Every finding on record at Edenbrook of Platteville

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 53 residents who reside in the facility. Surveyor observed dust coating the light fixtures and sprinkler heads within the facility's stove hood unit. Surveyor observed [NAME] D sanitizing the food prep area with a bucket of sanitizer that did not test the correct parts per million and was no longer warm. [NAME] D was unsure how long the sanitizer is good for before it needs to be changed out. Surveyor observed Corporate Maintenance Man E who has a full head of hair and a full beard to be in the food preparation/clean dishware area without donning hair restraints. Surveyor observed 3 garbage cans, that were not currently being used, in the kitchen to be full or overflowing onto the floor and to be uncovered. Surveyor observed DA G (Dietary Aide) to be spraying food debris off dirty plates splashing her own clothing. Then Surveyor observed DA G carrying clean dishes up against her wet shirt. Evidenced by:Example 1On 6/9/26 at 10:15 AM, Surveyor and DM C (Dietary Manager) observed the stove hood unit together, noting dust to be coated on the sprinkler heads and the light fixtures. DM C indicated the maintenance department usually cleans these. Example 2Facility policy, titled Sanitary Conditions/Dietary Policies and Procedures, undated, includes: . The chemical solution must be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Manual Washing and Sanitizing- . a chemical solution maintained at the correct concentration, based on periodic testing. at least when initially filled and as needed.Facility policy, titled Chemical Cleaning and Sanitation, issued 1/1/18, includes: Many factors influence the effectiveness and safety of sanitizers. Some of these factors are: concentration: if concentration is too low, it won't effectively sanitize and if it is too high it can be toxic. Water temperature. most sanitizers are most effective between 65 and 120 degrees Fahrenheit. To test concentration of sanitizer in sink and buckets, fill a small container with sanitizing solution from filled sink. Allow solution to cool to room temperature. Dip test strip in solution. Hold for 10 seconds. Remove and read strip.On 6/10/26 at 10:37 AM, Surveyor observed [NAME] D using sanitizer solution from a small bucket to sanitize counter and robo-coupe base. Surveyor asked [NAME] D how she knows the solution is at the correct concentration for sanitizing. [NAME] D grabbed a roll of orange testing paper and dipped one strip into the small bucket. The orange strip did not change color. [NAME] D indicated the strip was to change a green color. [NAME] D filled another bucket with sanitizing solution from the three-compartment sink. She dipped another orange strip into the newly filled bucket. The strip changed to a green color. [NAME] D indicated this meant the parts per million were between 150-200. [NAME] D stated, I don't know when it was changed out last and I am not sure how often the buckets should be changed. [NAME] D indicated she would need to wipe the areas again using the new solution with the correct concentration.On 6/11/26 at 9:36 AM, DM C (Dietary manager) indicated the sanitizing solution concentration should be checked prior to using it and as needed. DM C indicated the solution can only sit for a couple hours in the small buckets before it is no longer at the correct concentration and will no longer sanitize. Example 3Facility policy, titled Infection Control-Dietary, includes: Hairnets, coverings or clean caps shall be worn at all times in the Dietary Department and applied appropriately to keep hair from contacting exposed food, clean utensils and single-service/use items, unwrapped hair restraints must entirely cover all hair. Beards are to be trimmed and covered with beard restraint and mask if applicable.On 6/10/26 at 10:39 AM, Surveyor observed Corporate Maintenance Man E, with hair exposed on his head and face, in the facility's kitchen near clean dishes and open food without donning hair restraints. DM C (Dietary Manager) indicated Corporate Maintenance Man E should be using hair restraints while working in the kitchen. Example 4On 6/11/26 at 9:05 AM, Surveyor observed 3 garbage containers in the facility's kitchen to be full or overflowing onto the floor and to be uncovered. Dietary Aide F indicated there is a lid for each container and the lids should be on.On 6/11/26 at 9:36 AM, DM C (Dietary manager) indicated garbage receptacles, in the kitchen, should have lids on them while they are not in use. Example 5On 6/11/26 at 9:05 AM, Surveyor observed DA G (Dietary Aide) to be spraying food debris off dirty dishes. Surveyor observed DA G's shirt to be speckled with water and damp. Then Surveyor observed DA G handling clean dishes to put them away. DA G indicated during interview that her shirt got wet from spraying off the dirty dishes and she does not usually wear an apron, but she should because there is potential for her dirty shirt to come in contact with the clean dishes.On 6/11/2026 at 9:36 AM, DM C (Dietary manager) indicated there is potential for dishwashing staff to contaminate clean dishes if they get water spray on their clothing and then their clothing comes into contact with clean dishes. DM C indicated he has disposable aprons in the kitchen for staff to use and he will educate staff on using them while washing dirty dishes.

Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 out of 3 supplemental residents (R24, R30, R303). R24 received a full tab of Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) instead of a half tab as ordered on 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/17/25, 3/18/25, 3/20/25, and 3/21/25. R30 received 1 mg of lorazepam instead of the 0.5 mg ordered on 2/1/25. R303 received Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg instead of the Hydrocodone-Acetaminophen Oral Tablet 5-325 mg as ordered on 4/6/25. Evidenced by: The facility policy, entitled Medication Error and Drug Interactions, dated 8/1/15 with last revision date 2/12/24, states in part: . Definition: Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order . Example 1: R24 was admitted to the facility on [DATE] and has diagnoses that include Major Depressive Disorder, Type 2 Diabetes Mellitus, and Primary Osteoarthritis (a painful, chronic condition that occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down). R24's Minimum Data Set (MDS) Assessment, dated 2/5/25 indicates R24 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating R24 is cognitively intact. R24's Physician Orders include, in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram). Give 1 tablet by mouth every 6 hours as needed for pain. Start Date: 11/7/24. Discontinue date: 3/22/25. -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give 0.5 tablet by mouth every 6 hours as needed for pain. Start Date: 3/22/25. R24's MAR (Medication Administration Record) for March 2025 indicates in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. One full tablet given on: 3/8/25 at 1:23 AM 3/9/25 at 12:22 AM 3/10/25 at 1:12 AM 3/12/25 at 1:14 AM 3/17/25 at 12:08 AM 3/18/25 at 12:12 AM 3/20/25 at 2:04 PM 3/21/25 at 11:34 PM R24's Progress Note on 3/27/25 states in part: . on 3/5/25 ADON F (Assistant Director of Nursing) requested that [Resident Name] Norco (Hydrocodone-Acetaminophen) be decreased to a half tab per [Resident Name]'s request On the overnight pharmacy delivery on 3/6/25 there was a card of Norco 5/235 mg 1/2 tabs sent and received. The new card was signed in to the narcotic book according to policy. However, there was no new script sent to [Facility Name] indicating there was a change in dosage for Norco. The nurse signing in the medication did not realize that there was a change in dosage. All of the nurses were continuing to administer the PRN (as needed) dose of Norco 5/325 mg full tab because that was the order that was in PCC (Point Click Care electronic health record), and we had a card for that strength . Please note: Despite the physician decreasing the dosage to 1/2 tabs on 3/5/25, R24 continued to receive the full tab strength until 3/21/25. On 4/19/25, Surveyor interviewed R24 and asked her if her pain was well managed. R24 stated that it was, but that for a while she was getting too much of her pain medication, which she didn't like because it made her too drowsy all day. Example 2: R30 was admitted to the facility on [DATE] and has diagnoses that include Anxiety Disorder, Dementia severe, with psychotic disturbance, Alzheimer's Disease, late onset, Major Depressive Disorder, Repeated falls, Weakness. R30's MDS Assessment, dated 2/24/25, indicates R30 has a BIMS score of 00 out of 15, indicating R30 is severely cognitively impaired. R30's Physician Orders include, in part: -Lorazepam 0.5 mg (milligram) tablet. Give 0.5 mg by mouth two times a day for anxiety disorder, unspecified at 1200 (12:00 PM) and 2000 (8:00 PM). -Lorazepam 1 mg tablet. Give 1 tablet by mouth two times a day for anxiety disorder, unspecified at 0800 (8:00 AM) and 1600 (4:00 PM). R30's Progress Note on 2/2/25 states, in part: . the resident was given 1 mg lorazepam at HS (bedtime) instead of the ordered dose of 0.5 mg . Example 3: R303 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus and Major Depressive Disorder, unspecified. R303's MDS Assessment, dated 4/8/25, indicates R303 has a BIMS score of 15 out of 15, indicating R303 is cognitively intact. R303's Physician Orders include, in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 8 hours as needed for pain. R303's Progress Note on 4/6/25 states, in part: . resident had received a hydrocodone-acetaminophen 7.5-325 mg when they were prescribed hydrocodone-acetaminophen 5-325 mg . On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) and asked her about the process for when medications are received from the pharmacy. ADON D stated that she didn't really know for sure because she had never been a part of that process, as the medications are usually delivered on the PM and night shifts. Surveyor asked ADON D who was responsible for entering the physician orders onto PCC (Point Click Care electronic health record). ADON D stated that sometimes the float nurse would put them in, sometimes the medication nurse would put them in, and sometimes she would put them in. Surveyor asked ADON D if the doctors ever used e-script (electronic prescribing) and would send them directly to the pharmacy. ADON D indicated that they try to encourage the doctors to give them the prescription but if it was a narcotic the physician would have to escribe, but if it was a regular medication like Tylenol, they would just give them the order. Surveyor asked ADON D what the process was for e-scripted medications like narcotics. ADON D indicated that usually the doctor would give them the order so that they could enter it into PCC and then the doctor would send the e-script to Omnicare Pharmacy. Surveyor asked ADON D who was responsible for verifying that the physician orders were entered correctly into PCC. ADON D stated that the floor nurses would enter the orders but that they need to be confirmed by another nurse, herself or the DON (Director of Nursing). On 4/15/25 at 2:18 PM, Surveyor interviewed DON B and asked her if the doctors use e-script to send medication orders directly to the pharmacy. DON B stated that sometimes they do. Surveyors asked DON B what the process was when the doctor uses e-script. DON B indicated that the doctor would send their prescription to the pharmacy, and they would receive a fax so that they could enter it into PCC. Surveyor asked DON B who was responsible for verifying that the physician orders were entered correctly. DON B stated any of the nurses could do that. Surveyor asked DON B about R24 receiving multiple doses of the wrong medication dose. DON B stated that the pharmacy received the order but did not send it to the facility. DON B indicated that when they get an order from the doctor, they enter it right away, but that they don't know when a doctor faxes the pharmacy and doesn't call or send them a copy so that it can be transcribed. DON B stated that when the card with 1/2 tabs was received for R24, the nurse should have caught it. DON B indicated that they did an investigation into this situation and that the nurse's weren't doing their checks. DON B stated that it is still their responsibility as the nurse, and that education was given to the nurses involved with the medication error. DON B stated that she did a bigger education in the winter going over the narcotic policy, but that she does education with the nurses directly whenever it is needed. Surveyor asked DON B if it was her expectation that the physician orders be correctly entered and followed. DON B stated yes, that was her expectation. Despite having online education completed in November 2024 on Avoiding Medication Errors and a Monthly Nurse's Meeting on Controlled Medication Management in January 2025, medication errors continued in February 2025, March 2025 and April 2025 without further house-wide education.

Based on observation, interview and record review, the facility did not provide toileting assistance for dependent residents for 1 of 1 supplemental resident (R39) reviewed for Activities of Daily Living (ADLs) assistance. Staff did not assist R39 with toileting assistance after an incontinent episode. Evidenced by: Facility policy, entitled Activities of Daily Living (ADL), dated 3/15/21, with revision date of 2/25/25 states in part: Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services . Procedure: .2. The facility will provide care and services for the following activities of daily living: . Toileting: Assisting with using the bathroom and maintaining cleanliness . R39 was admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 Diabetes Mellitus, Weakness, Generalized Anxiety Disorder, Hypertension, Unspecified Dementia, moderate with mood disturbance, Major Depressive Disorder, Altered Mental Status, Disorientation unspecified, Repeated Falls, Muscle Wasting and Atrophy, Unsteadiness on Feet, and Unspecified Abnormalities of Gait and Mobility. R39's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/25 documented that R39 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R39 has moderate cognitive impairment. R39's Care Plan, includes, in part: Focus: The resident has an ADL self-care performance deficit r/t (related to) weakness, moderate dementia with mood disturbances. Date Initiated: 3/8/24. Revision Date: 2/20/25 Goal: The resident will maintain current level of function in toileting through next review date. Date initiated: 3/8/24. Revision Date: 9/29/24. Intervention: Toilet Use Assist - One. Date Initiated 3/8/24. Focus: Actual for alteration in elimination (bladder incontinence) r/t dementia, altered mental status, weakness. Date Initiated: 3/8/24. Revision Date: 12/17/24. Goal: Resident will be clean, dry and odor free daily through staff assistance and interventions through next review. Date Initiated: 3/8/24. Intervention: Position body with pillows/support devices. Date initiated 7/20/22 .Offer to toilet resident q2 (every two) hours, remind resident to use call light for assistance, check frequently. Date Initiated: 3/8/24. Revision Date: 12/17/24. Focus: I am at risk for alteration in skin integrity related to weakness, reduced mobility . Date Initiated: 3/8/24. Revision Date: 4/15/25. Intervention: Keep my skin clean and dry. Date initiated 3/8/24. R39's CNA (Certified Nursing Assistant) Kardex includes, in part: -3/16/24 Offer to toilet resident q2 hours, remind resident to use call light for assistance, check frequently -Assist [Resident Name] with toileting approximately every 2 hours 3/16/24 -Incontinence care after each incontinent episode -Incontinent brief due to incontinence -Scheduled Toileting Program Q2 hours -Toilet Use Assist - One On 4/14/25 at 1:55 PM, Surveyor observed R39 in the post-acute rehab living room sitting in her wheelchair a few feet from the nurse's station. Surveyor observed that R39 was wearing a short sleeve top and light peach colored capri pants. Surveyor observed that R39's pants were wet on the backside from the knees down. Surveyor walked to the nurse's station and smelled a strong urine odor coming from R39. On 4/14/25 at 2:00 PM, Surveyor observed CNA H (Certified Nursing Assistant) and two other CNAs sitting at the nurse's station a few feet away from R39. On 4/14/25 at 2:02 PM, Surveyor observed CNA K walk by R39 while assisting another resident with ambulation. On 4/14/25 at 2:10 PM, Surveyor observed ADON D (Assistant Director of Nursing) sitting at the nurse's station a few feet away from R39. On 4/14/25 at 2:19 PM, Surveyor observed CNA K walk by R39 again. On 4/14/25 at 2:21 PM, Surveyor observed CNA K and PT L (Physical Therapist) walk by R39 sitting in her wheelchair. On 4/14/25 at 2:22 PM, Surveyor observed CNA M walk by R39 while pushing the Hoyer lift. On 4/14/25 at 2:27 PM, Surveyor observed ADON D walk by R39 pushing the EZ Stand lift. On 4/14/25 at 2:28 PM, Surveyor observed RN E (Registered Nurse), LPN N (Licensed Practical Nurse), and CNA O walk by R39 sitting in her wheelchair. On 4/14/25 at 2:29 PM, Surveyor observed CNA G stop and talk to R39 sitting in her wheelchair, and then continue on. On 4/14/25 at 2:30 PM, Surveyor observed LPN N walk by R39 twice, carrying two pitchers of water. On 4/14/25 at 2:40 PM, Surveyor observed AD J (Activities Director) stop and talk with R39, invite her to the afternoon activity, and then continue on. On 4/14/25 at 2:45 PM, Surveyor observed R39 wheel herself into her room and look for something in her bedside table. On 4/14/25 at 3:07 PM, Surveyor observed R39 wheel herself back out into the living room. On 4/14/25 at 3:10 PM, Surveyor observed CNA O walk by R39 again. On 4/14/25 at 3:34 PM, Surveyor observed CNA G and CNA M take R39 into her room and shut the door. On 4/14/25 at 3:44 PM, Surveyor observed R39 be wheeled out of her room and back to the living room wearing navy blue pants and a different shirt. On 4/14/25 at 3:45 PM, Surveyor interviewed CNA M and asked her how soaked R39's incontinence brief was when she changed her. CNA M stated that it was moderately soaked. Surveyor asked CNA M if there was a strong urine odor from R39. CNA M replied no that the urine odor was not too bad. Surveyor asked CNA M when was the last time R39 had been assisted to the bathroom. CNA M stated that she started at 2:00 PM and didn't know when R39 was last assisted to the bathroom. Surveyor asked CNA M how often R39 was to receive toileting assistance. CNA M stated R39 was to be toileted every 2-3 hours. Surveyor asked CNA M that if R39's clothes were soaked through, could that be a dignity concern? CNA M nodded yes. On 4/14/25 at 3:48 PM, Surveyor interviewed CNA G and asked her how soaked R39's incontinence brief was when she changed her. CNA G stated that the brief was very soaked and that R39 had to have a complete clothing change and be washed up head to toe because she was soaked in urine. Surveyor asked CNA G if there was a strong urine odor from R39. CNA G replied yes there had been a strong urine odor. Surveyor asked CNA G when the last time R39 had been assisted to the bathroom. CNA G stated that she came in at 2:00 PM so she wasn't sure. CNA G looked in the charting history to find out when R39 was last assisted to the bathroom, and said the last time R39 was toileted was 12:16 PM. Surveyor asked CNA G how often R39 was to receive toileting assistance per her care plan. CNA G stated R39 was to be toileted every 2 hours. Surveyor asked CNA G if waiting that long and being soaked in urine could be a dignity concern. CNA G replied yes, that was definitely a dignity issue, since R39 was soaking wet when she changed her. On 4/14/25 at 3:54 PM, Surveyor interviewed AD J and asked her if she could see R39's clothing were soiled with urine or a smell of urine odor when she stopped and invited her to activities. AD J stated yes, she smelled the urine odor today and had smelled it before on other days as well but had not seen R39's wet pants. AD J indicated that R39 could be very irritable at times and refuses help. Surveyor asked AD J if being soaked with urine and wearing wet pants would be considered a dignity concern. AD J replied yes, that was definitely a dignity concern. On 4/14/25 at 3:57 PM, Surveyor approached R39 sitting in the dining room in her wheelchair watching TV. Surveyor told R39 she looked nice in her new clothes and asked how she felt. R39 stated that she felt much better now that she was wearing dry clothes. On 4/14/25 at 3:59 PM, Surveyor interviewed DON B (Director of Nursing) and asked her about R39's two-hour toileting schedule. DON B stated that R39 often refuses, so she gives them a 2-3 hour toileting window. Surveyor shared with DON B the observation of R39 sitting for two hours in soiled, wet pants and smelling strongly of urine. Surveyor asked DON B what her expectation was for the staff regarding assisting R39 with toileting needs. DON B stated she would expect them to follow the toileting schedule and intervene if they saw or smelled urine. Surveyor asked DON B if this situation would be a dignity concern for R39. DON B replied yes, 100% that would be a dignity issue. The facility failed to provide toileting assistance to a dependent resident, resulting in R39's loss of dignity due to sitting in visibly soiled clothes for two hours.

Based on observation, interview, and record review the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident's (R19) reviewed for dialysis and 2 of 2 supplemental residents reviewed for dialysis (R28, R49). R19, R28, and R49's care plans did not include emergency actions for any staff; no Nurses, CNA's (Certified Nursing Assistants) or any Ancillary staff (i.e. housekeeping, dietary, therapy, etc.). Staff were not able to voice the appropriate procedure if they encountered bleeding from a dialysis site. R19 and R49 did not have a soft clamp present in room to aid in a bleeding emergency. This is evidenced by: The Facilities Policy and Procedure entitled Care of Hemodialysis Resident dated 1/28/25, documents in part: .Post Dialysis .If bleeding occurs from fistula (surgical connection between an artery and a vein typically in the arm) site, apply pressure with clean gauze for 5-10 minutes. Repeat until bleeding stops. If unable to stop the bleeding, call the dialysis center or the physician for further instructions .External Catheters .A smooth clamp should be kept at the bedside for emergency situations . Example 1 R19 is a long-term resident of the facility. R19 has the following diagnoses: end stage renal disease, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, and dependence on renal dialysis. R19 has an external catheter for his dialysis treatments. R19 did not have a soft clamp in room for an emergency situation. R19's care plan for end stage renal disease does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. It is important to note that R19 is also on an anticoagulant medication (medication that delays or prevents blood clots from forming or growing) which could cause R19 to bleed more easily and take longer to stop bleeding. Example 2 R28 is a long-term resident of the facility. R28 has the following diagnoses: end stage renal disease, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, and dependence on renal dialysis. R28 has a fistula for his dialysis treatments. R28's care plan for chronic renal failure documents the following intervention- .Monitor fistula for bleeding . R28's care plan does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. Example 3 R49 is a short-term resident of the facility. R49 has the following diagnoses: end stage renal disease and dependence on renal dialysis. R49 has an external catheter for his dialysis treatments. R49 did not have a soft clamp in room for an emergency situation. R49's care plan for chronic renal failure r/t (related to) End stage disease does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. On 4/15/25 at 12:50 PM, Surveyor interviewed LPN P (Licensed Practical Nurse). Surveyor asked LPN P what action she would take if she found a resident bleeding from their dialysis site, LPN P stated apply pressure and get EMS (Emergency Medical Services) here. Surveyor asked LPN P if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, LPN P said no emergency kit that I know of. On 4/15/25 at 12:56 PM, Surveyor interviewed CNA Q (Certified Nursing Assistant). Surveyor asked CNA Q what action she would take if she found a resident bleeding from their dialysis site, CNA Q stated get nurse right away. Surveyor asked CNA Q how she would get the nurse right away, CNA Q said yell out down the hallway and turn on the call light. Surveyor asked CNA Q what she would do for the resident in that situation, CNA Q replied comfort them. Surveyor asked CNA Q if she would apply pressure to the area that is bleeding, CNA Q stated no the nurse does that. On 4/15/25 at 12:56 PM, Surveyor interviewed CNA T. Surveyor asked CNA T what action she would take if she found a resident bleeding from their dialysis site, CNA T stated get nurse right away. Surveyor asked CNA T how she would get the nurse right away, CNA T said yell out down the hallway or use radio to page the nurse. Surveyor asked CNA T what she would do for the resident in that situation, CNA T replied comfort them. Surveyor asked CNA T if she would apply pressure to the area that is bleeding, CNA T stated, I don't know much about this. On 4/15/25 at 01:01 PM, Surveyor interviewed LPN R. Surveyor asked LPN R what action she would take if she found a resident bleeding from their dialysis site, LPN R replied she would alert the RN (Registered Nurse), make sure there is pressure on it, and call EMS. Surveyor asked LPN R if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, LPN R stated no kit with clamp, use gloves and clean towel if around. On 4/15/25 at 01:03 PM, Surveyor interviewed RN E. Surveyor asked RN E if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, RN E stated no kit with clamp or tourniquet in it, we do not have that here. On 4/15/25 at 1:05 PM, Surveyor interviewed CNA S. Surveyor asked CNA S what action he would take if he found a resident bleeding from their dialysis site, CNA S stated get the nurse. Surveyor asked CNA S how he would get the nurse, CNA S said by putting the call light on. Surveyor asked CNA S what he would do for the resident in that situation, CNA S replied comfort the resident. Surveyor asked CNA S if there was anything else he would for the resident, CNA S could not voice anything else. Surveyor asked CNA S if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, CNA S stated no emergency kit that he knows of. On 4/15/25 at 1:07 PM, Surveyor interviewed ADON D (Assistant Director of Nursing). Surveyor asked ADON D if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, ADON D stated no kit with clamp or tourniquet. On 4/15/25 at 2:14 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B would you expect your CNA's and Nurses to know how to handle bleeding from a dialysis site, DON/IP B stated yes. Surveyor asked DON/IP B if a dialysis resident is bleeding from their dialysis port (catheter, fistula) what would you expect your staff to do, DON/IP B said respond with first aid, dressing or gauze, use a tourniquet or just apply pressure, and call 911. Surveyor asked DON/IP B do each of your dialysis residents have an emergency kit (clamp, clean gauze) easily accessible in the event of a bleeding emergency, DON/IP B replied not in their room. Surveyor asked DON/IP B are you aware of what your Policy and Procedure for dialysis residents says for emergency actions, DON/IP B said have to look at. It is important to note that the Policy and Procedure speaks to applying pressure with clean gauze to a fistula site and using a soft clamp to a catheter site.

Based on observation, 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, for 1 of 15 residents (R253) reviewed for infection control. The facility failed to recognize CDC (Centers for Disease Control) guidance that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. This is evidenced by: The facility policy titled Enhanced Barrier Precautions, dated 3/6/24, indicates in part: . Overview: Enhanced Barrier Precautions (EBP) will not only focus on residents with infection or colonization with MDRO's (Multi Drug Resistant Organism) but will also address residents at risk for developing or becoming colonized. Enhanced Barrier Precautions are precautions that are between Standard Precautions and Contact Precautions. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound . during specific high-contact resident care activities . Purpose: . High contact resident care activities include Wound care: any skin opening requiring a dressing . Procedure: 1. Standard Precautions should be applied to all residents at all times. 2. Transmission-based precautions should be applied to all residents when standard precautions alone do not prevent pathogen transmission. 3. EBP are used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. a. EBP are indicated for residents with any of the following: . Wounds and/or medical devices even if the resident is not known to be infected or colonized with a MDRO. b. Wounds generally include chronic wounds, not short-lasting wounds . Examples of chronic wounds include, but are not limited to, pressure ulcers . d. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility . CDC (Centers of Disease) guidance for the Implementation of Personal Protective Equipment in Nursing Homes to Prevent the Spread of Multi Drug Resistant Organisms (MDROs) states the following: 1. Enhanced Barrier Precautions (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. 2. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO (Multiple Drug-Resistant Organism) colonization status b. Infection or colonization with an MDRO. 3. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs, more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available . Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who by definition have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) which contributes to the silent spread of MDROs. Findings include: R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression, unspecified. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section M0300 of the MDS indicates R253 has two Stage 3 pressure ulcers present upon admission. According to the Centers for Medicare and Medicaid Services (CMS) a Stage 3 pressure ulcer is defined as Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. R253's physician orders include: -Location: stage 3 pressure injury to right and left buttocks. Cleanse with normal saline or wound cleanser, and pat dry. Apply calcium alginate to wound beds and cover with large silicone border 9X9 or sacral dressing only. Do not use white border gauze on skin. Change once daily and PRN (as needed) for soiled or saturated dressing. One time a day for skin integrity. Start Date: 3/24/25. No end date. On 4/10/25 at 9:50 AM, Surveyor observed wound care on R253's wounds with LPN C (Licensed Practical Nurse). Surveyor observed LPN C wash hands and don gloves but no gown. Surveyor asked LPN C about the PPE (Personal Protective Equipment) cart and EBP (Enhanced Barrier Precautions) sign located between R253's room and the next room. Surveyor asked LPN C if R253 was on enhanced barrier precautions. LPN C stated no, that the cart and sign were placed there for the next room but not for R253. LPN C then entered R253's room and proceeded to complete wound care. When removing the old dressings, a small laceration from the white border foam dressing caused R253 to begin bleeding, dripping blood all over the floor. LPN C applied pressure with paper toweling and pushed R253's call light for assistance. ADON D (Assistant Director of Nursing) entered the room and LPN C requested the blood spill kit. ADON D left the room and returned a few minutes later with the blood spill kit. Note: At no time did LPN C or ADON D don a gown, despite R253's wound continuing to drip blood all over the floor. On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D and asked if R253 was on EBP. ADON B replied no, R253 was not on EBP. Surveyor asked ADON D what her expectation would be for PPE when the staff do wound care dressing changes. ADON D stated that it was her expectation that staff wear gloves only when doing wound care dressing changes. On 4/15/25 at 2:15 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R253 was on EBP. DON B stated no, he was not on EBP because he did not have a history of an MDRO. Surveyor asked DON B if it was her expectation that nurses where gowns when doing wound care. DON B stated yes, that was her expectation. The facility was not following CDC recommendations to recognize that all chronic wounds warrant EBP to prevent the development and transmission of communicable diseases and infections.

Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) for 1 of 3 residents (R253) reviewed for pressure injuries. R253 is at risk for PI (pressure injury) development. R253 was admitted with two stage 3 PIs. Staff did not confirm accurate measurements were taken of R253's PI upon admission and weekly to ensure that R253's PIs did not deteriorate. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. The facility's policy titled Pressure Injury Prevention and Wound Care Management, dated 8/26/18, with last revision date of 3/4/24, states in part, Purpose . To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown . Policy . A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Procedure: Risk Identification and Assessment: A complete assessment is essential to an effective pressure injury prevention and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers, as well as the level and nature of their risks . 8. Documentation of the wound characteristics will be completed in PCC (Point Click Care) using the PCC Skin and Wound Assessment. This assessment is started in the mobile application. If a device is not available or in need of service, the documentation will be completed in the resident's electronic medical record. Consent for photography will be obtained in the admission packet . R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section GG0130 of the MDS indicates that R253 requires partial/moderate assistance from staff for toileting and dressing needs, and is dependent on staff bathing, transfers, and bed mobility. Section H0300 of the MDS indicates R253 is frequently incontinent of bladder and bowel. Section M0300 of the MDS indicates R253 had two Stage 3 pressure ulcers upon admission. R253's Comprehensive Care Plan, states in part: Focus: I have an alteration in skin integrity - pressure wounds #5 sacrum, #6 coccyx. Date Initiated: 3/24/25. Revision on: 4/2/25. Goal: My alteration in skin integrity will show signs of improvement in healing by the review date. Date Initiated: 3/25/25. Intervention: Assess/monitor the alteration in my skin integrity and document status weekly. Date Initiated: 3/24/25. R253's Wound Evaluation for #5 Pressure Ulcer - Stage 3. Location Sacrum, indicates the following measurements: 3/24/25: 2.09 cm (centimeter) square area; 2.15 cm length; 1.26 cm width 3/30/25: 1.61 cm square area; 1.93 cm length; 1.17 cm width Week of 4/6/25: no measurements 4/13/25: 0 cm square area; 0 cm length, 0 cm width R253's Wound Evaluation for #6 Pressure Ulcer - Stage 3. Location Coccyx, indicates the following measurements: 3/24/25: 0 cm square area; 0 cm length, 0 cm width 3/30/25: 0 cm square area; 0 cm length, 0 cm width 4/6/25: 0.74 cm square area; 2.38 cm length; 1.16 cm width Week of 4/13/25: no measurements (It is important to note that there were pictures taken upon admission and weekly, but not all of the pictures had corresponding measurements taken). On 4/15/25 at 1:01 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked her who was responsible for ensuring wound measurements were completed upon admission. NHA A stated that it varies depending on who is the schedule that day, but that the ADONs (Assistant Director of Nursing) typically do them. On 4/15/25 at 1:14 PM, Surveyor interviewed ADON F (Assistant Director of Nursing) and asked her who was responsible for ensuring that resident admission assessments were complete. ADON F stated that she does the bulk of the admission. Surveyor asked ADON F who was responsible for ensuring wound measurements were completed. ADON F indicated that typically the floor nurses complete the skin checks and take the wound pictures and then the ADONs will go through and review them along with the care plans and ensure there are treatment orders in place. Surveyor reviewed R253's missing wound measurements with ADON F, who stated that there must have been a miscommunication between the phone camera that they use and the charting system because it doesn't translate to PCC (Point Click Care electronic health record). ADON F indicated that they have helix stickers, and the camera phone takes the measurements of the wounds, and with the stickers on there the camera can gauge the size of the wound based on the sticker. Surveyor asked ADON F if the measurements could be taken and entered into PCC manually. ADON F replied yes, the measurements could be taken and entered into the resident's medical record manually. Surveyor asked ADON F if R253's medical record should have been reviewed to ensure there were measurements in PCC upon admission and weekly. ADON F stated yes, that R253's medical record should have been reviewed to ensure all measurements were taken and recorded in PCC. Surveyor asked ADON F if it was important to have admission and weekly measurements to determine the wound history and to gauge if the wound was improving or deteriorating. ADON F agreed that yes, that was important. On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D and asked her who is responsible for making sure that resident admissions were complete. ADON D stated that depending on which unit, either herself or ADON F would do the full head to toe assessment with the resident and enter all the admission assessments in PCC. Surveyor asked ADON D who was responsible to take wound measurements and ensure their accuracy. ADON D stated that the floor nurses or the float nurse would take the wound measurements. Surveyor asked ADON D who verifies the wound measurements are accurate and complete. ADON D indicated that DON B (Director of Nursing) would look at the wound pictures and determine if it is labeled correctly and staged correctly then DON B closes that assessment. On 4/15/25 at 2:18 PM, Surveyor interviewed DON B about the admission process and who was responsible for taking wound measurements on admission. DON B stated that the nurses would be taking the wound measurements. Surveyor asked DON B who was responsible for verifying the measurements were completed and accurate. DON B stated that the nurses should be verifying the measurements. Surveyor reviewed R253's missing measurements in PCC. DON B indicated that those measurements weren't taken because the floor nurses use a wound camera and that the wound measurements get transferred to PCC but that the measurements did not translate in this case. DON B indicated that the day after an admission the ADON does an audit, but they were looking at the pictures and not the measurements, not realizing that the measurements didn't transfer into PCC. DON B stated that was an error on their part and she would be educating all the nurses on how to use the wound phone so that it works correctly Surveyor asked DON B if it was her expectation that wound measurements be taken on admission and weekly. DON B stated yes that was her expectation. R253 was admitted to the facility with two Stage 3 pressure ulcers. The facility failed to ensure complete and accurate documentation of these wounds' progressions, including admission and weekly measurements of the wounds it should be noted based on facility pictures there was no evidence of decline in the PI's.

Based on observation, interview, and record review, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident's (R) reviewed (R253) who have a mental health diagnosis as well as a history of self-harm statements. R253 verbalized suicidal ideation which was not recognized by the facility and was not taken seriously. R253's statement was not documented in his medical record, interventions were not put in place, R253's POA (Power of Attorney) and PCP (Primary Care Physician) were not notified, increased monitoring was not initiated, and R253's care plan was not updated. Findings include: Facility policy, titled Responding to Intent of Self-Harm or Suicide Threat, dated 8/1/15 with last revision date of 9/6/24, states in part: Purpose: To establish a process to meet the psychosocial and emotional needs of each resident and to identify risk of suicidal and/or parasuicidal thoughts, behaviors, and action. The process will ensure resident suicide threats are taken seriously and interventions for prevention are put in place immediately. Definitions: Suicidal Ideation: Verbal expressions of thoughts of harming oneself that may or may not lack specific intent or associated actions and which are generally vague, passing thoughts related to poorly defined, circumstantial issues . Procedure: 1. Any staff member who becomes aware of a resident's intent to inflict self-harm, including but not limited to suicidal ideation . is required to report the behavior to the nurse and/or social worker immediately or as soon as possible given the situation. 2. The nurse is to contact the resident's physician . to seek appropriate treatment. 3. The DPOA/Responsible party will be notified of the resident's intent to inflict self-harm . 12. In the event that the risk does not warrant hospitalization or transfer to more acute care . staff may be requested to provide routine checks as directed . these checks are to be documented in the medical record. These routine checks are to continue until . deemed no longer necessary . 14. Continued documentation must be kept ongoing. Said documentation to include all plans, goals, interventions and care plan updates when applicable. Always document efforts, situation, observations, date and times, location, witnesses, staff members present, outcomes, who was contacted and who made the contact as well as future plans for safety. R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression, unspecified. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section D0150 of the MDS indicates that R253 feels down, depressed, or hopeless half or more of the days, has trouble falling or staying asleep, or sleeping too much several days of the week, and sometimes feels social isolation. R253's Comprehensive Care Plan, states in part: Focus: The resident has a potential psychosocial well-being problem r/t (related to) admission, diagnosis of Depression, getting angry easily/swearing at family/staff and has a hard time calming down. Date Initiated: 3/24/25. Revision on: 4/9/25. Goal: Resident will demonstrate adjustment to nursing home placement by next review date. Date Initiated: 3/24/25. Revision on: 4/2/25. Intervention: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Date Initiated: 3/24/25 . Increase communication between resident/family/caregivers about care and living environment. Explain all procedures and treatments, medications, results of lab tests, condition changes, rules, options. Date Initiated: 3/24/25 . Monitor/document resident's feelings relative to unhappiness, anger, loss. Date Initiated: 3/24/25. On 4/9/25 at 10:40 AM, Surveyor interviewed R253, who was upset about not being able to go home. On 4/9/25 at 10:50 AM, Surveyor interviewed NHA A (Nursing Home Administrator) about R253's desire to go home. NHA A indicated that R253 thought he was being discharged today, but it was really next Wednesday, and that he was upset about that. On 4/10/25 at 9:50 AM, Surveyor observed R253's provided by LPN C (Licensed Practical Nurse). When removing the old dressings, a small laceration from the white border foam dressing caused R253 to begin bleeding, dripping blood all over the floor. LPN C applied pressure with paper toweling and pushed R253's call light for assistance. ADON D (Assistant Director of Nursing) entered the room and LPN C requested the blood spill kit. ADON D left the room and returned a few minutes later with the blood spill kit. R253 became upset and verbalized concern that this new open area would prevent him from going home next week. R253 stated, I wish someone would take me out to the street and just run me over. What the hell do I have to for; I'm serious. LPN C reassured R253 that the plan was still for him to return home with home health services to help with the wound care. R253 continued to be upset and asked that the Surveyor leave the room. On 4/10/25 at 1:57 PM, Surveyor interviewed ADON D about their facility's suicide policy. ADON D stated that she didn't know but she would look it up and get back to Surveyor with that information. Surveyor asked ADON D what the process would be if a resident made a self-harm statement. ADON D stated they would remove from the room anything they can harm themselves with and ensure their environment is safe. Surveyor repeated back to ADON D the statement that R253 had made that morning during wound care and asked what should be done in this situation. ADON D stated she would check with him to see if he has any plans or any means to accomplish what he said, and she would do follow-up with him. ADON D stated she would also let the social worker know that he made the statement. Surveyor asked if any of this follow-up had been done or if she had let the social worker know. ADON D replied that she did not have the chance to see SW I (Social Worker) yet, but she could send her an email. Surveyor asked ADON D if there should be some urgency to this situation. ADON D stated that if she felt that he was serious yes, but that R253 is rather disgruntled currently because of miscommunication over his discharge plans. ADON D stated that she took it as an offhand remark because he's not happy to be here and he really wants to go home, but that if he had said it with a different demeanor, she would have thought red flags. On 4/10/25 at 2:03 PM, Surveyor interviewed LPN C about the facility's suicide policy. LPN C stated that first she would make sure they are free from harm and then she would report to the administrator. LPN C stated that depending on what type of suicide threat, if there is a weapon or anything involved, she would notify the local police department that there could be someone in danger, and from there she would contact the on-call doctor to see about sending them out for further evaluation. Surveyor repeated back to LPN C the statement that R253 had made that morning during wound care and asked what should be done in that situation. LPN C stated she had just reassured him that they were working toward his ultimate goal of getting him home like he wants to. Surveyor asked LPN C if statements like R253 made should be taken seriously. LPN C stated that she did take it seriously because he was upset, however she did not feel like he could realistically get out in the street and do harm to himself in that way. Surveyor asked LPN C if she had reported to anyone what R253 had said. LPN C indicated that the only person she told was ADON D who was in the room when the statements were made. LPN C indicated that she and ADON D had talked about some of the statements that he had made and decided that it was important to reassure him that they would work to get him healed and, on the path, to home. LPN C stated that in the moment she was more focused on trying to control his bleeding and holding pressure and that his safety right in the moment was more important than the statement he had made. On 4/10/25 at 2:21 PM, Surveyor interviewed SW I (Social Worker) and asked what the process was if a resident made a suicidal statement. SW I stated that if someone expresses that they are suicidal, she usually will do an assessment that asks if they are a harm to themselves, if they have a plan in place, and do they feel safe. SWI indicated that staff would notify her of the statement and then she would go talk to the resident, but if she wasn't in the building she would hope people would know the policy to keep people safe, see if they have a plan, and to keep watch on them like 1:1 monitoring. Surveyor asked SW I if she was aware of the self-harm statement made that morning by R253. SW I said, I just heard about if five minutes ago. Surveyor asked SW I what the process would be now that she was made aware of R253's statement. SW I said she would sit down with him and ask him if he feels suicidal, and if he expressed that he was serious she would ask if that was his plan or if he had another plan in place and if he felt safe. SW I indicated that if R253 was indeed suicidal and had a plan, she would put him on 1:1 monitoring and update the doctor right away as well as notifying the POA (Power of Attorney) if he had one. SW I indicated that currently R253 was playing cards, and he was in a safe environment, but that she did plan on interviewing him and making sure that he was not suicidal and didn't have a plan in place. Surveyor asked SW I if it was her expectation that staff would have notified her right away of R253's suicidal statement. SW I said, yes, she would definitely want to be notified right away so she could make sure he was not serious. Surveyor asked SW I what her next steps in this situation would be. SW I stated she would follow-up with R253 and enter a progress note in his medical record. On 4/10/25 at 2:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked about the statement that R253 had made that morning during wound care. DON B stated she had spoken with LPN C, who explained the new wound triggered him into feeling anxious about not being able to go home, so LPN C stayed with him to calm him down and to determine if it was serious or if he was just saying that. DON B stated that R253 was much better now, and that LPN C had talked him through it and reassured him that he would be able to still go home. DON B stated that she felt that LPN C and ADON D had handled the situation appropriately, that if he was serious and had a plan then they should have updated the doctor and his family and the social worker. Surveyor asked if LPN C or ADON should have documented his statement somewhere in his medical record. DON B indicated that if there is no further threat then she didn't think it was necessary. DON B stated that LPN C did enter a progress note indicating that R253 had become upset about a new area opening up during wound care, and that she had stayed with him and talked with him until he had calmed down. DON B stated that it would have been different if R253 had a plan, then they would have notified the social worker, updated the care plan, and notified the doctor if necessary. DON B indicated that LPN C had assessed R253 and determined that he didn't mean it. On 4/10/25 at 2:48 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about the situation that happened during R253's wound care and the suicidal statement he had made. Surveyor asked NHA A what her expectation was when a resident made a self-harm statement. NHA A stated she would expect that they would assess the resident immediately to determine if there is an imminent threat or danger. NHA A stated that with R253 it was hard to say because since admission he was upset over his situation and didn't want to be there. Surveyor asked NHA A if R253 had ever made suicidal comments before today. NHA A stated that R253 had made statements before like I want to die and Dr [Name] put me here to rot and die. Surveyor asked NHA A what should have been done when R253 made his suicidal statement this morning. NHA A stated they would need to look at the seriousness of it and determine if there was potential threat to himself and other residents, reaching out the doctor, having the social worker come do a depression screening and possibly contacting a psychiatrist if someone was very depressed with suicidal thoughts. NHA A stated that she felt the statement R253 made today should potentially be looked at as his desire to cause harm to himself, and that when people make those statements they need to determine if that is serious. Surveyor asked NHA A if more follow-up and monitoring should have been done. NHA A stated that they needed to go talk to R253 and see if there was an immediate threat or he was just saying that. Surveyor asked NHA A if there should be some urgency to following up when residents made suicidal statements. NHA A stated yes, that she would have expected that there would have been quicker follow-up including reaching out to the doctor and letting the social worker know so that she could go and talk to him. The facility failed to recognize and take seriously a verbalized suicidal threat by a resident with a history of Depression who had expressed suicidal ideation in the past. Prompt follow-up with the resident was not completed, nor was a monitoring plan put in place to ensure his safety.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 sampled residents (R2). R2 is at risk for falls and was left unsupervised in a bathroom, still connected to a mechanical lift, and experienced a fall while unsupervised. R2 was also observed to not have an anti-rollback device installed on his wheelchair as stated in his care plan. This is evidenced by: The facility policy entitled, Sit-to-Stand Mechanical Lift-SNF, dated 8/22/23, states, in part: . Purpose: To assist residents with transfers who are able to bear weight with some assistance. Employees will use the sit to stand mechanical lift per policy to ensure safety for the resident and the employee. Procedure: 1. Sit to stand mechanical lift will be used with two caregivers .8. Transfer according to manufacture direction guidelines . The mechanical lift used in the transfer has manufacturer recommendations that state, in part: Intended use . [Product Name] shall always be handled by a trained caregiver, continuously attending to the resident . R2 admitted to the facility on [DATE] with diagnoses that include Parkinson's disease (brain disorder that causes problems with movement, balance, and coordination), type 2 diabetes mellitus, Crohn's disease (inflammatory bowel disorder), irritable bowel syndrome, dementia, polyneuropathy (peripheral nerve damage causing pain, decreased sensation, and weakness), unsteadiness on feet, and muscle wasting and atrophy. R2 has an activated Healthcare Power of Attorney. R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/21/24, indicates R2 has a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Section GG indicates R2 is dependent on staff for toileting hygiene, toilet transfers, chair/bed-to-chair transfers, and to move from sitting to standing. Section GG also indicates that the facility could not attempt to assess R2 walking 10 feet due to a concern for resident safety. R2's Comprehensive Care Plan, states, in part: . Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Parkinson's, DM2 (Diabetes mellitus type 2), Crohn's disease, GERD (gastroesophageal reflux disease), MDD (Major Depressive Disorder), IBS (irritable bowel syndrome), rhabdomyolysis. Date Initiated: 5/20/24. Interventions: . Dressing assist - two person assist . toilet use assist- [Mechanical Lift Product Name] . Focus: The resident has limited physical mobility r/t Parkinson's. Date initiated: 5/20/24. Interventions/Tasks: AMBULATION/LOCOMOTION- WHEELCHAIR-MANUAL. AMBULATION/LOCOMTION- [Mechanical Lift Product Name]. AMBULATION/LOCOMTION ASSIST- FRONT WHEELED WALKER . TRANSFER ASSIST- Two person assist with transfers. Focus: The resident has impaired cognitive function or impaired through processes r/t Parkinson's diagnosis. Date Initiated: 5/20/24. Interventions/Tasks: Ask yes/no questions in order to determine resident's needs. COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distraction-turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed . Present just one thought, idea, question or command at a time. Focus: The resident is HIGH risk for falls r/t Parkinson's disease, poor safety awareness. 4/6/24, 5/22/24, 5/24/24, 6/10/24, 6/20/24, 6/23/24, 7/8/2024, 7/13/24, 8/23/24, 8/25/24, 8/31/24, 9/2/24. Date initiated: 5/20/2024. Revision on: 9/4/2024 Interventions/Tasks: 4/8/24 anti-rollbacks added to w/c (wheelchair). 5/24/24 have up in w/c when anxious and place in dining area for more observation of patient. 6/10/24- Intervention is to put resident into recliner following meals and after toileting. 8/23/24- Do not leave unattended on the toilet. 8/31/24- scheduled toileting for 2100 (9:00 PM). 9/2/24- Room changed to room [ROOM NUMBER]. Assist R2 up in wheelchair before breakfast and provide a snack as needed 6/23/24. Day shift to check on R2 at the beginning of the 6 am shift 7/15/24. Get resident up to the bathroom x1 on NOC (night shift) at 0200 (2:00 AM) to try to have a BM (bowel movement) (7/8/2024). Intervention is to put in bed between 7-7:30 pm to assure no attempts to put self in bed. Q 1-hour checks. Scheduled toileting program (Q 2 hours). Provide/offer snacks in between meals and/or with signs of restlessness. PT/OT (Physical therapy/Occupational Therapy) to evaluate and treat. Low bed. Gripper socks on when up (4/7/24). Skid Resistant shoes. Focus: Vulnerability: Resident being dependent on staff for cares and transfers. Initiated on 05/20/2024. Interventions/Tasks: . Provide safe environment . R2's Fall Report, dated 8/23/24 at 14:20 (2:20 PM), states, in part: . Nursing Description: CNA (Certified Nursing Assistant) alerted this nurse that Pt (Patient) had a change of plane while sitting on [Mechanical Lift] in bathroom. Arrived at patients room. Pt was sitting on left side of toilet, his bottom was not on the floor, as it was on the sling of the EZ stand. PT also had his left arm on his sink bracing himself along with right arm holding onto handle bar. Resident Description: Resident Unable to give Description. Was this incident witnessed: N Immediate Action Taken: Description: New intervention will be to not leave patient unattended in [Mechanical Lift] while in bathroom. Mental Status: Baseline for individual, Oriented to Time, Oriented to Person . Predisposing Physiological Factors: Gait imbalance, Weakness/Fainted, Impaired Memory. On 9/18/24 at 12:15 PM, Surveyor observed R2 seated in a mechanical wheelchair in the dining room. The mechanical wheelchair was not equipped with an anti-rollback device as stated in the comprehensive care plan. On 9/17/24 at 2:15 PM, Surveyor interviewed CNA C. CNA C was the CNA who reported R2's fall on 8/23/24. CNA C described the incident. As CNA C started her shift and got report, she was told that R2 was in the bathroom on the mechanical lift. CNA C went in to check on R2 who told CNA C he needed more time. CNA C left the room to assist a different resident who needed help. When CNA C returned to R2 to see how he was doing, R2 was half-off the toilet and holding on to the sink and one of the lift handles to try to hold himself up. CNA C got the nurses attention without leaving the resident and he was assisted off the toilet. CNA C stated that when she found R2 after the fall, he was still connected to the mechanical lift. Surveyor asked CNA C what she believed to be the root cause for R2's fall. CNA C stated that R2 tried to stand while he was still connected to the sling and the sling slipped so that it was no longer supporting R2. Surveyor asked CNA C if she normally leaves R2 alone in the bathroom. CNA C stated she normally stays within his line of sight so that she can ensure his safety, but at this time she was called away to assist another resident. Surveyor asked CNA C if R2 is supposed to have an anti-rollback device installed on his wheelchair. CNA C stated, Absolutely. On 9/17/24 at 2:19 PM, Surveyor asked CNA C to identify which lift was being utilized the day of the fall. CNA C identified the EZ stand lift. On 9/17/24 at 2:25 PM, Surveyor interviewed CNA D. CNA D described the appropriate transfer procedure utilizing a mechanical lift and states that staff always needed 2 people to transfer a resident. Surveyor asked CNA D if residents could be left alone in the bathroom while connected to a lift. CNA D stated that it depends on the resident; some residents who are cognitively impaired or have poor safety awareness should be supervised more closely while in the bathroom. On 9/17/24 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation is for staff while transferring residents with a mechanical lift. DON B stated that there needs to be two (2) staff present while the mechanical lift is in motion. Surveyor asked DON B what her expectation is for staff supervising residents while connected to a mechanical lift. DON B stated that it depends on the resident, and that this information should be included in the care plan if they are safe to be left alone in the bathroom or not. Surveyor asked DON B if R2 was able to be left unsupervised while connected to a lift. DON B stated he is not anymore. After the fall on 8/23/24, it was decided that he was not able to be left in the bathroom unsupervised. Surveyor asked DON B if she had completed any staff education regarding mechanical lift procedure, fall prevention, or supervision after R2's fall. DON B stated she did not because prior to the fall, R2 had not had any incidents while being unsupervised in the bathroom, so an intervention was just added to the care plan after the fall. Surveyor asked DON B if R2 is supposed to have an anti-rollback device on his wheelchair. DON B stated if it is on the care plan, it should be on his wheelchair. On 9/17/24 at 3:04 PM, DON B returned after consulting with staff to inform Surveyor that R2 is supposed to have an anti-rollback device on his wheelchair; however, when R2 had his shower day yesterday (9/16/24) he was accidentally returned to the wrong wheelchair.

Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 1 resident (R1) reviewed for pain. R1 complained of pain during pericare. R1 was observed to wince and cry due to the pain. At no point during this interaction did staff stop care and let R1 take a break, or immediately notify the nurse of R1's pain. Evidenced by: The facility policy, Pain Management and Assessment, revised 4/27/22, indicates in part the following: The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living. Evaluate for behavioral responses to pain: a. facial wrinkling/grimacing; c. crying or moaning; g. decreased interaction. Non-pharmacological interventions (i.e. repositioning resident, turning lights off, warm cloth, etc.) will be attempted prior to the use of PRN (as needed) analgesics whenever appropriate. Use of interventions and effectiveness will be documented. R1 was admitted to the facility 4/9/24 with diagnoses including, but not limited to, spondylosis, osteoporosis, dementia, major depressive disorder single episode, total retinal detachment, occlusion and stenosis of bilateral carotid arteries, muscle wasting and atrophy. R1's Admission Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) of 13, indicating she is cognitively intact. R1's PHQ-9 indicates Minimal Depression. R1 is her own person. R1's Certified Nursing Assistant (CNA) Kardex documents, in part, the following: Transfer, Toileting, Bathing, Bed Mobility, Dressing assist of one (1). In addition, Toileting indicates the following interventions: Apply barrier cream to peri area after each incontinent episode; Check and change resident as needed due to incontinence; Incontinence care after each incontinent episode; Record bowel movement pattern each day. Describe amount, color, and consistency; Scheduled Toileting Program for incont (incontinent) episode at 3 hours. The section Skin indicates other pain intervention: May use lotion and water on wash clothes to remove bm more gently; offer whirlpool baths more frequently as she allows, apply barrier cream/ointment with peri care interaction, other medication cream or pads as ordered. On 7/30/24 at approximately 12:30 PM, Surveyor spoke with CNA/Scheduler C (Certified Nursing Assistant/Scheduler). Surveyor asked CNA/Scheduler C to described what occurred during her shift on 7/7/24. CNA/Scheduler C stated, she was working as 1/2 Bath Aide and 1/2 CNA. CNA/Scheduler C stated, at approximately 1:30 PM, she answered R1's call light. CNA/Scheduler C stated, When washing her up I could feel her wince and My hands are huge, and I was trying to be gentle. CNA/Scheduler C stated, she observed a tear on R1's nose. CNA/Scheduler C stated, when she could see R1 was in pain she pushed R1's call light for assistance and nobody answered my call light. CNA/Scheduler C stated, she finished cleaning R1 up and transferred her to the recliner. CNA/Scheduler C asked RN E to follow up regarding R1's pain. On 7/24/24 the Administrator spoke with CNA/Scheduler C (Certified Nursing Assistant) regarding an allegation made by R1. The Nursing Home Administrator (NHA) asked CNA/Scheduler C to explain what occurred on 7/7/24 with R1. CNA/Scheduler C summarized she went to assist R1 due to a call light being on. She had stool stuck in her butt crack, so it was hard to get off. It wasn't soft stool but wasn't hard. It was sticky. As I was wiping her, I could see her body wince and she started to cry. She said it was very painful. At that point, I pulled her call light in the bathroom to see if I could have the nurse come in to assist since she was in a lot of pain. I tried to just pat her back and forth with a wash cloth instead of rubbing. It took about 10-15 minutes to get her all cleaned up. I told her, I'm sorry and that I was doing my best to not hurt her, but also had to get the stool off her. After I was completed, I applied a barrier cream to her and assisted with clean clothes. I went straight to the nurse on duty RN E (Registered Nurse) and asked her if she had anything more she could give or do for R1's butt pain as she was crying because of the pain. Administrator asked if R1 had said anything to her to stop. CNA C said she did not verbally say stop. She just said it was painful and I told her I was sorry. It is important to note, during this incident of incontinence and pericare, CNA/Scheduler C indicates the following: As I was wiping her, I could see her body wince and she started to cry and she was crying because of the pain. At no point during this interaction did CNA/Scheduler C stop cares and let R1 take a break, nor did CNA/Scheduler C physically go notify the RN E. RN E (Registered Nurse) statement indicates as follows: CNA C approached me on 7/7/24 and asked if R1 is always in a lot of pain during toileting/pericare. CNA C told me that R1 was crying and verbalized she was in a lot of pain. CNA C asked if I could give her something for her butt pain specifically. I explained to her that I did not have anything for butt pain besides the calmoseptine cream. I worked a 16-hour shift and interacted with R1 off and on that day and she did not express being in distress or any pain to me. On 7/30/24 at 2:50 PM, Surveyor spoke with RN E (Registered Nurse). RN E works PRN (as needed) at the facility. Surveyor asked RN E to described what occurred during her shift on 7/7/24. RN E stated on 7/7/24 she worked from 6:00 AM-10:00 PM. RN E stated CNA/Scheduler C reported to her that she had just assisted R1 with incontinence care and it was quite painful for her. RN E stated, CNA/Scheduler C wanted her to check in with R1 after that. RN E stated when she went in the room R1 was resting in her chair. RN E stated, she did not want to disturb R1 and did not wake her up. RN E stated, during her 16-hour shift R1 did not mention the allegation. RN E stated the only order she has for R1's bottom was Calmoseptine. Collateral Statements from 7/7/24 Self Reportable: LPN D (Licensed Practical Nurse) - R1 stated to LPN D that she needed help in the bathroom and CNA/Scheduler C came in to wash her up. Resident stated, it hurt so bad and said she yelled out because it was so painful it got worse. She (R1) doesn't want her bathing her or washing her up anymore. She did it hard and it hurt. Nurse wrote up a concern form to Administrator. On 7/30/24 at 2:30 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). Surveyor asked LPN D to described what occurred during her shift on 7/7/24. LPN D stated, R1 reported to her that CNA/Scheduler C was Very rough and Rough washing up my bottom and Look at her (CNA/Scheduler C), look at me she is much bigger than me and She was right there washing and didn't stop. LPN D stated she reported this to NHA A (Nursing Home Administrator). On 7/30/24 at 9:10 AM, Surveyor spoke with R1. R1 stated she has a concern with CNA/Scheduler C, R1 stated, CNA/Scheduler C treated me very roughly, more than roughly, cruelly. R1 added, I call it a brutal beating. Surveyor asked R1 did CNA/Scheduler C say anything to you. R1 stated, she didn't answer just kept on going. On 7/20/24 at 3:20 PM, Surveyors spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, what did R1 report regarding the 7/7/24 allegation. NHA A stated, R1 reported, She (CNA/Scheduler C) wiped me really hard, and it hurt. and was really painful. NHA A stated, R1 shared she has hemorrhoids and has some pain to her private area after having 6 babies. NHA stated, R1 stated she asked CNA/Scheduler C to stop but she kept on doing it and didn't say anything. NHA A stated, CNA/Scheduler C stated R1 did not tell her to stop; however, she observed and stated that R1 was crying and in visible pain. Surveyor asked NHA A, did you educate CNA/Scheduler C and other staff regarding pain and stopping cares when a resident is in pain. NHA A stated that she, DON B (Director of Nursing) and HR (Human Resources) provided education to CNA/Scheduler C over the phone; however, there is no documentation that CNA/Scheduler C was educated regarding pain. NHA A stated that other staff were not educated regarding pain. Surveyor asked NHA A, should you have educated CNA/Scheduler C and all other staff regarding pain following this allegation. NHA A stated, Yes.

Based on interview, record review, and policy review, the facility failed to ensure that 3 of 3 resident (R47, R23, and R35) residents reviewed for unnecessary medications had an order for an as-needed (PRN) psychotropic medication which did not extend beyond 14 days, without a physician assessment and documented rationale. Findings include: Review of a facility policy titled, Psychotropic Medication, revised on 05/25/21 and provided by the facility, stated, .PRN (as needed) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order . Review of a facility policy titled, Medication Regimen Review (MRR), revised on 03/03/20 and provided by the facility, stated, .The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of MRRs .The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record . Example 1: R47 was admitted on [DATE] with diagnosis of dementia with agitation and bipolar disorder (serious mental illness of bouts of depression and increased activity/excitability). Review of R47's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating R47 had moderate cognitive impairment. Review of the September 2022 MRR revealed a physician's order, which originated on 09/08/22, for Ativan (lorazepam, an anti-anxiety medication), 0.5 milligrams every 12 hours as needed for agitation. R47's Care Plan, revised 09/08/22 stated, Administer medications as ordered. Monitor/document for side effects and effectiveness. My medications for behavior are: Ativan (lorazepam) for anxiety, and Lexapro for bipolar depression. Review of a Pharmacy Consultant Note dated 09/28/22 indicated, Note Text: Please see consultant report. Further documentation found under the Miscellaneous tab revealed the pharmacist's recommendation: R47 has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: lorazepam 0.5 mg every 12 hours as needed for agitation. Recommendation: Please discontinue PRN lorazepam, tapering, as necessary. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of the medication, and the rationale for the extended time period. Review of R47's Medication Administration Records (MAR) for September, October, and November 2022, revealed R47 continued to receive the medication eight times after the 14 day stop date. Review of R47's EMR revealed no documentation by the resident's physician of the clinical rationale for continued use of the Ativan without any attempts at a gradual dose reduction until 11/04/22. During an interview on 01/04/23 at 3:39 PM, the DON B (Director of Nursing) stated that on 11/01/22, R47's doctor had notified the facility via telephone that the lorazepam was discontinued as of that date. The DON did not provide any documentation by the physician related to the clinical rationale for continued use of the medication, or documentation of the risks versus benefits of continued use being discussed. Example 2 R23 was admitted on [DATE] with diagnoses including macular degeneration, hallucinations, and muscle wasting. Review of R23's Care Plan revised 09/07/22, indicated he was prescribed antipsychotic medication related to delusions, striking out, hitting, biting, and hallucinations. Review of R23's annual MDS dated [DATE] included a BIMS score of 11 out of 15 indicating R23 had moderate cognitive impairment. Review of R23's Orders included lorazepam (antianxiety medication) 1mg tablet to be given every 24 hours as needed for anxiety and dated 05/09/22 with a stop date of 10/13/22. Review of R23's document titled Consultation Report, dated 08/25/22 and provided by the facility, revealed the pharmacist's comment that R23 .has a PRN order for an anxiolytic, which as been in place for greater than 14 days without a stop date: lorazepam 1mg every 24 hours as needed for anxiety; note has a routine order for lorazepam 1mg every morning. Recommendation: Please discontinue PRN lorazepam, tapering as necessary . The order was not discontinued by the physician until 09/25/22. Review of R23's MAR revealed R23 did not receive any PRN doses of lorazepam from May 2022-August 2022 and one dose of PRN lorazepam on 09/07/22. Example 3 R35 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. Review of R35's Care Plan, dated 08/10/22, included use of antianxiety medication related to anxiety disorder and required assistance with self-care tasks related to dementia. Review of R35's quarterly MDS dated [DATE] revealed a BIMS score of zero out of 15 indicating R35 had severe cognitive impairment. Review of R35's Order Summary Report, included lorazepam 0.5mg tablet every 24 hours as needed for increased anxiety, dated 08/10/22 with a stop date of 02/10/23. Review of R35's Consultation Reports revealed the pharmacist did not address psychotropic drug use beyond 14 days related to PRN use. Review of R35's MAR, revealed R35 did not receive any PRN doses of lorazepam in August 2022, refused one dose on 09/16/22, none administered in October or December 2022, and received one dose of lorazepam 0.5mg on 11/23/22 and 11/24/22. During an interview on 01/05/23 at 11:43 AM, RPh E stated that psychotropic medications not used as an antipsychotic medication should be limited to 14 days; if the physician feels the order needs to be extended beyond the 14 days there should be a rationale documented by the physician. Interview on 01/04/23 at 11:21 AM with DON B confirmed R23, R35, and R47 had a PRN order for an anxiolytic (lorazepam) that was in place for greater than 14 days without a stop date but should have been. Additionally, the DON confirmed that the physician did not respond to pharmacy recommendations in a timely manner.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure oxygen therapy equipment was maintained per physician's order for 1 of 1 (R1) residents reviewed for respiratory care. R1 was to have the filter of his oxygen concetrator cleaned weekly. Observations found the filter to be covered with lint and dust. Findings include: Review of the facility policy titled, Oxygen Administration and Storage, last reviewed 04/26/22, read, Filters should be removed and cleaned by rinsing with clear, cool water weekly to maximize flow rate of clean air. Review of the undated user manual for the oxygen concentrator read, To reduce the risk of infections it is very important to keep your equipment clean .Cleaning Your Oxygen Equipment: Clean any filters with warm water and let dry before putting them back in the machine . R1 was admitted on [DATE] with diagnoses of obstructive sleep apnea and a history of COVID-19. Review of R1's Care Plan, revised on 12/27/22 had a focus area of altered respiratory status/difficulty breathing r/t (related to) heart failure, obesity, chronic sinusitis, and low oxygen levels with activity. The care plan indicated R1 was to receive oxygen at two liters per minute. The care plan did not address cleaning the oxygen concentrator filter. R1's undated Order Summary report, revealed R1 was to receive oxygen at 2 liters a minute as needed. The orders also indicated, since 07/24/22, the oxygen filter was to be cleaned once a week. R1's Medication Administration Record (MAR), dated 01/2022 revealed the filter on R1's oxygen concentrator was to be cleaned weekly on Sundays. The MAR was signed as completed 01/01/22. Surveyor made observations on 1/3/23 at 10:17 AM, 1/4/23 at 8:15 AM. Both observations revealed the oxygen concentrator filter had an accumulation of dirt and lint covering the entire surface of the filter. During an observation and interview on 01/04/23 at 1:16 PM, RN C (Registered Nurse) stated oxygen concentrator filters were cleaned on the night shift. RN C verified the filter on R1's oxygen concentrator was dirty. During an interview on 01/04/23 at 1:26 PM, DON B (Director of Nursing) stated she expected the oxygen concentrator filters to be cleaned weekly when the tubing was changed. DON B stated there was not a system for monitoring to ensure filters were cleaned weekly. The DON identified the initials on the MAR as RN D's. During an interview on 01/05/23 at 10:34 AM, DON B stated she had talked with RN D and RN D had stated she was called away from R1's room prior to cleaning the oxygen concentrator filter and forgot to go back and clean it.

Based on interviews, record reviews, and policy review, the facility failed to identify and report PRN (as needed) psychotropic drug use beyond 14 days without a documented rationale for 1 of 3 residents (R35) reviewed for psychotropic medications out of a total sample of 13 residents. R35 had an order for as needed lorazepam, an antianxiety medication. There was no stop date after 14 days, and no assessment for the continued use of the medication. Findings include: Review of a facility policy titled, Psychotropic Medication, revised on 05/25/21 and provided by the facility, revealed, .PRN (as needed) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order . R35 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of R35's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of zero out of 15 indicating R35 had severe cognitive impairment. Review of R35's Care Plan, dated 08/10/22, included use of antianxiety medication related to anxiety disorder and required assistance with self-care tasks related to dementia. Review of R35's Physician Orders, dated 08/10/22 included lorazepam (anti-anxiety) PRN for anxiety with a stop date of 02/10/23 beyond 14 days after the order date. Review of R35's Psychiatry Consult Note, dated 12/19/22 and provided by the facility, did not include use of lorazepam PRN for anxiety. Review of R35's Medication Administration Record (MAR), revealed R35 did not receive any PRN doses of lorazepam in August 2022, resident refused one dose on 09/16/22, none administered in October or December 2022, and received one dose of lorazepam 0.5mg on 11/23/22 and 11/24/22. Review of R35's Consultation Reports revealed the pharmacist did not address psychotropic drug use beyond 14 days related to PRN use during monthly reviews from August 2022 through December 2022. During an interview on 01/05/23 at 11:43 AM, the RPh E (Registered Pharmacist) stated that psychotropic medications not used as an antipsychotic medication should be limited to 14 days. If the physician feels the order needs to be extended beyond the 14 days there should be a rationale documented by the physician. RPh E was not aware of R35 having a prn lorazepam order that exceeded 14 days without physician rationale/documentation. During an interview on 01/05/23 at 4:10 PM, DON B (Director of Nursing) confirmed the pharmacist's Consultation Reports from August 2022 through December 2022 did not identify that R35 had an order for psychotropic prn administration of lorazepam beyond 14 days.

Based on interviews, record reviews, and policy reviews, the facility failed to ensure antibiotics were not used for an excessive duration and without adequate monitoring for 1 of 5 residents (R35) reviewed for unnecessary medications in a total sample of 13 residents. R35 was receiving a prophylactic antibiotic for a history of UTIs (Urinary Tract Infections). There was no rationale for R35 to receive this medication. Findings include: Review of the facility policy titled, Antibiotic Stewardship, provided by the facility and revised on 12/20/19, stated the purpose was to promote appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use .The nurse will utilize the McGeers Minimum Criteria protocol .to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made .The nurse will notify the physician/practitioner of resident change of condition and evaluation information will communicate to the provider the infection criteria protocol to treat the respective infection. If antibiotics are ordered prior to any diagnostic testing or outside of the parameters of the McGeer Minimum Criteria the nurse will request a written note from the physician/practitioner as to the rationale and will document such request . R35 was admitted to the facility on [DATE] with diagnoses that included dementia and urinary incontinence (uncontrolled leakage of urine). There was no mention of chronic urinary tract infections. Review of R35's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating R35 had severe cognitive impairment. Additionally, the MDS indicated that R35 had not had any infections within the past 30 days. Review of R35's Physician Orders, dated 08/10/22 included nitrofurantoin (antibiotic) for prophylactic (preventive) related to a history of chronic UTI (urinary tract infection). Review of R35's McGeer's Infection Criteria assessment dated [DATE], revealed Section B Urinary Tract Infections (UTIs) was not filled out which indicated the resident must have at least one of the following signs or symptoms: acute dysuria (painful urination), fever, or elevated white blood cells and at least one of the following: acute costovertebral angle pain and tenderness, suprapubic pain, gross hematuria (blood in urine), new or marked increase in incontinence, new or marked increase in urgency, or new or marked increase in frequency .Section E Communication with Physician stated If orders do not meet criteria, has the physician been informed and has the physician given a rationale for continued antibiotic use? R35 just completed cefdinir 300mg BID (twice daily) for 7 days for a UTI (urinary tract infection). She admitted on nitrofurantoin 100mg daily ongoing, prophylactically due to chronic UTIs. UA culture grew klebsiella pneumoniae on 08/02/22 [sic]. Review of R35's most recent urine culture was dated 08/02/21, over a year prior to her admission to the facility. Review of R35's Care Plan dated 08/10/22, included prophylactic antibiotic usage with interventions including monitoring/documenting/reporting signs and symptoms of UTI to include fever, abdominal pain, mental status change, weakness, functional decline, nausea, vomiting, dark cloudy urine, foul smelling urine, blood in urine, pus in urine. Review of R35's Progress Notes, revealed from 8/9/22 through 1/4/23, R35 had no signs or symptoms of urinary tract infections. Review of R35's physician progress note, dated 08/22/22, revealed the physician stated that R35 had a history of .chronic UTI's and was on prophylactic treatment, but I think that has been stopped . Visit notes from September 2022 through 01/04/23 did not address long term, prophylactic use of antibiotics or monitoring of laboratory values. Review of R35's pharmacist Consultation Report, dated 11/30/22, recommended, Please discontinue nitrofurantoin while monitoring for signs and symptoms of recurrent UTI. Rationale for Recommendation: The potential for developing pulmonary fibrosis, hepatotoxicity, C.difficile infection, and peripheral neuropathy increases with duration of use . As of 01/04/23, the physician had not responded to the pharmacy recommendation. Review of R35's Medication Review Report, dated 11/07/22 indicated the physician reviewed the nitrofurantoin order and approved continued use with no documented rationale. During an interview on 01/05/23 at 11:43 AM, RPh E (Registered Pharmacist) stated that when residents are on prophylactic antibiotics, recommendations are made to the physician that include providing a statement indicating why there is a need for prophylactic antibiotic use and they also suggest periodic monitoring for renal function, etc. The goal was to ensure there was no organ damage related to long term use of antibiotics. Review of a letter sent to physicians in August 2022, provided by DON B (Director of Nurses), stated in part, .The facility understands that as the primary care doctor or nurse practitioner, you know your patients' history and may still choose to place your patient on an antibiotic despite not meeting the McGeer Criteria. The facility asks that you provide us with a statement to support this for facility records . During an interview on 01/05/23 at 12:30 PM, DON B confirmed that R35 was admitted to the facility on [DATE] with orders for nitrofurantoin for chronic UTI. DON B stated that an annual notification goes out to all physicians, with the most recent notification dated August 2022 and referenced above. Additionally, all residents must have a physician order for antibiotics, and McGeer's Criteria assessment must be performed by the nurse prior to the start of antibiotics. During an interview on 01/05/23 at 4:10 PM, DON B stated that she spoke with R35's physician regarding laboratory monitoring and confirmed that the most recent laboratory monitoring was in July 2022, there were no current orders on file for monitoring laboratory values, and that the physician had provided verbal orders for the discontinuation of nitrofurantoin as of 01/05/23 without rationale. DON B's expectation related to pharmacist recommendations was for the physician to respond to any recommendations within 30 days; DON B confirmed that the physician had not responded to the pharmacists recommendation regarding discontinuation of nitrofurantoin prior to this surveyor bringing it to her attention or prior to her call to the physician's office. The physician was not available for interview.

Based on observation, interview, and record review, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and were not discarded after the expiration date for 1 of 12 sampled (R31) and 1 of 1 supplemental resident's (R21). R21's [MEDICATION(S)] eye drop has no open or expiration date. R31's [MEDICATION(S)] expired in 08/2019. This is evidenced by: The facility policy and procedures titled, Medication Storage, revision date 4/17/17, states in part . Purpose: To ensure medications and biological are stored in a safe, secure storage and safe handling. Procedure: General Guidelines; 3. No discontinued, outdated, or deteriorated medications should be available for use in the facility. All such medications are destroyed per policy. 4. Expired medications are to be removed from areas medication carts prior to or at the time of expiration. The facility policy and procedure titled, Medication Expiration Dates, issue date 8/01/15, states in part . Purpose: To identify medication expiration dates and provides recommendations for disposal in accordance with manufacturer recommendations. Procedure: 2. The date of the opening should be noted on the medication package or container at the time of opening. 5. Specific manufacturer recommendations for prescription medications and solutions will be followed based on specific time frames after opening. Twenty-Eight (28) Days Multi-dose vials (with preservatives) unless otherwise specified by manufacturer recommendations. Sixty (60) Days Eye Drops unless other specified by manufacturer recommendation According to drugs.com, [MEDICATION(S)] 1% eye drops container should be discarded 4 weeks after opening. Example 1 R21 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's Physician Orders, dated 10/05/21, documents in part: [MEDICATION(S)] Suspension 1% ([MEDICATION(S)]). Instill 1 drop in both eyes two times a day related to OTHER SPECIFIED [CONDITION(S)]. On 10/18/21 at 11:55 AM, Surveyor observed the medication cart with RN C (Registered Nurse). Surveyor observed R21's [MEDICATION(S)] 1% eye drops without an open date or expiration date. [MEDICATION(S)] suspension 1%. Instill 1 drop in both eyes two times a day related to other specified [CONDITION(S)]. Eye drop dispensed from Pharmacy on 9/07/21. On 10/18/21 at 12:02 PM, Surveyor interviewed RN C. Surveyor asked RN C if eye drops should have an open or expiration date on them. RN C indicated that when opened an open date should be placed on the bottle. Surveyor asked RN C how long R21's eye drops are good for. RN C looked at the bottle of eye drops and stated, They expire in 2023. On 10/20/21 at 8:23 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how long eye drops are good for once open. DON B stated, Typically 28 days. Surveyor asked DON B how long [MEDICATION(S)] eye drops are good for. DON B stated, I will have to check. On 10/20/21 at 8:27 AM, DON B came back to Surveyor and stated, [MEDICATION(S)] eye drops are good for 28 days. Example 2 R31 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R31's Physician Orders, dated 9/11/19 documents in part: [MEDICATION(S)] HCL ([MEDICATION(S)]) tablet 12.5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for dizziness. On 10/18/21 at 11:55 AM, Surveyor observed medication cart medications with RN C. Surveyor observed R31's [MEDICATION(S)] 12.5 MG with an expiration date of 08/2019. [MEDICATION(S)] HCL ([MEDICATION(S)]) tablet 12.5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for dizziness. On 10/18/21 at 11:59 AM, Surveyor interviewed RN C. Surveyor asked RN C if R31 still takes [MEDICATION(S)]. RN C stated, Once and awhile. I would have to look and see when he last received it. Surveyor asked RN C about expiration date review. RN C stated, We look at them but I think someone else checks the carts. Surveyor asked RN C if medication was expired. RN C stated, Yes, that should have been discarded a while ago. Note: [MEDICATION(S)] expired on 08/2019. On 10/18/21, Surveyor reviewed R31's MAR's (Medication Administration Record) from September and October. R31 received expired [MEDICATION(S)] one time in September (9/11/21) and one time in October (10/14/21) from the expired medication card. On 10/18/21 at 4:07 PM, Surveyor interviewed DON B. Surveyor asked DON B if medication should be used after expiration date. DON B stated, No, it should be discarded. The facility failed to ensure that all medications were given an open or expiration date once opened and failed to discard expired medications.

Based on observation, interview and record review, the facility failed to ensure care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 3 residents (R1). R1 was placed on perpetual isolation due to offsite weekly outpatient [MEDICAL TREATMENT] appointments. Findings include: Per State Operations Manual 483.10 (a) The resident has the right to a dignified existence, self-determination .483,10(a) (1) A facility must treat each resident with respect and dignity and care for eaach resident in a manner and in and environment that promotes maintenance or enhancement of his or her qulaity of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. 483.10 (a)(2) The facility must provide equal access to quality care regardless of diagnosis . The facility's COVID-19 policy states, Residents receiving [MEDICAL TREATMENT] at an outside center: will be placed on droplet precautions to reduce the risk of spreading COVID-19. R1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. His most recent BIMS (Brief Interview for Mental Status) shows a score of 15, which indicates R1 is cognitively intact. R1 attends [MEDICAL TREATMENT] 3 days per week. On 5/17/20, R1 submitted a grievance regarding having to be on continual isolation. The facility spoke with the ombudsman and the resident, but it was decided R1 needed to stay on droplet precautions. On 7/10/20, R1 again submitted a grievance along with a letter explaining, in detail, the precautions he takes when outside of his room during transport and while at [MEDICAL TREATMENT]. R1 also stated that he understood CDC (Center for Disease Control) recommendations and would follow all masking and social distancing rules. The facility followed up by providing R1 with county data regarding COVID-19 and assisted R1 in accessing the information. It was explained to R1 that once cases had lowered to a specific level and the county reached a specific status, his droplet precaution restrictions would be lifted. In addition, the facility's medical director provided a letter to R1 stating the current policy should be implemented. The facility did not change their policy and decided to keep R1 and other [MEDICAL TREATMENT] residents on continual droplet precautions indefinitely. On 8/11/20 at 12:30 PM, Surveyor interviewed R1 outside his doorway. R1 stated the facility will not allow him outside of his room, not even to check the menu on the bulletin board down the hall. R1 stated that he can go outside if he schedules a time, but has to be by himself. R1 stated that he feels like a leper because he cannot come out of his room and cannot see other people when he goes outside. R1 stated that when staff come in his room, they have to wear gowns, gloves, shields and a mask. R1 stated he can social distance from other residents and respects the rules. On 8/11/20 at 3:30 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated that R1 is on isolation and that he is not to be outside when others are outside, even when wearing a mask and social distancing. DON B also stated there have been some group activities outside involving crafts. Residents are to social distance and wear masks during these activities. R1 is not allowed outside with other residents, but can go outside after the other residents come back inside the facility so he can partake in the same activity by himself. R1 is alert and oriented and able to articulate all precautions necessary to safely exit his room and social distance in the presence of others. The facility continues to require R1 to be in transmission based precautions (TBP) despite several communications by the Department of Public Health stating continued TBP for those on [MEDICAL TREATMENT] is not warranted. The psychosocial risk significantly outweighs the benefit of continue TBP when R1 leaves one controlled environment and goes to another controlled environment. R1 feels his is being treated unfairly due to his need of continued [MEDICAL TREATMENT]. The facility has failed to ensure R1's right to a dignified existence and to be treated fairly despite of his diagnosis.

Based on interview, medical record review, facility documentation review and policy review, the facility did not provide a Comprehensive Infection Prevention and Control Program to help prevent the transmission of communicable disease and infections. This had the potential to affect all residents and staff at the facility. The facility had gastroenteritis/norovirus and acute respiratory illness/influenza outbreaks from January-April, (YEAR). The facility did not consistently implement precautions in a timely manner, they did not track signs and symptoms of residents and staff in a contemporaneous (real time) manner, they did not keep Line Lists, they did not track where staff worked, some staff did not remain off duty for the correct amount of time, therapy staff did not treat well residents first and then treat ill residents during outbreaks, and there is discrepant information between facility documentation related to the illnesses. This is evidenced by: The facility policy dated 5/2013, entitled Recommendations and Work Restriction for Employees with Infectious or Communicable Diseases reads, in part: Influenza Restrict from work for at least 7 days from onset of illness AND until employee has no fever (without medication) for 24 hours. Employees must be off 7 days regardless of [MEDICAL CONDITION] treatment or early resolution of symptoms . Norovirus Exclude from duty for a minimum of 48 hours after the resolution of symptoms. The facility utilizes the 10/19/17 Wisconsin Division of Public Health (DPH) Reporting, prevention and control of acute respiratory illness outbreaks in long-term care facilities (LTCF) as a standard of practice (SOP). This document identifies acute respiratory illness (ARI), also called 'influenza like illness' (ILI), is defined as illness characterized by any two (2) of the following: Fever* Cough (new or worsening, productive or nonproductive) Rhinorrhea (runny nose) or nasal congestion Sore throat Myalgia (muscle aches) greater than the resident's norm *Fever may be difficult to determine among elderly residents. Therefore, the definition of fever used for ARI is defined as temperature two degrees Fahrenheit above the established baseline for that resident. A respiratory disease outbreak in a LTCF is defined by DPH as three or more residents and/or staff from the same unit with illness onsets within 72 hours of each other who have: Pneumonia, or ARI, or Laboratory-confirmed [MEDICAL CONDITION] or bacterial infection (including influenza). The facility uses the 12/2017 DPH Recommendations for Prevention and Control of Acute Gastroenteritis Outbreaks in Wisconsin Long-Term Care Facilities as a SOP. This document defines an outbreak of AGE (Acute Gastroenteritis) in a facility as the presence or more diarrhea or vomiting than would usually be expected in the facility, or in a particular unit, for that time of year. A simple threshold for when to suspect an AGE outbreak is when three or more residents and/or staff experience AGE symptoms within a 72-hour period and have a geographic commonality (i.e. same wing, unit, floor). A specific case definition for norovirus could be: Acute onset of vomiting and/or diarrhea (three or more loose stools in a 24-hour period) in a resident or staff member and whose symptoms have no other apparent cause. Facility-wide surveillance may include one or more of the following strategies: Maintaining Line Lists of ill residents and staff with specific disease syndromes (i.e. gastrointestinal (GI) illness, respiratory illness). Reviewing 24-hour Logs for residents with GI illness and tracking how many residents on each wing or floor are experiencing similar symptoms. The facility is designated by three units: East Rooms 101-113. South Rooms 115-126. Rehab 201-226. JANUARY (YEAR) ARI/ILI/INFLUENZA: RESIDENTS: R110's Nursing Progress Note, of 12/28/17 at 3:26 PM, identified R110 had symptoms of a moist cough and a temperature of 99.2 orally. On 12/29/17 at 5:43 PM, R110's Nursing Progress Notes identified R110 had symptoms of increased moist cough and sounded nasally congested. R110's Nursing Progress Note, on 12/29/17 at 7:14 PM, identified R110 as having a congested cough, lungs with crackles bibasilar and scattered expiratory rhonchi. A Progress Note, for 1/1/18 at 11:00 AM, identified R110's O2 sat (oxygen saturation) as 88-90% on room air. O2 was applied at 2 liters. R110 had crackles on inspiration and expiration in left upper and lower bases of left lung and lung sounds diminished in her right lower lobe. R110 had audible wheezes and having frequent moist cough. MD (Medical Doctor) was consulted and orders were obtained for a chest x-ray and an influenza test. On 1/1/18, R110 tested positive for influenza. R110 was not put on droplet precautions until 1/1/18, when the facility learned R110 was positive for influenza. Of note, per standard of practice R110 should have been placed on transmission based precautions when R110 presented with acute respiratory like illness symptoms on 12/29/18. Neither the Line List nor R110's Progress Notes identify when the droplet precautions were discontinued for R110. On 5/9/18, during the interview with DON B (Director of Nursing), RN J (Registered Nurse) and RN K. Surveyor asked for verification of the date R110 was started on droplet precautions. DON B said it was on 1/1/18 after the positive influenza result was received. The Line List identifies R10's onset of symptoms date as 1/30/18, but no symptoms are listed. It identifies R10 was positive for influenza on 1/31/18. The Line List identifies R10 was put on droplet precautions, but does not identify the date this was started. The OIT identifies R10's symptoms were congestion and being tired. On 1/31/18, when R10 tested positive for influenza, the East Unit was quarantined. STAFF: The (MONTH) (YEAR) Employee Call-In Log identified: RN D's symptom onset date was 1/1/18. The log identified RN D had respiratory symptoms and aches, pains and cough. The Employee Call-In Log listed RN D's recovery date also as 1/1/18; although, the OIT identified RN D's onset date as 1/3/18. On 1/4/18, MW E (Maintenance Worker) called in with respiratory signs and symptoms, fever/chills. The facility had not identified where MW E had been working in the facility prior to her symptom onset date. The facility did not include MW E on the OIT, because she was diagnosed with [REDACTED]. On 1/8/18, DOR F (Director of Rehab) had onset of respiratory symptoms, fever, (vomiting) and a 99.8 temperature. The Employee Call-In Log identified DOR F's recovery date was also 1/8/18, for this first set of symptoms, which is also the onset date. DOR F was diagnosed with [REDACTED]. The Employee Call-In Log identifies DOR F returned to work on 1/10/18. On 1/15/18, DOR F called in with respiratory symptoms including fever. There was no recovery date listed for DOR F after these reported symptoms. The OIT does not include DOR F, despite DOR F's respiratory symptoms. On 1/14/18, LPN G (Licensed Practical Nurse) left her shift with a fever. LPN G returned to work on 1/18/18 and left after two hours with respiratory symptoms and tested positive for Influenza A. The facility did not track or trend where LPN G had been working. On 1/18/18, LPN H called in with sore throat and fever. On 1/18/18, LPN H tested positive for Influenza A. The facility had not identified where LPN H had been working and there was no well date identified for LPN H. On 1/20/18, CNA I called in for respiratory symptoms of fever and chills. CNA I tested negative for influenza, but did test positive for strep throat and was put on antibiotics. CNA I's recovery date is listed as 1/26/18; although, her return to work date was 1/22/18. The facility had not identified where CNA I had been working. JANUARY (YEAR) GI ILLNESS/NOROVIRUS: RESIDENTS: None. STAFF: On 1/3/18, LPN L called in 1/3/18 with symptoms of nausea, vomiting and diarrhea. LPN L's recovery date was listed as 1/4/18 and LPN L returned to work on 1/6/18. Neither the Employee Call-In Log nor summary identify where LPN L had been working. Of note tracking and trending the area a staff member works is vital in aiding in identifying a potential outbreak. On 1/25/18, BOM C (Business Office Manager) called in with symptoms of nausea and vomiting. FEBRUARY (YEAR) ARI/ILI/INFLUENZA: RESIDENTS: None. STAFF: The (MONTH) (YEAR) Employee Call-In Log identified: On 2/1/18, DON B had onset of respiratory symptoms. No recovery date is listed for DON B. On 2/3/18, LPN O had onset of symptoms of chills, cough, nausea, aches and fever 101.6. LPN O tested positive for Influenza A. There is no recovery date listed for LPN O. It is does not identify where LPN O recently worked. On 2/4/18, CNA I called in with symptoms of fever, cough, chills, sweating, congestion and aches. CNA I's recovery date is listed as 2/4/18 the same date of illness onset. The Call-In Log identifies CNA I tested positive for influenza. It is not identified where CNA I recently worked. On 2/5/18, HSK P (Housekeeper) called in with symptoms of fever, cough and congestion. The Call-In Log identifies HSK P's well date also as 2/5/18. HSK P tested positive for Influenza A. It was not identified where HSK P was working. On 2/6/18, FC Q (Floor Care) called in with respiratory symptoms. FC Q's well date was listed as 2/6/18; although, FC Q tested positive for Influenza A. It was not identified where FC Q was working. During interview with DON B, RN J and RN K, they stated they did identify an outbreak among staff. As well as R10 being positive for influenza on 1/31/18. FEBRUARY (YEAR) GI ILLNESS/NOROVIRUS: RESIDENTS: None. STAFF: The Employee Call-In Log identified: On 2/1/18, CNA M had onset of nausea, vomiting and fever. CNA M's well date is listed as 2/2/18. It is not identified where CNA M had last worked. On 2/1/18, CNA N called in with symptoms of nausea, vomiting and headache. CNA N's well date is listed as 2/1/18 at 5:00 AM. CNA N returned to work on 2/2/18 at 6:00 AM. CNA N had not been off work for 48 hours after last symptom per standard of practice. The facility did not identify where CNA N had last worked. On 5/9/18 at 11:38 AM, Surveyor asked RN J if CNA N had been off for 48 hours after last symptom. RN J said no, and they started education. On 2/11/18, CNA S called in with symptoms of nausea and vomiting. CNA S's well date was also listed as 2/11/18 at noon. CNA S returned to work on 2/12/18 at 2:00 PM. CNA S had not been off work for 48 hours after resolution of symptoms of nausea and vomiting. It was not identified where CNA S had last worked. On 2/13/18, CNA T called in with symptoms of nausea, vomiting, chills and body aches. CNA T's well date was 2/14/18. CNA T returned to work on 2/15/18. CNA T had not been off 48 hours after resolution of symptoms. The facility did not identify where CNA T had been working. MARCH (YEAR) GI/NOROVIRUS RESIDENTS: The Acute Gastroenteritis/Norovirus Case Report Worksheet identified R23 had onset of symptoms of vomiting, diarrhea and abdominal cramps on 3/28/18. R23 had a stool culture done and R23 tested positive for Norovirus. On 3/29/18: CNA R was ill with symptoms of nausea, vomiting and diarrhea. The summary reads, in part: On 3/29/18, night shift nurse sent home CNA R (name) for complaints of nausea at 1 AM. She called and said she vomited on her drive home from work. (CNA R) had been the PM Float from 4-10 PM on 3/27 and 4-10 PM on 3-28 On 3/29/18, the Employee Call-In Log and Acute Gastroenteritis/Norovirus Case Report Worksheet identified LPN U was ill with nausea, vomiting and diarrhea. The summary identified (LPN U) worked on rehab 2-10 PM on 3/27 and 3/29. She states at the end of her shift on 3/29 she felt nauseated. At 4 AM on 3/30 she started to have diarrhea . On 3/29/18: RN V was ill with symptoms of diarrhea and abdominal cramps. RN V was not on the Employee Call-In Log, but was listed on the Acute GI/Norovirus Case Report Worksheet. HSK W was ill with symptoms of nausea and vomiting. The facility lists nor summary identify where these employees worked just prior to onset of symptoms. During the interview on 5/9/18 that began at 10:30 AM, Surveyor asked when they identified the outbreak. DON B said they did not know what CNA R's other symptoms were other than that she left with nausea. RN J and DON B stated it was not until a day or two later that they had learned that CNA R had vomiting. Surveyor asked about the summary identifying CNA R called and reported that she had vomited on her way home. The summary reads as though the vomiting occurred on 3/29/18. The Acute Gastroenteritis/Norovirus Case Report Worksheet also identified CNA R's symptoms of vomiting, diarrhea and abdominal cramps. DON B said they did not know what CNA R's symptoms were until a day or two later, because CNA R did not report her symptoms. DON B said they also did not know about LPN U's symptoms until a day of two later. Surveyor asked if staff is to report symptoms of communicable disease. RN J said yes and we have educated on that. On 3/30/18, eight residents experienced onset of acute Gastroenteritis/norovirus symptoms. R16 on the east wing. R40 on the Rehab Unit. R42 on the Rehab Unit. R38 on the Rehab Unit. R32 on the Rehab Unit. R26 on the Rehab Unit. R111 on the Rehab Unit. R112 on the East Unit. The facility did not identify they had a gastroenteritis/norovirus outbreak until 3/30/18. On 3/31/18, the following residents were ill with gastroenteritis/norovirus symptoms. R41 on the Rehab Unit. R14 on the East Unit. R12 on the Rehab Unit. R22 on the East Unit. On 3/31/18, the following staff was ill with gastroenteritis/norovirus symptoms. HSK X and CNA Y. The gastroenteritis/norovirus outbreak continued into (MONTH) (YEAR). See below. APRIL (YEAR) GASTROENTERITIS/NOROVIRUS OUTBREAK: RESIDENTS: On 4/1/18, the following residents had onset of gastroenteritis/norovirus symptoms: R53 on the Rehab Unit. R51 on the East Unit. R25 on the East Unit. R37 on the East Unit. R18 on the South Unit. R113 on the East Unit. On 4/2/18, the following residents had onset of gastroenteritis/norovirus symptoms: R43 on the Rehab Unit. On 4/3/18, the following residents had onset of gastroenteritis/norovirus symptoms: R15 on the South Unit. R45 on the South Unit. R27 on the South Unit. R28 on the East Unit. On 4/4/18, the following resident had onset of gastroenteritis/norovirus symptoms: R44 on the South Unit. On 4/6/18, the following resident had onset of gastroenteritis/norovirus symptoms: R114 on the South Unit. They lifted the quarantine for the Rehab Unit on 4/5/18, but restarted it on 4/7/18, when R30 in the Rehab Unit had onset of symptoms. On 4/7/18 the following residents had onset of gastroenteritis/norovirus symptoms: R54 on the East Unit. R30 on the Rehab Unit. On 4/14/18, R17 had onset of gastroenteritis/norovirus symptoms. R17 was on the Rehab Unit. R17 was not included on the Acute Gastroenteritis/Norovirus Case Report Worksheet. RN J told Surveyor he was not included, because his onset of symptoms was after the outbreak had resolved. STAFF GASTROENTERITIS/NOROVIRUS: 4/1/18 the following staff had onset of gastroenteritis/norovirus symptoms: DA EE (Dietary Aide). 4/2/18 the following staff had onset of gastroenteritis/norovirus symptoms: LPN Z. LA AA (Laundry Aide). 4/4/18 the following staff had onset of gastroenteritis/norovirus symptoms: DA BB. 4/5/18 the following staff had onset of gastroenteritis/norovirus symptoms: HSK CC. 4/6/18 the following staff had onset of gastroenteritis/norovirus symptoms: CNA DD. The Call-In Log identifies CNA DD had symptoms of nausea, vomiting and diarrhea. CNA DD's recovery date is 4/7/18 at noon. CNA DD returned to work on 4/8/18 at 2:00 PM. CNA DD was not off 48 hours after resolution of her last symptom. 4/7/18 the following staff had onset of gastroenteritis/norovirus symptoms: CNA R. 4/10/18 the following staff had onset of gastroenteritis/norovirus symptoms: Nursing employee JJ. (Title not on staff list). Cook KK. The facility lifted the facility wide quarantine on 4/10/18, despite staff continuing with symptoms as recent as 4/10/18 and continued with onset of symptoms on 4/18/18. 4/12/18 the following staff had onset of gastroenteritis/norovirus symptoms: AD LL. 4/13/18 the following staff had onset of gastroenteritis/norovirus symptoms: DA MM. 4/15/18 the following staff had onset of gastroenteritis/norovirus symptoms: SW NN (Social Worker). 4/16/18 the following staff had onset of gastroenteritis/norovirus symptoms: CNA I. 4/18/18 the following staff had onset of gastroenteritis/norovirus symptoms: RN PP. LA/HSK QQ. The facility had not identified where staff had worked prior to onset of first symptoms to aide in determining if an outbreak is occurring among residents and staff on the same unit/s. APRIL (YEAR) ARI/ILI/INFLUENZA: Residents: On 4/17/18: R2 became ill with respiratory symptoms and tested positive for Influenza A. R2 was on the East Unit. R4 had onset of respiratory symptoms and tested positive for Influenza A. R17 was on the South Unit. On 4/18/18: R54 had onset of respiratory symptoms and tested positive for Influenza A. R54 was on the East Unit. On 4/19/18: R33 had onset of a non-productive cough. Though later tested positive for Influenza A. R33 was on the East Unit. R25 had onset of respiratory symptoms and tested positive for Influenza A. R25 was on the South Unit. The facility did not identify they had a respiratory outbreak on 4/19/18. The facility did not identify the outbreak until 4/21/18. On 4/20/18: R19 had onset of symptoms of influenza. R19 tested positive for Influenza A. R19 was on the South Unit. On 4/21/18: R115 had onset of respiratory symptoms, identified on the (MONTH) (YEAR) OIT, Influenza A. R115 was not on the Line List. R115 was on the South Unit. R15 had onset of respiratory symptoms and tested positive for Influenza A. R15 was on the South Unit. R6 had onset of respiratory symptoms and tested positive for Influenza A. R6 was on the East Unit. R22 had onset of respiratory symptoms and tested positive for Influenza A. R22 was on the East Unit. On 4/26/18: R48 had onset of respiratory symptoms and tested positive for Influenza A. R48 was on the Rehab Unit. R48 was moved from the Rehab Unit to the East Unit, when it was learned R48 was positive for Influenza A. During the interview with DON B, RN J and RN K on 5/9/18, Surveyor asked them to explain the rationale for moving R48 from the Rehab Unit to the East Unit. DON B said because R48 tested positive for influenza, so to keep it from spreading to the Rehab Unit. DON B stated R48 was in agreement with the move. DON B stated they put all residents on the Rehab Unit on [MEDICATION NAME] as a precaution. STAFF: 4/17/18: AD OO had onset on respiratory illness including fever. 4/19/18: CNA FF had onset of respiratory symptoms including fever. On 4/23/18, CNA FF tested positive for Influenza A. 4/21/18: CNA GG had onset of respiratory symptoms including fever. 4/22/18: CNA DD had onset of respiratory symptoms. CNA DD tested positive for Influenza B. HSK HH had onset of respiratory symptoms including fever. RN K had onset of symptoms including fever and cough. The Employee Call-In Log reads RN K had been sent home from work on 4/23/18, with temperature and symptoms. 4/24/18: CNA II had onset of respiratory symptoms. The Call-In Log identifies CNA II had a fever, but the OIT identifies CNA II had fatigue and cough, but no temperature. On 4/21/18, 16 residents were tested for influenza, 11 tested positive and 5 tested negative. On 5/9/18, beginning at 10:30 AM, Surveyors met with DON B, RN J and RN K to discuss the facility's infection control and prevention program and to discuss the outbreaks the facility experienced. This interview was conducted from 10:30 AM-12:00 PM and resumed at 1:45 PM-3:20 PM. Surveyor asked how they designate the facility by units for tracking purposes and when considering outbreaks. RN J explained the facility units are: rooms 101-113 is the East Unit, rooms 114-126 is the South Unit and rooms 201-226 is the Rehab Unit. Surveyor asked if they track where staff last worked to assist in identifying an outbreak. DON B said they attach a copy of the schedule to the Call-In/Tracking Logs. Surveyor identified the concern that information is not included on the Call-In Logs, worksheets or Outbreak Tools. Surveyor asked where they document the dates of when precautions are put in place and discontinued for ill residents, as that information is not on the Line Lists. DON B said it is charted in the Nurse's Notes. Surveyor reviewed notes for several residents who had been on precautions and this information was not consistently documented in Nursing Progress Notes. Surveyor asked when they do education, regarding infection control prevention measures at the onset and/or during outbreaks, how do they ensure staff that are not working, receive the necessary education. DON B said they put the information at the Nurse's Stations for staff to review and they try to catch staff as they come on duty. DON B said she contacts staff and they have a week to make up the education. Staff was immediately educated on who was on precautions, the type of precautions and what PPE (Personal Protection Equipment) they need to use. There was not documentation to show that all staff had been educated. During the above interview, Surveyor asked to see the original Line Lists that were done as residents symptoms occurred, as the Line Lists provided are in alphabetical order, not by chronological order. On 5/9/18, at approximately 2:30 PM, during the interview with DON B, RN K and RN J, Surveyor asked if they place residents who were experiencing respiratory symptoms and diagnosed with [REDACTED]. Surveyor asked how they determine an outbreak when their Line List goes in alphabetical order by resident last name and not chronologically, when symptoms occur. DON B said they go by the Alert Charting and Change of Condition Logs; they are kept on the units (See interview with RN J on 5/10/18 regarding Alert Charting and Change of Condition Logs). On 5/10/18, at approximately 10:00 AM, Surveyor again asked for the original Line Lists for the outbreaks that occurred from January-April (YEAR). On 5/10/18 at 10:22 AM, RN J told Surveyor you have the Line Lists. Surveyor showed RN J the computerized Line Lists that Surveyor did have and explained Surveyor wanted to see the original Line Lists used to track resident illness symptoms that would have been on the units. RN J said, So we need to put an active Line List at Nurse's Stations. Surveyor said that would be part of your Comprehensive Infection Control Surveillance Program. After a few minutes, RN J returned, gave Surveyor a blank Alert Charting Log and Issue: Change of Condition sheet and said that is where the nurse's chart signs and symptoms. Surveyor asked to see those sheets, especially for the times of the outbreaks since (MONTH) (2018). RN J said they do not keep them, only for about a month. Surveyor asked if she could see the ones they had for the past month, as that would contain some information related to the (MONTH) (YEAR) outbreaks. RN J said they don't have those either. Surveyor asked to see the ones for yesterday (5/9/18) and for so far today (5/10/18). RN J said there are none. The facility does not keep the Daily Alert Charting or Change of Condition Sheets that would identify onset dates of symptoms and other information to track ill residents and help identify potential outbreaks. On 5/10/18 at 10:45 AM, Surveyor interviewed LPN H and asked how the staff monitors anyone having signs and/or symptoms of illness/infections. LPN H said they use the Alert Charting Log Tool, which is kept in a 3 ring binder entitled 24 Hours. LPN H said that nurses will add residents to this when they exhibit signs or symptoms, or if after the 9:00 AM meeting by management, they may come up and put someone on it. LPN H showed this Surveyor a copy of the Alert Charting Log she had with her. On 5/10/18 at 2:30 PM, Surveyor interviewed OT RR (Occupational Therapist) regarding gastroenteritis/norovirus or ARI/influenza outbreaks. OT RR was asked if therapy see residents in a particular order. OT RR said they have a set schedule every day, unless something comes up. Surveyor asked OT RR if they do anything differently during an outbreak. OT RR said no, we go by the schedule pretty much. Surveyor asked, if you have an ill person scheduled, then a healthy person after them, how would you see them? OT RR said as they are scheduled. Surveyor asked, would see sick people intermingled with healthy people? OT RR said, Yes, if that's how the schedule is.

Based on interview and record review, the facility did not ensure that residents received notice of bedhold prior to transfer to hospital. The facility did not give bedhold notice to 5 of 5 residents (R11, R21, R33, R39, R50) reviewed for bedhold notification. R11, R21, R33, R39, and R50 did not receive bedhold notice prior to going to the hospital. Evidenced by: Example 1 R11 has [DIAGNOSES REDACTED]. R11 was hosptalized on [DATE] and 10/27/17. No bedhold notifications were found in R11's medical record. Example 2 R21 has [DIAGNOSES REDACTED]. R21 was hosptalized on [DATE]. No bedhold notification was found in R21's medical record. Example 3 R33 was discharged to the hospital on [DATE] with pneumonia and Influenza A. R33 was not provided written information regarding the facility bedhold policy. Example 4 R39 was discharged to the hospital on [DATE]/18 and 4/1/18 with abdominal pain. R39 was not provided written information regarding the facility bedhold policy. Example 5 R50 was discharged to the hospital on [DATE] with a [MEDICAL CONDITION]. R50 was not provided written information regarding the facility bedhold policy. On 5/9/18 at 1:35 PM, Surveyor interviewed BOM C (Business Office Manager) about bedhold. BOM C stated that they don't do bedholds, because our census is so low. BOM C stated that if a resident was Medical Assistance (MA) payor type, then facility had 15 days to hold bed before discharge and that the facility usually takes back their residents. BOM C stated they did not give paper notification to any residents because of low census. On 5/10/18 at 6:35 AM, Surveyor interviewed NHA A (Nursing Home Administrator) if they had a bedhold policy. NHA A stated she didn't know if she had an actual policy, but will check. On 5/10/18 at 6:40 AM, NHA A brought policy entitled Bedhold Policy to Surveyor. NHA A stated that they haven't been giving the bedhold notifications for a long time, because census has been low.

Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 6 abuse allegations involving residents (R2). On 12/21/17, R2 reported an allegation of staff verbal abuse, this was reported to the NHA A (Nursing Home Administrator) and the allegation was not reported to the state agency. Evidenced by: The facility's Abuse or Neglect Reporting policy states, in part: Staff members report suspected abuse or neglect of patients to supervisor. Supervisor . complete an evaluation visit .a notification is made to the . state and/or local authorities . All suspected and alleged violations involving .verbal, mental . abuse . by anyone are reported immediately to Administrator . guidelines: . No serious Bodily Injury-within 24 hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the suspicion must be reported within 24 hours of forming the suspicion .). R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 BIMS (Brief Interview for Mental Status) score is 13, indicating cognitively intact. Review of the facility's grievances included a Concern Form, dated 12/21/17, notes that R2 reported to ADON C (Assistant Director of Nursing) that a nurse gave him his pills an hour late, shut his bedroom door, told him he was going to die here, and R2 stated the nurse told him to quit being a [***] ing[***] . The Concern Form notes that ADON C called NHA A on 12/21/17, on the phone, about R2's concern. NHA A told ADON C that he would follow up with R2. ADON C notes that ADON provided one to one discussion with R2 and that he was satisfied with the resolution. ADON C took the nurse's statement, which indicated that R2 was swearing at the nurse. ADON C updated R2's care plan to have 2 present when approaching R2. On 2/15/17, Surveyor interviewed ADON C about R2's concern, on 12/21/17, asking if this incident should have been investigated and reported to the state agency. ADON C stated that she reported it to NHA A and indicated that it should have been reported to the state, since it was an allegation of abuse. On 2/15/18 at 1:50 PM, Surveyor interviewed NHA A about R2's concern on 12/21/17. NHA A stated that he meets with R2 daily, but that he was off duty 12/21/17-12/26/17. Surveyor asked NHA A what he would expect staff to do if a resident reported an allegation of verbal abuse. NHA A stated that if there was a claim of verbal abuse, the staff should assure that the resident is safe, suspend the staff in question and complete an investigation. NHA A stated that this was not done on 12/21/17 and should have been.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further potential abuse for 1 of 6 residents reviewed (R2). On 11/28/17, R2 made an allegation of sexual abuse. The facility completed an investigation and reported to the state agency, but did not have evidence that staff were educated to prevent further abuse to R2 or other residents. Evidenced by: R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2's BIMS score is 13, indicating cognitively intact. On 11/28/17, the facility submitted a self -report to the state agency for abuse regarding R2. R2 reported to NHA A that a CNA (Certified Nursing Assistant) entered her fingers into R2's rectum a few days ago. The facility suspended the employee pending investigation. The facility's investigation did not include evidence of providing education to the accused CNA or other staff to prevent further potential abuse to R2 or other residents. On 2/15/18 at 1:50 PM, Surveyor interviewed NHA A about R2's allegation of abuse, on 11/28/17. Surveyor asked NHA A if education was provided to the CNA or to other staff regarding this allegation of abuse, in order to prevent further potential abuse to R2 or other residents; NHA A stated that he thought he had talked to the CNA. NHA A stated that there was no documentation that education was provided to staff regarding this event, and that it should have been completed.

Based on interviews and record review, the facility did not ensure that 1 of 1 resident reviewed with a [MEDICAL CONDITION] received proper treatment and care for [MEDICAL CONDITION] (R8). R8 is full code in the event of a [MEDICAL CONDITION], and breathes through a [MEDICAL CONDITION]. The facility admitted R8 (Resident) without ensuring that all nurses were trained in caring for a resident with a [MEDICAL CONDITION], without developing an emergency plan, and without assuring the all the proper equipment was available in R8's room to be used in an emergency. When R8 received a new type [MEDICAL CONDITION] on [DATE] the facility failed to assure that the [MEDICAL CONDITION] were readily available to staff. The facility's failure to ensure that staff had the appropriate equipment readily available to respond to an emergency and knew how to respond in an emergency created a finding of immediate jeopardy. Immediate jeopardy began on [DATE]. The NHA was notified on [DATE] at 4:00PM that immediate jeopardy existed. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The University of Pittsburgh Medical Center's guide for [MEDICAL CONDITION] care, dated 2007, If your [MEDICAL CONDITION] comes out or becomes blocked, you need to have a plan to deal with the emergency situation quickly. If you are unable to solve the problem quickly, call 911. If the [MEDICAL CONDITION] comes out and another tube is not available. The stoma (neck opening) may stay open for a short period of time. 1. If possible, reinsert the old [MEDICAL CONDITION]. 2. If you cannot insert the old one, insert a hold a hollow tube such as a straw, suction catheter, or inner cannula into the stoma. Sometimes the smaller inner cannula can be inserted until emergency help arrives. 3. If using a straw, suction catheter, or inner cannula, replace with a new [MEDICAL CONDITION] or old [MEDICAL CONDITION] as soon as possible. Emergency kit should include the following supplies: A clean [MEDICAL CONDITION] set with obturator, water soluble lubricant, such as [MEDICATION NAME], suction catheter, syringe, if you have a cuffed [MEDICAL CONDITION], sterile saline bullets, gloves, [MEDICAL CONDITION] ties, a smaller size [MEDICAL CONDITION] set with obturator. Remember to make an emergency plan. Standard of Practice: John Hopkins titled difficulty inserting the New [MEDICAL CONDITION], dated [DATE]: 1. If the patient normally requires oxygen, place oxygen over the stoma site. 2. Gather the equipment needed for [MEDICAL CONDITION] (trach) tube change. 3. Always have a [MEDICAL CONDITION] and ties available at all times. 4. Wash hands if you have time. 5. Put the Obturator in the [MEDICAL CONDITION] and put a few drops of water on the end. 6. Remove [MEDICAL CONDITION] if it is around the neck. If it is partially in the stoma, you can try to gently reinsert the [MEDICAL CONDITION]. If you cannot insert the old tube, go to the 7th step. 7. Insert the [MEDICAL CONDITION] and quickly remove the Obturator. 8. Re-insert the inner cannula. 9. [MEDICAL CONDITION]. Difficulty inserting the New [MEDICAL CONDITION]: 1. Check to make sure the patient is positioned with chin pointing toward the ceiling and neck is extended. 2. Try to reinsert [MEDICAL CONDITION]. Do not force the trach. 3. If it still does not enter, try to reinsert the old tube. Since this tube was in before, it should pass into the stoma without difficulty again. 4. If the [MEDICAL CONDITION] does not fit try [MEDICAL CONDITION] that is a smaller than the size the patient normally uses. Always keep a [MEDICAL CONDITION] available when changing the tube. 5. If this measure is unsuccessful, take a suction catheter and put it in the stoma. Hold in place and cut approximately 5 cm or 2 inches from the stoma. The catheter will keep the stoma open. 6. Try to insert the [MEDICAL CONDITION] over the suction catheter. Always hold the catheter to prevent migration into the trachea. 7. If the above measures fail, administer oxygen if the patient normally requires oxygen. If it is evident the patient is able to breath via her mouth, the Ambu bag can be used and placed over the mouth; otherwise just direct the oxygen toward the stoma. 8. Call 911. The facility's Cardio-Pulmonary Resuscitation: Adult Policy (revised ,[DATE]) states in part: Procedure: 1. Upon discovering unresponsive patient with no breathing or no normal breathing (i.e. on gasping) call for help . 6. Ventilations with a [MEDICAL CONDITION] attach resuscitation bag to [MEDICAL CONDITION] and give 1 breath every ,[DATE] seconds . SUGGESTED DOCUMENTATION (emphasis included): Time of day, condition of patient, interventions provided, time CPR started, staff involved/witnessing event and patient response . -It is important to note that this policy does not address the specific steps to take in the event of an airway obstruction with a resident with [MEDICAL CONDITION] or the need to have [MEDICAL CONDITION] at the resident bedside for emergencies. R8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R8 had a [MEDICAL CONDITION] placed on [DATE]. R8 and was admitted to the facility with a cuffless (number 6) Shiley (plastic) trach. R8's quarterly MDS (Minimum Data Set) indicates a BIMS (Brief Interview for Mental Status) score of 15 indicating that R8 is cognitively intact. R8 has chosen to be full code in the event of a [MEDICAL CONDITION]. R8's comprehensive care plan dated [DATE] includes in part: Focus: Has/at risk for respiratory impairment related [MEDICAL CONDITION] due to C,[DATE] fracture. Goal: Maintain patent airway. Interventions: Evaluate lung sounds and VS (vital signs) as needed. Report abnormalities to physician, Position upright as possible for meals and afterwards, Therapy evaluation and treatment as ordered, Obtain pulse oximetry and report abnormal findings. Elevate head of bed. Suction per physician orders.[MEDICAL CONDITION] per protocol. It is important to note that R8's care plan does not address her full code status or what steps to follow in an emergency (such as airway obstruction) in regards to her airway. R8's physician orders [REDACTED]. [DATE]: May suction [MEDICAL CONDITION] 14fr. (French) cath PRN (as needed); Change [MEDICAL CONDITION] daily and PRN, [MEDICAL CONDITION] month (will be done at MD appointment) and PRN R8's medical record includes in part: Nursing Progress Notes: [DATE] at 7:37 PM .Is wearing a 6 cuffless [MEDICAL CONDITION]. [DATE] at 4:27 AM: . (R8) has [MEDICAL CONDITION] humidification and times sounds wheezy. Suctioning provided when resident is unable to clear own secretions .Assist of two for ADL's and transfers . [DATE] at 12:15 PM Resident (R8) asked the RN to suction her and was doing so. (R8) then had a concerned look on her face. I consulted the RN on the floor regarding resident's condition. Updated MD on resident's condition and received new order to send to ER for Respiratory distress. Resident then left facility at approx. 11:45 (AM) by ambulance to ER . -It is important to note that this progress note does not include a complete nursing assessment of R8's condition such as: vital signs, respiratory quality, condition of R8 and does not include what specific actions the nursing staff took to relieve R8's respiratory distress or R8's response to nursing actions before the ambulance arrived. Upon request the facility provided no additional documentation of this event. [DATE] at 10:45 PM: Resident (R8) has required some light suctioning x 2 [MEDICAL CONDITION] evening. No respiratory distress noted. Humidification in place [MEDICAL CONDITION] all times . Resident did state earlier that she felt exhausted from the day's events. On [DATE] ED (Emergency Department) Provider Note includes in part: At 12:13 PM: (R8) sent from the nursing home after an episode of respiratory distress .recently had increased secretions from the [MEDICAL CONDITION] and during routine [MEDICAL CONDITION] care and suctioning patient developed respiratory distress. Inner cannula was removed with some improvement when it was replaced she had increased issues. She did have some color change but did not lose consciousness . Review of Systems: Constitutional: Negative for fever. Respiratory: Positive for cough, choking and shortness of breath .[MEDICAL CONDITION] place Air movement normal .Her mood appears anxious .Initial Impressions: Increased [MEDICAL CONDITION] secretions. Episode of respiratory distress during [MEDICAL CONDITION]. Will evaluate for possible aspiration event. ED course/Medical decision making: This episode likely represents an episode of mucus plugging obstruction of her inner cannula . Lab workup and chest x-ray are unremarkable. On [DATE] R8's History and physical report notes in part: that R8 underwent an outpatient surgical procedure to [MEDICAL CONDITION] for treatment of [REDACTED]. The treatment included re-cannulation and balloon dilation of proximal tracheal stenosis and Debridement of proximal tracheal scar [MEDICAL CONDITION] tissue then a 6 Jackson (metal)[MEDICAL CONDITION] placed and R8 returned to the facility. On [DATE] at 7:05 AM Surveyor observed that there was no Jackson [MEDICAL CONDITION] kit (outer cannula, inner cannula and obturator) at R8's bedside. On [DATE] at 8:05 AM Surveyor interviewed RN (Registered Nurse) E and went into R8's room. Surveyor and RN E observed that there was [MEDICAL CONDITION] (6 Jackson outer cannula, inner cannula with obturator) at R8's head of the bed. Surveyor asked RN E what supplies should be available at the bedside if R8 had an emergency with [MEDICAL CONDITION](such as R8'[MEDICAL CONDITION] coming out or needing CPR). RN E looked through items at R8's bedside stand and stated, It should be here in the room at the head of her bed. RN E noted that the ambu bag hanging on the IV pole near R8's bed did not have the right connection to attach to R8's newer 6 [MEDICAL CONDITION]. When Surveyor asked where [MEDICAL CONDITION] could be found for R8, RN E stated that they should be on the crash cart which is stored in the clean utility room. RN E took Surveyor to the unit's clean utility room, behind the nurses station, (approximately 70 feet from R8's bedside) and noted that R8's 6 [MEDICAL CONDITION] was not on the emergency cart but on the counter across from the crash cart amongst other supplies. On [DATE] at 1:05 PM Surveyor interviewed RN H about training that she has received for emergencies, such as providing CPR, with a [MEDICAL CONDITION] patient. RN H stated that she has not received any training from the facility specifically for [MEDICAL CONDITION] patients, but she knew to place the ambu bag over the resident'[MEDICAL CONDITION] administering breaths. On [DATE] at 1:45 PM Surveyor interviewed RN I about emergency care of a resident who is full code with a trach. RN I stated that this actually happened (with R8). We called 911, and got the crash cart and paged a Code Blue; she (R8) stopped breathing. We had a meeting afterward, that day, to talk about what happened. I asked for that IV pole with the ambu bag. I haven't really had training, I've asked for more. Surveyor asked what RN I would do if R8'[MEDICAL CONDITION] come out. RN I stated that [MEDICAL CONDITION] need to go back in, that she would need to use sterile technique. When Surveyor asked how she would get it back in, RN I stated that she have to do this carefully inserting it in a downward motion. Surveyor asked if she would use an obturator to replace [MEDICAL CONDITION], RN I stated, What is that? Surveyor explained that that an obturator is a [MEDICATION NAME] end device for [MEDICAL CONDITION] used to guide [MEDICAL CONDITION] into the airway and RN I stated, Oh yes I would use that. On [DATE] at 2:00 PM, Surveyor interviewed LPN D regarding [MEDICAL CONDITION] training and what to do in the event [MEDICAL CONDITION] comes out. LPN D indicated she would go to the supply room and get a new one and replace it. LPN D indicated she would assess the resident, and if he/she was in distress she would make them comfortable. LPN D indicated she would update the MD if needed and replace [MEDICAL CONDITION]. Surveyor asked LPN D if she would need to connect any equipment to the ambu bag. LPN D indicated that she was not sure what to attach to an ambu bag. LPN D indicated that she was not up to speed on that and would have to call an RN. Surveyor asked LPN D if she has had any training on how to take care of a resident with a [MEDICAL CONDITION]. LPN D indicated that she did not have [MEDICAL CONDITION] at the facility but did have a nurse show her how to change [MEDICAL CONDITION] if it came out when she first started 2 and a half years ago. On [DATE] at about 3:15 PM, Surveyor asked ADON (Assistant Director of Nursing) C about having smaller [MEDICAL CONDITION] available for R8, ADON C searched in R8's room with Surveyor present, and could not find any smaller [MEDICAL CONDITION]. Later ADON C indicated that the facility did have extra size smaller [MEDICAL CONDITION] replacements for R8 in the facility, however these were 4 Shiley (plastic) inner cannulas (not Jackson [MEDICAL CONDITION]) which the facility indicated could be used to replace the 6 Jackson (metal) inner cannula. It is important to note that the [MEDICAL CONDITION], Jackson (metal)[MEDICAL CONDITION] were not readily available in the facility or at R8's bedside. On [DATE] at about 3:30 PM Surveyor interviewed RN E about R8's respiratory event on [DATE]. RN E stated that she had responded to a call for assistance to R8's room on [DATE] and that R8 had some breathing, she was making gurgling sounds and she was not coding. RN E stated that R8 remained alert throughout this time. She stated that RN I had changed R8's inner cannula and R8's color had turned a little purple. RN E stated that she was assisting in the room and she thought that RN K had given 2 breaths via the ambu bag over R8's mouth and R8 responded with normal breaths. RN E stated that R8 had a mucous plug. RN E stated that right after the event on [DATE] with R8, the DON (Director of Nursing) and former NHA (Nursing Home Administrator) met and contracted a respiratory therapist to come in and check on R8 needs. On [DATE] at 2:55 PM Surveyor interviewed RN K asking about R8's respiratory event on [DATE]. RN K stated that RN I had called me in and tried to suction R8, and heard nothing, there was no air movement, so a Code Blue was called. R8 grabbed at her neck as if to indicate that there was no air going into her trach. Someone went to get oxygen and RN E came into the room with the crash cart. RN K stated that she placed the ambu bag over R8's mouth and covered [MEDICAL CONDITION] and gave her a couple of breaths with the ambu bag, and her respirations improved, which she knew to do based on her previous nursing experience. The EMT's came pretty quickly and RN K stepped out of the room. RN K stated that having some guidelines in place for emergency care would be good to have. Despite facility knowledge that R8 was at risk having had experienced a respiratory obstruction on [DATE] and was full code, the facility failed to assure that the necessary emergency supplies were readily available at R8's bedside after R8 had her [MEDICAL CONDITION] device changed on [DATE]. The facility had no evidence that the contracted respiratory therapist or any other staff had reviewed R8's needs for [MEDICAL CONDITION] after R8 received a [MEDICAL CONDITION] [DATE]. The facility had no evidence that all nursing staff was trained in emergency procedures for R8. The facility's failure to have trained professional nurses in the facility with readily available equipment to be used in an emergency and its failure to assure that R8 would be provided with appropriate emergency medical assistance if her [MEDICAL CONDITION] airway became obstructed created an immediate jeopardy situation. The facility removed the immediate jeopardy on [DATE] by taking the following actions: -Reviewing and revising R8's care plan. -Providing immediate reeducation to all licensed nursing staff on ensuring [MEDICAL CONDITION] residents have [MEDICAL CONDITION] and Ambu bags with appropriate adapters in their rooms. -Licensed nurses were also immediately reeducated on providing rescue breathing for [MEDICAL CONDITION] patients. -Licensed nurses were also educated on [MEDICAL CONDITION] insertion/reinsertion policy and [MEDICAL CONDITION] care. -No nurse will assume duties until education is provided. -The Director of Nursing or designee will complete daily audits each shift for 14 days, then daily for 14 days on residents with tracheostomies to ensure extra inner cannulas [MEDICAL CONDITION] with obturator, including one size [MEDICAL CONDITION] at head of the bed and ambu bags with appropriate adapters are in the resident's rooms. Cross reference F520

Based on interview and record review the facility did not ensure that 1 resident (Resident 2) from 2 incidents reviewed was free from verbal and mental abuse. Resident 2 alleged that he was abused by Certified Nursing Assistant (CNA) C. Resident 2 stated that CNA C would blow up gloves and pop them near him, would humiliate him and took a picture of feces that was in his belly button. CNA D stated that CNA C yelled at Resident 2 and would swear at Resident 2 each time they cared for Resident 2 (calling him an "asshole" and "[***] "). CNA D did not report these instances to staff at the facility until 10/24/14 when CNA C would not stop swearing at Resident 2. When interviewed, Resident 2 stated that CNA C humiliated him, made him feel as if he was not wanted, and that he hated CNA C. Resident 2 became upset and began crying while recounting his encounters with CNA C. This is evidenced by: The facility's policy titled "Patient Protection Practice Guide" dated 11/2011 states in part, "According to the State Operations Manual" (SOM), Appendix PP, 'Abuse is the willful infliction of injury, unreasonable confinement, intimidations or punishment with resulting physical harm, pain or mental anguish. The most critical step toward detecting abuse is acknowledging that no one should be subjected to violent, abusive, humiliating or neglectful behavior. 'Verbal Abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. 'Mental abuse' includes, but is not limited to, humiliation, threats of punishment or deprivation. 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Resident 2 has [DIAGNOSES REDACTED]. Resident 2 is his own decision-maker. According to "Census List" dated 11/6/14, on 9/2/14 Resident 2 was readmitted to a unit in the facility different from the previous unit in which he had resided for greater than three years. "Physician's Statement Certification of Regained Capacity" dated 9/1/11 states "I have personally examined (Resident 2) and certify that the patient/resident no longer meets the statutory definition of incapacity. (Resident 2) is again, able to receive and evaluate information effectively or to communicate decisions to such an extent that the patient/resident now possesses capacity to manage his or her health care decisions." According to "Discharge Summary", Resident 2 was discharged from an acute care setting and readmitted to the facility on [DATE]. The facility completed an admission Minimum Data Set (MDS) assessment for Resident 2, with a reference date of 9/9/14. Section C of this assessment, Cognitive Status, notes that Resident 2 scored 15 (of 15 possible) points on the Brief Interview for Mental Status, indicating that Resident 2 is cognitively intact. Section G, Functional Status, notes that Resident 2 needs extensive 2 person physical assistance with bed mobility, transferring, toileting, and personal hygiene. Section D, Mood, notes that Resident 2 has symptoms of feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, and trouble with concentration. Section I, Active Diagnoses, notes a [DIAGNOSES REDACTED]. "Concern Report" dated 10/24/14 (initially) completed by RN E states, "Date received: 10/24/14. Concern initiated by: Patient (checked); Concern reported to: staff; Staff member: (RN E); Describe the concern using factual terms: Resident stated that he became upset c CNAs tonight when he had to wait to be put to bed and when CNA (CNA C) was leaving room 'he flipped me the damn bird.' CNA was already gone when resident informed." The facility completed an "Alleged Nursing Home Mistreatment Report" on 10/27/14 at 3:45 PM. This report states, "Date occurred: 10/24/14 ...Resident stated to the Night Registered Nurse that he became upset with CNA tonight when he had to wait to be put to bed. The resident alleges that when (CNA C) was leaving his room "he flipped me the damn bird." Registered Nurse noted that upon receiving allegation from resident, the CNA was already gone for the night, having completing his evening shift." The facility began their investigation on 10/27/14 and completed the following: "Misconduct Incident Report ...On 10/24/14 resident reported to the night shift nurse that after he became upset with (CNA C) for having to wait, (CNA C) flipped him the bird as he was leaving the room. At that time (CNA C) was no longer working and was not scheduled to work again until 10/28/14. Upon learning of this situation, (Nursing Home Administrator (NHA) A) immediately spoke with (Resident 2). (Resident 2) stated that he had felt he had waited a very long time and ended up urinating in his pants and on the floor. When (CNA C) came, (Resident 2) stated he was upset he had to sit in wet pants and (CNA C) responded by saying, 'well don't go in your pants then.' (Resident 2) stated that later that night (CNA C) took (Resident 2's) phone and took a picture of the 'poop in his belly button' and said, 'here I'll show you.' (NHA A) was then given (Resident 2's) phone from (Resident 2's) pocket and he asked NHA to look for the picture that was saved. A picture was discovered on (Resident 2's) phone taken on 10/24/14 around 9pm that appeared to be bm (bowel movement). Resident also states that around 9:45pm when (CNA C) was walking out of (Resident 2's) room, (CNA C) flipped the bird by putting up his middle finger and trying to hide it by the side of his face/ear. Resident states that in the past (CNA C) has taken off a glove and blown it up with air and popped it in (Resident 2's) ear ...Accused CNA did not work and had no contact with resident, and after reported to NHA, CNA was suspended r/t (related to) investigation. Immediate education was provided to staff on reporting all types of abuse, neglect and misappropriation and also on appropriate interactions with residents and the use of multimedia equipment in the facility. Skin check was completed on resident. Resident was placed on alert charting for changes in mood and behavior. All interviewable residents were interviewed. (CNA C) was interviewed, along with the CNA he was working with when the alleged event occurred. In conclusion, resident alleged (CNA C) took a picture on (Resident 2's) phone of bm in his belly button to show him, flipped him the bird when he walked out of his room and in the past has blown up a glove after he has taken it off and popped it in his ear. Per (CNA C's) statement, he did take a photo of (Resident 2's) phone of bm in (Resident 2's) belly button because (Resident 2) asked him to. (CNA C) states he originally refused to take the picture but (Resident 2) then became upset so he ended up taking the picture, but did not report this to the nurse. (CNA C) denies popping a glove in his ear and flipping (Resident 2) the bird at any time. (CNA F) who was working with (CNA C) at the time of the alleged incident occurred, stated she was in the room with (CNA C) at one period of time, but did not see any of the allegations take place. She also stated she has never seen (CNA C) blow up a glove and pop it in (Resident 2's) ear. She went on to state that (Resident 2) and (CNA C) often joke around and sometimes when (Resident 2) is in a bad mood he won't want to joke with (CNA C) and she has never seen (CNA C) continue to joke with him after that point. (CNA C) was suspended and had no further contact with any residents after this incident was reported to staff. (Resident 2) was not observed to have any adverse reaction, nor did he have any new skin alterations noted. No new suspicious skin issues noted with any residents after skin sweep was completed on all residents. It has been concluded that the CNA took the picture on (Resident 2's) phone of bm in his belly button and showed it to (Resident 2). Although this was inappropriate, abuse, neglect and/or misappropriation have been unsubstantiated." The facility interviewed CNA C on 10/28/14. This document titled "Statement" states, "Did you flip (Resident 2) off when you left the room? No, that is disrespectful. I would never do that to a resident. Have you ever blown up a glove and popped it? No, I don't know where that came from. Did (Resident 2) make any additional complaints to you about the care we (SIC) was receiving? No. Did you tell the nurse at any time about all this that happened? No. Have you ever had (Resident 2) become this upset with you in the past? Yeah. It's usually when we lay him down. He gets very upset. The only reason you took the picture is because he told you to, and you initially told him no? Yes. Do you believe (CNA F) was in the room with you at this time? Yes. Did you tell (Resident 2) that he had BM in his belly button? Yes. Why did you tell him that? I have no idea. I shouldn't have said that. We usually joke around a lot." CNA C wrote a statement on 10/28/14. This document states, "When me and (CNA F) were taking (Resident 2) down to his room, he was very frustrated with us because we took a long time to get him. (Resident 2) voided himself and (CNA F) got a little frustrated and him, 'He could hold it longer than what he thought.' When we put him to bed (CNA F) went over to talk to (roommate) because she was crying. I was helping (Resident 2) by taking his pants off and he still seemed very mad at us. So I went to lay him down and yelled at me but he always yells when you lay him down because he has a hurt back. (CNA F) and I went on to clean (Resident 2) up. After we were all done he had BM in his belly button and he told me to take a picture to show it to him. He was very upset that I said no and kept yelling to tell me to take it. So I did and I realize that I should've just went to the nurses station. (Resident 2) calmed down throughout the night. He only pressed his call light to get a popsicle or to get a urinal. (Different handwriting added to CNA C's statement): We joke around alot (SIC). I shouldn't have told him about BM in his belly button. Has become this upset in the past. Believes (CNA F) was with him. I did not flip him off. Has never popped a glove in his ear/face. Made no complaints to (CNA C) about care. Did not tell nurse about situation." The facility interviewed Resident 2 on 10/27/14. This document states, "8p (8:00 PM)-9p (9:00 PM)- (Resident 2) stating first of all I waited nearly 2 hours to go to bed. Couldn't hold it so I peed in my pants and onto the floor. (Resident 2) had call light on. Why do I always go to bed last? (CNA C) stated we have a lot of other people to help. Well I had to go and went in my pants and on the floor and get wet in my pants. (CNA C) stated, 'Well don't go in your pants then' turned light off and left. 9:45 p (PM) (CNA C) came back in. (Resident 2): Why the hell am I the last to bed? (CNA C) and that girl helped me to bed. We got too many people to do and need more help. (CNA C) took my phone out and took a picture of BM poop in my belly button and said, 'here I'll show you.' Today, Monday (10/27/14, 11:40 AM) Resident took phone out of pocket and asked NHA (this writer) to look for picture saved on phone. In the past this CNA (CNA C) has taken off a glove and blown it up with air and popped in my ear. 9:45 p while walking out of room (CNA C) flipped me the bird -put up his middle finger from me trying to hide it but I saw it. (RN E) and (CNA H) provided good care when (CNA C) left." Surveyor spoke with Resident 2 on 11/6/14 at 9:20 AM. Resident 2 stated that on PM shift, there is a CNA (CNA C) who is always so rude to him. "(CNA C) is always so rude to me, ever since he has been here, I have hated him. (CNA C) comes in at night with another CNA and talks bad to me. The other CNA states that he has no right to talk to me like that." Resident 2 stated that he has told (NHA A) about this. Surveyor asked Resident 2 if he knew who the girl CNA was. Resident 2 stated that he thought it was (CNA D or CNA F). Resident 2 stated that CNA C takes a glove and blows it up with his mouth and slaps it near his ear. Surveyor asked Resident 2 how often this happens. Resident 2 stated that this has happened approximately five times. Resident 2 stated that this hurts his ear and that at first he kind of let it go. Resident 2 stated that one day he thought he should tell someone, as this happens every time he (CNA C) works. Resident 2 stated that he feels like CNA C was abusing him. Resident 2 stated that on 10/24/14 CNA C stated, "Give me your phone" and took a picture of his belly button that had feces in it. Resident 2 stated that he did not ask (CNA C) to do this and he does not know why he would do this. Resident 2 stated that (CNA C) thought it was funny. Resident 2 stated, "It didn't make me feel good, I tell you that-humiliated me." Resident 2 stated that (CNA C) then just left the feces in his belly button and did not wash him up. Resident 2 stated that he told the nurse (unaware of name) that night. Resident 2 stated that on that same night, he had his call light on for 30 minutes and (CNA C) came in and said, "Now what do you want?" Resident 2 stated that (CNA C) give him "the finger" when he walked out. Surveyor noted that Resident 2 was upset and crying at this time during the interview. Resident 2 stated, "It makes me feel like I'm not wanted. He just poked fun of me." Resident 2 stated that he had to wait for the night shift staff to help him. Resident 2 stated that he told (CNA H) about (CNA C) leaving him a mess and about the gloves incidents. Resident 2 stated that (CNA H) stated, "Why?!" Resident 2 stated that this happened on Friday night, October 24th and that (NHA A) spoke with him on the next Monday. Resident 2 stated that he did inform the night nurse of this on Friday, October 24th. Resident 2 stated that it did not feel good to have a glove popped in his ear. Resident 2 stated that he thinks (CNA C) put the "poop" in his belly button. Resident 2 stated that he is upset that all of this happened. Surveyor spoke with CNA D on 11/6/14 at 3:40 PM. CNA D stated the she has worked with (Resident 2) and with CNA C. CNA D stated that she worked on 10/24/14 on (Resident 2's) unit with CNA C. CNA D indicated that the schedule did not show this because she switched units with another CNA. Surveyor asked CNA D to tell her what happened on the night of 10/24/14. CNA D stated that it was not only that night that this happened, and that this happened "basically every night she worked with (CNA C) and (Resident 2)." CNA D stated that (CNA C) was "in the wrong and was immature." CNA D stated that (CNA C) would call (Resident 2) an "asshole" and was "rude" to him. CNA D stated that (CNA C) would call (Resident 2) a "[***] ." CNA D stated that at times, (Resident 2) would "egg it on." CNA D stated that she would say, "That's enough" and then it would be silent and awkward." CNA D stated that (Resident 2) would say, "Hey!" and then smile. CNA D stated that she did not know if it was meant to be mean each time, but that some of the times it was meant to be mean to (Resident 2). CNA D stated that (Resident 2) knew that it hurt her to see him treated like this and (Resident 2) would say, "I don't have to deal with (CNA C)." Surveyor asked CNA D if she had seen (CNA C) take a glove and blow it up with air and pop it near or on (Resident 2's) ear. CNA D stated that she was told about this from (Resident 2) but was only told after (CNA C) was no longer working at the facility. Surveyor asked CNA D if she ever heard (CNA C) yell at Resident 2. CNA D stated that she heard (CNA C) yell, "Well don't go in your pants" in a mean way. CNA D stated that this happened on 10/24/14 when she was walking down the hallway. CNA D stated that she could hear this from the hallway and that (CNA C) was not screaming, but was yelling at (Resident 2). CNA C stated that (Registered Nurse (RN) E) was on that night. Surveyor asked CNA D if she was aware of other instances where (CNA C) mistreated residents. CNA D stated that she knew there was a time where (CNA C) did not do PM cares for residents and that (CNA C) would eat food from another resident's plate and take his cookies. Surveyor asked CNA D if she thought that (CNA C) was abusing (Resident 2). CNA D stated that she did think this was abuse. Surveyor asked CNA D who she told about these times where (CNA C) abused (Resident 2). CNA D stated that she told (RN E) that night (10/24/14) because this was the night it "went the furthest" and (CNA C) "would not stop this time." CNA D stated that she has been trained on abuse and indicated that she was aware of the types of abuse. CNA D stated that abuse could be physical, emotional, verbal and sexual. Surveyor asked CNA D if any of these types of abuse portrayed what (CNA C) was doing to (Resident 2). CNA D stated that he (CNA C) was "emotionally and verbally abusing" (Resident 2). At 4:12 PM, Surveyor again spoke with CNA D. Surveyor asked CNA D how long this had been going on. CNA D stated, "Months." CNA D stated that when (Resident 2) returned from the hospital he was moved to the Rehab unit. CNA D stated that she took the concern to the nurse on 10/24/14 because (CNA C) would not stop calling (Resident 2) an[***] and a [***] . Surveyor asked CNA D if the other incidents she observed met the definition of abuse, to her. CNA D stated that it did. CNA D stated that (Resident 2) would make comments to her that he did not like (CNA C). CNA D stated that this conversation with Surveyor was the first interview that she has had regarding (CNA C) and (Resident 2), that she had not been interviewed by facility staff as part of the facility investigation. Surveyor spoke with CNA H on 11/6/14 at 10:17 AM. CNA H stated that she works night shift at the facility and did work on 10/24/14. CNA H sated that she was in (Resident 2's room) with (RN E) and that (Resident 2) told (RN E) that (CNA C) had given him the finger and that this was all she had heard. CNA H stated that she had to wash (Resident 2) up that night and that there was a spot of feces in his belly button. CNA H stated that she did not hear anything about the phone incident or anything about a glove being popped. CNA H stated that (Resident 2) was not happy about getting "the finger" from (CNA C). CNA H stated that she assumed the nurse (RN E) would follow up on this. Surveyor spoke with Social Worker (SW) G on 11/6/14 at 12:30 PM. SW G stated that she worked on 10/26/14 and received a "Concern Report" either in her mailbox or under her office door. SW G stated that the Concern Report was completed by RN E. SW G stated that the report indicated that (CNA C) gave (Resident 2) the middle finger. SW G stated that she talked to (Resident 2) on 10/26/14 and he seemed to be doing fine. SW G stated that she did not ask (Resident 2) any further questions regarding treatment from (CNA C). SW G stated that (Resident 2) has no history of making false allegations against staff. SW G stated that she did not inform (NHA A) of this situation until the next day, Monday, 10/27/14. SW G stated that she did not recognize this situation as abuse. SW G stated that she did not talk to any staff about this incident. The alleged and observed incident occurred on 10/24/14. The "Timecard" for CNA C notes that CNA C worked on 10/24/14 from 1:54 PM to 10:06 PM. This document also notes that CNA C worked on 10/25/14 from 1:54 PM to 10:02 PM. The facility did not ensure that all residents were free from further potential abuse from CNA C after the allegation was observed by CNA H and reported to RN E. CNA D indicated that she informed RN E of her observation of CNA C calling Resident 2 an[***] and a [***] on 10/24/14 and that CNA C would not stop despite her asking CNA C to stop. CNA D's "Time Detail" notes that CNA D worked on 10/24/14 from 3:59 PM to 12:02 AM. The facility provided "Time Detail" for all staff who worked on 10/24/14. There is no evidence that CNA F worked on 10/24/14. CNA F's "Timecard" does not include hours worked on 10/24/14. "Daily Staffing Schedule Sheets" indicate that CNA C worked 13 days in September, 2014. Of the 13 days worked, all were worked on Resident 2's unit. "Daily Staffing Schedules" indicate that CNA C worked 13 days in October, 2014. 11 of the 13 days worked by CNA C were on Resident 2's unit. CNA C's Personnel File indicates that he was hired at the facility on 4/10/14. CNA C was provided discipline on 7/6/14 for not reporting to the next shift that three residents remained on bedpans at the end of his shift. CNA C was disciplined on 8/31/14 for not completing bedtime cares, not washing residents up and leaving them to sleep in their clothing from the previous day. On 10/21/14, CNA C was noted to only use one assist to transfer a resident who required two caregivers to assist with transferring, resulting in a fall. According to "Employee Warning Notice" dated 10/30/14, CNA C did not "maintain acceptable standards of respect for & courtesy to patients, visitors, coworkers & supervisors. Employee took a picture of BM in resident's belly button c (with) residents cell phone." The facility indicated that CNA C was terminated from the facility on 10/30/14 due to these reasons.

Based on interview and record review, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for 1 of 2 incidents reviewed. The facility did not have evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse while the investigation was in progress for 1 of 2 incidents reviewed. CNA D stated that CNA C yelled at Resident 2 and would swear at Resident 2 each time they cared for Resident 2 (calling him an "asshole" and "[***] "). CNA D did not report these instances to staff at the facility until 10/24/14 when CNA C would not stop swearing at Resident 2. CNA D reported the 10/24/14 incident on 10/24/14 to Registered Nurse (RN) E, who left a note for the facility Social Worker (SW G). SW G did not report the allegation from RN E until Monday, 10/27/14. CNA C was allowed to work on 10/25/14. The facility did not protect Resident 2 and other residents from further potential abuse despite their knowledge of abuse (CNA D) and allegations of abuse from Resident 2. Because the facility did not immediately report the allegation to Nursing Home Administrator (NHA) A, an investigation was not initiated on 10/24/14 when the facility became aware. The facility did not begin an investigation until 10/27/14 and then did not complete a thorough investigation into the allegations as the facility did not interview appropriate staffs who had knowledge of mistreatment by CNA C to Resident 2. Failure to immediately report allegations of abuse by CNA C to Resident 2 allowed the abuse to continue and to escalate to the point that it did on 10/24/14. When interviewed, Resident 2 stated that CNA C humiliated him, made him feel as if he was not wanted, and that he hated CNA C. Resident 2 became upset and began crying while recounting his encounters with CNA C. This is evidenced by: The facility's policy titled "Patient Protection Practice Guide" dated 11/2011 states in part, "According to the State Operations Manual" (SOM), Appendix PP, 'Abuse is the willful infliction of injury, unreasonable confinement, intimidations or punishment with resulting physical harm, pain or mental anguish. The most critical step toward detecting abuse is acknowledging that no one should be subjected to violent, abusive, humiliating or neglectful behavior. 'Verbal Abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. 'Mental abuse' includes, but is not limited to, humiliation, threats of punishment or deprivation. 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, misappropriation or crime involving a patient. The administrator is responsible for the investigating, reporting and coordination of the investigation process of any alleged or suspected abuse regardless of the source of the concern." Resident 2 has [DIAGNOSES REDACTED]. Resident 2 is his own decision-maker. According to "Census List" dated 11/6/14, on 9/2/14 Resident 2 was readmitted to a unit different from the previous unit in which he had resided for greater than three years. "Physician's Statement Certification of Regained Capacity" dated 9/1/11 states "I have personally examined (Resident 2) and certify that the patient/resident no longer meets the statutory definition of incapacity. (Resident 2) is again, able to receive and evaluate information effectively or to communicate decisions to such an extent that the patient/resident now possesses capacity to manage his or her health care decisions." According to "Discharge Summary", Resident 2 was discharged from an acute care setting and readmitted to the facility on [DATE]. The facility completed an admission Minimum Data Set (MDS) assessment for Resident 2, with a reference date of 9/9/14. Section C of this assessment, Cognitive Status, notes that Resident 2 scored 15 (of 15 possible) points on the Brief Interview for Mental Status, indicating that Resident 2 is cognitively intact. Section G, Functional Status, notes that Resident 2 needs extensive 2 person physical assistance with bed mobility, transferring, toileting, and personal hygiene. Section D, Mood, notes that Resident 2 has symptoms of feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, and trouble with concentration. Section I, Active Diagnoses, notes a [DIAGNOSES REDACTED]. "Concern Report" dated 10/24/14 (initially) completed by RN E states, "Date received: 10/24/14. Concern initiated by: Patient (checked); Concern reported to: staff; Staff member: (RN E); Describe the concern using factual terms: Resident stated that he became upset c CNAs tonight when he had to wait to be put to bed and when CNA (CNA C) was leaving room 'he flipped me the damn bird.' CNA was already gone when resident informed." RN E, who is no longer employed at the facility, did not report this allegation to the administrator but, instead, left a note for the social worker. Surveyor spoke with Social Worker (SW) G on 11/6/14 at 12:30 PM. SW G stated that she worked on 10/26/14 and received a "Concern Report" either in her mailbox or under her office door. SW G stated that the Concern Report was completed by RN E. SW G stated that the report indicated that (CNA C) gave (Resident 2) the middle finger. SW G stated that she talked to (Resident 2) on 10/26/14 and he seemed to be doing fine. SW G stated that she did not ask (Resident 2) any further questions regarding treatment from (CNA C). SW G stated that (Resident 2) has no history of making false allegations against staff. SW G stated that she did not inform (NHA A) of this situation until the next day, Monday, 10/27/14. SW G stated that she did not recognize this situation as abuse. SW G stated that she did not talk to any staff about this incident. The facility completed an "Alleged Nursing Home Mistreatment Report" on 10/27/14 at 3:45 PM. This report states, "Date occurred: 10/24/14 ...Resident stated to the Night Registered Nurse that he became upset with CNA tonight when he had to wait to be put to bed. The resident alleges that when (CNA C) was leaving his room "he flipped me the damn bird." Registered Nurse noted that upon receiving allegation from resident, the CNA was already gone for the night, having completing his evening shift." Despite the fact that the incident had occurred on 10/24/14, the facility did not begin its investigation until 10/27/14. The investigation concluded the following: "Misconduct Incident Report ...On 10/24/14 resident reported to the night shift nurse that after he became upset with (CNA C) for having to wait, (CNA C) flipped him the bird as he was leaving the room. At that time (CNA C) was no longer working and was not scheduled to work again until 10/28/14. Upon learning of this situation, (Nursing Home Administrator (NHA) A) immediately spoke with (Resident 2). (Resident 2) stated that he had felt he had waited a very long time and ended up urinating in his pants and on the floor. When (CNA C) came, (Resident 2) stated he was upset he had to sit in wet pants and (CNA C) responded by saying, 'well don't go in your pants then.' (Resident 2) stated that later that night (CNA C) took (Resident 2's) phone and took a picture of the 'poop in his belly button' and said, 'here I'll show you.' (NHA A) was then given (Resident 2's) phone from (Resident 2's) pocket and he asked NHA to look for the picture that was saved. A picture was discovered on (Resident 2's) phone taken on 10/24/14 around 9pm that appeared to be bm. Resident also states that around 9:45pm when (CNA C) was walking out of (Resident 2's) room, (CNA C) flipped the bird by putting up his middle finger and trying to hide it by the side of his face/ear. Resident states that in the past (CNA C) has taken off a glove and blown it up with air and popped it in (Resident 2's) ear ...Accused CNA did not work and had no contact with resident, and after reported to NHA, CNA was suspended r/t (related to) investigation. Immediate education was provided to staff on reporting all types of abuse, neglect and misappropriation and also on appropriate interactions with residents and the use of multimedia equipment in the facility. Skin check was completed on resident. Resident was placed on alert charting for changes in mood and behavior. All interviewable residents were interviewed. (CNA C) was interviewed, along with the CNA he was working with when the alleged event occurred. In conclusion, resident alleged (CNA C) took a picture on (Resident 2's) phone of bm (bowel movement) in his belly button to show him, flipped him the bird when he walked out of his room and in the past has blown up a glove after he has taken it off and popped it in his ear. Per (CNA C's) statement, he did take a photo of (Resident 2's) phone of bm in (Resident 2's) belly button because (Resident 2) asked him to. (CNA C) states he originally refused to take the picture but (Resident 2) then became upset so he ended up taking the picture, but did not report this to the nurse. (CNA C) denies popping a glove in his ear and flipping (Resident 2) the bird at anytime. (CNA F) who was working with (CNA C) at the time of the alleged incident occurred, stated she was in the room with (CNA C) at one period of time, but did not see any of the allegations take place. She also stated, she has never seen (CNA C) blow up a glove and pop it in (Resident 2's) ear. She went on to state that (Resident 2) and (CNA C) often joke around and sometimes when (Resident 2) is in a bad mood he won't want to joke with (CNA C) and she has never seen (CNA C) continue to joke with him after that point. (CNA C) was suspended and had no further contact with any residents after this incident was reported to staff. (Resident 2) was not observed to have any adverse reaction, nor did he have any new skin alterations noted. No new suspicious skin issues noted with any residents after skin sweep was completed on all residents. It has been concluded that the CNA took the picture on (Resident 2's) phone of bm in his belly button and showed it to (Resident 2). Although this was inappropriate, abuse, neglect and/or misappropriation have been unsubstantiated." The facility interviewed CNA C on 10/28/14. This document titled "Statement" states, "Did you flip (Resident 2) off when you left the room? No, that is disrespectful. I would never do that to a resident. Have you ever blown up a glove and popped it? No, I don't know where that came from. Did (Resident 2) make any additional complaints to you about the care we (SIC) was receiving? No. Did you tell the nurse at any time about all this that happened? No. Have you ever had (Resident 2) become this upset with you in the past? Yeah. It's usually when we lay him down. He gets very upset. The only reason you took the picture is because he told you to, and you initially told him no? Yes. Do you believe (CNA F) was in the room with you at this time? Yes. Did you tell (Resident 2) that he had BM in his belly button? Yes. Why did you tell him that? I have no idea. I shouldn't have said that. We usually joke around a lot." The facility completed one additional staff interview, with CNA F. "Employee states she frequently works with (CNA C). She state that (CNA C) often jokes around with (Resident 2) and (Resident 2) jokes right back. Sometimes (Resident 2) is in a bad mood and won't want to joke with (CNA C) and I have never seen (CNA C) continue to joke with him after that point. I worked Friday October 24th PM shift with (CNA C) and did not see him interact inappropriately with any residents including (Resident 2). We did go into his room together and he had urinated on the floor. We got him cleaned up, and I noticed him roommate (name) was crying as she does very often. I asked her what was wrong and if I could do anything for her and she stated no, there was nothing wrong and she didn't know why she was crying. I then left the room and didn't have any other contact with him." CNA C wrote a statement on 10/28/14. This document states, "When me and (CNA F) were taking (Resident 2) down to his room, he was very frustrated with us because we took a long time to get him. (Resident 2) voided himself and (CNA F) got a little frustrated and him, 'He could hold it longer than what he thought.' When we put him to bed (CNA F) went over to talk to (roommate) because she was crying. I was helping (Resident 2) by taking his pants off and he still seemed very mad at us. So I went to lay him down and yelled at me but he always yells when you lay him down because he has a hurt back. (CNA F) and I went on to clean (Resident 2) up. After we were all done he had BM in his belly button and he told me to take a picture to show it to him. He was very upset that I said no and kept yelling to tell me to take it. So I did and I realize that I should've just went to the nurses station. (Resident 2) calmed down throughout the night. He only pressed his call light to get a popsicle or to get a urinal. (Different handwriting added to CNA C's statement):We joke around alot (SIC). I shouldn't have told him about BM in his belly button. Has become this upset in the past. Believes (CNA F) was with him. I did not flip him off. Has never popped a glove in his ear/face. Made no complaints to (CNA C) about care. Did not tell nurse about situation." The facility interviewed Resident 2 on 10/27/14. This document states, "8p (8:00 PM)-9p (9:00 PM)- (Resident 2) stating first of all I waited nearly 2 hours to go to bed. Couldn't hold it so I peed in my pants and onto the floor. (Resident 2) had call light on. Why do I always go to bed last? (CNA C) stated we have a lot of other people to help. Well I had to go and went in my pants and on the floor and get wet in my pants. (CNA C) stated, 'Well don't go in your pants then' turned light off and left. 9:45 p (PM) (CNA C) came back in. (Resident 2): Why the hell am I the last to bed? (CNA C) and that girl helped me to bed. We got too many people to do and need more help. (CNA C) took my phone out and took a picture of BM poop in my belly button and said, 'here I'll show you.' Today, Monday (10/27/14, 11:40 AM) Resident took phone out of pocket and asked NHA (this writer) to look for picture saved on phone. In the past this CNA (CNA C) has taken off a glove and blown it up with air and popped in my ear. 9:45 p while walking out of room (CNA C) flipped me the bird -put up his middle finger from me trying to hide it but I saw it. (RN E) and (CNA H) provided good care when (CNA C) left." The facility did not ask Resident 2 which other staff were present, during their interview with Resident 2 on 10/27/14. The facility did not investigate into the popping of the glove in Resident 2's ear allegation. The facility did not interview all staff who worked with Resident 2 and CNA C on 10/24/14. Surveyor spoke with Resident 2 on 11/6/14 at 9:20 AM. Resident 2 stated that on PM shift, there is a CNA (CNA C) who is always so rude to him. "(CNA C) is always so rude to me, ever since he has been here, I have hated him. (CNA C) comes in at night with another CNA and talks bad to me. The other CNA states that he has no right to talk to me like that. " Resident 2 stated that he has told (NHA A) about this. Surveyor asked Resident 2 if he knew who the girl CNA was. Resident 2 stated that he thought it was (CNA D or CNA F). Resident 2 stated that CNA C takes a glove and blows it up with his mouth and slaps it near his ear. Surveyor asked Resident 2 how often this happens. Resident 2 stated that this has happened approximately five times. Resident 2 stated that this hurts his ear and that at first he kind of let it go. Resident 2 stated that one day he thought he should tell someone, as this happens every time he (CNA C) works. Resident 2 stated that he feels like CNA C was abusing him. Resident 2 stated that on 10/24/14 CNA C stated, "Give me your phone" and took a picture of his belly button that had feces in it. Resident 2 stated that he did not ask (CNA C) to do this and he does not know why he would do this. Resident 2 stated that (CNA C) thought it was funny. Resident 2 stated, "It didn't make me feel good, I tell you that-humiliated." Resident 2 stated that (CNA C) then just left the feces in his belly button and did not wash him up. Resident 2 stated that he told the nurse (unaware of name) that night. Resident 2 stated that on that same night, he had his call light on for 30 minutes and (CNA C) came in and said, "Now what do you want?" Resident 2 stated that (CNA C) give him "the finger" when he walked out. Surveyor noted that Resident 2 was upset and crying at this time during the interview. Resident 2 stated, "It makes me feel like I'm not wanted. He just poked fun of me." Resident 2 stated that he had to wait for the night shift staff to help him. Resident 2 stated that he told (CNA H) about (CNA C) leaving him a mess and about the gloves incidents. Resident 2 stated that (CNA H) stated, "Why?!" Resident 2 stated that this happened on Friday night, October 24th and that (NHA A) spoke with him on the next Monday. Resident 2 stated that he did inform the night nurse of this on Friday, October 24th. Resident 2 stated that it did not feel good to have a glove popped in his ear. Resident 2 stated that he thinks (CNA C) put the "poop" in his belly button. Resident 2 stated that he is upset that all of this happened. Surveyor spoke with CNA F on 11/6/14 at approximately 2:00 PM. CNA F stated that she did not have knowledge of abuse from (CNA C) to other residents including (Resident 2). CNA F stated that she did not work on 10/24/14 but did work 10/23/14 with (CNA C) and (Resident 2). CNA F stated that the only thing that sticks out was the (Resident 2's) roommate was crying. Surveyor spoke with CNA D on 11/6/14 at 3:40 PM. CNA D stated the she has worked with (Resident 2) and with CNA C. CNA D stated that she worked on 10/24/14 on (Resident 2's) unit with CNA C. CNA D indicated that the schedule did not show this because she switched unites with another CNA. Surveyor asked CNA D to tell her what happened on the night of 10/24/14. CNA D stated that it was not only that night that this happened, and that this happened "basically every night she worked with (CNA C) and (Resident 2)." CNA D stated that (CNA C) was in the wrong and was immature. CNA D stated that (CNA C) would call (Resident 2) an "asshole" and was rude to him. CNA D stated that (CNA C) would call (Resident 2) a "[***] ." CNA D stated that at times, (Resident 2) would "egg it on." CNA D stated that she would say, "That's enough" and then it would be silent and awkward. CNA D stated that (Resident 2) would say, "Hey!" and then smile. CNA D stated that she did not know if it was meant to be mean each time, but that some of the times it was meant to be mean to (Resident 2). CNA D stated that (Resident 2) knew that it hurt her to see him treated like this and (Resident 2) would say, "I don't have to deal with (CNA C)." Surveyor asked CNA D if she had seen (CNA C) take a glove and blow it up with air and pop it near or on (Resident 2's) ear. CNA D stated that she was told about this from (Resident 2) but after (CNA C) was no longer working at the facility. Surveyor asked CNA D if she ever heard (CNA C) yell at Resident 2. CNA D stated that she heard (CNA C) yell, "Well don't go in your pants" in a mean way. CNA D stated that this happened on 10/24/14 when she was walking down the hallway. CNA D stated that she could hear this from the hallway and that (CNA C) was not screaming, but was yelling at (Resident 2). CNA C stated that (Registered Nurse (RN) E) was on that night. Surveyor asked CNA D if she was aware of other instances where (CNA C) mistreated residents. CNA D stated that she knew there was a time where (CNA C) did not do PM cares for residents and that (CNA C) would eat food from another resident's plate and take his cookies. Surveyor asked CNA D if she thought that (CNA C) was abusing (Resident 2). CNA D stated that she did think this was abuse. Surveyor asked CNA D who she told about these times where (CNA C) abused (Resident 2). CNA D stated that she told (RN E) that night (10/24/14) because this was the night it went the furthest and (CNA C) would not stop this time. CNA D stated that she has been trained on abuse and indicated that she was aware of the types of abuse. CNA D stated that abuse could be physical, emotional, verbal and sexual. Surveyor asked CNA D if any of these types of abuse portrayed what (CNA C) was doing to (Resident 2). CNA D stated that he (CNA C) was emotionally and verbally abusing (Resident 2). At 4:12 PM, Surveyor again spoke with CNA D. Surveyor asked CNA D how long this had been going on. CNA D stated, "Months." CNA D stated that when (Resident 2) returned from the hospital he was moved to the Rehab unit. CNA D stated that she took the concern to the nurse on 10/24/14 because (CNA C) would not stop calling (Resident 2) an[***] and a [***] . Surveyor asked CNA D if the other incidents she observed meet the definition of abuse, to her. CNA D stated that it did. CNA D stated that (Resident 2) would make comments to her that he did not like (CNA C). CNA D stated that this conversation with Surveyor was the first that she has had regarding (CNA C) and (Resident 2). Despite having knowledge of CNA C abusing Resident 2 for "months," CNA C did not report this until 10/24/14, which allowed the abuse to continue. Surveyor spoke with CNA H on 11/6/14 at 10:17 AM. CNA H stated that she works night shift at the facility and did work on 10/24/14. CNA H stated that she was in (Resident 2's room) with (RN E) and that (Resident 2) told (RN E) that (CNA C) had given him the finger and that this was all she had heard. CNA H stated that she had to wash (Resident 2) up that night and that there was a spot of feces in his belly button. CNA H stated that she did not hear anything about the phone incident or anything about a glove being popped. CNA H stated that (Resident 2) was not happy about getting "the finger" from (CNA C). CNA H stated that she assumed the nurse (RN E) would follow up on this. The alleged and observed incident occurred on 10/24/14. "Timecard" for CNA C notes that CNA C worked on 10/24/14 from 1:54 PM to 10:06 PM. This document notes that CNA C worked on 10/25/14 from 1:54 PM to 10:02 PM, thus the facility did not ensure that all residents were free from further potential abuse from CNA C after the allegation was observed by CNA H and RN E. CNA D indicated that she informed RN E of her observation of CNA C calling Resident 2 an[***] and a [***] on 10/24/14 and would not stop despite her asking CNA C to stop. CNA D's "Time Detail" notes that CNA D worked on 10/24/14 from 3:59 PM to 12:02 AM. The facility provided "Time Detail" for all staff who worked on 10/24/14. There is no evidence that CNA F worked on 10/24/14. "Daily Staffing Schedule Sheets" indicate that CNA C worked 13 days in September, 2014. Of the 13 days worked, all were worked on Resident 2's unit. "Daily Staffing Schedules" indicate that CNA C worked 13 days in October, 2014. 11 of the 13 days worked by CNA C were on Resident 2's unit. CNA C's Personnel File indicates that he was hired at the facility on 4/10/14. CNA C was provided discipline on 7/6/14 for not reporting to the next shift that three residents remained on bedpans at the end of his shift. CNA C was disciplined on 8/31/14 for not completing bedtime cares, not washing residents up and leaving them to sleep in their clothing from the previous day. On 10/21/14, CNA C was noted to only use one assist to transfer a resident who required two caregivers to assist with transferring, resulting in a fall. According to "Employee Warning Notice" dated 10/30/14, CNA C did not "maintain acceptable standards of respect for & courtesy to patients, visitors, coworkers & supervisors. Employee took a picture of BM in resident's belly button c (with) residents cell phone." The facility indicated that CNA C was terminated from the facility on 10/30/14 due to these reasons. Surveyor spoke with NHA A on 11/6/14 at 2:45 PM. NHA A stated that he determined which staff to speak with regarding the allegations made by (Resident 2) based on what (Resident 2) stated during their interview. Resident 2 named CNA F as the individual who was working with CNA C during the 10/24/14 incident. Surveyor and Surveyor spoke with NHA A and Director of Nursing (DON) B on 11/6/14 at 4:50 PM. Surveyor informed NHA A and DON B did not interview all key staff regarding Resident 2's allegation of mistreatment by CNA C. Surveyor informed NHA A and DON B of CNA D's knowledge of verbal abuse by CNA C. Surveyor informed NHA A and DON B of staff's knowledge of the incidents and lack of immediate protection, reporting and investigation by the facility.

Based on interview and record review the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property for 1 of 2 incidents reviewed. Resident 2 alleged that he was abused by Certified Nursing Assistant (CNA) C. Resident 2 stated that CNA C would blow up gloves and pop them near him, would humiliate him and took a picture of feces that were in his belly button. CNA D stated that CNA C yelled at Resident 2 and would swear at Resident 2 each time they cared for Resident 2 (calling him "asshole" and "[***] "). Contrary to facility policies and procedures, CNA D did not report these instances to staff at the facility until 10/24/14 when CNA C would not stop swearing at Resident 2. CNA D reported the 10/24/14 incident on 10/24/14 to Registered Nurse (RN) E, who left a note for the facility Social Worker (SW G). Contrary to facility policies and procedures, SW G did not report the allegation from RN E until Monday, 10/27/14. CNA C was allowed to work on 10/25/14. The facility did not protect Resident 2 and other residents from further potential abuse despite their knowledge of abuse (CNA D) and allegations of abuse from Resident 2. The facility did not complete a thorough investigation into the allegations, as the facility did not interview appropriate staffs who had knowledge of mistreatment by CNA C to Resident 2. The facility did not operationalize their policy. The facility did not ensure that knowledge of abuse was reported to the facility administrator, and did not complete a thorough investigation into the allegations. Failure to implement facility policies and procedures allowed the abuse to Resident 2 to continue and to escalate to the point that it did on 10/24/14 and allowed for the potential for further abuse to occur on 10/25/14. When interviewed, Resident 2 stated that CNA C humiliated him, made him feel as if he was not wanted, and that he hated CNA C. Resident 2 became upset and began crying while recounting his encounters with CNA C. This is evidenced by: The facility's policy titled "Patient Protection Practice Guide" dated 11/2011 states in part, "According to the State Operations Manual" (SOM), Appendix PP, 'Abuse is the willful infliction of injury, unreasonable confinement, intimidations or punishment with resulting physical harm, pain or mental anguish. The most critical step toward detecting abuse is acknowledging that no one should be subjected to violent, abusive, humiliating or neglectful behavior. 'Verbal Abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. 'Mental abuse' includes, but is not limited to, humiliation, threats of punishment or deprivation. 'Neglect' means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Employees are educated upon hire and annually on the abuse prevention program including the immediate reporting of any suspicion of abuse, neglect, misappropriation or crime involving a patient. The administrator is responsible for the investigating, reporting and coordination of the investigation process of any alleged or suspected abuse regardless of the source of the concern...According to CMS (Centers for Medicare and Medicaid Services) F225, the facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in process. Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough and objective investigation of any allegation of abuse...Abuse against patients can be initiated by various people within the center. The center supports and protects patients, family members and staff from harm during an investigation of abuse. Protective actions depend upon the people involved. Any allegation of abuse must be immediately reported to the supervisor and the abuse prevention coordinator. The administrator follows the investigation process...Patient protection actions include immediately removing the patient from contact with alleged abuser during the investigation. If the incident involves a center employee, the employee is suspended pending completion of the investigation" Resident 2 has [DIAGNOSES REDACTED]. Resident 2 is his own decision-maker. According to "Census List" dated 11/6/14, on 9/2/14 Resident 2 was readmitted to a unit different from the previous unit in which he had resided for greater than three years. "Physician's Statement Certification of Regained Capacity" dated 9/1/11 states "I have personally examined (Resident 2) and certify that the patient/resident no longer meets the statutory definition of incapacity. (Resident 2) is again, able to receive and evaluate information effectively or to communicate decisions to such an extent that the patient/resident now possesses capacity to manage his or her health care decisions." The facility completed an admission Minimum Data Set (MDS) assessment for Resident 2, with a reference date of 9/9/14. Section C of this assessment, Cognitive Status, notes that Resident 2 scored 15 (of 15 possible) points on the Brief Interview for Mental Status, indicating that Resident 2 is cognitively intact. Section G, Functional Status, notes that Resident 2 needs extensive 2 person physical assistance with bed mobility, transferring, toileting, and personal hygiene. Section D, Mood, notes that Resident 2 has symptoms of feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite or overeating, and trouble with concentration. Section I, Active Diagnoses, notes a [DIAGNOSES REDACTED]. Failure to immediately report an allegation of abuse. Surveyor spoke with CNA D on 11/6/14 at 3:40 PM. CNA D stated the she has worked with (Resident 2) and with CNA C. CNA D stated that she worked on 10/24/14 on (Resident 2's) unit with CNA C. CNA D indicated that the schedule did not show this because she switched unites with another CNA. Surveyor asked CNA D to tell her what happened on the night of 10/24/14. CNA D stated that it was not only that night that this happened, and that this happened "basically every night she worked with (CNA C) and (Resident 2)." CNA D stated that (CNA C) was in the wrong and was immature. CNA D stated that (CNA C) would call (Resident 2) an "asshole" and was rude to him. CNA D stated that (CNA C) would call (Resident 2) a "[***] ." CNA D stated that at times, (Resident 2) would "egg it on." CNA D stated that she would say, "That's enough" and then it would be silent and awkward. CNA D stated that (Resident 2) would say, "Hey!" and then smile. CNA D stated that she did not know if it was meant to be mean each time, but that some of the times it was meant to be mean to (Resident 2). CNA D stated that (Resident 2) knew that it hurt her to see him treated like this and (Resident 2) would say, "I don't have to deal with (CNA C)." Surveyor asked CNA D if she had seen (CNA C) take a glove and blow it up with air and pop it near or on (Resident 2's) ear. CNA D stated that she was told about this from (Resident 2) but after (CNA C) was no longer working at the facility. Surveyor asked CNA D if she ever heard (CNA C) yell at Resident 2. CNA D stated that she heard (CNA C) yell, "Well don't go in your pants" in a mean way. CNA D stated that this happened on 10/24/14 when she was walking down the hallway. CNA D stated that she could hear this from the hallway and that (CNA C) was not screaming, but was yelling at (Resident 2). CNA C stated that (Registered Nurse (RN) E) was on that night. Surveyor asked CNA D if she was aware of other instances where (CNA C) mistreated residents. CNA D stated that she knew there was a time where (CNA C) did not do PM cares for residents and that (CNA C) would eat food from another resident's plate and take his cookies. Surveyor asked CNA D if she thought that (CNA C) was abusing (Resident 2). CNA D stated that she did think this was abuse. Surveyor asked CNA D who she told about these times where (CNA C) abused (Resident 2). CNA D stated that she told (RN E) that night (10/24/14) because this was the night it went the furthest and (CNA C) would not stop this time. CNA D stated that she has been trained on abuse and indicated that she was aware of the types of abuse. CNA D stated that abuse could be physical, emotional, verbal and sexual. Surveyor asked CNA D if any of these types of abuse portrayed what (CNA C) was doing to (Resident 2). CNA D stated that he (CNA C) was emotionally and verbally abusing (Resident 2). At 4:12 PM, Surveyor again spoke with CNA D. Surveyor asked CNA D how long this had been going on. CNA D stated, "Months." CNA D stated that when (Resident 2) returned from the hospital he was moved to the Rehab unit. CNA D stated that she took the concern to the nurse on 10/24/14 because (CNA C) would not stop calling (Resident 2) an[***] and a [***] . Surveyor asked CNA D if the other incidents she observed meet the definition of abuse, to her. CNA D stated that it did. CNA D stated that (Resident 2) would make comments to her that he did not like (CNA C). CNA D stated that this conversation with Surveyor was the first that she has had regarding (CNA C) and (Resident 2). "Daily Staffing Schedule Sheets" indicate that CNA C worked 13 days in September, 2014. Of the 13 days worked, all were worked on Resident 2's unit. "Daily Staffing Schedules" indicate that CNA C worked 13 days in October, 2014. 11 of the 13 days worked by CNA C were on Resident 2's unit. CNA D did not immediately report allegations of abuse against Resident 2, allowing the abuse to go on for " months. " Failure to immediately investigate an allegation of abuse "Concern Report" dated 10/24/14 (initially) completed by RN E states, "Date received: 10/24/14. Concern initiated by: Patient (checked); Concern reported to: staff; Staff member: (RN E); Describe the concern using factual terms: Resident stated that he became upset c CNAs tonight when he had to wait to be put to bed and when CNA (CNA C) was leaving room 'he flipped me the damn bird.' CNA was already gone when resident informed." RN E, who no longer works at the facility, left this note for the social worker, who did not see it until two days later. Surveyor spoke with Social Worker (SW) G on 11/6/14 at 12:30 PM. SW G stated that she worked on 10/26/14 and received a "Concern Report" either in her mailbox or under her office door. SW G stated that the Concern Report was completed by RN E. SW G stated that the report indicated that (CNA C) gave (Resident 2) the middle finger. SW G stated that she talked to (Resident 2) on 10/26/14 and he seemed to be doing fine. SW G stated that she did not ask (Resident 2) any further questions regarding treatment from (CNA C). SW G stated that (Resident 2) has no history of making false allegations against staff. SW G stated that she did not inform (NHA A) of this situation until the next day, Monday, 10/27/14. SW G stated that she did not recognize this situation as abuse. SW G stated that she did not talk to any staff about this incident. Failure to prevent further potential abuse The alleged and observed incident occurred on 10/24/14. "Timecard" for CNA C notes that CNA C worked on 10/24/14 from 1:54 PM to 10:06 PM. This document notes that CNA C worked on 10/25/14 from 1:54 PM to 10:02 PM. The facility did not ensure that all residents were free from further potential abuse from CNA C after the allegation was observed by CNA H and RN E. CNA D indicated that she informed RN E of her observation of CNA C calling Resident 2 an[***] and a [***] on 10/24/14 and would not stop despite her asking CNA C to stop. CNA D's "Time Detail" notes that CNA D worked on 10/24/14 from 3:59 PM to 12:02 AM. Failure to complete a thorough investigation The facility completed an "Alleged Nursing Home Mistreatment Report" on 10/27/14 at 3:45 PM. This report states, "Date occurred: 10/24/14 ...Resident stated to the Night Registered Nurse that he became upset with CNA tonight when he had to wait to be put to bed. The resident alleges that when (CNA C) was leaving his room "he flipped me the damn bird." Registered Nurse noted that upon receiving allegation from resident, the CNA was already gone for the night, having completing his evening shift." The facility began their investigation on 10/27/14 and completed the following: "Misconduct Incident Report ...On 10/24/14 resident reported to the night shift nurse that after he became upset with (CNA C) for having to wait, (CNA C) flipped him the bird as he was leaving the room. At that time (CNA C) was no longer working and was not scheduled to work again until 10/28/14. Upon learning of this situation, (Nursing Home Administrator (NHA) A) immediately spoke with (Resident 2). (Resident 2) stated that he had felt he had waited a very long time and ended up urinating in his pants and on the floor. When (CNA C) came, (Resident 2) stated he was upset he had to sit in wet pants and (CNA C) responded by saying, 'well don't go in your pants then.' (Resident 2) stated that later that night (CNA C) took (Resident 2's) phone and took a picture of the 'poop in his belly button' and said, 'here I'll show you.' (NHA A) was then given (Resident 2's) phone from (Resident 2's) pocket and he asked NHA to look for the picture that was saved. A picture was discovered on (Resident 2's) phone taken on 10/24/14 around 9pm that appeared to be bm. Resident also states that around 9:45pm when (CNA C) was walking out of (Resident 2's) room, (CNA C) flipped the bird by putting up his middle finger and trying to hide it by the side of his face/ear. Resident states that in the past (CNA C) has taken off a glove and blown it up with air and popped it in (Resident 2's) ear ...Accused CNA did not work and had no contact with resident, and after reported to NHA, CNA was suspended r/t (related to) investigation. Immediate education was provided to staff on reporting all types of abuse, neglect and misappropriation and also on appropriate interactions with residents and the use of multimedia equipment in the facility. Skin check was completed on resident. Resident was placed on alert charting for changes in mood and behavior. All interviewable residents were interviewed. (CNA C) was interviewed, along with the CNA he was working with when the alleged event occurred. In conclusion, resident alleged (CNA C) took a picture on (Resident 2's) phone of bm (bowel movement) in his belly button to show him, flipped him the bird when he walked out of his room and in the past has blown up a glove after he has taken it off and popped it in his ear. Per (CNA C's) statement, he did take a photo of (Resident 2's) phone of bm in (Resident 2's) belly button because (Resident 2) asked him to. (CNA C) states he originally refused to take the picture but (Resident 2) then became upset so he ended up taking the picture, but did not report this to the nurse. (CNA C) denies popping a glove in his ear and flipping (Resident 2) the bird at anytime. (CNA F) who was working with (CNA C) at the time of the alleged incident occurred, stated she was in the room with (CNA C) at one period of time, but did not see any of the allegations take place. She also stated, she has never seen (CNA C) blow up a glove and pop it in (Resident 2's) ear. She went on to state that (Resident 2) and (CNA C) often joke around and sometimes when (Resident 2) is in a bad mood he won't want to joke with (CNA C) and she has never seen (CNA C) continue to joke with him after that point. (CNA C) was suspended and had no further contact with any residents after this incident was reported to staff. (Resident 2) was not observed to have any adverse reaction, nor did he have any new skin alterations noted. No new suspicious skin issues noted with any residents after skin sweep was completed on all residents. It has been concluded that the CNA took the picture on (Resident 2's) phone of bm in his belly button and showed it to (Resident 2). Although this was inappropriate, abuse, neglect and/or misappropriation have been unsubstantiated." The facility interviewed CNA C on 10/28/14. This document titled "Statement" states, "Did you flip (Resident 2) off when you left the room? No, that is disrespectful. I would never do that to a resident. Have you ever blown up a glove and popped it? No, I don't know where that came from. Did (Resident 2) make any additional complaints to you about the care we (SIC) was receiving? No. Did you tell the nurse at any time about all this that happened? No. Have you ever had (Resident 2) become this upset with you in the past? Yeah. It's usually when we lay him down. He gets very upset. The only reason you took the picture is because he told you to, and you initially told him no? Yes. Do you believe (CNA F) was in the room with you at this time? Yes. Did you tell (Resident 2) that he had BM in his belly button? Yes. Why did you tell him that? I have no idea. I shouldn't have said that. We usually joke around a lot." CNA C wrote a statement on 10/28/14. This document states, "When me and (CNA F) were taking (Resident 2) down to his room, he was very frustrated with us because we took a long time to get him. (Resident 2) voided himself and (CNA F) got a little frustrated and him, 'He could hold it longer than what he thought.' When we put him to bed (CNA F) went over to talk to (roommate) because she was crying. I was helping (Resident 2) by taking his pants off and he still seemed very mad at us. So I went to lay him down and yelled at me but he always yells when you lay him down because he has a hurt back. (CNA F) and I went on to clean (Resident 2) up. After we were all done he had BM in his belly button and he told me to take a picture to show it to him. He was very upset that I said no and kept yelling to tell me to take it. So I did and I realize that I should've just went to the nurses station. (Resident 2) calmed down throughout the night. He only pressed his call light to get a popsicle or to get a urinal. (Different handwriting added to CNA C's statement):We joke around a lot (SIC). I shouldn't have told him about BM in his belly button. Has become this upset in the past. Believes (CNA F) was with him. I did not flip him off. Has never popped a glove in his ear/face. Made no complaints to (CNA C) about care. Did not tell nurse about situation." The facility completed one additional staff interview, with CNA F. "Employee states she frequently works with (CNA C). She state that (CNA C) often jokes around with (Resident 2) and (Resident 2) jokes right back. Sometimes (Resident 2) is in a bad mood and won't want to joke with (CNA C) and I have never seen (CNA C) continue to joke with him after that point. I worked Friday October 24th PM shift with (CNA C) and did not see him interact inappropriately with any residents including (Resident 2). We did go into his room together and he had urinated on the floor. We got him cleaned up, and I noticed him roommate (name) was crying as she does very often. I asked her what was wrong and if I could do anything for her and she stated no, there was nothing wrong and she didn't know why she was crying. I then left the room and didn't have any other contact with him." The facility provided "Time Detail" (time cards) for all staff who worked on 10/24/14. There is no evidence that CNA F worked on 10/24/14. Surveyor spoke with CNA F on 11/6/14 at approximately 2:00 PM. CNA F stated that she did not have knowledge of abuse from (CNA C) to other residents including (Resident 2). CNA F stated that she did not work on 10/24/14 but did work 10/23/14 with (CNA C) and (Resident 2). CNA F stated that the only thing that sticks out was the (Resident 2's) roommate was crying. The facility did not interview additional staff that worked with CNA C on 10/24/14 or who have worked with CNA C in the past. The facility did not interview CNA D, who was the one who had witnessed the abuse and who had reported to RN E. The facility interviewed Resident 2 on 10/27/14. This document states, "8p (8:00 PM)-9p (9:00 PM)- (Resident 2) stating first of all I waited nearly 2 hours to go to bed. Couldn't hold it so I peed in my pants and onto the floor. (Resident 2) had call light on. Why do I always go to bed last? (CNA C) stated we have a lot of other people to help. Well I had to go and went in my pants and on the floor and get wet in my pants. (CNA C) stated, 'Well don't go in your pants then' turned light off and left. 9:45 p (PM) (CNA C) came back in. (Resident 2): Why the hell am I the last to bed? (CNA C) and that girl helped me to bed. We got too many people to do and need more help. (CNA C) took my phone out and took a picture of BM poop in my belly button and said, 'here I'll show you.' Today, Monday (10/27/14, 11:40 AM) Resident took phone out of pocket and asked NHA (this writer) to look for picture saved on phone. In the past this CNA (CNA C) has taken off a glove and blown it up with air and popped in my ear. 9:45 p while walking out of room (CNA C) flipped me the bird -put up his middle finger from me trying to hide it but I saw it. (RN E) and (CNA H) provided good care when (CNA C) left." The facility did not ask Resident 2 which other staff were present, during their interview with Resident 2 on 10/27/14. The facility did not investigate into the popping of the glove in Resident 2's ear allegation. The facility did not interview staff who worked with Resident 2 and CNA C on 10/24/14. The facility did not implement their policy as it relates to completing a thorough investigation. Surveyor spoke with NHA A on 11/6/14 at 2:45 PM. NHA A stated that he determined which staff to speak with regarding the allegations made by (Resident 2) based on what (Resident 2) stated during their interview. Resident 2 named CNA F as the individual who was working with CNA C during the 10/24/14 incident. Surveyor and Surveyor spoke with NHA A and Director of Nursing (DON) B on 11/6/14 at 4:50 PM. Surveyor informed NHA A and DON B did not interview all key staff regarding Resident 2's allegation of mistreatment by CNA C. Surveyor informed NHA A and DON B of CNA D's knowledge of verbal abuse by CNA C. Surveyor informed NHA A and DON B of staff's knowledge of the incidents and lack of immediate protection, reporting and investigation by the facility.

Based on interviews and record reviews, the facility failed to follow proper sanitation and food safety requirements based on the following: During a family picnic, facility staff failed to perform the critical step of heating all parts of the shredded beef/pork mix to a temperature of at least 165 degrees Fahrenheit for 15 seconds within 2 hours to ensure the destruction of any potential pathogens (prior to serving). Facility staff failed to check the temperature of the shredded beef/pork mix to ensure it was at or above 135 degrees Fahrenheit, a critical step to prevent the growth of pathogens This failure resulted in a foodborne illness outbreak in which the following became ill: 13 out of 56 residents (Residents 1, 7, 8, 11, 12, 20, 21, 22, 23, 24, 25, 26, 27), 5 out of 43 visitors (Visitors Y, Z, AA, BB, CC) and 13 employees (Nursing Home Administrator-A (NHA-A), Certified Nursing Assistant (CNA-G), Kitchen General Manager-K (KGM-K), Maintenance Director-M (MD-M), Housekeeping/Laundry Supervisor-N (HLS-N), Staff Q, Staff-R, Staff-S, Staff-T, Staff-U, Staff-V, Staff-W, Staff-X) - all who attended the picnic, consistent with consumption of the beef/pork mix and became ill with loose stools. Additional examples of noncompliance at F371 include: Food temperatures were not consistently taken or recorded for every meal served. An open box of liquid eggs was found in the walk in refrigerator with no open or end date. An open bag of egg noodles and an open bag of pasta noodles were found with no open or end date. A toaster was found in the dry storage room that had not been cleaned after use. A large Hobart mixer was found with dried food particles on the upper structure by the mixing beater. An ice pack was found in the 200 wing kitchenette freezer sitting on top of a Popsicle. Internal temperature of mechanical dishwasher is not monitored by the facility. Findings include: Wisconsin Division of Public Health, "FOODBORNE AND WATERBORNE DISEASE OUTBREAK INVESTIGATION MANUAL (February, 2008) defines foodborne outbreak when 2 or more persons experience a similar illness after ingestion of a common food Criteria for confirmation of ,[MEDICAL CONDITION]. perfringens: Average range for incubation period: 6-24 hours Clinical syndrome: Diarrhea (watery), colic, nausea and gas, (Vomiting and fever are uncommon and symptoms usually resolve within 24 hours). Characteristic Foods: Inadequately heated or reheated meats, meat pies, stews, gravy, sauces, refried beans Laboratory and Epidemiologic Criteria for Confirmation: Isolation of >105 C. perfringens/gm of implicated food, OR Isolation of C. perfringens in stool of ill persons, OR detection of [MEDICATION NAME] by latex agglutination (from stool [MEDICATION NAME] of culture isolates). According to the 2009 Food and Drug Administration Food Code (FDA-Food Code), Annexes, when food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of ,[MEDICAL CONDITION]. perfringens that may grow in meat, poultry, or gravy if these products were improperly cooled. Vegetative cells of C. perfringens can cause foodborne illness when they grow to high numbers. Highly resistant C. perfringens spores will survive cooking and hot holding. If food is abused by being held at improper holding temperatures or improperly cooled, spores can germinate to become rapidly multiplying vegetative cells. The 2009 Food and Drug Administration Food Code includes the following: 3-403.11 Reheating for Hot Holding. 1. (A) Except as specified under ?? (B) and (C) and in ? (E) of this section, potentially hazardous food (time/temperature control for safety food) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74oC (165oF) for 15 seconds ... P 4. (D) Reheating for hot holding as specified under ?? (A) - (C) of this section shall be done rapidly and the time the food is between 5?C (41?F) and the temperatures specified under ?? (A) - (C) of this section may not exceed 2 hours. P Example 1 On 8/30/2013, 10:20 AM, in activity room, surveyor # and Wisconsin Public Health Investigator-O (PHI-O) met with the following staff: Nursing Home Administrator-A(NHA-A), Maintenance Director-M (MD-M), Housekeeping/Laundry Supervisor-N (HLS-N), Speech Therapist D (ST-D), Kitchen General Manager-K (KGM-K) and Human Resource Director-P (HRD-P). During this time, NHA-A, MD-M, HLS-N, KGM-K all reported having had diarrhea following a facility picnic on 8/21/13. The one consistent food item was the shredded beef/pork mix at the facility picnic. ST-D ate the meat, however did not become ill. HRD-P did not eat the meat. On 8/30/2013, 11:09 AM - 11:16 AM, Nursing Home Administrator-A (NHA-A) reported to surveyor # and Public Health Investigator-O that he began having own symptoms early in the A.M. on 8/22/2013. NHA-A came into work later in the morning and after asking others about being ill, believed there was a problem and contacted the local public health department and Regional Field Operations Director for the southern region. To determine the source of the outbreak, surveyor # and Public Health Investigator-O (PHI-O) went on 8/30/2013, 1:45 PM - 2:45 PM to the Meat Processing Plant where the shredded beef/pork mix was processed. Surveyor # and PHI-O met with the owner and the onsite Department of Agriculture, Trade and Consumer Protection (DATCP) meat inspector (DATCP-DD). The DATCP-DD is onsite daily to assure compliance with regulations. Based on record review by PHI-O and report provided to surveyor # , it was determined that all required steps were followed and temperatures were within the required range for the shredded beef/pork mix that was served at the long term care facility's picnic on 8/21/2013: Cooler Temperature: 38 degrees Fahrenheit, Pork temperature 190 degrees Fahrenheit, Beef temperature, 190 degrees Fahrenheit, Pork and Beef combined - sent to Blast Chiller: 2:35 PM, temperature = 130 degrees Fahrenheit, 3:40 PM = 76 degrees Fahrenheit and 5:15 PM = 39 degrees Fahrenheit. According to the all the food codes, food must be cooled to 70 degrees Fahrenheit within 2 hours and 41 degrees Fahrenheit within 6 hours. Meat Processing Plant met all the requirements. According to email sent 8/30/2013, 4:48 PM, from Wisconsin Department of Public Health Epidemiologist-EE," The meat tested from the processing plant was not positive for perfringens by culture." On 8/30/2013, 10:58 AM - 11:09 AM, surveyor # and Public Health Investigator-O (PHI-O) were provided the following timeline of the day of the facility picnic: ? ~Approximately 7:00 AM, Maintenance Director-M (MD-M) picked up 61 pounds of shredded beef/pork mix (divided into 3 bags) and 35 pounds of potato salad. No temperature was taken; meat was precooked and transported in MD-M's pickup truck without any type of method for keeping meat cool. ~7:20 AM MD-M brought the shredded beef/pork mix to activity room. Speech therapist-D (ST-D) had two Nesco roasters with temperature set at 250 degrees Fahrenheit. ST-D stated the outside of the bags of meat felt cold. ST-D took two bags of the shredded beef/pork mix and put one bag each into the Nescos and mixed with a big spoon. ST-D stated came back about ? hour later and added 1/3 of the other bag, split it between the two Nescos. ST-D stated came back 2 hours later, 9:30 AM or 10:00 AM, stirred the meat in both Nescos, and then turned Nescos down to 200 degrees Fahrenheit. ST-D stated came back ? to 1 hour to stir the meat. ST-D stated the meat was in the two Nescos from 7:20 AM to 5:00 PM. ST-D stated the meat was not heated to the required 165 degrees Fahrenheit prior to going into the Nescos. Pre-cooked meat must be quickly reheated to 165 degrees Fahrenheit to kill any pathogens present. This would not occur in a slow cooking Nesco roaster. ~ST-D and Kitchen General Manager-K (KGM-K) stated the temperature of the meat was never taken throughout the entire process. On 8/29/13 at 12:30 PM, Surveyor interviewed Registered Dietician (RD) F - who was not at the picnic - regarding the food-borne illness outbreak of 8/22/13. RD F stated that foods should be temped the same way for food brought from an offsite source as food cooked on-site because residents eat the food. RD F stated that usually you should temp food prior to service, midway through service and when the last tray is served. RD F stated that the food code may not require that many temps but food should definitely be temped prior to service at a minimum. RD F stated that meat should be cooked to an internal temperature of at least 165 degrees Fahrenheit (F). Since the meat provided at the picnic was pre-cooked, RD F stated that it needed to be held at the proper holding temperature which should not fall below 140 degrees F. RD F stated that the dietary manager or food service staff should have temped the food prior to service to make sure it was at proper holding temperature. RD F stated that the facility has a new food service provider and this is the first time that the facility has used offsite food for the family picnic. In previous years the facility prepared food on-site for the picnic so this was a new situation. ~5:20 PM - Food for the picnic was served - Shredded beef/pork mix, potato salad On 8/30/13 Director of Nursing-B (DON-B) began an outbreak investigation and identified 31 individuals who became ill after the picnic: 12 residents, (R1, R7, R8, R11, R12, R20, R21, R22, R23, R24, R25, R26) and 13 employees, (Nursing Home Administrator-A (NHA-A), Certified Nursing Assistant,(CNA-G), Kitchen General Manager-K (KGM-K), Maintenance Director-M (MD-M), Housekeeping/Laundry Supervisor-N (HLS-N), Staff Q , Staff-R, Staff-S, Staff-T, Staff-U SV, Staff-W, Staff-X) all attended the picnic, all ate the pork/beef mix, and all came down with loose stools beginning 8/22/2013, except for Resident 27 (R27) who became ill with loose stools on 8/23/2013. Visitor-Y, Visitor-Z, Visitor AA, Visitor BB, and Visitor CC, were at the picnic, ate the shredded beef/pork mix and reported to DON becoming ill with loose stools. On 8/30/2013, 10:00 AM, surveyor # met in lobby with Wisconsin Public Health Investigator-O (PHI-O), in response to a report of a potential foodborne illness outbreak at the nursing home following an indoor picnic that was held on 8/21/2013. During the meeting with PHI-O, surveyor was informed that a stool sample tested positive for ,[MEDICAL CONDITION]. perfringens (Microbiology Results for Outbreak Sample #13-7350) PHI-O states that is consistent with the incubation time and symptoms. According to FoodSafety.gov, ,[MEDICAL CONDITION]. perfringen (C. perfringens) is one of the "most common causes of food poisoning in the United States." "C. perfringens infections often occur when foods are prepared in large quantities and are then kept warm for a long time before serving. That's why outbreaks of these infections are usually linked to institutions (such as hospitals, school cafeterias, prisons, and nursing homes) or events with catered food." On 8/30/2013, 10:22 AM, Kitchen General Manager-K (KGM-K) reported to surveyor # not understanding what a professional standard of practice for food safety is. KGM-K thinks it is the FDA Food Code, Wisconsin Food Code and ServSafe. KGM-K does not have any available of these standards in the kitchen. Surveyor # was also told by Kitchen General Manager-K (KGM-K) that in-services related to food safety are not done. Additional examples where the facility did not take temperatures of foods prior to serving include: Example 2 On 8/28/13 at 8:20 AM Surveyor reviewed the temperature log for the breakfast meal being served; no temperatures were logged for this meal. On 8/28/13 at 8:20 AM Surveyor interviewed Dietary Aide/Cook (DA/C) L. DA/C L stated she did not document the temperatures for the breakfast meal being served. DA/C L stated the temperatures were in her head. On 8/28/13 at 8:20 AM Surveyor reviewed the temperature log for the meals served 8/2013. There were a total of 72 meals served so far in 8/2013 and 21 of those meals with no meal temperatures documented. On 8/28/13 at 8:40 AM Surveyor interviewed DM K. DM K stated she would expect documentation temperatures to be logged at the time they are taken. DM K stated all meals should have temperatures logged to show accurate temperatures prior to serving. Example 3 According to the Food Code 3-501.17 Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking. (D) A date marking system that meets the criteria stated in ?? (A) and (B) of this section may include: (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under ? (B) of this section; The facility's "Food Safety Product Labeling & Dating Guide" policy, dated 1/27/12, includes the following: Storing Prepared Food, Product storage label: Date of preparation and/or use-by date. a. On 8/27/13 at 9:10 AM Surveyor observed an open box of liquid eggs in the walk in refrigerator. The box of liquid eggs had no open or end date. On 8/27/13 at 9:10 AM Surveyor interviewed Dietary Manager (DM) K. DM K stated she would expect the liquid eggs to have an open and an end date written on it. b. On 8/27/13 at 9:15 AM Surveyor observed an open bag of egg noodles and an open bag of pasta noodles with no open or end date. On 8/27/13 at 9:15 AM Surveyor interviewed Dietary Manager (DM) K. DM K stated she would expect the egg noodles and pasta noodles to have an open and an end date written on them. Example 4 a. On 8/27/13 at 9:20 AM Surveyor observed a toaster in the dry storage room. The interior of the toaster had bread crumbs scattered throughout. On 8/27/13 at 9:20 AM Surveyor interviewed Dietary Manager (DM) K. DM K stated the toaster is used every Wednesday during the breakfast meal. DM K stated she would expect staff to clean the toaster after each meal it is used for. b. On 8/27/13 at 3:30 PM Surveyor observed the large Hobart mixer in the kitchen. The large Hobart mixer was found with dried food particles on the upper structure by the mixing beater. On 8/27/13 at 3:30 PM Surveyor interviewed Dietary Manager (DM) K. DM K stated she would expect staff to clean the large Hobart mixer after each use. Example 5 On 8/27/13 at 12:30 PM Surveyor observed an ice pack in the 200 wing kitchenette freezer sitting on top of a Popsicle. On 8/27/13 at 4:00 PM Surveyor interviewed Director of Nursing (DON B. DON B stated she would expect there to be no nonfood items in the unit kitchenettes. Example 6 On 8/30/2013, at 11:51 AM, mechanical dishwasher area, Surveyor was told by Kitchen General Manager-K that the internal temperature of the mechanical dishwasher is not monitored as required by the food code.

Based on observation, interview and record review the facility did not ensure that 3 of 7 residents (Residents 10, 3 and 5) with pressure ulcers received the necessary care and treatment to promote healing, prevent infection, and prevent new ulcers from developing. Resident 10 was admitted to the facility with no pressure ulcers. Resident 10 subsequently developed unstageable ulcers on his heels. The facility failed to correctly identify, document, and evaluate the wounds and did not consult with the physician or family concerning appropriate treatments when the wounds deteriorated. The facility did not develop a plan to ensure that Resident 10 kept his legs elevated; the only plan was to remind him to elevate his legs - the efficacy of which is questionable since the resident has Alzheimer ' s disease and his ability to retain information is limited. The failure to provide Resident 10 with the care necessary to prevent the development of multiple, infected pressure ulcers created a finding of immediate jeopardy beginning 3/30/11. The facility was formally notified on 3/31/11 of the immediate jeopardy. The immediate jeopardy was removed on 3/30/11, when a Quality Performance Improvement Plan was initiated; the deficient practice continues at a scope/severity level of D (no actual harm with potential for more than minimal harm/isolated) as evidenced by the following examples, observed during survey on 3/30/11: Resident 3 was originally admitted to the facility with pressure ulcers. Although these ulcers were healed, Resident 3 developed a Stage 2 Pressure Ulcer to the left heel. The facility did not documented measures in place for prevention, or the specific stage or size of each individual ulcer. Resident 5 was admitted to the facility with pressure ulcers. Although these ulcers are assessed each week, the facility did not document the specific stage or size of each individual ulcer. Findings as follows: The facility indicates in their policy and procedure the use of the National Pressure Ulcer Advisory Panel guidelines found at www.npuap.org <http://www.npuap.org>. The International Guideline Prevention and treatment of [REDACTED]. Repositioning Documentation 5. Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime. Repositioning Education and Training 6. Education about the role of repositioning in pressure ulcer prevention should be offered to all persons involved in the care of individuals at risk of pressure ulcer development, including the individual and significant others (where possible). The use of support surfaces to prevent heel pressure ulcers 3.1. Ensure that the heels are free of the surface of the bed. 3.2. Heel-protection devices should elevate the heel completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type(s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and [MEDICATION NAME]. Relieve pressure under the heel(s) with Category/Stage I or II pressure ulcers by placing legs on a pillow to " float the heels " off the bed or by using pressure reducing devices with heel suspension. Category/Stage III, IV, and Unstageable Pressure Ulcers of the Heel Note: Selection of support surfaces is complex and cannot be determined solely on the basis of the category/stage of the ulcer. 1. Place the leg in a device that elevates the heel from the surface of the bed, completely offloading the pressure ulcer. 2. Apply the device according to the manufacturer's instructions. 3. Ensure that the device is not too tight and does not create additional pressure damage. Check device placement more frequently in individuals with [MEDICAL CONDITIONS], lower-extremity [MEDICAL CONDITION]; or who are likely to develop [MEDICAL CONDITION]. 4. Remove the device periodically to assess skin integrity. Example 1 Resident 10 was re-admitted to the facility on [DATE] after becoming weak at home and lowering himself to the floor and then not able to get back up. Resident 10's [DIAGNOSES REDACTED]. Resident 10's hospital History and Physical dated 1/30/11 indicates the he has 2+ [MEDICAL CONDITION] to his extremities with diffuse [DIAGNOSES REDACTED] (redness) over the lower legs and not open or draining at this time. Resident 10 was placed on oral antibiotics for [MEDICAL CONDITION] while in the hospital. Resident 10's MDS assessment reference, dated 2/11/11, indicates that his Brief Interview for Mental Status (BIMS) score is 15 out of 15, although Resident 10 is not his own legal decision maker. The MDS states that Resident 10 is independent with his bed mobility, transfers, and ambulating. Resident 10's MDS indicates no pain and a weight of 272 pounds. Resident 10's MDS dated [DATE] section M (skin conditions) indicates that Resident 10 is at no risk for pressure ulcers and does not have a history of pressure ulcers, nor any venous or arterial ulcers. The MDS indicates that Resident 10 does not use a pressure relieving device for chair or bed and does not have a turning/repositioning program. Resident 10's initial skin assessment reveals that he has no open areas on his legs or feet, but he is identified as having scaly/dislocation from [MEDICAL CONDITION] on his lower legs. The assessment indicates that his pedal pulses could not be palpated and has pedal [MEDICAL CONDITION]. Resident 10's Braden score (which is part of the admission assessment) dated 1/31/11 states that he is at low risk. However, in the scoring guidelines on the Braden Score form, it indicates that if the resident has other major risk factors present (advanced age, fever, poor dietary intake of protein, diastolic BP below 60) advance to the next level. Resident 10's initial comprehensive care plan dated 2/1/11 has a problem for at risk for alteration in skin integrity related to: [MEDICAL CONDITION], diabetes, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. However, please note that a review of Resident 10's medical record does not indicate the [DIAGNOSES REDACTED]. The interventions, which were not initiated until 2/15/11, state to apply moisturizers to skin as needed and to encourage/assist as needed to reposition frequently. It is important to note that the care plan does not indicate what " reposition frequently " means, or how the assistance is to be accomplished. A review of Resident 10's nursing notes from 1/31/11-2/9/11 reveals that Resident 10 had bilateral lower extremity [MEDICAL CONDITION] described as 2+. On 2/11/11 at 10:00 AM a nursing note states see SBAR (a situation, background, assessment and request form). This form is what the facility uses to document a change of condition call to the MD. The SBAR dated 2/11/11 at 10:12 AM states that staff noted that BLEs (bilateral lower extremities) to be [MEDICAL CONDITION], reddened and weeping. The problem is worse. The form indicates the things that make the problem worse as "not elevating legs" and things that would make problem better would be to "elevate is legs in bed at night." The form also indicates an 8 by 3 cm (centimeter) area of yellow slough was noted on BLE. Resident denies pain in BLE, noted that there was a significant difference in legs in a short time. The SBAR indicates that Resident 10 does not elevate legs often enough. The orders received from the nurse practitioner are to start [MEDICATION NAME] 100 mg BID x 7 days check CBC today culture wound on left leg and ace wraps to BLE on during day off at night and apply 1/2 strength [MEDICATION NAME] and [MEDICATION NAME] cream to BLE BID (two times a day). Although the SBAR indicates that Resident 10 does not elevate his legs "often enough" it does not indicate what the staff is to do about it and there were no changes to the care plan. The culture of Resident 10's leg wound 2/14/11 [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus). On 2/17/11 Resident 10 was seen by the nurse practitioner and an Unna boot to both legs and change every 2 days and prn was ordered. Elevate legs at intervals throughout day was also ordered but no specific approaches to accomplish this were added to the care plan for Resident 10. A progress note from the nurse practitioner's visit dated 2/17/11 indicates that nursing staff reports that over the last week the patient had increased [DIAGNOSES REDACTED] with progressively worsening opened areas with scant serous drainage. 2-3 plus [MEDICAL CONDITION] bilaterally with generalized [DIAGNOSES REDACTED] superficial open areas with serous drainage; [MEDICAL CONDITION] with venous statis derm changes and ulcerations. Staff is to strongly reinforce the need to elevate legs throughout the day. The above information should have given the facility an indication that Resident 10 was at high risk for pressure ulcers in is lower extremities. The plan indicates that the facility should strongly reinforce the need to elevate legs throughout the day; however, review of documentation does not indicate an individualized plan to get the Resident 10 pressure relief. 2/18/11 Resident 10 was started on the antibiotics Bactrim [MEDICATION NAME] 7 days due to [MEDICAL CONDITION] infection. Please note that this was 4 days after [MEDICAL CONDITION] infection was identified on the laboratory results. (Cross reference F157.) A nursing note on 2/20/11 at 9:30 PM states that Resident 10 was up in the rocking chair most of the day and that Resident 10 had to be reminded to elevate feet and legs... A nursing note on 2/27/11 at 9:30 PM states that Resident 10 spends most of his time in dining area on wing and sleeps in rocking chair on wing. There are no changes in the plan of care to identify how nursing staff is to encourage/assist Resident 10 in elevating his lower extremities. A nursing note on 3/2/11 at 2:45 AM indicates 1-2+ [MEDICAL CONDITION] to Resident 10's BLEs. A nursing note on 3/5/11 at 2:00 PM states facility was unable to apply the Unna boot due to unavailability and ace wraps to be used temporarily until unna boot is received. A note at 2:35 PM states 2 + [MEDICAL CONDITION] to BLE's. A nursing note on 3/6/11 at 9:00 PM states that Resident 10 has 1+ [MEDICAL CONDITION]. A nursing note on 3/7/11 (no time noted) states that Resident 10 has 2+ [MEDICAL CONDITION] in BLE and that Resident 10 has to be reminded to put legs up every so often. Again, there are no changes to the care plan to identify for staff the interventions they should employ to ensure that Resident 10 elevates his lower extremities or the education of Resident 10 or his family on the consequences of not elevating his lower extremities. A nursing note on 3/8/11 at 11:00 PM states that Resident 10 has 1-2+ [MEDICAL CONDITION] in BLE...Needs to be reminded to put legs up. A nursing note on 3/10/11 at 10:00 AM indicates that NP (nurse practitioner) here to see resident. Open areas found on bilateral heels, with new treatment orders received. POA (Power of attorney) updated and discussed possibility of bringing in resident ' s own recliner from home d/t (due to) resident not liking to be in bed. A physician's orders [REDACTED]. Recliner chair for room. The facility was aware of Resident 10's increase in [MEDICAL CONDITIONS] infection in his lower legs. An order was received to elevate Resident 10's legs throughout the day on 2/17/11. Resident 10's wound assessment dated [DATE] states open areas to bilateral bottoms of feet noted this AM. Area to left foot measures 1 x 1 x 0.2 cm moderate amount of sanguinous drainage. Pt (patient) states minimal pain to areas. Dry skin periwound. No [DIAGNOSES REDACTED]. Rt foot measures 1.5 x 1.5 x 0.2 cm granulation tissue to wound bed. Scant amount of sanguineous drainage present. Order received for [MEDICATION NAME] Matrix dressing and foam dressing, wrap with Kerlix cleanse with normal saline prior. Periwound skin to right foot dry no [DIAGNOSES REDACTED]. Minimal pain to area. States is tender and a little sore. A nursing note on 3/12/11 at 10:30 AM states needs encouragement to keep legs elevated. A note on 3/13/11 (no time noted) states 2 plus [MEDICAL CONDITION] noted and with frequent encouragement patient elevated BLE x 3 this shift. Again, although the facility notes in the documentation that Resident 10 needs encouragement to keep his legs elevated, there is no indication that they are informing Resident 10 or his family about the consequences of keeping his legs dependent and do not have an individualized program designed to ensure that the legs are indeed elevated. On 3/16/11 Resident 10's wound assessment states 2 open areas noted to left heel measuring 0.6 cm x 0.9 cm x <0.1 cm and 0.3 cm to 0.3 cm x < 0.1 cm. Both areas with granulation tissue and moderate amount of serosanguineous drainage. Periwound dry. Area to right heel measuring 1.5 x 1.5 x 0.2. Granulation tissue to wound bed with moderate amount serosanguineous drainage noted. Periwound with slight maceration. Resident states mild pain and tenderness to area, mostly when ambulating. Encourage to elevate BLE throughout day. This note again reiterates a plan that does not appear specific or to be adequate to ensure that Resident 10's legs are elevated. A nursing note on 3/17/11 at 9:00 PM states Resident 10 was up all day. Has recliner in rehab day area to sit in to elevate legs. Non compliant with keeping legs elevated. This note does not indicate what the facility did regarding the noncompliance to educate Resident 10 or his family on the consequences of noncompliance. 3/18/11 at 2:00 PM a note states compression stockings were ordered and will arrive the following week, will use ace wraps until arrive. 3/22/11 a note a 3:00 AM states Resident up sitting in chair in dining area on wing all night. Refuses to go to bed or elevate feet in recliner. Although Resident 10 was documented as non-compliant with elevating his legs the facility did not re-assess as to why he was refusing, or implement other measures to ensure compliance. The nursing notes do not document refusals of elevating legs until the wounds were discovered on 3/10/11. On 3/23/11 Resident 10's wound assessment is documented as follows: Open areas to left heel measures 0.5 x 0.5 x <0.2 cm depth each. Scant drainage serous present. hard dry skin periwound. Right heel measures 1.5 x 2 x 0.2 cm dark slough present to 50% of wound bed. 50% granulation. Moderate purulent drainage present. Denies pain to area. Periwound slightly macerated. New area to right lateral ball of foot: measures 2 cm x 1.5 cm 0 depth. Recommend treatment of [REDACTED]. Periwound skin normal in appearance. Wears bilateral boots at night. Please note that the wound on right heel is worse than the week before is now presenting with dark slough and purulent drainage. New orders were received for a treatment to the new open area on the ball of right foot; however, there is no physician update to the worsening rt heel ulcer. 3/23/11 a nursing note at 10:00 PM states that Resident 10 sleeps in the day area upright in chair or couch encouraged raising BLE off floor but refuses. There is no indication of what staff did regarding Resident 10's refusal. On 3/28/11 a platform was placed under Resident 10's easy chair to assist in independent transfers to assist in getting his legs elevated more often. On 3/29/11, 9:30 AM to 10:15 am, Surveyor observed Resident 10 in the day area sitting on a small love seat/couch. Resident 10 was sitting with his eyes closed and both feet directly on the floor resting on the heel and outside of his feet. Resident 10 had on non skid socks. Resident 10's legs and feet were noted to be very [MEDICAL CONDITION] from foot to thigh. Surveyor observed Resident 10 sitting in that position for 45 minutes without moving. A small plastic stool about 8-10 inches high was observed next to the couch. During that time frame no staff was observed to encourage Resident 10 to elevate his legs or provide an alternative method of pressure relief such as pressure relief boots. On 3/29/11, 11:00 AM to 11:45 AM, Surveyor observed Resident 10 sitting in the day area at a table with his legs not elevated and his feet directly on the floor resting on the heel and outside of his feet. During that time frame no staff was observed to encourage Resident 10 to elevate his legs or provide an alternative method of pressure relief such as pressure relief boots. On 3/29/11 at 6:15 PM Surveyor observed Resident 10's bed to have a regular pressure reduction mattress on his bed. On 3/29/11, 6:30 to 7:30 PM, Surveyor observed Resident 10 playing cards at a table with peers with his feet under the table resting directly on the floor resting on the heel and outside of his feet. Resident 10 was observed to sit in this position for 1 hour. During that time frame no staff was observed to encourage Resident 10 to elevate his legs or provide an alternative method of pressure relief such as pressure relief boots. A nursing entry on 3/30/11 at 2:35 AM states Refuses to elevate lower extremities is sleeping in common areas and encouraged to elevate LE but will not do so. On 3/30/11, Surveyor noted this entry placed by DON B which indicates that on 3/29/11, at 7:30 PM Resident 10 was playing cards. CNA encouraged him to put his feet on foot stool which was next to him. Resident did not want his feet elevated. Talked to him amount importance of elevating feet. Re-approached by RN and put feet on foot stool there is no evidence the facility developed alternative methods of pressure relief, such as pressure relief boots due to the refusal. On 3/30/11, at 7:15 AM Surveyor observed Resident 10 sitting in day room on the couch with the plastic stool under his legs, resting on his calves, causing pressure to the calf areas, with his feet hanging off the stool. Due to the heaviness of Resident 10's legs his calves were indented where the stool edges were touching his calves about 3/4 of an inch. Surveyor asked Resident 10 if he has pain and Resident 10 responded that just usually when he walks and then when he gets going it gets better. Surveyor asked Resident 10 about wearing boots on his feet at night and Resident 10 replied that he only wears those socks as nothing else fits; he has worn no boots. Even though the pressure is not on his heels during this observation, there is evidence of pressure to the calf areas due to the observation of indentation. On 3/30/11, at 7:35 AM Interviewed DCD Wound Nurse D regarding how Resident 10 received the ulcers to his feet. Wound Nurse D stated that his ulcers are a combination of his diabetes, chronic [MEDICAL CONDITION], venous stasis, and poor fitting diabetic shoes. That the bottoms of his shoes were unpadded and insoles were purchased. Resident 10's feet were too [MEDICAL CONDITION] for the shoes, now he just wears the socks with padded dressings. DCD D indicated that the facility found the left and right lower heels on 3/10/11, the ulcers were stage 2's with granulation tissue and sanguinous drainage but not red, with dry skin. Last week his left heel was drastically improved to 2 very small areas it is a healing stage 2. Right foot had little slough and granulation tissue and purulent and serious drainage. Interventions that were in place were to encourage to elevate feet, he knows the importance of elevating legs, he gets anxious about being able to get up independently and go to the bathroom. He sits in his recliner on occasion, and we encourage him to elevate his legs. Wound Nurse D stated that she has not seen the wounds since last week, but will do wound rounds today. Surveyor asked Wound Nurse D what type of mattress should be used for Resident 10's ulcers. Wound Nurse D indicated that with a stage 1 and 2 we use the regular pressure reduction mattress, and then a 3 or 4 we are to use an overlay pressure relief mattress. Surveyor asked Wound Care Nurse D about the area on Resident 10's lateral right foot. Wound care nurse stated that she "attributed it to his [DIAGNOSES REDACTED]." The lateral ball of his foot was not open when she had seen it last week; it was just red. Wound Care nurse D states that she does the weekly wound assessments and documents an assessment unless the nurses need me to look at the wound before that. Surveyor asked what interventions were added after the red area was found on the right foot. Wound Nurse D indicated the facility just used the same dressing as the other open areas, a foam protection dressing and encouraged him to elevate his feet. Wound Nurse D indicated Resident 10's problem is "mostly that he forgets due to his dementia, when you tell him to elevate it he usually does." Even though Resident 10's initial intervention was to encourage to elevate his feet due to his [MEDICAL CONDITION] and [MEDICAL CONDITION], the facility did not implement new interventions to ensure that Resident 10 elevated his legs. When his bilateral heels opened, the intervention was to elevate heels as able, and to wear boots at night to offload heels. However, there is no evidence that Resident 10 used these boots, and when he received a new pressure area to the lateral aspect of his right foot, no new interventions were initiated. On 3/30/11 at 10:45 AM, Surveyor observed LPN H, not the wound nurse, do Resident 10's dressing change. Resident 10's right heel was observed to be approximately 2 cm by 2 cm and unable to estimate depth. The ulcer bed had black slough in the ulcer with purulent drainage on the dressing and sanguinous drainage also, the Peri wound appeared macerated and the ulcer is unstageable. A very foul odor was noted coming from ulcers on right foot. The lateral ball of foot ulcer measures approximately 2 cm x 2 cm and unable to estimate depth. Yellow/tan slough covering most of ulcer with purulent drainage and a very foul odor. Periwound red and macerated. LPN H completed the dressing change to each foot wound. Normal saline was used to clean each wound and then LPN H used skin prep around each wound, followed by [MEDICATION NAME] matrix, and a [MEDICATION NAME] foam padding, and taped the dressing to the foot. Then ace wraps to lower extremities were applied. LPN H did not measure the wound even though measuring the ulcers was scheduled to be done that day. Surveyor interviewed LPN H right after the dressing change about the appearance of the right foot ulcers. LPN H stated the ulcer was between a stage 2-3 and questioned if Resident 10 had [MEDICAL CONDITION], as there were signs of possible infection from the odor and LPN H would have to check the previous documentation as the ulcer looks worse. It should be noted that the wound nurse did not do the scheduled weekly assessment / measuring of Resident 10's ulcers when the dressing changes were done on 3/30/11. LPN H did not document Resident 10's worsening ulcers and evidence of infection to the right foot wounds. Surveyor was concerned about the right foot wounds due to (1) signs and symptoms of infection, (2) the deterioration of the ulcers per documentation and observation, (3) LPN H ' s statement that the ulcer was worse, and (4) Resident 10 ' s history [MEDICAL CONDITION] in his wounds. Because of this concern, Surveyor asked Wound Nurse D to evaluate the wounds on Resident 10 ' s right foot. On 3/30/11 at approximately 5:15 PM Wound Nurse D observed the Resident 10's ulcers. Resident 10's assessment is documented as: Area to left heel lateral area measures 0.5 x 0.4 x 0.1 cm. Slough to wound bed periwound without redness. Medial area measures 0.1 x 0.2 x < 0.1. Epithelization to wound bed. Scant amount of serous drainage present... Rt heel wound measures 1.5 x 1 cm x 0.2 cm. Dark slough present to inner wound bed. Granulation present to 0.1 cm perimeter of wound bed. Dry skin present to periwound. Slight maceration present to periwound. Right foot lateral area measures 1.5 cm 2 x 0.1 cm. Slough to 50% wound bed. Granulization 50% of wound bed. Moderate amount of serosanguinous purulent drainage. Scant odor present. Slight maceration to periwound. Redness noted to periwound.. Pt wears foam to areas. Compression stockings BLE's. Pt encouraged to elevate BLE either in recliner or with foot stool. Pt is non-complaint at times with elevation of feet. Reminded educated patient this day on importance of elevating feet to promote healing. (Please remember that Resident 10 has a [DIAGNOSES REDACTED].) The notes indicate a call was placed to MD on status of wound. A nursing note on 3/30/11 at 5:45 PM states "new orders received and noted per (Physician name /NP name) to culture pressure areas on right foot related to drainage and odor. NP to see pt on rounds on 3/31/11." On 3/30/11 at 4:30 PM Surveyor observed Resident 10 and a wooden box platform with a pillow on top of the box was also noted by Resident 10, the left foot was resting on the pillow with his leg off the box as appropriate. The right foot was observed with the pillow pushed backward and his foot was resting on the wooden box on the lateral side, where the pressure ulcers are. On 3/30/11 at 5:30 PM Surveyor interviewed Registered Dietitian S regarding Resident 10 and his weight gain and pressure ulcers. RD S stated, "I recall that the ulcers were due to his shoes but remember talking to nursing and they really were not sure what the ulcers were yet. I was notified of the open areas and wrote recommended stress tabs with zinc to promote healing and then to follow up. I usually place residents on supplements but since he had already gained weight (10 pounds in 30 days and 23 pounds in 90 days) I did not want to do that. Surveyor asked RD S about Resident 10's low [MEDICATION NAME] level 2.3 on 1/31/11 and also that the level dropped to 2.2 on 2/22/11. RD S stated, "I would review (the labs) the next time I seen (Resident 10) to see if he was responding. We do have protein powder but most people do not like it." On 3/30/11 at 5:50 PM Surveyor interviewed Wound Nurse D regarding Resident 10 ' s right foot wounds. Wound Nurse D stated, "Right foot has slough in the heel and is worse. The new area (to lateral ball of foot) is now open it has slough and granulation and we are going to culture it, because of odor; his legs always had an odor, little drainage not a lot but it was bloody and purulent and there was redness around periwound. The top of the right foot is unstageable it was red the previous week. The heel is unstageable due to the slough. I think (the cause of the ulcers is) a combination of [MEDICAL CONDITION] and poor circulation, diabetes, ill fitting shoes but cannot rule out pressure." Surveyor asked Wound Nurse D on 3/23/11 when the right heel wound worsened and dark slough was present with purulent drainage what steps were done. Wound Nurse D stated, "The physician should have been called and updated on the decline in wound, a stage 3 mattress should have been placed on his bed due to the slough present. Every time someone looks at him they should be encouraging him to elevate his legs. Sometimes he just won't put them up it is care planned to encourage to elevate them." Surveyor asked Wound Nurse D why each weekly assessment does not have a stage indicated for each wound. Wound Nurse D stated that she understood that staff would only document staging of the pressure ulcers for the MDS and not for weekly assessments. A nurse practitioner progress note, dated 3/31/11 at 5:36 PM states: A [AGE] year old with a history of [MEDICAL CONDITION] with [MEDICAL CONDITION] requirement intermittent Unna boot placement. Unna boots were discontinued several weeks ago and doing well until the last 1-2 weeks when nursing staff reported an increase in [MEDICAL CONDITIONS] with a significant increase in breakdown of heels right greater than left. Nursing staff has made a significant effort to get the patient to elevate his legs and keep weight off his heels however he requires constant redirection...Wt 285#...Lungs clear with no cough or shortness of breath...Lower extremity with stasis derm changes noted bilaterally with significant [MEDICAL CONDITION] and [MEDICAL CONDITION] is an open area on right heel approximately 2.5 cm in diameter with eschar and scant drainage. Left heel open area approximately 0.75 cm with granulating tissue...pedal pulses not palpable. Assessment: [MEDICAL CONDITION] with chronic venous changes, pressure ulcers of the heels bilaterally secondary to noncompliant in behavior and underlying [MEDICAL CONDITION], and anxiety with possible OCD. Plan Culture of right heel...apply Unna boots...The pt agrees to bed rest for 2 hours in the am and 2 hours in the afternoon. Check BNP and CMP although the patent does not seem to have any respiratory distress. Continue with present dose of [MEDICATION NAME] as increase in past with no significant impact in [MEDICAL CONDITION]. On 3/31/11, Resident 10 received an order for [REDACTED]. On 4/1/11 at 9:00 AM resident 10's lab results were faxed to physician. Resident 10's abnormal labs were as follows: BUN 22 (normal is 7-18), Total Protein is 5.9 (normal is 6.4-8.2) , [MEDICATION NAME] 2.1 (normal is 3.4-5.0), BNP was 1630 (Normal is 0-100). On 4/1/11 at 3:00 PM the nursing staff filled out an SBAR alerting the physician of increased pain in feet with independent resident transfers. Wounds are getting worse, wound consultant here and wants pt admitted to hospital get doppler studies and a wound consult and possible IV antibiotics if needed. BNP drawn yesterday was 1630. Pt ulcers looking worse every day and legs are more reddened. New orders received to transport to hospital for evaluation of wounds and doppler studies. Resident 10's hospital admission note, dated 4/1/11, states that he was admitted through the emergency room with increasing dependency [MEDICAL CONDITION] and dyspnea as well as new onset of severe right foot pain. He has been having some increasing lower extremity dependency and a weight gain of 10 pounds as well as some mild increase in baseline dyspnea. Today he started having severe pain of sharp lancing character in the lateral aspect of his right fourth and fifth metatarsal, largely just whenever weight bearing. Resident 10's "Discharge Day Progress Note" states feeling much better breathing comfortable, weight down from 130 kg (286 pounds) to 116 kg (255 pounds) A significant [MEDICATION NAME] of 14 kg (31 pounds) occurred during admission. Cultures [MEDICAL CONDITION], Pseudomonas, and diphtheroids of his right foot wounds. On 4/5/11 a consultation of Resident 10's [MEDICAL CONDITION] of lower extremity [MEDICAL CONDITION] and pseudomonas from superficial cultures of the right foot. The findings included underlying [MEDICAL CONDITION] and [MEDICAL CONDITION]. The cultures were positive [MEDICAL CONDITION] in the wounds, and do appear to be pressure ulcers. Osteo[DIAGNOSES REDACTED] was ruled out. The immediate jeopardy was removed when the facility implemented the following: -A facility wide skin sweep conducted on 3/30/11 -Reviewed Resident 10's chart and MD notified of the multiple unstageable odor, drainage, and redness. New orders received and implemented. Braden scale updated Push tool reviewed and updated care plan. Support surface reviewed and appropriate mattress placed. -Review of all residents in house with pressure areas and a comprehensive review done to ensure proper care and treatment of [REDACTED]. -Identity any other residents by reviewing MDS Braden and other assessment tools and review/revise as necessary. -Inserviceing of licensed sta

Based on observation, interview and record review the facility failed to consult with the resident's physician when a significant change in condition in a resident's status occurred for 2 residents out of 15 reviewed (Residents 10 and 5). On 2/14/11 the facility was informed that Resident 10 [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus) in his lower leg wound [MEDICAL CONDITION]. A physician was not consulted with until 2/18/11 and Resident 10 was started on antibiotics. This is a 4 day delay in treatment. Resident 10's pressure ulcers on his right heel had progressed to a stage 3 with dark slough and purulent drainage identified during weekly wound assessment on 3/23/11 and a new pressure area was found on his right lateral ball of foot. A physician was not informed of the signs and symptoms of an infection. On 3/30/11 Resident 10's Right foot wounds were unstageable with redness, very foul odor and purulent drainage. These wounds deteriorated with signs and symptoms of infection. Surveyor requested wound nurse to assess wound. The wound nurse requested an order for [REDACTED]. Resident 10 had a 10 pound weight gain in one month that was not called to the physician. Resident 5's Nurse's Notes document Resident 5 to be showing signs of a possible wound infection. These Nurse's Notes also state the wound clinic would be consulted. There is no evidence that the wound clinic, or a physician, was indeed consulted regarding these signs of a possible infection. Findings as follows: Example 1 Resident 10 was re-admitted to the facility on [DATE] after becoming weak at home and lowering himself to the floor and then not being able to get back up. Resident 10's [DIAGNOSES REDACTED]. Wound Culture On 2/11/11 at 10:00 AM a nursing note states see SBAR (situation, background, assessment and request), a document used by the facility for a change of condition call to the MD. The SBAR dated 2/11/11 at 10:12 AM states that staff noted BLEs (bilateral lower extremity) to be [MEDICAL CONDITION], reddened and weeping. An 8 by 3 cm (centimeter) area of yellow slough noted on BLE. Resident denies pain in BLE, noted that there was a significant difference in legs in a short time. The orders received from the nurse practitioner are to start [MEDICATION NAME] 100 mg BID x 7 days check CBC today, culture wound on left leg, and ace wraps to BLE on during day off at night and apply 1/2 strength [MEDICATION NAME] and [MEDICATION NAME] cream to BLE BID (two times a day). On 2/14/11 the culture of Resident 10's leg wound [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staph Aureus). However, there was no consultation with the physician/nurse practitioner and Resident 10 was not started on the antibiotics Bactrim [MEDICATION NAME] 7 days until 2/18/10, for [MEDICAL CONDITION] infection. The facility did not contact Resident 10's physician for 4 days after [MEDICAL CONDITION] positive culture was identified, thus delaying treatment for [REDACTED]. Weight Gain A nutritional Risk Assessment form dated 2/4/11 indicates the following information related to Resident 10's nutritional risk score of 13, which places Resident 10, by the facility's assessment, as a high nutritional risk: BMI greater than 27(is 38.2), 5 or more drugs daily, [DIAGNOSES REDACTED]. Resident 10's admit weight was 273#. The form indicates the facility will weigh Resident 10 weekly x 4 then monthly if stable. A nutritional note dated 3/11/11 states that Resident 10 has open areas on bilateral heels. Current weight is 283#. This weight is up 10# in 30 days and up 23 pounds in 90 days. The weight gain is documented as unplanned and undesirable. Stress tabs with zinc daily to promote healing. Labs on 2/22/11- [MEDICATION NAME] 2.2 (please note that this is lower than labs on 1/30/11). RD to follow up. There is no documentation that Resident 10's physician was informed regarding his 10 pound weight gain in 30 days. A Physician's Progress note on 3/12/11 indicates that Resident 10's legs are more [MEDICAL CONDITION] than they have in the past with some increased problems with his feet...his weight is 282 which is within 5 pounds of what he has weighed for the past several months. Lungs clear and extremities have 4+ [MEDICAL CONDITION] of the lower extremity and [MEDICAL CONDITION] up to the thighs as well. Continue current measures, elevate legs has been encouraged local care of legs and any ulcers. Although the physician documented information is incorrect as on admission Resident 10's weight was 272 the 282 above indicates that Resident 10's weight is up 10 pounds in approx 30 days the physician was not updated on the error. On 3/30/11 at 5:30 PM Surveyor interviewed Registered Dietitian S regarding Resident 10 and his weight gain and pressure ulcers. RD S stated, "I recall that the ulcers were due to his shoes but remember talking to nursing and they really were not sure what the ulcers were yet. I was notified of the open areas and wrote recommended stress tabs with zinc to promote healing and then to follow up. I usually place residents on supplements but since he had already gained weight (10 pounds in 30 days and 23 pounds in 90 days) I did not want to do that. Surveyor asked RD S about Resident 10's low [MEDICATION NAME] level 2.3 on 1/31/11 and also that the level dropped to 2.2 on 2/22/11. RD S stated, "I would review (the labs) the next time I seen (Resident 10) to see if he was responding. We do have protein powder but most people do not like it." Deteriorated wound Resident 10's wound assessment dated [DATE] states open areas to bilateral bottoms of feet noted this AM. Area to left foot measures 1 x 1 x 0.2 cm moderate amount of sanguinous drainage. Pt (patient) states minimal pain to areas. Dry skin periwound. No [DIAGNOSES REDACTED]. Rt foot measures 1.5 x 1.5 x 0.2 cm granulation tissue to wound bed. Scant amount of sanguineous drainage present. Order received for [MEDICATION NAME] Matrix dressing and foam dressing, wrap with Kerlix cleanse with normal saline prior. Periwound skin to right foot dry no [DIAGNOSES REDACTED]. Minimal pain to area. States is tender and a little sore. On 3/16/11 Resident 10's wound assessment states 2 open areas noted to left heel measuring 0.6 cm x 0.9 cm x <0.1 cm and 0.3 cm to 0.3 cm x < 0.1 cm. Both areas with granulation tissue and moderate amount of serosanguinous drainage. Periwound dry. Area to right heel measuring 1.5 x 1.5 x 0.2. Granulation tissue to wound bed with moderate amount serosanguinous drainage noted. Periwound with slight maceration. Resident states mild pain and tenderness to area, mostly when ambulating. Encourage to elevate BLE throughout day. On 3/23/11 Resident 10's wound assessment is documented as follows: Open areas to left heel measures 0.5 x 0.5 x <0.2 cm depth each. Scant drainage serious present. hard dry skin periwound. Right heel measures 1.5 x 2 x 0.2 cm dark slough present to 50% of wound bed. 50% granulation. Moderate purulent drainage present. Denies pain to area. Periwound slightly macerated. New area to right lateral ball of foot: measures 2 cm x 1.5 cm 0 depth. Recommend treatment of [REDACTED]. Periwound skin normal in appearance. Wears bilateral boots at night. Please note that the wound on right heel is worse than the week before is now presenting with dark slough and purulent drainage. New orders were received for a treatment to the new open area on the ball of right foot; however, there is no physician update to the worsening rt heel ulcer. On 3/30/11 at 10:45 AM, Surveyor observed LPN H, not the wound nurse, do Resident 10's dressing change. Resident 10's right heel was observed to be approximately 2 cm by 2 cm and unable to estimate depth. The ulcer bed had black slough in the ulcer with purulent drainage on the dressing and sanguinous drainage also, the Peri wound appeared macerated and the ulcer is unstageable. A very foul odor was noted coming from ulcers on right foot. The lateral ball of foot ulcer measures approximately 2 cm x 2 cm and unable to estimate depth. Yellow/tan slough covering most of ulcer with purulent drainage and a very foul odor. Periwound red and macerated. Surveyor interviewed LPN H right after the dressing change about the appearance of the right foot ulcers. LPN H stated the ulcer was between a stage 2-3 and questioned if Resident 10 had [MEDICAL CONDITION], as there were signs of possible infection from the odor and LPN H would have to check the previous documentation as the ulcer looks worse. It should be noted that the wound nurse did not do the scheduled weekly assessment / measuring of Resident 10's ulcers when the dressing changes were done on 3/30/11. LPN H did not documentation Resident 10's worsening ulcers and evidence of infection to the right foot wounds and Surveyor was concerned about the right foot wounds due to signs and symptoms of infection, per documentation and observation the wound had deteriorated, LPN H stated the ulcer was worse, and Resident 10 has history [MEDICAL CONDITION] in his wounds. Surveyor asked Wound Nurse D to evaluate the wounds on his right foot. On 3/30/11 at approximately 5:15 PM Wound Nurse D observed the Resident 10's ulcers, Resident 10's assessment is documented as: Area to left heel lateral area measures 0.5 x 0.4 x 0.1 cm. Slough to wound bed periwound without redness. Medial area measures 0.1 x 0.2 x < 0.1. Epithelization to wound bed. Scant mount of serous drainage present... Rt heel wound measures 1.5 x 1 cm x 0.2 cm. Dark slough present to inner wound bed. Granulation present to 0.1 cm perimeter of wound bed. Dry skin present to periwound. Slight maceration present to periwound. Right foot lateral area measures 1.5 cm 2 x 0.1 cm. Slough to 50% wound bed. Granulization 50% of wound bed. Moderate amount of serosanguinous purulent drainage. Scant odor present. Slight maceration to periwound. Redness noted to periwound.. Pt wears foam to areas. Compression stockings BLE's. Pt encouraged to elevate BLE either in recliner or with foot stool. Pt is non-complaint at times with elevation of feet. Reminded educated patient this day on importance of elevating feet to promote healing, please remember that Resident 10 has a [DIAGNOSES REDACTED]. The notes indicate a call was placed to MD on status of wound. A nursing note on 3/30/11 at 5:45 PM states "new orders received and noted per (Physician name /NP name) to culture pressure areas on right foot related to drainage and odor. NP to see pt on rounds on 3/31/11." On 3/30/11 at 5:50 PM Surveyor interviewed Wound Nurse D regarding Resident 10 right foot wounds. Wound Nurse D stated, "Right foot has slough in the heel and is worse. The new area (to lateral ball of foot) is now open it has sough and granulation and we age going to culture it, because of odor; his legs always had an odor, little drainage not a lot but it was bloody and purulent and there was redness around periwound. The top of the right foot is unstageable it was red the previous week. The heel is unstageable due to the slough. I think (the cause of the ulcers is) a combination of [MEDICAL CONDITION] and poor circulation, diabetes, ill fitting shoes but cannot rule out pressure." Surveyor asked Wound Nurse D on 3/23/11 when the right heel wound worsened and dark slough was present with purulent drainage what steps were done. Wound Nurse D stated, "The physician should have been called and updated on the decline in wound, a stage 3 mattress should have been placed on his bed due to the slough present. Every time someone looks at him they should be encouraging him to elevate his legs. Sometimes he just won't put them up it is care planned to encourage to elevate them." Example 2 Resident 5's [DIAGNOSES REDACTED]. Resident 5's wounds include an extensive Chronic Abdominal Wound and Pressure ulcers. Resident 5's Nurses Notes document the following information: 3/24/11 - 6:30 pm: "...Pt (Patient) had heavy amount of purelent (sic) drainage coming from wounds. Drainage had a very foul odor to it. Left side of abdomin (sic) was reddend (sic), more tender et (and) warm to touch... Will update wound clinic tomorrow since that is who deals with pt's wounds... Abdominal folds had reddend (sic) tissue, more red than normal..." 3/25/11 - 6:00 pm: "...Wounds still draining moderate amt (amount) of purlent (sic) drainage. Still has foul odor. Abdomin on L (left) side still red / warm, hard to the touch...will continue to monitor." There is no evidence in Resident 5's record that a physician or the wound clinic was consulted regarding Resident 5's possible infection. On 3/30/11 Surveyor spoke with DCD E and Consultant Nurse L regarding Resident 5's wound documentation of 3/24/11 and 3/25/11. Surveyor asked if the wound clinic had indeed been notified on 3/25/11 regarding Resident 5's condition. DCD E and Nurse Consultant L stated they would look into this. On 3/30/11 at 1:52 pm Nurse Consultant L showed Surveyor the facility's "24 Hour Board" for 3/25/11. On this form was documentation stating a call had been placed to Resident 5's primary physician and a response was pending. It does not indicate why the physician was called, or what information had been left in the message. Surveyor asked if the "24 Hour Board" was a permanent part of residents' records. Nurse Consultant L stated it was not. At this time RN (Registered Nurse) K, who had made the notation on the "24 Hour Board" joined the conversation and stated that on 3/25/11 he had not seen the same wound appearance as was documented on 3/24/11 so he did not call the wound clinic, but instead called Resident 5's primary physician "to update him (that) there was an indication " that an infection may be present, "but I did not see anything". RN K stated that by the end of his shift, no return call had come in to the facility. Surveyor asked RN K if he had documented his wound assessment and that he had called the physician in Resident 5's record. RN K stated he had not and that he would make a late entry. On 3/30/11 at 3:50 pm, at the facility's request, Surveyor spoke with Resident 5's Primary Physician, Dr M, who was at the facility making rounds. Surveyor spoke with Dr M regarding the documentation noted in Resident 5's record on 3/24/11 and 3/25/11, and the 24 Hour Board noting he (Dr M) had been called on 3/25/11. Surveyor asked Dr M if he had any information regarding these Nursing entries. Dr M stated that if a nurse documents that they are going to call then they should have called. Dr M could not say if he had received a message regarding Resident 5 on 3/25/11, but stated "I understand what you are saying, they should have followed up, but it would not have made a clinical difference in the care (for Resident 5)."