Every finding on record at Edgewater Haven Nursing Home

Based on observation, staff interview, and record review, the facility did not ensure 3 treatment carts were locked when unattended and did not ensure 1 of 2 medication carts and 1 medication storage room were free of expired medications and supplies. This practice had the potential to affect more than 4 of the 46 residents residing in the facility.Treatment carts on the 300 and 500 wings were left unlocked and unattended. The 300 north medication cart contained expired medications and supplies. The 300 wing medication room contained expired medication, supplements, food items, and medical supplies.Findings include: The facility's Pharmacy Policy and Procedure Manual, Storage and Maintenance of Medication policy, dated April 15th, indicates: 1. All drugs and biologicals are to be stored in a locked designated cabinet .All medications, except those requiring refrigeration, shall be kept in locked medication carts and cabinets. 2. Outdated refrigerator items must be removed from the refrigerator .8. Medication must be checked regularly for expiration dates and deterioration. Expired items are to be removed from use and returned to the pharmacy or disposed of according to facility procedures. 9. Medications no longer in use are returned .or destroyed or credited where applicable in accordance with state and federal regulations.On 8/12/25 at 5:25 AM, Surveyor entered the 500 wing and an observed an unlocked treatment cart in the hallway. The treatment cart contained medicated creams, ointments, and powders. Surveyor interviewed Registered Nurse (RN)-G who indicated treatment carts should be locked when unattended.On 8/12/25 at 5:30 AM, Surveyor entered the 300 wing and noted the 300 south and 300 north treatment carts were unlocked and unattended. The treatment carts contained medicated creams, ointments, and powders. At 5:31 AM, Surveyor interviewed AM shift RN-H who indicated treatment medication carts should be locked when unattended and directed Surveyor to night shift RN-I.On 8/12/25 at 5:33 AM, Surveyor interviewed RN-I who confirmed treatment carts should be locked when unattended.On 8/12/25 at 11:18 AM, Surveyor observed the 300 north medication cart and noted the following expired items:~ 3 povidone-iodine swab sticks that expired 3/2025~ 21 povidone-iodine prep pads that expired 3/2025~ 32 [NAME] oil emulsion dressings that expired 5/2025~ Gold Bond medicated powder for R33 that expired 6/2023~ Triamcinolone 0.1% cream for R17 that expired on 5/4/25~ Nystatin powder for R18 that expired on 7/31/25Surveyor also observed the 300 wing medication room and noted the following expired items:~ 3 Premier Protein chocolate shakes that expired on 6/30/24~ An Anoro Ellipta inhaler for R16 that expired 12/2024~ A bottle of fluticasone propionate nasal spray for R16 that expired 5/2025~ 14 AutoShield insulin pen needles for R16 that expired 6/2025~ 9 Unifine pen tips plus insulin pen needles for R16 that expired on 12/28/23~ Glucose central solution EvenCare G3 that expired on 1/11/24~ 1 bottle of Aspirin 325 milligrams that expired 4/2025~ 1 bottle of Lantus insulin for R7 that expired on 7/11/25~ 1 container of Thick & Easy orange juice that expired on 11/30/24~ 1 vanilla Novasource renal dialysis shake that expired on 7/25/25~ 1 bottle of Hershey's chocolate syrup that expired 4/2025~ 10 boxes of InteliSwab COVID 19 rapid tests that expired on 10/31/24~ 8 blue top blood vials that expired on 7/31/25~ 13 blunt fill needles with filters that expired on 3/31/25~ 16 dark green top blood vials that expired on 5/2/25On 8/12/25 at 12:32 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-J who verified the expiration dates of the above items and confirmed the items were expired.On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed expired items should not be in medication carts or medication storage rooms.

Based on observation, staff and resident interview, and record review, the facility did not provide the appropriate treatment and services related to bowel and bladder continence for 2 residents (R) (R23 and R41) of 16 sampled residents.R23 had an indwelling catheter and was continent of bowel which was noted on R23's plan of care. During an observation of care on 8/13/25, staff put an incontinence product on R23. R41's care plan did not reflect a need or desire to wear two incontinence products at once. During an observation of care on 8/12/25, staff applied two incontinence products to R41. Findings include:The facility's Urinary policy, dated 9/7/22, indicates: .Nursing staff will develop an individualized plan of care for all residents .1.From 8/11/25 to 8/13/25, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE] and had diagnoses including bacterial pneumonia, severe sepsis, benign prostatic hyperplasia (BPH), chronic kidney disease stage 3, pressure ulcer of sacral region stage 2, and retention of urine. R23's Minimum Data Set (MDS) assessment, dated 7/17/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R23 had intact cognition. The MDS assessment also indicated R23 had an indwelling catheter and was always continent of bowel. A care plan indicated R23 had an indwelling catheter and was continent of bowel. The care plan did not indicate the need for R23 to wear an incontinence product.On 8/13/25 at 8:29 AM, Surveyor observed catheter care for R23. Certified Nursing Assistant (CNA)-E was in the shower room with R23 who was clad in a brief and a gown. On 8/13/25 at 1:52 PM, Surveyor interviewed CNA-K who indicated R23 is not incontinent of bowel and communicates to staff when R23 needs to have a bowel movement. On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a resident needs an incontinence product, it should be noted on the resident's care plan. DON-B directed Surveyor to speak with Registered Nurse (RN)-L who maintained residents' care plans. On 8/13/25 at 2:14 PM, Surveyor interviewed RN-L who confirmed bowel assessments and nurse charting indicated R23 was not incontinent of bowel and did not need to wear an incontinence product. RN-L also confirmed the use of an incontinence product was not listed on R23's care plan or status sheet. On 8/13/25 at 3:00 PM, Surveyor interviewed R23 who indicated R23 did not request to wear a brief and was not sure why staff put a brief on R23. 2. From 8/11/25 to 8/13/25, Surveyor reviewed R41's medical record. R41 was admitted to the facility on [DATE] and had diagnoses including fracture of the left femur, anxiety disorder, osteoarthritis, and mixed incontinence. R41's MDS assessment, dated 6/12/25, had a BIMS score of 14 out of 15 which indicated R41 had intact cognition. The MDS assessment also indicated R41 was frequently incontinent of urine but always continent of bowel.A care plan indicated R41 was incontinent of bladder and wore adult briefs. On 8/12/25 at 6:05 AM, Surveyor observed peri-care for R41. CNA-E removed R41's brief and assisted R41 to the toilet. CNA-E then placed a pad liner in a pull-up product for R41. When Surveyor asked if R41 wore two incontinence products, CNA-E indicated R41 wore two incontinence products most of the time because R41 urinated heavily. On 8/13/25 at 1:48 PM, Surveyor interviewed R41 who indicated a nurse decided R41 needed to wear two incontinence products. R41 indicated R41 did not request to wear two incontinence products related to heavy urination. On 8/13/25 at 1:54 PM, Surveyor interviewed DON-B who indicated staff should not apply double incontinence products unless requested by the resident or the resident's representative. DON-B indicated the use of double incontinence products should be noted on the resident's care plan and status sheet. DON-B directed Surveyor to speak with RN-L who maintained residents' care plans. On 8/13/25 at 2:14 PM, Surveyor interviewed RN-L who reviewed R41's medical record and indicated it did not appear that R41 or R41's representative requested double incontinence products for R41. RN-L indicated CNAs are instructed not to apply double incontinence products unless requested by the resident or the resident's representative or instructed to do so by DON-B or the nursing supervisor.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R7) of 1 sampled resident received dialysis care and services in accordance with the facility's policy.Findings include:The facility's Dialysis policy, dated 10/29/20, indicates under care protocols for arteriovenous (AV) fistula or graft access point: .7. There must be communication between the facility and the dialysis center. The appropriate communication should be sent with the resident in a binder to each dialysis session. The dialysis staff should return a report when the resident returns to the facility which includes basic information including pre- and post- weights, vital signs, and any other pertinent information obtained during the procedure.The facility's Nursing Home Dialysis Transfer Agreement, dated August 2018, indicates: .The Center will develop a written protocol governing specific responsibilities, policies, and procedures to use in rendering dialysis services to designated residents at the Center, including but not limited to the development and implementation of a designated resident's care plan relative to the provision of dialysis services.From 8/11/25 to 8/13/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, anemia, chronic kidney disease stage 5, and dependence on renal dialysis. R7 was R7's own decision maker. R7's medical record indicated R7 received dialysis and had an AV fistula.A care plan, initiated 9/18/14, indicated R7 required dialysis related to end stage renal disease (ESRD). The care plan did not include R7's dialysis days or times or indicate how R7 was transported to and from the dialysis center.R7 had an order for daily weights. Surveyor reviewed R7's weights for 7/8/25 to 8/12/25 and noted R7's medical record did not contain documented weights or indicate weights were communicated to the dialysis center on 7/19/25, 7/24/25, 7/26/25, and 7/29/25.On 8/12/25 at 1:56 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who indicated nurses enter R7's dialysis dates and times on a calendar. CNA-K indicated R7 takes a dialysis binder with R7 to the dialysis center.On 8/12/25 at 2:08 PM, Surveyor interviewed R7 who verified R7 receives dialysis. R7 indicated staff need to provide R7's weight, vital signs, medication, and breakfast before R7 leaves for dialysis appointments. R7 indicated R7's weight is also obtained at the dialysis center before and after dialysis. R7 indicated the dialysis center is supposed to document on a continuity of care document in the front of the binder that the facility sends with R7 and that R7 drops off at the nurses' station upon return.On 8/13/25 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-F who confirmed a continuity of care document is sent with R7 to each dialysis session. RN-F indicated the document contains R7's input and output, medications administered, contact information, vital signs, and weight. RN-F confirmed R7 had an order for daily weights and indicated the dialysis center did not consistently report back to the facility for the times R7 was there. RN-F indicated the dialysis center should provide the facility with R7's pre- and post-weights and changes that occur. RN-F indicated the dialysis center puts new orders in the front pocket of the binder for staff tor review.On 8/13/25, Surveyor reviewed communication sheets from the dialysis center and noted the facility received 6 communication sheets from the dialysis center from 1/2025 to 8/13/25.On 8/13/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the dialysis center should communicate R7's pre- and post-weights, vital signs, and other pertinent information following each dialysis session. DON-B also verified R7's care plan should include R7's dialysis days and times and indicate that R7 receives dialysis services.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R3 and R23) of 16 sampled residents. Staff did not follow enhanced barrier precautions (EBP) during the provision of care for R3.Staff did not follow EBP or ensure a catheter bag and tubing were not in contact with the floor during the provision of care for R23.Findings include:The facility's Enhanced Barrier Precautions (EBP) policy, dated 6/22/24, indicates: EBP expand the use of personal protective equipment (PPE) and refer to the use of a gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing .Residents colonized with a targeted MDRO will be placed on EBP and staff will wear a gown and gloves for high-contact activities. Residents with indwelling medical devices or chronic wounds regardless of having an MDRO will be placed on EBP. Examples of high-contact resident cares activities requiring gown and glove use for EBP include: Dressing; Bathing; Transferring; Providing hygiene; Changing linens; and Device care or use: Urinary catheter.The facility's Daily Care Required for a Resident with Indwelling Catheter policy, dated 2/11/21, indicates: .8. Observe bag. Bag should not touch floor .1.On 8/11/25 at 10:19 AM, Surveyor observed Certified Nursing Assistant (CNA)-D assist R3 into an electric wheelchair. Surveyor observed a sign on R3's door that indicated R3 was on EBP. Surveyor noted CNA-D did not wear a gown during the transfer. Surveyor also observed CNA-D hold R3's catheter bag, help put R3's feet on the wheelchair pedals, and hang R3's catheter bag from the wheelchair.2. On 8/13/25 at 7:26 AM, Surveyor noted a sign on R23's door that indicated R23 was on EBP. When Surveyor entered R23's room to observe care, Surveyor noted CNA-E transferred R23 to a wheelchair while wearing gloves but not a gown. When asked if R23 was on EBP and if PPE was needed for cares, CNA-E indicated R23 was on EBP and CNA-E would get a gown when R23 was in the shower room. CNA-E put R23's catheter bag in a cover, removed linens from R23's bed, and removed a Chux pad from R23's chair. CNA-E then removed gloves, cleansed hands, and covered R23 with a blanket that was on R23's recliner. Surveyor noted R23's catheter tubing was on the floor. When Surveyor indicated the catheter tubing was on the floor, CNA-E clamped the tubing to R23's wheelchair with ungloved hands.On 8/13/25 at 8:29 AM, Surveyor entered the shower room to observe catheter care for R23. CNA-E donned a gown prior to entering the shower room and assisted R23 to the grab bars so R23 could stand. CNA-E put R23's catheter bag on the shower room floor and replaced R23's wheelchair with a shower chair. CNA-E then picked up and gave the catheter bag to R23 to hold while R23 got in the bathtub.On 813/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should wear a gown and gloves during high-contact cares for residents on EBP, including transfers, catheter care, and changing/handling linens. DON-B also indicated catheter bags and tubing should not be on the floor.

Based on staff interview and record review, the facility did not have qualified staff onsite to supervise kitchen operations. This had the potential to affect all 47 residents residing in the facility. Dietary Manager (DM)-D did not have a qualified certification to manage the kitchen. DM-D stated DM-D had access to a contracted Registered Dietician (RD) who worked remotely and was not onsite for supervision. Findings include: On 6/24/24 at 11:48 AM, Surveyor interviewed DM-D who stated DM-D worked as the Dietary Manager for a little over one year and was in the process of taking a ServeSafe course and another unknown course that was assigned by the facility's food service vendor. DM-D confirmed DM-D was not certified as a Dietary Manger. DM-D stated DM-D had access to an RD via phone and email, but the RD did not work onsite due to COVID-19. DM-D stated the RD came to the facility last month for training, but that was the first time DM-D saw the RD. On 6/24/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated NHA-A would contact their food service vendor to find out what training DM-D was enrolled in. On 6/26/24 at 2:16 PM, NHA-A stated DM-D was enrolled in a ServeSafe course of 3/19/24, but was not enrolled in another course. NHA-A confirmed DM-D was hired on 3/22/23 and verified DM-D had not completed the ServeSafe course or any further coursework to gain certification as a Dietary Manager. NHA-A provided Surveyor with proof of enrollment in an approved Dietary Manager course which DM-D was enrolled in as of 6/25/24.

Based on observation, staff interview, and record review, the facility did not ensure food was stored in accordance with professional standards for food service safety. This practice had the potential to affect all 47 residents residing in the facility. Boxes containing food intended for resident use were stored on the floor in the freezer. Raw meats were stored over pre-cooked food in a reach-in cooler. Findings include: The Wisconsin Food Code documents at Preventing Contamination from the Premises 3-305.11 Food Storage: (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 centimeters (6 inches) above the floor. (B) Food in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling equipment as specified under S 4-204.122. The Wisconsin Food Code documents at Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food-Separation, Packaging, and Segregation: (A) Food shall be protected from cross contamination by: .separating raw animal foods during storage, preparation, holding, and display from: (a) Raw ready-to-eat foods including other raw animal food such as fish .or other raw ready-to-eat foods such as vegetables, and (b) Cooked ready-to-eat foods .(2) Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (a) Using separate equipment for each type, or (b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented, and (c) Preparing each type of food at different times or in separate areas .(4) .storing the food in packages, covered containers, or wrappings. The facility's Safe Food Handling policy, dated 4/4/24, indicates: .8. Food must be stored at least 18 inches above the floor. 9. Uncooked food may not be stored over cooked food. On 6/24/24 at 11:45 AM, Surveyor conducted a tour of the kitchen with Dietary Manager (DM)-D who stated the facility followed the Wisconsin Food Code. Surveyor observed a walk-in freezer with 16 boxes stacked on the floor. DM-D stated, We just got a shipment in so I will put those up (on shelves). Surveyor noted hand-written dates of 6/20 on the outside of some of the boxes. DM-D stated the hand-written dates indicated the date the boxes were delivered. DM-D confirmed some of the boxes had not just arrived and stated the boxes should be put on shelves. On 6/24/24 at 12:10 PM, Surveyor and DM-D observed a reach-in cooler that had food items stored on wire rack shelving in the following order from top to bottom: Top shelf: Beverages, pre-made eggs, and cooked pancakes Second shelf: Cooked ham and smoked bacon Third shelf: A tray of glazed pork wrapped with bacon and a cardboard box labeled Uncooked Chicken Breasts. DM-D confirmed the pork and chicken were raw/uncooked. Bottom shelf: A container of raw fish, raw ground beef loaves, and a container of cooked ham. DM-D confirmed the ham was fully cooked and the fish and beef were raw/uncooked. Following the observation, Surveyor interviewed [NAME] (CK)-E who stated raw meat should be stored on the bottom shelf but there was no room. DM-D rearranged the items and put the cooked food items above the raw meats and the uncooked chicken breasts on the bottom shelf. DM-D then instructed CK-E to place a pan under the box of uncooked chicken breasts. On 6/24/24 at 12:12 PM, Surveyor interviewed DM-D who confirmed raw meats should not be stored above cooked food.

Based on staff interview and record review, the facility did not ensure 1 resident (R) (R22) of 2 residents reviewed for hospitalization s received the proper notice of transfer, reason for transfer, location of transfer, and appeal rights. R22 was transferred to the hospital on 4/25/24 and was not provided a written transfer notice. Findings include: On 4/25/24, Surveyor reviewed R22's medical record. Documentation indicated R22 was transferred to the emergency room (ER) on 4/25/24 and returned to the facility the same day with a diagnosis of constipation. R22's medical record did not include documentation that a written transfer notice was provided to R22. On 6/26/24 at 12:57 PM, Surveyor interviewed Director of Nursing (DON)-B and Social Worker (SW)-F who verified the facility did not provide a written transfer notice for R22 on 4/25/24. DON-B stated the facility did not have a transfer/discharge notice form or a policy for transfer notices but needed to include a form and policy in their future process. On 6/26/24 at 1:20 PM, Surveyor received a document titled Appeal Process for Involuntary Discharge from SW-F who stated residents received the document on admission but the document was not provided for transfers/discharges and was not signed.

Based on staff interview and record review, the facility did not ensure monitoring for adverse reactions of high risk medications for 2 residents (R) (R9 and R22) of 5 residents reviewed for unnecessary medications. R9 was prescribed bumetanide (a diuretic medication) for congestive heart failure (CHF) and chronic kidney disease (CKD). The facility did not monitor R9 for adverse reactions or side effects of bumetanide. R22 was prescribed furosemide (a diuretic medication) for hypertension. The facility did not monitor R22 for adverse reactions or side effects of furosemide. Findings include: The facility did not provide a Medication Monitoring/Medication Management Policy. 1. On 6/26/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] with diagnoses including respiratory failure, CHF, diabetes, and CKD. R9's Admission Minimum Data Set (MDS) assessment, dated 9/15/23, indicated R9 received diuretic medication. R9's medical record indicated R9 was prescribed bumetanide 4 mg (milligrams) twice daily on 6/7/24 for CHF and CKD. Surveyor noted R9's plan of care contained interventions for daily weights, to call cardiology with a weight gain of 5 pounds in a week, a fluid restriction, lab monitoring, and hydration monitoring; however, R9's plan of care did not contain monitoring interventions for adverse reactions or side effects of bumetanide. On 6/26/23 at 10:28 AM, Surveyor interviewed Director of Nursing (DON)-B who verified side effects of bumetanide include orthostatic hypotension, hyponatremia (low blood sodium), hypokalemia (low potassium level), chest pain, cramp, dizziness, weakness, and confusion. DON-B verified although some interventions were in place there were no specific monitoring interventions for adverse reactions or side effects of bumetanide in R9's orders or care plan. 2. On 6/26/24, Surveyor reviewed R22's medical record. R22 was admitted to the facility on [DATE] with diagnoses including dementia, lupus, CKD, and hypertension. R22's Annual MDS assessment, dated 11/10/23, indicated R22 was prescribed diuretic medication. R22's medical record indicated R22 was prescribed furosemide 40 mg once daily for hypertension on 8/29/23. Surveyor noted R22's plan of care did not contain monitoring interventions for adverse reactions or side effects of furosemide. On 6/26/24 at 11:54 AM, Surveyor interviewed DON-B who verified R22's plan of care did not contain monitoring for adverse reactions or side effects of furosemide. DON-B verified the side effects of furosemide include orthostatic hypotension, hyponatremia, hypokalemia, blurred vision, skin photosensitivity, anorexia, headache, cramps, drowsiness, dizziness, and muscle spasms. DON-B stated staff do nursing assessments, but the assessments do not indicate they are completed for diuretic monitoring.

Based on staff interview and record review, the facility did not ensure the resident environment remained free of accident hazards for 1 resident (R) (R17) of 1 resident reviewed for smoking. R17 was a known smoker. The facility did not complete a smoking assessment for R17. Findings include: The facility's Smoking-Free Policy, dated 1/14/20. indicates: Residents will agree not to smoke or use electronic cigarettes .at Edgewater Haven upon admission in the facility, or on the grounds .Residents who wish to continue to smoke must do so off the grounds by signing out with help of family or friends . On 6/24/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] with diagnoses including fracture to left pubis, post traumatic stress disorder (PTSD), acute myocardial infraction (heart attack), and Takotsubo syndrome (sudden temporary weakening of the muscular portion of the heart). R17's Minimum Data Set (MDS) assessment, dated 2/16/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R17 had intact cognition. R17 did not have an activated Power of Attorney (POA) and made R17's own healthcare decisions. During the entrance conference on 6/24/24 at 9:49 AM, Nursing Home Administrator (NHA)-A stated the facility was smoke-free and there were no residents in the building who smoked. On 6/24/24 at 11:13 AM, Surveyor interviewed R17 who stated R17 could smoke when R17 wanted to smoke. R17 stated R17 had a flag for R17's wheelchair and had to go to the curb to smoke. On 6/25/24, Surveyor reviewed R17's care plan which stated, Resident will refrain from using tobacco products, e-cigarettes and vaping devices while at Edgewater Haven. On 6/25/24 at 2:40 PM, Surveyor interviewed Registered Nurse (RN)-C who confirmed R17 smoked independently. RN-C stated R17 needed to sign R17's self out at the nurses' station and staff provided R17's cigarettes and lighter. RN-C stated R17 smoked at the curb and returned the cigarettes and lighter to staff when R17 returned to the building. On 6/25/24 at 2:52 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R17 smoked and stated R17 did not need a smoking assessment because R17 did not smoke on facility grounds. DON-B verified R17's lighter was kept at the nurses' station, but was unsure if R17's cigarettes were kept at the nurses' station. When Surveyor asked about monitoring for R17, DON-B stated R17 went to therapy to ensure R17 was safe to leave the grounds. On 6/25/24 at 2:55 PM, Surveyor interviewed NHA-A who stated R17 was R17's own person and did what R17 wanted. NHA-A confirmed R17 used an orange flag provided by therapy when R17 left the facility and stated R17 was assessed by therapy as safe to leave the building. NHA-A stated staff can smoke on facility property, however, residents are not permitted to smoke on facility property. NHA-A stated R17 signed a non-smoking consent prior to admission and said R17 is the only resident who smokes. On 6/26/24, Surveyor reviewed a discharge status and recommendation therapy note for R17, dated 3/6/24. The therapy note did not include information related to R17's ability to safely smoke or leave facility property.

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection, such as COVID-19, which had the potential to affect all 42 residents (R) of the facility. Throughout the survey, observations were made in which: - Staff did not sanitize goggles when moving from a positive Covid-19 resident to a negative resident room or change their contaminated N95 masks prior to caring for a resident that is negative for Covid-19; - R2 and R36 were in precautions for positive Covid-19. The isolation bins that hold contaminated linens and trash were inside the room approximately 10 feet from the door to the corridor with the residents beds by the door. Staff disposed of their PPE and walked passed the residents to leave the room, unprotected. - Staff were noted to not wear goggles at all times in resident care areas; and - Improper hand hygiene was noted with wound dressing changes for two residents (R2 and R40) Because there were four active Covid-19 cases among residents and several staff were off work related to Covid-19 positivity, this has the potential to affect all residents, staff, and visitors in the building. This is evidenced by: - The community transmission rate was medium for Covid-19 during the survey. The facility has been in and out of outbreak mode for Covid-19 since 09/02/2020. The facility had a break in cases from 4/13/2021- 8/30/2021 when another case was identified. The facility was again in outbreak mode from 8/30/21 to 02/03/2022. On 4/9/22, another outbreak started and this outbreak continues to present day. - The facility policy titled, Infection Prevention and Control Coronavirus Disease 2019 (Covid-19) suspected or Confirmed, dated 2/2/22 directs staff to wear goggles and facemasks during outbreak mode. The facility directs staff to cover the N95 masks with a surgical mask prior to entering rooms of residents confirmed or suspected of Covid-19 infection. Upon exiting resident rooms, staff are directed to remove and dispose of surgical masks, gloves and gowns. The goggles/face shields are worn all day and are considered multi-use equipment. Note: The facility is currently in Contingency Mode for N95 masks due to the difficulty in acquiring ample supply from their vendors. Under Cleaning and Disinfecting, the policy directs staff, .Any type of equipment that goes into multiple resident rooms needs to be disinfected . Cleaning must be done after each use . The policy goes on to direct staff in cleaning/disinfecting eye protection and states, .Eye protection should be removed and reprocessed . if it becomes visibly soiled . Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution . - Surveyor reviewed Centers of Disease Control and Prevention (CDC) publication titled, Interim Infection Prevention and Control Recommendations to Prevent the [CONDITION(S)]-CoV-2 Spread in Nursing Homes, with most recent update 02/02/2022. In this update, CDC recommended under Source control options for HCP (Health Care Providers), If (N95 masks) are used during the care of a patient with [CONDITION(S)]-CoV-2 infections . they should be removed and discarded after the patient care encounter and a new one should be donned . This publication goes on to state that healthcare personnel who enter the room of a patient with suspected or confirmed . infection should adhere to Standard Precautions and use NIOSH-approved N95 or equivalent respirator, gown, gloves, and eye protection. - In the CDC publication, Strategies for optimizing the Supply of Eye Protection dated 9/13/2021, the CDC states, .In areas of substantial to high transmission in which healthcare personnel are using eye protection for all patient encounters, extended use . may be considered as a conventional capacity strategy . Reusable eye protection should be cleaned and disinfected after each patient encounter . - On 5/17/22 at 11:29 AM, and again on 5/19/22 at 9:00 AM, Surveyor interviewed RN C (Registered Nurse and Infection Preventionist) regarding expected practice of staff while the facility is in an outbreak mode, of which there are currently four Covid positive cases of residents and several staff members. RN C stated the expected practice for PPE (Personal Protective Equipment) during an outbreak is that staff are to wear N95 masks at all times, with all residents. Staff can cover their N95 masks with a surgical mask upon entering a Covid positive resident room in order to save the mask, as their vendors are currently limiting the supply the facility can order each month. Upon leaving a positive resident room, staff are to discard the surgical mask. RN C stated she is having a difficult time getting a handle on the outbreaks and have been in and out of outbreak mode since September of 2020. She stated the facility would be going through at least 200 masks a day if the staff changed them out each time they left a resident's room. She stated the facility is currently in contingency with N95 masks. RN C stated they will be exploring the use of different vendors to help get out of contingency. RN C stated expected practices of staff in relation to goggle and visor use was that staff are to disinfect eye protection when moving from a Covid-19 positive room to a non-positive room. - On 5/18/22 at 2:48 PM, Surveyor interviewed HIC L (Health Information Coordinator). HIC L does all the PPE ordering for the facility. HIC L stated the PPE supplies are limited by the facility vendors.For quite a while during the beginning of the pandemic, I was unable to get any N95 masks. The Moldex brand was totally unavailable so we fit tested all the staff for the 3M styles and ordered them based on availability. The majority of our 8210s and 1860s we obtained from Emergency Management . HIC L stated that the facility is still being limited by vendors and that the facility has fit tested staff at least five times in order to accommodate the mask availability. She stated that the facility continues to explore other vendors to meet the facility's need for N95 masks. Example 1: On 5/16/22 at 1:24 PM, Surveyor observed CNA M (Certified Nursing Assistant) enter the room of Resident (R) 2. CNA M was already wearing goggles and an N95 mask. R2 was currently positive for Covid-19 infection. CNA M donned an isolation gown and a pair of gloves prior to entering the room. CNA M did not cover the N95 mask with a surgical mask, as directed in the facility policy. CNA M transferred R2 to his bed in order to conduct catheter care and monitoring for Surveyor. Once care was completed, CNA M removed her gown and gloves and placed into the contaminated receptacle, located near the window and at least 10 feet inside the room. She then exited the room, walking past R2, unprotected, who was in his bed and near the door. CNA M then walked to the nursing desk and washed her hands. CNA M did not remove and disinfect her goggles and proceeded with additional resident care activities. There also was no changing of the now contaminated N95 mask. Example 2: On 5/16/22, between the hours of 6:30 AM - 4:30 PM, Surveyor noted all staff working on 500 unit wore goggles and N95 masks throughout entire day of observation by Surveyor. Staff were noted to don a blue cloth isolation gown and gloves prior to entering three rooms on Contact/Droplet precautions for positive Covid-19. Upon exiting each room, they properly removed the gown and gloves inside each room and sanitized their hands. The staff wore the same N95 mask from room to room, even upon entering resident rooms that were not positive for Covid-19. Also noted, staff did not sanitize their goggles when leaving a positive room and prior to entering a negative Covid-19 resident room. Staff did not cover their N95 masks with a surgical mask prior to entering Covid positive rooms . Example 3: On 5/17/22 at 11:23 AM, Surveyor observed HSKG N (Housekeeping) in the doorway of R3's room. R3 was currently positive for Covid-19 infection. HSKG N had no eye protection on her face. Surveyor approached HSKG N and asked to explain the procedure to follow when cleaning a room in which the resident is on Covid precautions. HSKG N stated she is to put on gown, gloves, mask, and goggles, clean the room, then upon leaving room, dispose of everything inside the room. She is to then wash her hands. HSKG N stated that she is to wear an N95 mask and either goggles or a face visor all day and to don a gown and gloves upon entering rooms in which there is a positive Covid-19 case. Surveyor asked her where her goggles were and why she was not wearing them. She searched her cleaning cart for goggles and was unable to find them. HSKG N then stated, I lost them or someone took them. Surveyor then asked if she had been working all morning without her goggles. HSKG N stated, Yes, I was. I can't find my goggles. Surveyor then asked if there was a means for her to get another pair and HSKG N stated there was, I just haven't gotten around to getting them. Surveyor then asked HSKG N if she was aware that the facility is in Outbreak Status related to positive cases of Covid-19? HSKG N stated that she was aware and, I do have goggles I just don't know where they are. I will go and get a new pair. At 11:30 AM, Surveyor approached RN C (Registered Nurse and Infection Preventionist) regarding the observation made. RN C stated that all staff were given goggles or a face visor and were instructed to wear them at all times in the building with the exception of breaks. Example 4: On 5/17/22 at 12:01 PM, Surveyor was returning to the Conference Room and noted two staff on the 300 Unit without eye protection on. CNA O (Certified Nursing Assistant) and CNA I were in and out of resident rooms. CNA O had her goggles sitting on top of her head. CNA I only had her eyeglasses in place with no visor or goggles covering them. There was a resident on the unit with Covid-19 positive test results. Upon Surveyor's questioning, both CNAs stated they were unaware that the facility was in outbreak mode. CNA O then placed her goggles over her eyes, but CNA I stated that her goggles do not fit properly with her eyeglasses. She stated that she has tried three different pairs of goggles and none work and she breaks out with the visor. At 12:20 PM, Surveyor approached RN C (Registered Nurse and Infection Preventionist) regarding the observation. RN C stated all staff were assigned a pair of goggles appropriate for them. I will get (CNA I) a pair that fit over her glasses right now. Example 5: On 5/19/22 at 8:09 AM, Surveyor observed LPN Q working on the 500 Unit. LPN Q had an N95 mask in place but no eye protection. There were two positive Covid-19 resident cases on this date on the Unit. Surveyor asked LPN Q what education she has received regarding source control when in an outbreak situation. LPN Q replied that she was to wear the N95 mask and goggles. She stated, I know, I literally just came out of the office and did not put them on. I should put them on. Example 6: On 05/16/22 at 01:27 PM, Surveyor observed certified nursing assistant (CNA) G and CNA H going into R36's room, which is a COVID positive resident room. Staff put on full PPE and a surgical mask over their N95. On 05/16/22 at 01:37 PM, Surveyor asked CNA G why they put a surgical mask over her N95 - that is just what we were told to do. Surveyor asked if they do anything with their goggles. CNA G indicated no. The CNAs did not disinfect goggles. Example 7: On 05/17/22 at 07:42 AM, Surveyor observed CNA I getting ready to go into R36's room who is COVID positive, CNA I put on gown, gloves, and a surgical mask over her N95. On 05/17/22 at 08:03 AM, CNA I came out of the COVID positive room with the N95 that she wore in the room and goggles on. Goggles were not disinfected once she was in the hallway. Example 8: On 05/17/22 at 08:10 AM, Surveyor observed RN J gowning up to go into COVID positive room. RN J put a surgical mask over her N95, put on gown, face shield, and gloves, and brought in R36's breakfast and medicine. On 05/17/22 at 08:18 AM, Surveyor observed RN J exit the COVID positive room. Surveyor could hear RN J washing her hands before exiting. When RN J came out of the room, RN J threw away her surgical mask in the garbage can in the hallway. RN J did not sanitize her face shield. Interviews: On 05/19/22, at 11:10 AM, Surveyor interviewed CNA R regarding isolation precautions and PPE (Personal Protective Equipment). CNA R has worked for the facility for 2 years. When asked what type of precautions a Resident with [CONDITION(S)] should be on, she stated, contact. When asked what type of precautions a Resident with Norovirus should be on, she stated, droplet/airborne, and for Influenza she stated, droplet/airborne. When asked what type of PPE should be worn in a room for a Resident with [CONDITION(S)], she stated, gown, gloves, and for Norovirus/Influenza, she stated, N95, mask, gloves, goggles, or shield. When asked what PPE should be worn in a room for a Resident during a COVID-19 outbreak, she stated, gown, gloves, goggles, face shield, N95. When asked what PPE should be worn in hallway in Resident care areas during a COVID-19 outbreak, she stated, N95 and goggles. When asked how often an N95 and goggles/face shield should be worn in Resident care areas during a COVID-19 outbreak, she stated, all the time. On 05/19/22, at 11:20 AM, Surveyor interviewed CNA O regarding isolation precautions and PPE. CNA O has worked for the facility for [AGE] years. When asked what type of precautions a Resident with [CONDITION(S)] should be on, she stated, contact. When asked what type of precautions a Resident with Norovirus should be on, she stated, droplet/airborne, and for Influenza she stated, droplet/airborne. When asked what type of PPE should be worn in a room for a Resident with [CONDITION(S)], she stated, gown, gloves, and for Norovirus/Influenza, she stated, N95, mask, gloves, goggles, or shield. When asked what PPE should be worn in a room for a Resident during a COVID-19 outbreak, she stated, gown, gloves, goggles, face shield, N95. When asked what PPE should be worn in hallway in Resident care areas during a COVID-19 outbreak, she stated, N95 and goggles. When asked how often an N95 and goggles/face shield should be worn in Resident care areas during a COVID-19 outbreak, she stated, all the time. Example 9: - The facility policy and procedure for Hand Hygiene, dated 6/8/2020 directs staff to perform hand hygiene during these times (not all-inclusive): - having direct contact with resident; - before donning gloves; - before handling clean or soiled dressings; - before moving from a contaminated body site to a clean; - after contact with body fluids or excretions . and wound dressings if hands are not visibly soiled; and - after removing gloves. On 5/17/22 at 7:39 AM, Surveyor observed LPN P (Licensed Practical Nurse) conduct a treatment and dressing change to R34's feet. During the treatment, the following was observed: - LPN P initially washed her hands and donned a pair of gloves. - LPN P then removed the old dressing to the left foot. The dressing contained a moderate amount of purulent (yellowish to brown) drainage. The wound was approximately the size of a quarter coin and contained a dark brown to black center. Brown to black tissue was also observed around the edge of the wound from 3 o'clock to 9 o'clock. LPN P did not wash or sanitize her hands after removing the soiled dressing. Instead, she proceeded to wash the wound with normal saline and patted it dry with a 4 x 4 gauze pad. LPN P then opened a non-adherent dressing and two packages of triple antibiotic ointment. She then squeezed the ointment over the non-adherent dressing and placed this over the wound. She then wrapped the wound with Kerlix gauze and taped into place. Following the treatment to the left foot, LPN P did not remove the gloves and wash or sanitize her hands. Instead, she proceeded to replace the sock and boot to left foot. LPN P then removed her soiled gloves and without washing or sanitizing her hands, donned a fresh pair of gloves. She then removed the boot and sock from R34's right foot. There was no dressing in place on this wound and LPN P stated the area is left open to the air and only gets skin prep to the area. LPN P washed the wound with normal saline and without removing the gloves and washing or sanitizing her hands, proceeded to apply skin prep to the wound. LPN P then removed her gloves and washed her hands. At 7:58 AM, Surveyor interviewed LPN P regarding the observation made. Surveyor asked LPN P what she has learned regarding hand hygiene during dressing changes. During her explanation, LPN P stated, Oh yeah, when removing the old, I should have sanitized my hands. Sometimes you just do do do. I forgot. On 5/17/22 at 1:55 PM, Surveyor interviewed RN C (Registered Nurse and Infection Preventionist) regarding the observation made with LPN P. RN C stated the correct practice is that nurses are to wash their hands upon entering the room, don gloves, and remove the old dressing. Staff should then remove the gloves and wash or sanitize their hands, then proceed to clean the wound. After cleaning the wound, staff should then remove their gloves once again and sanitize or wash their hands, apply a new pair of gloves and proceed with the treatment ordered, whether it is to apply a cream/ointment or new dressing. Example 10: R40 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/18/22, at 10:00 AM, Surveyor observed RN D perform a dressing change to R40's wounds to right foot. RN D gathered supplies from treatment cart, donned PPE appropriately, entered room, told R40 what she is going to do. Set up a clean field and dirty field. Got supplies ready. Placed a clean barrier on bed under right foot and a garbage can has been placed on the floor under his foot. RN uses dirty scissors to cut old bandage off and throws it in the trash. She then removes the old packing from the heel wound and throws in the garbage. The packing is wet with bloody drainage on it. There are 2 wounds noted, 1 on right outer foot and 1 on heel. Wound beds are clean with granulation tissue and beefy red bed. RN D does not remove her gloves prior to cleansing the wounds. RN D takes gauze soaked in solution that is in a med cup and cleanses each wound separately. RN D removes her gloves, sanitizes her hands, and dons new gloves. 05/18/22 12:39 PM, according to infectious disease progress/culture note dated 03/24/22, Resident has [CONDITION(S)] [CONDITION(S)]. Resident sees wound clinic, infectious disease, and has been receiving hyperbaric treatments. 05/18/22 01:02 PM, wound measurements, assessments, treatments, and wound clinic notes reviewed with no issues noted. 05/18/22 01:21 PM, Surveyor interviewed RN D in which she stated the process should be that before touching, remove old bandage and clean (still considered dirty until clean), then change gloves to clean when doing the clean dressing change.

Based on observation and interview, the facility did not ensure staff stored, prepared, and distributed food according to professional standards. This had the potential to affect all 42 residents. -Food in fridge was not covered and dated -Not maintaining temp logs for cooler/freezer/dishwashing machine -Staff are not practicing appropriate glove use This is evidenced by: On 05/16/22 at 9:25 AM during initial tour with Dietary Supervisor (DS) E, Surveyor observed coolers, cooler temps, and freezer temps were all within normal range. When Surveyor asked to see the temperature logs for the coolers and freezers May 1st through the 8th, no temps were documented on the log. Surveyor asked DS E if that meant it was not done. DS E indicated yes. On 05/16/22 at about 9:35 AM, Surveyor observed the 2 coolers side by side; one of the coolers had the desserts for the lunch and supper meals in individual dishes on a tray with nothing covering them and not dated. On 05/17/22 at about 11:15 am, Surveyor observed the same coolers which had today's lunch and supper desserts in them; all desserts were covered individually with lids or saran wrap and dated. On 05/17/22, Surveyor asked the DS E, who was the acting cook on duty on 05/16/22, about the desserts in the cooler not being covered on 05/16/22. DS E indicated had not covered the desserts the day before. On 05/16/22 at 9:55 AM, during tour of the dish room, Surveyor asked to see the temperature logs. DS E asked Dietary Aide F where the log was and she indicated there was not one. DS E went to her office and got a new blank log. Surveyor asked DS E if that meant the temps have not been done all month. DS E indicated yes. On 05/17/22 at 11:25 AM, Surveyor observed Cook K temping lunch. Cook K washed hands after temping food and put on new gloves. She then picked up a pen, wrote her temps down, uncovered plates, loaded the steam table, grabbed plates, dished up soup with a ladle, picked up a cold sandwich with the same gloved hands, then picked up a handful of lettuce with the same gloves and put it on a plate. She continued dishing up plates with the same gloves on, picking up the cold sandwiches and grabbing a hand full of lettuce without removing her gloves in between touching non-food items. On 05/17/22 at 12:00 PM, Surveyor interviewed DS E and asked if the above practice was the appropriate way to dish up trays. DS E indicated that she should have been changing her gloves or using tongs. The facility policy entitled, Safe Food Handling, dated January 20, 2021, reads in part 21. Gloved hands are considered food contact surface that can become contaminated or soiled, so it is imperative that gloves get changed between tasks to avoid cross-contamination.

Based on observation, interview, and record review, the facility did not ensure the nurse staffing information was accurate on the daily staff posting. This had the potential to affect all 42 residents. The facility staff postings did not include actual hours worked for staff. This is evidenced by: Surveyor reviewed the nursing staff postings for May 2, 2022 - May 16, 2022. The posted nurse staffing dated May 16, 2022 reads in part . Shift 6am-2pm # of RNs 2 # of Med Techs 1 # of CNAs 5 Total nsg staff this shift 11 Off to the right side it reads, Staff working less than 8 hours this shift 1 CNA OR (orientated) 1 CNA 0.50 hr DON 1.50 hr Shift 2pm-10pm # of LPNs 3 # of CNAs 5 Total nsg staff this shift 8 Shift 10pm - 6am # of RNs 1 # of LPNs 1 # of CNAs 3 Total nsg staff this shift 6 Off to the right side it reads, Staff working less than 8 hours this shift 1 CNA 10-6 On 05/18/22 at 12:30 pm, Surveyor interviewed Health Information Coordinator (HIC) L and asked who was responsible for filling out the daily staff posting. HIC L indicated that the night shift nurse fills out the daily posting and she collects them the following day to make any changes needed due to call ins and then files them for 18 months. Surveyor asked HIC L if she was trained on how the nurse staffing was filled out. HIC L indicated many [NAME] ago by a DON. Surveyor asked HIC L how they came up with 11 staff for the 6am - 2 pm shift. HIC L indicated that 2 RNs, 1 med tech, 5 CNAs, 1 CNA 1, 1 CNA 0.50, and DON 1.50. Surveyor told HIC L that when Surveyor looked at the posting and saw total of 11 total nursing staff for the 6 am - 2pm shift I would think 11 staff times 8 hours would be a total number of 88 hours of nursing staff for that shift. HIC L indicated that the shifts are 7.75 hours. HIC L agreed that the posting does not specify the actual hours worked by staff.

Based on observation, interview, and record review the facility did not conduct a thorough assessment for 1 (R9) out of 13 sampled residents. R9 was not assessed for his tobacco chewing habit. This is evidenced by: R9 was admitted to the facility for long term care in (MONTH) (YEAR). R9 has the following, but not all inclusive, Diagnoses: [REDACTED]. On 04/29/19, Surveyor interviewed R9 who was seated in his room, watching television. Surveyor made daily observations during the 3 day survey of R9 having tobacco in his lower front gum. R9 was also observed spitting the tobacco juice into a plastic bottle several times during the 3 day survey. R9 stated he has chewed tobacco every day and has done so since he was 5 years old. R9 stated staff are aware of his tobacco product use, but they don't complain about it. R9 stated his tobacco supplies were kept in a safe place in his room and there was no danger of others finding the tobacco. Surveyor conducted a comprehensive record review on 05/01/19 and was unable to locate any tobacco use care plan for R9. On 03/26/19 R9 was examined by the dentist who noted abnormal gums due to chewing tobacco use. The facility had completed a quarterly MDS (Minimum Data Set) assessment in (MONTH) 2019 and did not note the dentist's findings. The facility completed an annual MDS assessment for R9 on 08/06/18. Section J1300 asked if the resident used tobacco products of any kind. The facility answered this questions as no. On 05/01/19 at 8:15 a.m., Surveyor interviewed the MDS RN (Registered Nurse) coordinator regarding R9's tobacco use. The MDS RN stated she was unaware of R9's tobacco use. The MDS RN stated had she known of the tobacco use, she would have marked yes to questions J1300 for R9. On 05/01/19 at 10:00 a.m., Surveyor discussed lack of assessment and no care plan for R9's tobacco use with the DON (Director of Nurses). The DON stated she had worked in the facility for [AGE] years and was unaware of R9's tobacco use. The DON stated she knew R9 had a history of [REDACTED]. Surveyor requested a copy of R9's tobacco use assessment and care plan reflecting R9's tobacco use. The DON stated there was no assessment or care plan for R9's tobacco use as the people who would have completed those documents were unaware of the tobacco use.

Based on observation, interview, and record review the facility did not develop a care plan for 1 (R9) out of 13 sampled residents. R9 had no care plan for his tobacco chewing habit. This is evidenced by: R9 was admitted to the facility for long term care in (MONTH) (YEAR). R9 has the following, but not all inclusive, Diagnoses: [REDACTED]. On 04/29/19, Surveyor interviewed R9 who was seated in his room, watching television. Surveyor made daily observations during the 3 day survey of R9 having tobacco in his lower front gum. R9 was also observed spitting the tobacco juice into a plastic bottle several times during the 3 day survey. R9 stated he has chewed tobacco every day and has done so since he was 5 years old. R9 stated staff are aware of his tobacco product use, but they don't complain about it. R9 stated his tobacco supplies were kept in a safe place in his room and there was no danger of other residents finding the tobacco. Surveyor conducted a comprehensive record review on 05/01/19 and was unable to locate any tobacco use assessment or care plan for R9. On 03/26/19 R9 was examined by the dentist who noted abnormal gums due to chewing tobacco use. The facility reviewed R9's care plan in April, 2019 and did not recognize the dentist's findings. Surveyor interviewed nursing staff, activity staff, housekeeping staff, and all staff were aware of R9's tobaccos use. On 05/01/19 at 10:00 a.m., Surveyor discussed lack of assessment and no care plan for R9's tobacco use with the DON (Director of Nurses). The DON stated she had worked in the facility for [AGE] years and was unaware of R9's tobacco use. The DON stated she knew R9 had a history of [REDACTED]. Surveyor requested a copy of R9's tobacco use assessment and care plan reflecting R9's tobacco use. The DON stated there was no assessment or care plan for R9's tobacco use as the people who would have completed those documents were unaware of the tobacco use. Please see F636 for additional staff interviews.

Based on observations and interviews, the facility did not ensure staff handled medications so as not to contaminate them for 3 of 4 residents reviewed (R21, R29, and R43). RN D (Registered Nurse) was noted, during medication administration, to don a glove onto her right hand, obtain pills into the gloved hand, and touch multiple presumed contaminated surfaces, while handling resident medications, without changing her glove. This was observed for 3 residents. This is evidenced by: On 3/6/18, beginning at 4:30 PM, Surveyor observed RN D administer medications to R21, R29, and R43. RN D donned a glove on her right hand. For each resident, RN D's practice was to: ~ Gather her keys from her pocket; ~ Obtain each medication from the drawers of her medication cart; ~ Gather each medication into her gloved hand and place it into a plastic medication cup; and ~ Obtain a pen and sign each medication gathered in her medication and/or narcotic book. RN D did not remove the glove and sanitize her hand after touching a contaminated surface, and prior to touching the next resident's medications. This practice had great potential to transmit any microbe from RN D's medication cart, medication and narcotic book, keys, and pen to every resident's medication RN D placed into her gloved hand. Surveyor spoke with RN D after the observation, about her practice. RN D indicated she could not remove medications from the packaging and place them into the plastic medication cup, without crushing the cup. RN D stated she could not touch medications with her bare hands, so she opted to wear a glove so she could handle each medication. Surveyor relayed the observations to RN D, including those in which RN D touched contaminated surfaces and then touched resident medications, without removing her glove. RN D concurred her practice had the potential to transmit disease and infection. On 3/7/18 at 7:42 AM, Surveyor spoke with RN E. RN E indicated she was the Infection Prevention Practitioner. Surveyor relayed the observation as note above. RN E stated staff should be washing their hands or using an alcohol based sanitizer after touching anything considered contaminated. RN E indicated RN D's practice was not a good practice.

Based on observation, interview, and record review, the facility did not ensure 1 of 9 sampled residents with dementia (R17) received the necessary care and treatment to maintain their highest psychosocial well-being. R17 had a [DIAGNOSES REDACTED]. Subsequently, on 3/6/18, after R17's sleep had been interrupted and forced by 3 staff members to take a shower, R17 did not want, R17 was noted emotionally distressed, agitated, and wandering the hall of the dementia care unit requiring 1 to 1 staff observation in order to prevent R17 from harming herself or other residents. Findings. Surveyor completed a review of R17's clinical record and noted the following. R17 had current [DIAGNOSES REDACTED]. R17's most current MDS (Minimum Data Set), dated 1/2/18, indicated R17; ~ Had a BIMS (Brief Interview for Mental Status) score of 3, indicating a severe cognitive impairment; ~ Required the assistance of 1 to 2 staff persons for all aspects of care, except eating; ~ Had physical behavior symptoms directed towards others on 1 to 3 days during the look back period; ~ Had verbal behavior symptoms directed towards others on 4-6 days during the look back period; ~ Had other behavioral symptoms not directed towards others on 4-6 days during the look back period; and ~ Behaviors put resident at significant risk for injury, interfered with care, interfered with activities and social interactions, interfered with the living environment, and put other at significant risk. R17's care plan titled, .Altered Thought Process . and .Self Care Deficit , dated 1/11/18, had the following approaches. ~ .Consult with Charge Nurse .if .verbalizes feeling depressed or anxious, or displays non-verbal S/S (signs and symptoms) of depression, anxiety, such as angry outbursts, combative toward staff, yelling or accusatory toward staff, throwing objects, resisting food/med's (medications)/cares, crying, increased restlessness/agitation, lack of interest in usual activity . ~ .1:1 conversation . ~ .Offers snacks, distraction such as TV. Likes doing word search and crossword puzzles, reading religious material, listening to music .pet visits .going outdoors . ~ .If resistive leave alone with supervision . ~ .Redirect from 500 wing northern exit door . ~ .Provide redirection, cueing and reminders to her as needed . ~ .Reproach . ~ Offer .to choose .own nap and bed times . Surveyor requested R17's social history. Surveyor received a social history from another facility, dated 3/25/15. The social history recapitulated R17's legal status, hospitalization history, social history, financial status, and prognosis. The social history did not include R17's usual and current cognitive patterns, life patterns and preferences, simple pleasures, customary responses to triggers such as stress, pain, and anxiety, nor what non-pharmacological approaches were effective in reducing triggers. Surveyor requested a comprehensive assessment of R17's social history, including those areas not noted in the social history, dated 3/25/15. Surveyor received a form titled Recreation Therapy Notes. The information reiterated the approaches as noted on the care plan. The notes did not include R17's life patterns, preference, simple pleasure, what R17's triggers were, R17's responses to triggers or what approaches were effective in reducing R17's triggers. Surveyor also received a form titled Social Services Initial Assessment. The assessment received was 5 pages in total. Two of the pages were undated. Two of the pages were dated 3/7/18. One of the pages was dated 12/26/17 and 3/7/18. The area of the form, which directed staff to assess Social History, Mood and Behavior Patterns, and Mental and Psychological Disorders, were not completed. On 3/6/18 at 10:11 AM, Surveyor noted R17 was verbally agitated propelling wheelchair up and down hallway, in a hurried fashion, going into other resident rooms. RN B was close-by R17, preventing R17 from going into other resident rooms. Surveyor asked RN B why R17 was agitated. RN B indicated R17 had just had a shower, which causes R17 to become upset. Surveyor asked RN B why a shower caused R17 emotional distress. RN B was not sure. RN B indicated R17's mood is the best if R17 sleeps until 10:00 AM. RN B indicated, when R17 gets agitated, R17 will throw things. RN B stated she needed to keep a close eye on R17 to ensure R17 stayed out of the rooms with residents in them and to make sure R17 did not exit the unit. From 10:11 AM until 10:23 AM, RN B attempted to escort R17 to her room. R17 was resistive both physically and vocally, and persisted on trying to go into other resident rooms. On 3/6/18 at 10:23 AM, R17 attempted to open the doors twice at the end of the Dementia Care Unit, eliciting an alarm. R17 then proceeded to attempt to pull off the name on the wall, outside of room [ROOM NUMBER]. RN B removed R17 from the door and requested R17 not pull off the name. R17 returned to the door and again attempted to pull off the name. RN B attempted again to escort R17 to her room. R17 refused to go with RN B and attempted to go into room [ROOM NUMBER]. R17's verbal responses to RN B's requests were irrational and in an angered and irritated tone. RN B again attempted to escort R17 to her room. R17 refused again both physically, by planting her feet on the floor, attempting to strike out, and verbally. RN B requested the assistance of another staff person, at which point, RN B was able to escort R17 to her room. On 3/6/18 at 10:35 AM, Surveyor noted R17 in her room and no longer agitated. R17 was emotionally distressed for a period of at least 24 minutes following a shower. On 3/6/18 at 10:40 AM, Surveyor spoke with CNA C (Certified Nursing Assistant). CNA C indicated she worked full time on the unit in which R17 resided. CNA C indicated R17 liked to sleep until 9:00 AM to 9:30 AM. CNA C indicated R17 had been interrupted and re-approached too many times this morning, while trying to sleep, in an attempt to get R17 to eat breakfast. CNA C indicated if R17 doesn't sleep until she is ready to wake up, she wakes up angry. CNA C indicated if they let R17 wake up on her own, her attitude was much better. CNA C indicated R17 subsequently ate a little bit for breakfast, when she usually ate well. Surveyor asked CNA C about R17's shower. CNA C indicated she had just given R17 a shower. CNA C stated R17 did not like getting undressed and did not like getting her hair wet. CNA C indicated she was not sure why. CNA C indicated R17 did not want to take a shower this AM and it took 3 staff to complete the shower, as R17 was combative. CNA C indicated it periodically took 3 staff to complete R17's showers, as R17 was combative during the shower. R17 was woken up and then re-approached to eat breakfast, even though staff was aware R17 needed to wake up on her own. R17 was also given a shower R17 did not want, resulting in 3 staff members forcing R17 to take the shower. This caused R17 undo emotional distress, which lasted at least 24 minutes. R17's care plan contained no information or instruction to staff regarding R17's preferred wake times. The care plan contained no information regarding R17's dislike of showers. There was no direction to staff on how to manage R17's showers. It was critical for staff to complete a comprehensive assessment in order to drive a Person Centered Individualized Care Plan in order to avoid the emotional distress R17 had suffered. On 3/7/18 at 12:54 PM, Surveyor spoke with the SW (Social Worker). Surveyor asked the SW about R17's social history. The SW indicated she did not repeat the social history, as she thought it was all-inclusive. The SW indicated she felt they were addressing resident with dementia, including those with behaviors, in a comprehensive fashion.

Based on record review and interview, the facility did not ensure that at the time of transfer of a resident for hospitalization or therapeutic leave, the facility provided to the resident, and the resident representative, written notice which specifies the duration of the bed-hold policy during which the resident is permitted to return and resume residence in the facility and any associated costs in 4 of 4 residents reviewed for bed holds; (R (Resident) 2, 3, 4 and 6). R2 was transferred from the facility to a hospital and was not provided with a written notice of the duration of the bed hold and the associated costs. R3 was transferred from the facility to the hospital. R3's AHCPOA (Activated Health Care Power of Attorney) was not provided with written notice of the duration of the bed hold and the associated costs. R4 went on a therapeutic leave twice and was not provided with written notice of the duration of the bed hold and the associated costs for either leave. R6 was transferred to the hospital and was not provided with written notice of the duration of the bed hold and the associated costs. This is evidenced by the following: The facility's policy and procedure entitled Bed Hold and Return, dated 11/27/17, states, in part: Residents and their representatives will be provided with bed hold and return information at admission and before a hospital transfer or therapeutic leave. The facility will maintain in (sic) contact with the resident and representative while the resident is absent from the facility and arrange for their return if appropriate . . Bed Hold and Return notice before transfer. The facility will provide written information per the (Resident / Family Notification of Transfer or Discharge) form to the resident or resident representative before the resident is transferred to a hospital or the resident goes on therapeutic leave that specifies the following: . Duration . Reserve Bed Payment .The facility's policies regarding bed - hold periods permitting resident to return . On 12/28/17 at 11:47 AM, RN - Staff Development H told Surveyors: Since our census has been so low we do not do bed holds. They (residents) go to the hospital. They leave their stuff here and they come back to the same room. We didn't charge them anything. Example 1 R2's [DIAGNOSES REDACTED]. R2's record contains the following documentation: 12/11/17 Nurses Notes 3:20 PM: Per resident / families (sic) request resident would like to go to ER (emergency room ) via family transporting. Resident / family feels that something is not right. MD (name) gave orders to send to ER via family transporting . 12/11/17 Nurses Notes 7:00 PM: Writer called (Hospital) to check on status of ER visit. Resident admitted with pneumonia & UTI (Urinary Tract Infection) per ER staff. 12/21/17 Nurses Notes 4:15 PM: Arrived to facility via (illegible). readmitted to room (#). There is no documented evidence and the facility, was unable to provide evidence, that R2 was provided a bed hold for her hospital transfer on 12/11/17. Example 2 R3 was admitted to the facility on [DATE]. On 11/24/17, R3 was transferred from the facility to the hospital. R3 and her AHCPOA were not provided with written notice of the duration of the bed hold and the associated costs. Review of R3's medical record indicated R3 was transferred to the hospital on [DATE]. FM G (Family Member) was notified of the transfer, but there was no written documentation that notices for the bed hold and associated costs were given. On 12/28/17 at 10:30 AM, Surveyor asked R3 is she was given the bed hold notice when she was being transferred to the hospital. R3 indicated that the facility did offer her a bed hold and R3 indicated she did not sign anything. R3 indicated that Surveyor should talk to her son as he handles all of her paperwork. R3 returned to the facility on [DATE]. On 12/28/17 at 10:40 AM, Surveyor left a message for FM G to call back. Further review of R3's medical record indicated that R3 was transferred to the hospital on [DATE]. FM G was notified of the transfer, but there was no written documentation that a notice for the bed hold and associated costs were given. R3 returned to the facility on [DATE]. On 12/28/17 at 3:30 PM, DON B indicated that a bed hold was not given and the facility has not been giving out bed hold notices. DON B indicated she knows this has slipped through the cracks. On 12/29/17 at 10:30 AM, FM G returned the Surveyor's phone call. Surveyor asked FM G if the facility talked to him or provided written documentation about a bed hold when R3 was transferred to the hospital. FM G indicated that the facility never talked to him about a bed hold when his mother went to the hospital. FM G indicated that the family was not sure if there would be a bed for his mother when she was ready to return to the facility. Surveyor asked FM G if the facility provided him with a bed hold and associated costs on the second transfer to the hospital. FM G indicated 'no'. FM G indicated the family just assumed the facility would be holding the bed. Example 3 R4 was admitted to the facility on [DATE]. On 10/27/17, R4 went on a therapeutic leave and was not provided with written notice of the duration of the bed hold and the associated costs. Review of R4's medical record indicated R4 returned from a therapeutic pass on 10/29/17. There was no written documentation that notices for the bed hold and associated costs were given or the date of the therapeutic leave. On 12/28/17 at 10:45 AM, Surveyor interviewed RN F regarding where the bed hold notice would be located for R4 when she goes on therapeutic leave. RN F indicated that the family will sign the resident out. RN F indicated that the facility will automatically hold the bed as they are aware the resident will come back. Review of SW C notes, dated 11/20/17, includes, in part: R4 will be out overnight for Thanksgiving. Return Friday. Nrsg (nursing) aware. Review of R4's medical record did not document when R4 left for the therapeutic leave or returned. The facility did not provide written documentation that notices for the bed hold and associated costs were given. On 12/28/17 at 10:50 AM, Surveyor went to talk to R4 and a Certified Nursing Assistant indicated R4 was in the bathroom and vomiting at this time. Surveyor did not interview R4. Example 4 R6 was admitted on [DATE] and discharged to home on 11/4/17. R6 was admitted again on 11/13/17 and was transferred to the hospital on [DATE]. The facility did not provide R6 with written notice of the duration of the bed hold and the associated costs. Review of R6's medical record indicated there was no written documentation that notices for the bed hold and associated costs were given when R6 transferred to the hospital. R6 was discharged from the hospital to home on 11/27/17.

Based on interview and record review, the facility did not ensure that 1 of 3 residents (R1) out of a total 7 sampled residents for discharge planning were appropriately discharged . R1 was transferred to an Ambulatory Surgery Center for day surgery on [DATE]. R1 stayed overnight due to medical issues. The facility involuntarily discharged R1 from the facility when she did not return from day surgery on [DATE]. Evidenced by: The facility's Admissions Contract form, signed by R1 on [DATE], includes, in part, the following: Termination: Voluntary Termination. This agreement may be terminated by the Resident. Resident must provide (Nursing Home Name) at least 7 days written notice of his/her intention to terminate this Agreement. Involuntary Termination. (Nursing Home Name) may terminate this Agreement and discharge Resident for any of the following reasons: 1. Non-payment of charges, following reasonable opportunity to pay any deficiency. 2. If Resident requires care other than that which Home is licensed to provide. 3. If Resident requires care which the Home does not provide and is not required to provide under state law. 4. For medical reasons as ordered by a physician. 5. In case of a medical emergency or disaster. 6. For Resident's welfare or the welfare of other residents. 7. If Resident does not need nursing home care. 8. If the short-term care period for which Resident was admitted has expired. 9. As otherwise permitted by law. Except for removals under (1) and (5) above, no resident may be involuntarily removed unless an alternative placement that has accepted Resident for transfer is arranged. In addition, (Nursing Home Name) shall schedule a planning conference at least 14 days before the involuntary removal and with at least 7 days' notice of the conference to the Resident, Legally Authorized Representative if any, any appropriate county agency and others designated by the Resident. R1's [DIAGNOSES REDACTED]. R1 is her own decision maker. R1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] indicates R1 is cognitively intact, can understand and is understood, and has an active discharge plan in place to return to the community. R1's Nurse's Notes include, in part, the following entries: [DATE], 0435 (AM), resident left facility (with) friend for surgery. [DATE], 0845 (AM), Received call from RN (Registered Nurse) at (Ambulatory Surgery Center Name) who stated resident had shown up for surgery and was currently undergoing procedure at this time. Caller stated it would be determined after surgery whether or not resident would be staying overnight depending on how she is when she wakes up. Writer asked that the surgery center please call and inform (Nursing Home Name) on what/if they decide to keep her overnight or not, as well as they would need any and all new orders post-op sent to them via fax to ensure that they are received, to which they agreed. Will await to hear from surgery center at this time. [DATE], 1145 (AM), Spoke with RN (Registered Nurse) at (Ambulatory Surgery Center Name). Resident admitted to their facility for overnight stay following surgery d/t (due to) Resident's hx (history of) noncompliance. RN stated to this Writer that resident has informed them that she doesn't know if (she) will be coming back to (Nursing Home Name) when she leaves their care. Writer obtained direct # (number) to unit where resident will be overnight, (Nursing Home Name) to call in AM Tuesday (tomorrow) to see what resident's plan is and get an update. RN Supervisor and Social Worker all updated on the above. [DATE], 0900 (AM), Writer also reminded (Ambulatory Surgery RN) that when she (R1) does D/C (discharge) the surgical center is to fax us a copy of her D/C orders. [DATE], 12:00 (PM), Received faxed order for eye drops from (R1's eye physician). Writer called and spoke with (Ambulatory Surgery Center RN) R/T (related to) other med/insulin orders. (Ambulatory Surgery Center RN) stated (R1's eye physician) was only able to give eye orders and that (R1's Primary Care Physician) would need to be handling readmit orders. Fax sent to (R1's Primary Care Physician) for readmission orders [REDACTED] [DATE], 12:30 (PM), Resident back in facility - stated she took her own blood sugar and lunch meds as well as gave herself her own insulin per own supply. Stated, I'm leaving here; I need to start doing this stuff myself. [DATE], 1200 (1:00 PM), Writer went in to start admission ppwk (paperwork). Resident refused - stated she is going home today most likely (after) my apt (appointment) at 2:00 PM with (Managed Care Organization (MCO) Name). [DATE], 1325 (1:25 PM), Resident refused readmission weight as well as treatments. She is packing up her room. [DATE], 1445 (2:45 PM), Back to facility to pick up personal items, refused readmit assessment, left facility (with) items. R1's Social Service's Notes include, in part, the following entries: [DATE], Writer, DNS (Director of Nursing Services), unit supervisor, and SSA (Social Services Assistant) placed call to (RN at MCO Name). Made aware res (resident) has just let us, know she is having outpt (outpatient) eye surgery Monday. Aware of non-compliance issues continuing. Plan to meet w/ (with) res Monday pending whether they keep her overnight. (MCO Name) hasn't had time to check on respite CBRF (Community Based Residential Facility) placement. Res has looked at some apartment(s). Will further discuss d/c (discharge) planning Monday. [DATE], Updated (MCO Name) res out tonight for observation after surgery d/t non-compliance. Rescheduled d/c meeting for [DATE] at 2:00 PM. [DATE], Res returned from outpatient stay following eye surgery. She declined all readmit paperwork and assessments, stating she's here to pick up her things, meet w/ (MCO Name) and go home - chooses not to readmit. Tells nursing it would be a waste of time. She did meet with (MCO Name) and informed them she's returning home. Writer and unit supervisor answered several questions. Res asked if she would take Rx (medications) from here today or if would be called to pharmacy. Unable to send or call in as she is not a resident at this time - considered d/c AMA (Against Medical Advice) [DATE] when out for surgery. Friend and (MCO Name) aware. Friend suggested she complete admit (admittance). Res declined. (MCO NAME) and Writer suggest she contact her PCP (Primary Care Provider) to renew Rx. She called immediately - helped to private area for call. Did not readmit. D/C AMA [DATE]. Chart Closed. On [DATE] at 2:44 PM, Surveyor interviewed R1 via telephone. R1 stated, on [DATE], she left the facility for day eye surgery and was kept overnight due to an increase in her blood pressure. R1 stated when she returned to the facility, on [DATE], she was told she was no longer a resident, they could not give her any discharge paperwork, and no medications could be given to her. R1 stated Social Services and Nursing staff told her that she was discharged AMA and was not offered any assistance with her discharge except by the maintenance staff who helped her load her belongings into her friend's car. R1 stated she was never told she was discharged when she went to the Ambulatory Surgery Center. R1 stated RN E from (MCO Name) was present at the facility on [DATE]. On [DATE] at 2:54 PM, Surveyor interviewed SW D (Social Worker). SW D works for (MCO Name). SW D stated she was not at the facility on [DATE]; however, she did know that R1 was not given any medications from the facility on [DATE], and did not have a good plan on where she was going on [DATE]. SW D stated there was no final discharge plan to discharge R1 to the community on [DATE]. On [DATE] at 3:10 PM, Surveyor interviewed SW C. SW C stated R1 had gone out for eye surgery and did not want assessments done when she returned on [DATE], so we considered her discharged , because of not having assessments done. SW C stated the facility staff should have attempted to keep her in the facility until safe discharge could happen. On [DATE] at 3:26 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated R1 refused to be readmitted , refused to be assessed and refused to allow us to contact her physician. We considered her discharged because of this. On [DATE] at 12:15 PM, Surveyor interviewed RN E. RN E is R1's case worker for the MCO. RN E stated she was at the facility on [DATE] to meet with R1 to talk about discharge planning. RN E stated when she arrived at the facility; R1 was upset and informed her that she had been discharged from the facility, because she was gone overnight. RN E stated SW C informed her that it was the policy of the facility to discharge anyone who is gone overnight and she would have to be readmitted to get any medications or discharge paperwork from them. RN E stated the facility did not inform her that R1 would be discharged if she stayed overnight in the hospital after her eye surgery. RN E stated R1 was homeless and did end up finding a friend to stay with for a few days.

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 residents. The hand washing sink did not reach the minimum temperature to ensure effective handwashing. This is evidenced by: On 12/05/16 at 10:45 a.m. Surveyor entered the facility kitchen. Surveyor asked the DM (Dietary Manager) where the hand washing sink was located. The DM directed Surveyor to the hand washing sink in the kitchen. Surveyor proceeded to wash hands at the sink and noted the water temperature as lukewarm. Surveyor returned to the kitchen on 12/06/16 at 7:15 a.m. Surveyor washed hands in the same handwashing sink and found the water to be lukewarm. The hot water was left running. After 2 minutes the water temperature was tested in a cup and found to be only 94 degrees Fahrenheit. Surveyor proceeded to an alternate hand washing sink and found no problems with water temperatures. Surveyor asked Cook-A about the water temperature. Cook-A stated the water takes a long time and does not get hot enough. Surveyor asked Cook-A if staff use the sink for hand washing. Cook-A responded staff use the sink or the one in the dish room. Surveyor asked Cook-A how long the hand washing sink had not gotten hot enough. Cook-A responded it has been going on for quite some time. Surveyor remained in the kitchen and observed Cook-A and DA-B (Dietary Aide) preparing breakfast items for breakfast. Surveyor observed Cook-A and Dietary Aide -B wash their hands at the sink that had been tested for temperature and proceed to prepare breakfast items. Surveyor again tested the temperature of the hand washing sink and found the temperature to be 80 degrees Fahrenheit. On 12/06/16 at approximately 8:45 a.m. Surveyor spoke with the DM about the water temperatures in the hand washing sink. The DM indicated the temperature was not hot enough for staff to perform hand hygiene in the kitchen to sanitize staff hands.

Based on observation, record review, and interview the facility did not follow current standards of practice or the facility policy when administering medications via a [DEVICE] (stomach tube) for 1 out of 1 supplemental resident with a [DEVICE]. During the medication pass observation, Surveyor # observed RN (Registered Nurse)-C administer 4 medications mixed in a medication cocktail, not individually for R18. In addition, RN-C did not check placement of R18's [DEVICE] prior to medication administration or feeding via the [DEVICE]. This is evidenced by: On 12/07/16, Surveyor requested and received the facility policy titled Enteral Tube Medication Administration. According to the facility policy, all medications should be finely crushed, mixed with water, and given separately to avoid physical interaction of the medications then followed by a 5 ml (milliliter) water flush between each medication. The facility policies reflect the current standards of practice according to ASPEN (American Society for [MEDICATION NAME] and Enteral Nutrition.) According to ASPEN, [DEVICE] placement confirmation was required prior to all medications and feedings to avoid complications such as aspiration pneumonia, gastric erosion, and peritonitis (abdominal infection.) In addition, all medications should be given separately followed by 5-10 mls of water to flush between medications. This is to ensure proper absorption of each medication and prevent medication interactions. R18 was admitted to the facility on [DATE] for long term care. R18 had a history of [REDACTED]. R18 had a [DEVICE] placed as the only route to receive nutrition, hydration, and medications. Review of the physician orders [REDACTED]. On 12/05/16 at 1:05 p.m., Surveyor observed RN-C crush the following medications: [REDACTED]. RN-C added 15 mls of water to the medication mixture and created a medication cocktail. RN-C took a syringe, connected the syringe to the end of the [DEVICE], and pulled back on the plunger to check for placement of the tube. There was no evidence (residual stomach contents) of placement of the [DEVICE]. RN-C did not check placement of the [DEVICE] using the auscultation method prior to administering medications and feeding. RN-C then took a syringe filled with 60 mls of water, attached the syringe to the [DEVICE], and flushed the tube with the water. RN-C then filled the syringe with the medication cocktail and administered all medications into the [DEVICE]. RN-C then flushed the [DEVICE] with another 60 mls of water. RN-C poured 2 cans of [MEDICATION NAME] 1.5 (a total of 480 mls) plus 240 mls of water into the feeding bag and attached the feeding bag to R18's [DEVICE]. R18 received the feeding plus water via gravity. On 12/05/16 at 1:12 p.m., Surveyor interviewed R18 regarding the [DEVICE] care. R18 stated the nursing staff administered medications and feeding as the above observation. R18 stated approximately 2 months ago the [DEVICE] fell out and staff had to reinsert the [DEVICE]. R18 also stated several months ago the [DEVICE] fell out and staff was unable to reinsert. R18 stated the [DEVICE] was reinserted at the hospital. On 12/05/16 at 1:18 p.m., Surveyor # interviewed RN-C regarding the [DEVICE] medication and feeding. RN-C stated giving medications mixed together was the facility policy. RN-C stated the pharmacist would change the times of medications if the medications should not be mixed together. RN-C stated checking [DEVICE] placement via auscultation was not the facility policy. RN-C stated the above observation was consistent with her routine of administering medications and feeding to R18. On 12/07/16 at 10:00 a.m., Surveyor # interviewed the DON (Director of Nurses) regarding the facility policy on [DEVICE]s. The DON stated the facility policy requires the licensed nurse to check placement via auscultation prior to all medications and feeding. The DON further stated the facility policy requires the licensed nurse to administer each medication separately followed by 5 mls of water between medications. The DON stated RN-C should have checked placement via auscultation especially since there was no evidence of stomach contents and RN-C should have given medications separately, not in a medication cocktail.

Based on observations, interviews, and record review, the facility did not provide the necessary treatment to promote the healing of pressure ulcers for 1 of 1 sampled resident reviewed for pressure ulcers. Resident #8 was admitted to the facility on [DATE] with dermal stripping and denuded areas on her buttocks and a deep tissue injury on her left medial heel. Resident #8 was placed on the facility's standard mattress, a foam wheelchair cushion, and repositioning every 1.5 to 2 hours. By 02/14/14, Resident #8 developed a Stage II pressure ulcer to the coccyx. There were no changes to Resident #8's care plan. The pressure ulcer has not healed and has progressed to a Stage III on 09/24/14 with tunneling, drainage, odor and pain present during the observed dressing change. This is evidenced by: Surveyor # 's review of Resident #8's medical record included the following Diagnoses: [REDACTED]. Resident #8 has been under hospice care since 12/27/13. The MDS (Minimum Data Set) assessments, dated 12/20/13 and 1/09/14, indicate Resident #8 is at risk for the development of a pressure ulcer, has 1 unstageable pressure ulcer that was present on admission, and has pressure reducing devices in the wheelchair and bed. Resident #8's admission care area summary dated 01/09/14, included the following recommendations under pressure ulcers: continue scheduled turn/reposition every 1 1/2 to 2 hours, skin prep and barrier cream to bilateral buttocks twice a day and as needed, continue pressure reduction cushion in her wheelchair and pressure mattress on her bed. Resident #8's comprehensive care plan included a problem dated 01/20/14 of "Impaired skin integrity..." Approaches include the following: "...12/13/13 Reposition/turn every 1 and 1/2 to 2 hours, pressure reducing mattress on her bed, pressure reducing cushion on her w/c (wheelchair)[MEDICATION NAME] 1% cream to buttocks twice a day...skin prep and barrier cream to buttocks twice a day and as needed...continue skin alteration assessments until healed." Review of Resident #8's Skin Alteration Assessment, dated 12/16/13, indicated that upon admission, Resident #8 had a deep tissue injury to the left heel, and denuded areas on both buttocks. These areas were noted to be healed on 1/31/14. The Skin Alteration Assessment, dated 2/14/14, indicated Resident #8 developed a new pressure ulcer. "Coccyx. Stage II. 0.6 cm (centimeter) x 0.4 cm x 0.2 cm. Pressure reducing mattress on bed and cushion to wc (wheelchair). Turn/reposition sched (schedule) q (every) 1 1/2 - 2 hours..." Despite the development of a new pressure ulcer, no changes were made to Resident #8's plan of care to promote the healing of the pressure ulcer. Skin Alteration Assessments continued weekly with the condition of the pressure ulcer essentially unchanged. The 6/6/14 Skin Alteration Assessment indicated the pressure ulcer is now 1.5 cm x 1.0 cm x 0.5 cm, "100% slough (non-viable tissue)." When the wound bed is covered by slough, it is not possible to determine the stage of a pressure ulcer and it would be considered "Unstageable." Despite the presence of slough, the facility considered the pressure ulcer a Stage II. The nurse documents the same interventions that had been in place since admission and also "often refuses." There were no changes made to Resident #8's plan of care despite knowledge of Resident #8 refusing cares and that the current interventions were not appropriate for healing the pressure ulcer. On 06/13/14, the Skin Alteration Assessment indicated Resident #8's pressure ulcer to the coccyx is a Stage II, 1.5 cm, width 1.8 cm and depth 0.5 cm with 1.7 cm of tunneling or undermining (not specified which) present at 3-4 o'clock. Interventions in place continued to be pressure reducing mattress on bed and cushion to w/c turn and reposition scheduled 1 1/2 to 2 hours. "Resistive to turn and reposition schedule often refuses." There were no changes made to Resident #8's plan of care to promote the healing of the pressure ulcer. With tunneling or undermining present, the pressure ulcer should be considered a Stage III. From 06/13/14 through 09/11/14, Resident #8's pressure ulcer to the coccyx remained essentially unchanged. There were no changes made to Resident #8's plan of care. The Skin Alterations Assessment, dated 09/19/14, indicated the coccyx ulcer was a Stage II, 2.0 cm x 0.9 cm x 0.6 cm with 0.4 cm tunneling/undermining at 12-3 o'clock, 1.3 cm tunneling/undermining at 6-9 and 0.4 cm tunneling/undermining at 9-12 o'clock. Wound appearance red and bloody and moderate bloody exudate present. The nurse documented the wound had "Improved" even though it had shown deterioration. Interventions in place continued to be pressure reducing mattress and cushion to w/c, turn and reposition every 1 1/2 to 2 hours. On 09/24/14 at 10:30 a.m., Surveyor # observed a Lacura foam cushion on Resident #8's wheelchair. At 10:45 a.m., Surveyor # observed a blue gray mattress on Resident #8's bed (Geo-Mattress Max Foam Mattress). From 09/23/14 to 09/24/14, Surveyor # observed Resident #8 either in her wheelchair or in bed with the Lacura foam cushion or the blue gray standard mattress on her bed. On 09/24/14 at 9:50 a.m., Surveyor # observed Hospice RN-D (Registered Nurse) complete the pressure ulcer dressing change to Resident #8's coccyx. RN-H and CNA-G (Certified Nursing Assistant) assisted with the dressing change. RN-H and CNA-G assisted Resident #8 to a side lying position and provided comfort and diversion during the dressing change. RN-D had all supplies set up on the bedside table when Surveyor # entered the room. There was no barrier placed on the bedside table. RN-D stated Resident #8's old dressing had come off and Resident #8 had on an ABD pad to protect the ulcer until the dressing could be reapplied. RN-D washed hands and applied 2 pairs of disposable gloves. RN-D removed the ABD protective pad and proceeded to wash the coccyx ulcer with normal saline then pat dry with gauze. RN-D measured the wound which was 2 cm (centimeters) by 1.4cm by 0.4 cm. RN-D noted undermining at 7 o'clock to 12 o'clock that measured 0.9 cm. RN-D stated the pressure ulcer was a stage II. RN-H stated the pressure ulcer was a stage II-III. Surveyor # observed the pressure ulcer on Resident #8's coccyx to be a stage III ulcer with a healthy, intact periwound and a clean, pink wound bed. There was no evidence of an infection. RN-D removed the top layer of disposable gloves after completing the dirty task of removing the old dressing and washing the wound bed. RN-D did not change gloves, wash hands, and don clean gloves prior to applying the clean dressing to the coccyx ulcer. RN-D then placed a small amount of wound gel on a Q-tip and inserted the gel inside the ulcer. RN-D then inserted a small piece of calcium alginate rope into the ulcer bed, covered the primary dressing with an ABD pad and an opsite. RN-D removed gloves and washed hands once Resident #8 was positioned onto side and covered with a blanket. At 10:04 a.m., Surveyor # interviewed RN-D regarding the above observation. RN-D stated she was not wound certified; however had past experience and education on pressure ulcer care. Surveyor # asked if hospice staff are expected to follow the facility's standards of practice. RN-D stated Heartland Hospice staff are expected to comply with the nursing home standards and customary practices. The Surveyor asked if RN-D double gloving during dressing changes was appropriate. RN-D stated she always double gloved to eliminate the time a resident had to be exposed and potentially uncomfortable during a dressing change. RN-D stated double gloving to avoid hand washing between dirty and clean was an acceptable standard of practice. Surveyor # noted Resident #8 was lying on a standard pressure reducing mattress and had a foam cushion in the wheelchair. Surveyor # asked RN-D if those standard pressure reducing devices on the bed and in the chair were appropriate for a stage III pressure ulcer. RN-D was unaware of the appropriateness of these devices. RN-D stated these pressure reducing devices had been supplied by the nursing home. RN-D stated she would obtain a gel wheelchair cushion and an air over-lay bed mattress that would be appropriate for a stage III pressure ulcer. After chart review and discussion with nursing staff, RN-D stated she would stage Resident #8's pressure ulcer as a stage III. On 09/24/14, RN-D documented Coccyx Stage II-III length 2 cm, width 1.4 cm., depth 0.4 cm. Base granulated. Tunneling undermining 7-12 o'clock 0.9 cm, drainage serosang, slight odor. The summary indicated additional wheelchair cushion and mattress options would be explored to promote greater pressure reduction. This recommendation was made after the surveyor questioned RN-D. The facility nurse's notes, dated 09/24/14 at 6:00 p.m., indicated the following: "...New mattress put on bed. Reactive Air delivered by AdvaCare with setting (initially) between 3-4 (1 is soft and 10- is hard/firm). New w/c cushion...gel cushion put in wheelchair..." On 09/24/14 at 7:25 a.m., Surveyor # observed a Reactive Air Pro Mattress System on Resident #8's bed. Surveyor # spoke with CNA-G (Certified Nursing Assistant). CNA-G said she had worked with Resident #8 since her admission to the facility. CNA-G said prior to this mattress system, Resident #8 had the blue gray standard mattress that all of the residents have. The following approaches were added after the surveyor's entrance to the facility on [DATE]: "09/24/14 Gel cushion in w/c (Gel u seat) and Reactive air mattress with setting 3-4 initially (1 is soft with 10 hard/firm) (with pump). 09/25/14 wound care per md orders." These are the first changes to Resident #8's plan of care. On 09/25/14 at 9:40 a.m., Surveyor # interviewed the DON (Director of Nurses) and RN-J, who identified self as Resident #8's Unit Manager. RN-J stated Heartland Hospice RN comes weekly to assess Resident #8 and change the pressure ulcer dressing on the coccyx if needed. RN-J stated the mattress and wheelchair cushion were provided to Resident #8 by the nursing home. RN-J stated she was unaware she could ask Heartland Hospice to provide a more appropriate wheelchair cushion and bed mattress for Resident #8. RN-J stated she assumed it was up to Heartland Hospice to make those types of changes to Resident #8's care plan. RN-J stated Resident #8 was at high risk for pressure ulcer development due to Resident #8's frequent refusals to get out of bed and poor nutrition. RN-J stated the pressure ulcer on Resident #8's coccyx was unlikely to heal due to the risk factors. RN-J stated Resident #8 was given a high calorie supplement twice daily which Resident #8 consumed and enjoyed. Surveyor # asked if there had been any other nutritional interventions offered to help heal Resident #8's pressure ulcer. RN-J stated there had been no additional nutritional interventions tried. Surveyor # asked if the facility had increased the frequency or volume of the high calorie supplement which Resident #8 readily consumed. RN-J stated she did not think an increase in the high calorie supplement was considered. RN-J stated Resident #8's pressure ulcer on the coccyx began on 02/14/14 as a stage II and it remained a stage II. The facility identified Resident #8's risk factors for the development of pressure ulcers; however did not implement appropriate interventions to combat these risk factors. The DON stated the dressing change to Resident #8's coccyx was a clean procedure which required to remove gloves, wash hands, and don clean gloves between removing old dressing and cleaning the wound to apply the new dressing. The DON stated Heartland Hospice staff are to follow the facility's current standards of practice. The DON stated she was not aware of the double gloved technique that was used by RN-D during Resident #8's dressing change to the coccyx. The DON stated the double gloved technique was not a standard of practice the facility utilized. The DON stated prior to RN-D completing the dressing change for Resident #8 on 09/24/14, the DON had reminded RN-D to practice clean technique which included a barrier on the table for supplies and good hand hygiene practices. The DON stated RN-D was not accepting of the guidance.

Based on observations, interviews, and record review, the facility did not ensure that 1 of 2 sampled residents has the opportunity to refuse health care as outlined in the plan of care. On 8/22/11, the facility developed a care plan approach in which Resident #1 was only to be out of bed for lunch and supper. On 8/23/11, Resident #1 was observed to repeatedly tell staff he did not want to go to bed. Staff put Resident #1 to bed. Once in bed, Resident #1 cried, shouted, screamed and begged to get out of bed. Staff did not honor that request. This is evidenced by: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of his MDS (Minimum Data Set) assessment, dated 7/14/11, finds that he is able to express his needs and understands simple direction if phrased to elicit a yes or no answer. The CAAs state that if he wants something like a soda or to call his brother, he will shout loudly. His most current plan of care, created 4/4/11, finds that because of his impaired physical abilities, 2 staff members are to transfer him with a mechanical lift. He is dependent on staff for all dressing, bathing and hygiene task, except he is able to help staff with dressing his upper body if he is willing. He is incontinent of bowel and bladder. His thought processes are altered with his [DIAGNOSES REDACTED]." In addition, staff are to "Offer Resident #1 diversional activities. He used to enjoy coloring, painting, crafts, walks outside, weather permitting." In regards to his behaviors, the care plan states, "Resident may call out repeatedly without regard to socially appropriate responses. Staff to meet requests as needed with regard to safety and resident abilities." The plan of care also states Resident #1 has the "Potential for breakdown due to his decreased mobility and incontinence. The staff are to monitor the resident's skin, check for incontinence and change him every 2 to 3 hours, and assist with repositioning every one and a half hours. In addition, staff are to apply Skin Prep and [MEDICATION NAME] cream twice a day, use dimethicone wipes, and a house barrier cream as needed. Information regarding behaviors and medication were reviewed by Surveyor # . The resident has shown none of the expected side effects of his antipsychotic medications. The shift information shows that on a daily basis Resident #1 calls out. It does not note how often he calls out and if the calling out was with purpose and resolved when his need was met. On 8/23/11, Surveyor # continuously observed Resident #1 beginning at 7:25 a.m. Resident #1 slept until his blood sugars were checked at 9:28 a.m. He was then given breakfast in bed. He was assisted out of bed at 10:15 a.m. by CNA-C and CNA-D. On 8/23/11 at 10:47 a.m., Resident #1 first called out, "Help me!" when he was slowly wheeling himself half way up the hall from his room. At 10:53 a.m. he was at the nursing station and he called out, "I want my pop! I want my pop!" and it was given to him. When he was done at 11:05 a.m. he yelled that he was done. At 11:35 a.m., he called out his brother's name at a side door and his wanderguard alarm went off. At 11:40 a.m., he called out his brother's name and staff arranged to have him call and leave a message for his brother. While in the dining room awaiting lunch, Resident #1 called out his brother's name two times when he saw LPN-H (Licensed Practical Nurse). LPN-H did not acknowledge. Resident #1 called out his brother's name at 11:58 a.m. to CNA-D. CNA-D told the resident that his brother was not here and asked if he had the chance to call him earlier. Resident #1 responded, "Yeh, Yeh." At 12:26 p.m. during his meal, he called out for another drink and CNA-C got one for him. There was no other calling out until 12:52 p.m. when he asked a restorative aide for his brother and a pop. At 1:01 p.m., LPN-H got him the phone to leave a message on the answering machine for his brother, and gave Resident #1 his medications. Surveyor # observed Resident #1's calling out very infrequently that morning. His calling out was to voice wants and needs, and when those were satisfied he was quiet. At 1:05 p.m., Surveyor # observed CNA-C (Certified Nursing Assistant) and CNA-D propel Resident #1's wheelchair down to the end of the hall to his room. Three times while going down the hall, Resident #1 yelled out, "I don't wanna lay down!" CNA-C was overheard to say, "(Resident #1), we gotta lay you down." While in the room and while the aides were taking off his foot pedals, Resident #1 yelled out, "I don't wanna go to bed!" three times. CNA-C explained that it was being done to help heal his bottom. The resident yelled out, "No!" three times while the aides hooked up the mechanical lift. While the aides raised and lowered Resident #1, he screamed out 7 times, "I don't wanna lay down!" and began to cry. He then cried out more softly, "I don't wanna lay down." three more times. CNA-C told the resident, "When it gets all healed and such you'll be able to run around and such," and patted his shoulder. Despite Resident #1's request not to lay down, the staff put Resident #1 in bed. While physically rolling the resident to change his incontinence product, Resident #1 repeated, "No! No! No! No!" four more times. CNA-D told the resident, "You're O.K." Of note is that the earlier treatment cream was washed off in the process and no incontinence barrier cream was used afterwards. While the aides cleaned up the room and supplies, CNA-C told the resident, "Resident #1 we just told you you have to lay down. We're not gonna argue with you." CNA-D told the resident, "We have to do what the doctor wants. We're not doing this to be mean." Resident #1 was positioned on his left side and started to repeat in a small voice, "No. No. No. No. No. No. No." Resident #1 began to shout, "I wanna get up!" 2 times. CNA-C told him the television was on the Animal channel and there was a program he could watch. While Surveyor # , CNA-C, and CNA-D were leaving the room, Resident #1 shouted, "Can I get up?" two times. At 1:15 p.m., Surveyor # observed Resident #1 yell at RNS-B (Registered Nurse Supervisor), "I wanna get up!" This was after RNS-B gave the resident the phone to call his brother. RNS-B stated, "Do you want to color? There's a horse show on TV." Resident #1 shouted five times, "I want to get up!" Despite his numerous requests to get up, staff did not assist Resident to get out of bed. At 1:20 p.m., RNS-B was still with Resident #1 and he shouted, "Help me up!" 3 times at her. Resident #1 quieted to just, "No. No. No. No." while the restorative aide was helping him with his leg raises. At 2:35 p.m., Surveyor # was at the nursing station and heard 5 long screams coming from Resident #1's room. As the surveyor approached the room, Resident #1 was shouting at the top of his voice, "I wanna get up!" 5 times with 2 to 3 second intervals. Resident #1 began to yell out, "I gotta get up!" 12 times. Resident screamed out "Can I get up?" ten times. This went on until 2:44 p.m. Although staff were in the area, no staff intervened. On 8/23/11 at 2:44 p.m., Surveyor # interviewed RNS-B (RN Supervisor) about Resident #1's skin condition and the plan of care to keep Resident #1 in bed and allow him to get up for only lunch and supper in order to heal an open area, and the resident's calling out. Resident #1 was heard to scream one long scream while the surveyor and RNS-B were talking. RNS-B stated Resident #1 had a slit on his coccyx that had been attributed to incontinence. The resident had a denuded area back in February 2011 and that frequent repositioning had resolved the area along with an upgraded mattress, dimethicone wipes, skin prep, and [MEDICATION NAME] cream twice a day and a barrier cream. RNS-B stated Resident #1 was having "a good day overall, but not so much this afternoon." RNS-B stated when Resident #1 is up he will yell and he does not know he is doing so. RNS-B stated the doctors are aware of this and medication changes are being done." When asked if the doctors are aware of the degree and intensity of his calling out behaviors, RNS-B stated. "They've been told but I don't know if they grasp it." When asked about what staff can do about the behaviors, RNS-B stated staff use redirection, reminders, soda pop, and time outside. RNS-B stated staff will remind him not to shout, he will agree, but then shout, and deny he was shouting. When asked if there were any changes in the guidance to staff about how to react to his shouting, RNS-B stated there is nothing quite that formal. RNS-B stated the new plan of care to have the resident up only for lunch and supper was literally written yesterday. RNS-B stated at the Medicare meeting on 8/22/11, the decision was made to keep him in bed and get him up for lunch and supper. She stated this was done as the creams were improving the area but the treatment had to be more consistent in order to heal. RNS-B indicated that while the skin issues have been associated with incontinence, the restriction to bed is because Resident #1 will refuse to lay down to be changed. RNS-B stated, "He will refuse to be changed and is non-compliant. He has to be laying down to be changed because he doesn't stand well." At 3:35 p.m., Surveyor # again came on to the unit and heard Resident #1 screaming to the top of his voice, "Get me up!" 2 times. The resident's door was closed and he screamed, "I gotta get up!" 4 times. At 3:46 p.m., CNA-F and CNA-G came to get Resident "up for supper." Resident #1 was quiet then. On 8/23/11 at 9:41 a.m. Surveyor # interviewed RN-E (Registered Nurse). RN-E stated that there was an order not to get Resident out of bed except for lunch and supper. She stated staff are to get the resident up just before meals. She also stated this means Resident would have to be in bed for 20 hours a day. She stated the area is improving but Resident #1 will scream almost continuously when he's in bed. RN-E stated, "When he screams we have been told he has to stay there." RN-E stated she has spoken to the social worker and supervisor about this. She also stated that she has noted Resident #1 sleeps later in the morning and doesn't know if this is due to recent medication changes On 8/23/11 at 9:52 a.m., Surveyor # interviewed CNA-C. CNA-C stated Resident #1 has had to be in bed more since he's developed a sore on his bottom about a month ago. CNA-C stated that mentally, Resident #1 has the understanding of a 3-year-old. She stated Resident #1 calls out for his brother but the arrangement between his brother and the staff is to have him call 3 times a day. CNA-C stated he will call out for soda and is given as much as he wants. She stated when he is laid down, Resident will yell to get up. CNA-C stated staff have been told to "keep explaining it to him just like calling his brother." On 8/23/11 at 10:02 a.m. Surveyor # interviewed CNA-I. CNA-I reiterated that Resident #1 will call out for his brother and soda and they have been told to limit the calls and remind him of when he last spoke to his brother. He can also have as much soda as he likes. She stated when Resident #1 is laid down he will "scream to get up." CNA-I stated they have been told to let the nurse know, try to calm him and "talk him down." She stated staff try to explain to him why he has to stay in bed when he's screaming." On 8/23/11 at 1:10 p.m., Surveyor # interviewed CNA-D and CNA-C. These staff told the surveyor that they are to "redirect his attention" when he yells to get up. They stated, "Some times he gives up. We don't know what to do. We leave him for several minutes and sometimes he falls asleep. It really bothers him when he has to lay down." CNA-D recalled a recent night shift she worked when Resident #1 called out to get up from midnight to 4:00 a.m. and was not gotten up.