 PM, Surveyor observed RN C perform wound care on R1's left heel. LPN J and RN C entered R1's room. RN C placed a container with dressing supplies on a table by the door. RN C went to bathroom and washed hands with soap and water. RN C used a paper towel to turn off the faucet. LPN J was observed putting on gloves. Surveyor did not observe LPN J wash hands or use hand sanitizer prior to putting on gloves. LPN J uncovered R1's left foot and took off the blue boot. RN C placed towels on the bedside table and placed supply container on the towels. RN C took supplies out of the container and placed on the towel. RN C applied gloves and used a scissors from the supply container to cut the gauze wrap on the left foot. Surveyor did not observe RN C clean or sanitize the scissors prior to use. LPN J lifted R1's left leg off bed. Surveyor observed R1 grimace and moan. RN C removed the gauze bandage and placed it in a plastic bag on the bedside. RN C removed the ABD pad from left heel wound and placed it in the plastic bag. Surveyor observed a small amount of serosanguinous drainage on the ABD pad. No odor was noted. RN C removed the gloves, placed them in the plastic bag, and applied clean gloves. RN C did not wash hands or use hand sanitizer prior to donning new gloves. RN C opened a small vial of saline and wet a gauze pad. RN C wiped the wet gauze over the heel wound and removed the xeroform dressing that was adhering to the wound bed. RN C placed the gauze and xeroform in the plastic bag. Surveyor observed the wound bed appeared dark red with some slough noted in the wound bed. No measurements were done, but wound appeared deep with full thickness skin loss. RN C wet a second gauze pad with saline and swabbed wound bed. RN C disposed of gauze in the plastic bag. RN C opened a packet of skin prep and wiped the skin around wound edges. RN C removed the gloves, placed them in the bag, and applied clean gloves. RN C did not wash hands or use hand sanitizer prior to putting on clean gloves. RN C opened a package of xeroform dressing. RN C cut a small piece from xeroform using the same scissors used to cut the outer gauze bandage. Surveyor did not observe RN C clean or sanitize the scissors prior to cutting the xeroform. RN C placed xeroform on the wound. RN C removed the gloves and placed in plastic bag. RN C did not perform hand hygiene after removing the gloves. RN C placed the ABD pad over the left heel. RN C wrapped the left heel with roll gauze, taped with paper tape, and wrote date and initials on tape. LPN J replaced the blue boot on R1's left foot, removed gloves and left the room. Surveyor observed LPN J use hand sanitizer from a dispenser in the hall. RN C positioned a pad under R1's legs to float heels, placed blankets over feet, lowered the bed and placed a fall mat on the floor beside the bed. RN C tied the plastic bag with discarded supplies and placed a new bag in waste container. RN C placed supplies back in the container and placed cover on supply container. RN C then washed hands with soap and water in bathroom, dried hands and turned off faucet with paper towels. RN C picked up towels, supply container and tied plastic bag and left room. RN C was wearing a surgical mask that was not covering her nose during the wound care procedure. Following the procedure, Surveyor interviewed RN C about the R1's wound. RN C stated the wound on R1's heel was a pressure injury. RN C was not sure when it was first identified. RN C stated there was a different wound nurse working at that time. RN C was not sure what the previous wound nurse documented about the wound. RN C stated the wound was not a venous stasis ulcer. RN C stated R1 had a chronic venous stasis ulcer on the inner side of the left foot, but that was now scabbed over and they were not doing any wound care to that area. RN C stated based on measurements done yesterday, the heel wound was improving. RN C stated the wound care, measurements, and appearance of the wound should be documented on a weekly wound note, but that had not been done lately. On 07/06/22, at 3:56 PM, Surveyor noted a weekly wound documentation note on R1's chart dated 07/05/22 at 2:58 PM created by RN C. The note stated in progress. There was no documentation or wound measurements on the note. The document was blank. On 07/07/22, at 8:07 AM, Surveyor interviewed DON B and RN C about R1's left heel wound. Surveyor asked when the wound was identified. They were unsure when it was identified, and would look for documentation. Surveyor asked if a doctor or hospice was notified of the wound and orders for treatment received when the wound was first identified. They were unsure, but would look for documentation. Surveyor asked what at level the pressure injury was currently staged. RN C stated she did not feel sufficiently competent in wound care to stage a pressure injury. DON B, the facility wound nurse, stated she had never assessed the wound, so would not be able to stage it. Surveyor described the wound appearance during wound care observation yesterday, as a deep, full thickness wound with some slough in the wound bed. RN C agreed with that description. RN C and DON B agreed that described a stage 3 PI. Surveyor asked if a physician or hospice was consulted about the deteriorating condition of the wound. DON B and RN C stated they had not consulted anyone about R1's left heel PI deteriorating from a Suspected Deep Tissue Injury to a stage 3. RN C provided the wound care orders they were currently using to treat the left heel pressure injury. The order, dated 06/14/22, stated: Cleanse left foot venous stasis . Surveyor verified with RN C that the wound treated yesterday was a pressure injury on the heel and not the venous stasis ulcer. RN C confirmed the venous stasis ulcer was healed and RN C treated a pressure injury on the left heel. Surveyor asked if they had orders for wound care for a pressure injury. RN C and DON B stated they were just using the orders they had in place for the previous venous stasis ulcers. Surveyor asked if there was a care plan and interventions in place to prevent the development of a PI prior to the heel injury. They were unsure and would look for documentation. Surveyor asked if they implemented a care plan with interventions to promote wound healing and prevent deterioration in the current pressure injury when the new wound was identified. RN C and DON B stated they would look at R1's record to see if there was a PI care plan. Surveyor asked if there was documentation of weekly wound assessments which included measurements, description of the wound bed, staging of the pressure injury, description of surrounding skin, and any drainage or signs of infection. They stated there was not consistent documentation of the wound. DON B would look for additional documentation. No additional documentation was provided. On 07/07/22, at 8:17 AM, Surveyor reviewed wound care observation from 07/06/22 with RN C and DON B. RN C stated she did not do hand hygiene between glove changes and did not sanitize the scissors before cutting the xeroform dressing. DON B and RN C stated proper infection control procedure would be to perform hand hygiene after each glove removal, and sanitizing the scissors before cutting a dressing that is placed on the wound bed.

Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free of accident hazards as is possible for 1 of 3 sampled residents. Resident #2 used an Assist Bar with a pressure reducing air mattress; this was not assessed for safety. On 05/24/16 at approximately 2:00 p.m., Resident #2's arm was entangled between the grab rail and the mattress, resulting in a fractured humerus. This is evidenced by: The facility policy and procedure entitled Bed Rails/Side Rail policy, dated revised 05/16, states, in part, If assist bars are used with pressure-reducing air mattresses, they should be assessed for safety. On 06/14/16, Surveyor reviewed Resident #2's medical record. The medical record revealed the following information. Resident #2's [DIAGNOSES REDACTED]. A positioning assessment, dated 05/16/16, states in part, mattress - air overlay. In order to help her maneuvering in bed, Resident #2 used an assist bar. On 05/24/16, Resident #2 was observed with legs out of bed and arm in between the mattresses and grab rail. The Certified Nursing Assistant assisted Resident #2 to put her feet back into bed and Resident #2 removed the arm from the area between the mattress and grab rail on her own. Resident #2 moved her arm from the area independently. Resident #2 complained of left shoulder pain, was transferred to the emergency room and was diagnosed with [REDACTED]. Surveyor reviewed Resident #2's medical record, but was unable to locate an assessment for safety related to the use of the assist bar and the pressure reducing air mattress. Surveyor requested a copy of any safety assessments related to Resident #2 using the assist bar. At 3:40 p.m. on 06/14/16, the Nursing Home Administrator reported there had not been any safety assessment completed for the assist bars.

Based on record review and interview, the facility did not always ensure that one of two residents reviewed (Resident #1) receiving intravenous care received proper care and treatment for [REDACTED].#1 was found to have the cap left off of a Peripherally Inserted Central Catheter (PICC) line. This resulted in Resident #1 having to go to the hospital to have a new PICC line inserted. This is evidenced by: The facility's policy entitled, Administrative Policies for Infusion Therapy states in part: Nursing Responsibility: The nurse is expected to observe the accepted and expected standards of care to provide safe and effective IV (intravenous) therapy to residents. Maintenance and monitoring of therapies are according to these standards and are not guided by a prescriber's order. Care is given according to facility's policies and procedures which are based on the INS (Infusion Nurses Society) standards of practice, CDC (Centers for Disease Control) guidelines and other supporting research. The facility's policy entitled, Maintaining Patency of Peripheral and Central Venous Access Devices states in part: .6. To succeed with saline flushing, an injection cap with an anti-reflux design must be placed on the hub of EVERY lumen of EVERY vascular access device/catheter. Use aseptic technique . Aseptic technique is a method designed to prevent contamination from microorganisms. It involves applying the strictest rules and utilizing what is known about infection prevention to minimize the risks that you'll experience an infection. On 06/14/16, Surveyor reviewed Resident #1's medical record. Resident #1 was admitted to the facility on [DATE] with a PICC line in the left arm. Resident #1 receives IV antibiotics through the PICC line. Resident #1 has [DIAGNOSES REDACTED]. On 06/14/16, Surveyor reviewed the facility's Misconduct Incident Report. According to the facility's investigation on 05/31/16 at approximately 5:30 p.m., Licensed Practical Nurse (LPN) C flushed Resident #1's PICC line after an IV infusion was complete. LPN C could not find the cap for the PICC line, and stated to the Director of Nursing (DON) that she felt it was okay as the line was clamped. On 06/01/16, the PICC line was found in the morning without a cap on it. The medical record indicated that Resident # had [MEDICATION NAME] (an antibiotic) held on 06/01/16 due to a pending new PICC placement. Resident #1's medical record indicated that an appointment at the wound clinic on 06/01/16 was canceled due to Resident #1 having a new PICC line placed. On 06/02/16, Resident #1 went to the hospital and had a new PICC line placed in the right arm, due to contamination of one of the ports in the PICC line in left arm. The left PICC line was removed. On 06/14/16 at approximately 11:15 a.m., Surveyor interviewed Registered Nurse (RN) B, who is the facility's infection control nurse and nurse educator. RN B stated the facility has not completed any formal training, after the above incident with the nursing staff. RN B said the DON talked about the incident at the staff meeting on 06/02/16. RN B provided an attendance list from the meeting with the signatures of five nurses. The list does not include all nursing staff. RN B stated the facility is working with the pharmacy to do a formal IV training. On 06/14/16 at approximately 2:00 p.m., Surveyor discussed the above with the Nursing home Administrator.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains as free from accidents as possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 or 2 residents reviewed for falls. Resident #1 experienced five falls from [DATE] to [DATE]. A root cause analysis was not identified to determine the reason for the falls, and interventions to prevent future falls and injury were not implemented. Resident #1's sixth fall resulted in a subdural hematoma followed by hospice care. Resident #2 experienced a fall on [DATE] and the intervention of the restorative program to include balance and lower extremity strengthening was not completed to prevent future falls. This is evidenced by: 1. Resident #1's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], documented the brief interview for mental status (BIMS) score of 10, indicating cognition is moderately impaired. The MDS, dated [DATE], documented the BIMS score as severely impaired. Review of Resident #1's care plans document in part: Focus: The resident has an ADL self care performance deficit R/T CVA Dementia, Hx Syncope episodes E/B Left side weakness with neglect .Date initiated: [DATE] Revised on [DATE] .Interventions: .Toileting schedule: Day shift to check toilet need between 6 and 7 a.m. Toilet upon rising, after meals, especially around 1:30 p.m., before resting on bed and offer to toilet between 1 a.m. or 2 a.m. & q 2h prn during noc. Date Initiated: [DATE], Revision on: [DATE] Focus: The resident has had an extensive history of falls (prior to admission to LTC and during LTC stay.) poor communication/comprehension. Poor balance, Unsteady gait, Completely unaware of limitations with regard to safety R/T CVA, syncope history. Impulsive behaviors w/self transferring/not locking wheelchair brakes/requesting assistance to BR. Date initiated: [DATE]. Interventions: ENVIRONMENTAL: low bed, bariatric bed, used to maximize resident safety. Provide adequate light in room. Signage to remind resident to call for assistance. WC has anti-rear rolling brakes in place and front manual brakes to engage for transfers. FALL MAT EXIT SIDE OF BED. PLACE DYCEM UNDER FALL MAT TO PREVENT MAT SLIDING. Date initiated: [DATE], Revision on [DATE]. On the recertification survey completed on [DATE], Resident #1 was not included in the original sample that was reviewed for falls. Review of Resident #1's medical record documented multiple falls throughout the entire stay at the facility. Review of the fall reports, since recertification survey, read in part: [DATE] at 7:20 a.m., Resident #1 was found on the floor on her right side facing the bathroom. Another resident witnessed the fall and indicated Resident #1 was standing behind the wheelchair and leaned to her right and fell on to the floor and believed to bump her head on the floor. No injuries reported. Mental status is documented as being oriented to person and place. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident is to review the toilet schedule and last time toileted will be reviewed. The results of the investigation document the facility staff to review toileting schedule and encourage resident to call for assistance. Surveyor was unable to identify documented changes to the toileting schedule. [DATE] at 1:30 p.m., Resident #1's bathroom light was on and staff found Resident #1 sitting on her buttocks facing her toilet with her back up against her wheelchair and wheelchair brakes not locked. No injuries noted. Mental status is documented as being oriented to person and having predisposing physiological factors of being confused, impaired memory, incontinent, gait imbalance, impaired vision, recent change in medications/new, weakness/fainted. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident was to provide resident educations/training or re-instruction. The results of the investigation document the facility staff to assess bowel status, pharmacist review, toileting schedule in review and bladder scan. Surveyor was unable to identify documented changes to the toileting schedule, medication changes or other fall interventions. [DATE] at 10:00 p.m., Resident #1 was found lying on her left side on the floor next to her wheelchair, appeared to be sleeping and no injuries noted. Mental status is documented as being oriented to person and disoriented and having predisposing physiological factors of confused and impaired memory. Review of the interdisciplinary team documentation did not identify corrective actions taken to prevent recurrence of this incident. The results of the investigation document the facility staff updated the primary care provider and medication changes made for blood pressure monitoring also. Surveyor was unable to identify documented changes to blood pressure medications or other fall interventions. [DATE] at 9:30 p.m., Resident #1 found on the floor in the doorway to her room and she was sitting on her buttocks and no injuries noted. Mental status is documented as being oriented to person and having predisposing physiological factors of being confused. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident was to check on resident frequently. The results of the investigation are blank and were signed by the Director of Nursing Services (DNS), Nursing Home Administrator (NHA) and Social Worker (SW). Surveyor was unable to identify documented visual checks, or what frequent checks meant, on Resident #1 or other fall interventions. [DATE] at 6:20 p.m., Resident #1 was found on the floor in the bathroom facing sink with head on wall and knees bent and legs back. Resident #1's jeans and underwear down below her buttocks. Wheelchair was behind her with brakes locked and the pole from the brake was up against Resident #1's back. Resident #1's back had a 4 inch red mark with no open areas. Metal status is documented as being oriented to person, place and situation with predisposing physiological factors of impaired memory and gait imbalance. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident was to review toileting and orthostatic blood pressures. The results of the investigation are for facility staff to obtain orthostatic blood pressures, toileting schedule updated and communication with staff. Surveyor was unable to identify documented toileting schedule changes, documented orthostatic blood pressures or other fall interventions. There were no documented interviews with staff to investigate if a staff member transferred Resident #1 to the toilet and was left unattended. [DATE] at 10:00 p.m., Resident #1 was found on the floor in the middle of her room on her right side with blood on the floor noted to be from her head. Resident #1 was transported to hospital. Mental status is documented as being oriented to person with predisposing physiological factors of being confused and with gait imbalance. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident was the care plan amended to hospice services. The results of the investigation are in the facility report to state by self-report. Review of the emergency room head CT report documented a subdural hematoma overlying the left frontal and parietal lobes measuring 8 mm in thickness. Resident #1 returned to the facility on [DATE] with hospice services. [DATE] at 4:40 p.m., Resident #1 was sitting in wheelchair in dining room with head on table then Resident #1 slid back and out of wheelchair onto the floor with no noted injures. Mental status is documented as being disoriented with predisposing physiological factors of being drowsy. Review of the interdisciplinary team documentation identified the corrective actions taken to prevent recurrence of this incident was to allow resident to rest. The results of the investigation document Resident #1 was tired and fell asleep in dining room prior to supper. Allow resident to continue napping in bed through meals and provide meal when resident wakes up. [DATE] Resident #1 expired at the facility. On [DATE], Surveyor interviewed Registered Nurse (RN) A about Resident #1's falls. RN A indicated for the fall on [DATE] at 7:20 a.m. that the intervention of the fall was to review the toileting schedule and there were no changes to the schedule. RN A indicated Resident #1 was not always able to be educated when she was confused or upset. Surveyor asked RN A if there was any new intervention started. RN A indicated there were no new interventions. RN A indicated that after the fall on [DATE] at 1:30 p.m., Resident #1's bowel records were reviewed and there were no changes in bowel status so there was no new intervention and the toileting schedule was not changed. The bladder scan was completed on [DATE] and had no residual and no new interventions were started. The pharmacist reviewed the medications and had no recommendations and there were no new interventions started. RN A indicated the fall on [DATE] at 9:30 p.m. has no documentation of when Resident #1 was frequently checked on. Only verbal communication to staff to frequently check on Resident #1. RN A indicated there is no definition of the timing of what is frequently. Review of the Treatment Administration Record (TAR) identified the orthostatic blood pressures were not completed. RN A indicated after the fall on [DATE], the intervention that was started upon return from the hospital on [DATE] was a fall mat with dycem under to prevent it from sliding. RN A indicated Resident #1 had periods of confusion and upset about a family member and would be short of being one to one with Resident #1. RN B indicated the only blood pressure medication change she could identify was on [DATE] of Benazepril HCL 40 mg once a day to Benazepril HCL 20 mg once a day. 2. Resident #2's [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], document Resident #2 requiring limited physical assist of one staff member for transferring. Resident #2's BIMS score of 13 documents she is cognitively intact. On [DATE] at 12:00 p.m., Resident #2 fell in her room while walking with the walker unassisted and her legs slipped under her. Resident #2's mental status is oriented to person, situation, place and time. Review of the interdisciplinary team documentation identify the corrective actions taken to prevent recurrence of this incident was to encourage call light use for assistance in afternoon with increased fatigue and restorative aide to increase lower extremity strengthening. The results of the investigation are for facility staff to continue appropriate footwear and education with resident to call for assist when tired. Restorative Aide will add a program to resident's RA to include balance and lower extremity strength. Review of the restorative aide documentation of current program: Nursing Rehab #1: Ambulate with 4 wheel walker 4 x 80 feet, progress distance as tolerated cue for cont. breathing while walking 3 - 4x a week, 15 minutes. Review of the documentation identifies this was done on two times for the week of ,[DATE] - [DATE] and on [DATE] and [DATE]. Review of the restorative aide documentation of the new additional program: Transfers skill to practice balance with turns while ambulating. Review of the documentation identifies this was not completed. Surveyor reviewed the above with the DNS and agreed the program was not completed.

Based on interview, record review, and policy review, the facility did not ensure each resident receives the necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 3 of 8 residents experienced a decline in bowel incontinence without a comprehensive assessment and patterning bowel (Residents #3, 8, and 4). The facility also failed to assess Resident #6's significant weight changes as it related to his [DIAGNOSES REDACTED]. This is evidenced by: On 01/08/14, Surveyor received and reviewed a copy of the facility's bowel assessment policy, which was last revised September 2010. The policy states, in part: "Purpose: To assess bowel function appropriately. To identify effective bowel management programs. Procedure: Assessment. 1. During a 72-hour period, use the Hands On care plan application to document bowel function on the Voided Record...establish elimination patterns, including times, volume, circumstances and frequencies of incontinent episodes, use Bladder and Bowel Flow Sheet... 3. After the 72-hour observation has been completed, the Bowel Assessment (GSS #208) should be completed for residents who are incontinent or who have problems with elimination such as constipation or a history of impactions or a change in condition which affects elimination patterns... 4. Use the following assessment data to determine the need for a program: Physical and Mental Status...Bowel History...Nutritional History...Functional Ability...Medications...Environment... Note: Document monthly the evaluation of progress towards continence." Examples 1. On 01/07/14 at 7:55 a.m., Surveyor reviewed Resident #3's medical record. Resident #3 has [DIAGNOSES REDACTED]. Resident #3's comprehensive care plan indicates the resident is incontinent of his bowels. On 01/08/14, Surveyor reviewed Resident #3's Minimum Data Sets (MDS), dated [DATE] and 10/28/13. The MDS, dated [DATE], under section "H4. Bowel Continence," coded Resident #3 being "always continent," within the last five days of the completion of the MDS. The MDS, dated [DATE], under section "H4. Bowel Continence," coded Resident #3 being "frequently incontinent (2 or more episodes of bowel incontinence but at least one continent bowel movement)," within the last five days of the completion of the MDS. Resident #3's medical record did not indicate the resident had a significant medical or physical change, between 08/02/13 and 10/28/13. On 01/08/14, the Director of Nursing (DON) provided Surveyor with Resident #3's most recent facility three-day bowel assessment. Resident #3's bowel assessment form "GSS #208," was last completed on 08/29/2007. The "Evaluation: Recommendations" section of the bowel assessment is blank. According to Resident #3's most recent MDS', the resident went from always continent of his bowels, to being frequently incontinent of his bowels in two months. The facility did not assess the potential causes for Resident #3's decline in bowel incontinence, as well as possible interventions to be used, in order to improve the resident's bowel continence. No 72-hour bowel pattern observation was completed, per facility policy, as well. 2. On 01/06/14 at 2:37 p.m., Surveyor reviewed Resident #8's medical record. Resident #8 has [DIAGNOSES REDACTED]. Resident #8's comprehensive care plan indicates the resident is incontinent of her bowels and has the potential for having a small bowel obstruction. On 01/08/14, Surveyor reviewed Resident #8's MDS', dated 09/26/13 and 12/12/13. The MDS, dated [DATE], under section "H4. Bowel Continence," coded Resident #8 being "occasionally incontinent (one episode of bowel incontinence)," within the last five days of the completion of the MDS. The MDS, dated [DATE], under section "H4. Bowel Continence," coded Resident #8 being "frequently incontinent (two or more episodes of bowel incontinence but at least one continent bowel movement)," within the last five days of the completion of the MDS. Resident #8's medical record did not indicate the resident had a significant medical or physical change, between 09/26/13 and 12/12/13. On 01/08/14, the DON provided Surveyor with Resident #8's most recent facility three-day bowel assessment. Resident #8's bowel assessment form "GSS #208," was last completed on 08/13/2010. The "Evaluation: Recommendations" section of the bowel assessment is blank. According to Resident #8's most recent MDS', the resident went from occasionally to frequently incontinent of her bowels in three months. The facility did not assess the potential causes for Resident #8's decline in bowel incontinence, her potential of having a small bowel obstruction, as well as possible interventions to be used, in order to improve the resident's bowel continence. No 72-hour bowel pattern observation was completed, per facility policy, as well. On 01/08/14 at 1:20 p.m., Surveyor interviewed the DON as well as the MDS Coordinator D regarding the resident's decline in bowel incontinence and assessments. MDS Coordinator D stated completing the bowel assessments "has been an issue." MDS Coordinator D indicated the bowel assessment for each resident is initially completed after the resident's admission to the facility. The MDS Coordinator D also indicated she is starting to review the resident's bowel assessments quarterly, and attempting to re-do the assessments annually. MDS Coordinator D also indicated there was no recent bowel assessments completed for Residents #3 and 8, except for the assessments completed in 2007 and 2010, respectively. During the continued interview with the DON and MDS Coordinator D, Surveyor asked if Resident #3 is currently frequently incontinent of his bowels. MDS Coordinator D stated Resident #3 is still frequently incontinent due to his dementia. During the above interview, Surveyor asked if Resident #8 is still incontinent of her bowels. MDS Coordinator D stated Resident #8 has been frequently incontinent of her bowels, as the resident is unable to say when she needs to have a bowel movement. 3. Resident #4 has a history of dementia. Per the quarterly MDS, dated [DATE], Resident #4 was coded under section H0300 for bowel incontinence as (0) always continent of bowels with no bowel toileting program currently used. The annual MDS, dated [DATE], coded under section H0300 for bowel incontinence as a (1) occasional bowel incontinence with no bowel toileting program. Per medical record review by Surveyor on 01/06/14, the Bowel Assessment form dated 05/06/10 documented the resident is continent of bowels. There were no further updated bowel assessments since the resident's decline in bowel incontinence documented on the MDS dated [DATE]. On 01/08/14 at 3:35 p.m. during daily meeting with the facility, Surveyor requested further bowel assessments completed. No further information was provided. Example 4 Resident #6 has [DIAGNOSES REDACTED]. The American Medical Directors Association(AMDA) Clinical Practice Guideline for Heart Failure in the Long-Term Care Setting includes the signs that suggest heart failure,...[MEDICAL CONDITION], rales on lung exam, [MEDICAL CONDITION] ... and weight gain. The above guideline continues with monitoring for [MEDICAL CONDITION]: "Ongoing monitoring of the patient's condition and response to treatment is imperative. Assess fluid volume status by monitoring weight at least three times per week (more frequently if the patient's condition is unstable), Weight gain in a known heart failure patient is an important 'clue' the patient may be going into heart failure. The practitioner should specify the weight change at which he or she should be notified (generally 3-5 pounds.)" The medical record for Resident #6 was reviewed by Surveyor from 01/06/14 - 01/09/14. Review of Resident #6's care plan, dated 09/27/13, included: Alteration in fluid volume excess r/t (related to [MEDICAL CONDITIONS]). Long/short term goal: The resident will remain free of s/s (signs/symptoms) of [MEDICAL CONDITION]. Resolve date 12/27/13. Plans and approaches: Observe for s/s of [MEDICAL CONDITION], c/o (complaints) of chest pain, sob, (shortness of breath), coughing, congestion, pallor, [MEDICAL CONDITION], perspiration, cyanosis, raising of phlegm. Report to charge nurse. Check lung sounds with s/s of [MEDICAL CONDITION] (The care plan does not contain any approaches about weights or weight fluctuations to be reported.) A review of Resident #6's weights from the weight flow sheet reveals a weights of: 11/01/13 158.1 11/05/13 160.8 11/12/13 165.6 11/19/13 169.7 11/26/13 175.6 12/01/13 184.3 12/10/13 174.9 12/17/13 176.7 12/24/13 184.6 01/01/14 171.3 01/08/14 174.4 A review of the physician orders [REDACTED]. 12/06/13- Continue [MEDICATION NAME] 60 mg po daily through 12/09/13. Hold [MEDICATION NAME] 30 mg po daily until 12/10/13 ([MEDICAL CONDITIONS]) 12/14/13 -30 mg [MEDICATION NAME] Now, extra 30 mg [MEDICATION NAME] tomorrow 12/15/13 12/16/13 - [MEDICATION NAME] 60 mg every day today and tomorrow, [MEDICAL CONDITION], CKD, stage III, BMP in a.m. 12/23/13 -[MEDICATION NAME] DM 10 ml (milliliters) po HS and every 4 hours prn cough x 7 days. Update NP (nurse practitioner) 12/27. 12/27/13- Increase [MEDICATION NAME] 40 mg po daily ([MEDICAL CONDITIONS]) 12/28/13 - O2 at 2 liters via NC (nasal cannula) to keep SA O2 > 88 % 12/30/13 - [MEDICATION NAME] DM 100 mg/10 mg per 5 ml , 10 ml po bid or Q 4 hours prn cough x 30 days., [MEDICATION NAME] po tid x 7 days. 01/02/13 - Increase [MEDICATION NAME] 60 mg po daily 1/4/14 - 1/6/14, give additional [MEDICATION NAME] 20 mg now. ([MEDICAL CONDITIONS]). Metalozone 2.5 mg po 30 minutes before dose of [MEDICATION NAME] ([MEDICAL CONDITIONS]). Update NP on 01/06/14. Resume [MEDICATION NAME] 40 mg po daily ([MEDICAL CONDITIONS] on 01/7/14). The nurses' notes include in part: 12/14/13 "[MEDICAL CONDITION] present in both lower extremities pitting 2+ - 4+..." 12/16/13 "...discomfort to lower extremities due to [MEDICAL CONDITION]" 12/21/13 "[MEDICAL CONDITION] persists. 3+ pitting in LEs (lower extremities), generalized [MEDICAL CONDITION] in thighs and groin. Inspiration and expiratory wheezes heard..." 12/23/13 "LE 3+ [MEDICAL CONDITION]" 12/28/13 "Increased [MEDICAL CONDITION] on left side throughout." 12/29/13 "SOB with exertion..." There is not an assessment of lung sounds in the nurses' notes on 12/29/13, 12/30/13, 01/01/14, 01/02/14, 01/03/14, 01/04/14. There are no nurses' notes 01/05 and 01/06/14. The physician's orders [REDACTED].#, update NP if wt fluctuates up or down 3# or pt symptomatic. Surveyor interviewed the DON on 01/07/14 at 1:45 p.m. about the [MEDICAL CONDITION] signs and symptoms. The DON stated that the dietician directs on weight frequency. Surveyor asked if they have a standard of practice they follow to monitor for [MEDICAL CONDITION]. The DON stated, "No, the nurse practitioner is in the building three to four days a week and follows him, if she wanted the weight done more often she would have ordered it." Surveyor stated that the standard is to weigh more frequently to assess for fluid volume changes with the medication changes. The DON stated, "I have known this resident a long time, and he does this all the time." On 01/08/14 at 10:00 a.m., Surveyor interviewed Nurse Practitioner (NP) N about Resident #6. Surveyor asked if the resident had upper respiratory issues or [MEDICAL CONDITION]. NP N stated, "I feel with the fluid shifts in his body and lower extremities that it was [MEDICAL CONDITION]." Surveyor asked if any labs or x-rays were done to help determine the cause of the fluid. The NP stated, "No, we did not." Surveyor asked what standard of practice she follows to monitor weights for [MEDICAL CONDITION]. NP O stated, "We were getting inconsistent weights. I questioned if it was the scale, math error or inconsistency with the CNAs. Surveyor stated she was told that since the NP did not order it, it was not done more than weekly. NP O said, "I can order it, it does not mean it will get done." NP O said that in clinic practice daily weights would be done and fluctuations of two to three pounds would be reported, but that has not been done in this setting."

Based on interview, record review, and policy review, the facility did not ensure, based on the comprehensive assessment, each resident who enters the facility receives appropriate treatment and services to maintain or restore as much normal bladder function as possible, for 3 of 11 residents reviewed for a decline in bladder incontinence (Residents #2, 3, and 10). This is evidenced by: On 01/08/14, Surveyor received and reviewed a copy of the facility's bladder assessment policy, which was last revised in March 2010. The policy states, in part: "Purpose: -To assess /evaluate incontinence. -To identify and treat any transient/acute causes of incontinence. -To identify the type of urinary incontinence. -To select the appropriate interventions for each type of incontinence. -To assist the resident to regain the dignity and continence and bladder function. Equipment:...Note: It is important to determine if the resident is currently experiencing some level of incontinence or is at risk of developing urinary incontinence (RAI (Resident Assessment Instrument/Minimum Data Set) Section H). Procedure: Assessment. 1. The Bladder Assessment (GSS #216) is completed after incontinence is identified on admission, when urinary incontinence/indwelling catheter triggers on the MDS (Minimum Data Set) or at change of condition in cognitive, physical or urinal tract function affecting elimination pattern... 2. Complete an accurate assessment of factors that may predispose the resident to having urinary incontinence on the Bladder Assessment (GSS #216). The Bladder Assessment (GSS #216) should be used after the 72-hour observation period has been completed and a summary of the findings will be written on the GSS #216, along with the individualized toileting plan in applicable... 11. Initially, the evaluation of progress toward continence is recommended to be documented weekly in the Interdisciplinary Progress Notes (IDP) (GSS #239). Once a successful toileting program has been established, documentation should be done at least quarterly according to restorative nursing guidelines..." Example #1 On 01/06/14 at 3:06 p.m., Surveyor reviewed Resident #2's medical record. Resident #2's comprehensive care plan indicates the resident has the potential of urinary incontinence, which is due to [MEDICAL CONDITION], the use of diuretic medication and a history of a bladder suspension. The care plan does not address the type of urinary incontinence for Resident #2. On 01/08/14, Surveyor reviewed Resident #2's Minimum Data Sets (MDS), dated [DATE] and 12/13/13. The MDS, dated [DATE], under section "H2. Urinary Continence," has coded Resident #2 being "always continent," within the last five days of the completion of the MDS. The MDS, dated [DATE], under section "H2. Urinary Continence," has coded Resident #2 being "occasionally incontinent (less than five episodes of incontinence)," within the last five days of the completion of the MDS. Resident #2's medical record did not indicate the resident had a significant medical or physical change, between 10/03/13 and 12/13/13. On 01/08/14, the Director of Nursing (DON) provided Surveyor with Resident #2's most recent facility bladder assessment. Resident #2's bladder assessment form "GSS #216," was last completed in 2011. According to Resident #2's most recent MDS', the resident went from always continent of urine, to being occasionally incontinent of urine in two months. The facility did not assess the type of urinary incontinence, potential causes for Resident #2's decline in urinary incontinence, as well as possible interventions to be used, in order to improve the residents urinary continence. No 72-hour bladder pattern observation was completed, per facility policy, as well. Example #2 On 01/07/14 at 7:55 a.m., Surveyor reviewed Resident #3's medical record. Resident #3's comprehensive care plan states the resident is "occasionally incontinent" of urine due to having a [DIAGNOSES REDACTED]. The care plan does not identify the type of urinary incontinence for Resident #3. On 01/08/14, Surveyor reviewed Resident #3's MDS', dated 08/02/13 and 10/28/13. The MDS, dated [DATE], under section "H2. Urinary Continence," has coded Resident #3 being "occasionally incontinent (less than five episodes of incontinence)," within the last five days of the completion of the MDS. The MDS, dated [DATE], under section "H2. Urinary Continence," has coded Resident #3 being "frequently incontinent (five or more episodes of incontinence with at least one episode of incontinent voiding)," within the last five days of the completion of the MDS. Resident #3's medical record did not indicate the resident had a significant medical or physical change, between 08/02/13 and 10/28/13. On 01/08/14, the DON provided Surveyor with Resident #3's most recent facility bladder assessment. Resident #3's bladder assessment form "GSS #216," was last completed on 06/06/2008. According to Resident #3's most recent MDS', the resident went from occasionally to frequently incontinent of urine, in two months. The facility did not assess the type of urinary incontinence, potential causes for Resident #3's decline in urinary incontinence, as well as possible interventions to be used, in order to improve the residents urinary continence. No 72-hour bladder pattern observation was completed, per facility policy, as well. On 01/08/14 at 1:20 p.m., Surveyor interviewed the DON as well as the MDS Coordinator D regarding the resident's decline in bladder incontinence and assessments. MDS Coordinator D stated completing the bladder assessments "has been an issue." MDS Coordinator D indicated the bladder assessment for each resident is initially completed after the resident's admission to the facility. The MDS Coordinator D also indicated she is starting to review the resident's bladder assessments quarterly, and attempting to re-do the assessments annually. MDS Coordinator D also indicated there was no recent bladder assessments completed for Resident's #2 and 3, except for the assessments completed in 2011 and 2008, respectively. During the continued interview with the DON and MDS Coordinator D, Surveyor asked if Resident #3 is currently incontinent of his bladder. MDS Coordinator D stated Resident #3 is still incontinent of his urine. Example #3 Resident #10 has a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], documented in Section H2, no current toileting program and the resident was coded as a (1) occasionally incontinent (less than 7 episodes of incontinence). The annual MDS, dated [DATE], documented in Section H2, no current toileting program and the resident was coded as a (2) frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). On 01/08/14, Surveyor reviewed Resident #10's medical record. The record contained a bladder assesssment dated 08/10/10 which stated, "Incontinence-Frequency/Pattern of Incontinence: daily." Surveyor could not find a bladder assessment completed when Resident #10's incontience decreased from a occasionally incontinent to frequently incontinent documented on the MDS, dated [DATE]. On 01/08/14 at 3:35 p.m. during daily meeting with the facility, Surveyor requested further bladder assessments completed since 2010. No further information was provided.