Every finding on record at Fair View Nursing and Rehabilitation Center

Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 2 of 4 sampled residents (R1 and R2).R1 made an allegation of abuse against R2 to her daughter that was overheard by an RN (Registered Nurse). The RN did not report the allegation of abuse.CMS's indicates abuse is to be reported within 2 hours, as identified, in part, by 483.12(c)(1) as: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 2 hours if the events that cause the allegation do involve abuse and do not result in serious bodily injury, to the administrator of the facility and other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.This is evidenced by:The facility policy titled, Resident Safety and Abuse Prevention & (and) Reporting, undated, states in part .Policy: A. Reporting incidents:a. Any staff witnesses possible abuse, neglect, or misappropriation must:b. Report the incident to the Administrator or designee immediatelyH. Resident-to-Resident Abuse d. Reporting: i. Submit a completed Misconduct Incident Report (F-62447) within 24 hours of discovery. Note: According to the State Operations Manual any allegations involving abuse or resulting in serious bodily injury must be reported to the State Agency within 2 hours of discovery. The facility policy titled, Reporting Reasonable Suspicion of Crimes in Long Term Care Facilities, undated, states in part. Purpose: To ensure compliance with Federal and State Regulatory Agencies regarding the reporting of any reasonable suspicion of a crime committed against residents or individuals receiving care from the facility, promoting timely response to potential crimes, and protecting residents. Policy: D: If the events that cause suspicion result in serious bodily injury, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion. If the events do not cause serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion. Note: According to the State Operations Manual any allegations involving abuse or resulting in serious bodily injury must be reported to the State Agency within 2 hours of discovery. R1was admitted to the facility on [DATE]. Diagnoses include in part . cerebral infarction, closed fracture of the distal end of left radius and dementia.R2 was admitted on [DATE]. R2's diagnoses include in part. history of stroke, and dementia.Surveyor reviewed the facility self-report submitted 9/15/25 which states, R1 was overheard on the phone stating that a man had held her hand and had been kissing up on her and that she wasn't here for that. R1 had been on the phone with her daughter and charge nurse spoke with daughter once their conversation had ended. Daughter relayed the same information. Charge nurse made sure that resident was safe, care plan was updated to reflect that the accused and R1 are not to be left alone together. DON (Director of Nursing)/Administrator notified, law enforcement was contacted, and full investigation began. AHCPOA's (Activated Health Care Power of Attorney) for both parties notified. Nurses Note in R1's chart from 9/13/25 at 21:53 (9:53 PM) states, this past week staff has noticed resident holding hands with 1 of our male Resident's. Resident did not seem to mind holding hands with the male. At times she was seen wheeling up to him and at others he wheeled up to her. Resident was not observed trying to pull her hand away, moving away or looking uncomfortable. Tonight, while on the phone talking to her daughter she was overheard telling daughter about a man that lived here who wouldn't leave her alone. Told daughter she really didn't want him touching her and especially kissing up on her. Staff has not observed any kisses being exchanged. After she was off the phone writer spoke with Resident about the male Resident and was assured if she didn't want him to touch her staff would keep them apart. Resident said she would like that as she really didn't want him to touch her. Resident was assured this was a safe place and we would keep her safe from unwanted advances. About an hour after speaking with Resident [name] her daughter called and spoke with writer about moms concerns about the male resident. Daughter assured that staff had already spoke with her mom and had reassured her that male Resident would be kept away from her. Daughter also voiced concern that Mom was afraid to go to sleep for fear the male Resident would enter her room. Reassured daughter that male Resident was wheelchair bound and had no idea what her moms name was or where her room is at. Reassured daughter that writer would go in and let Resident know she will be safe in her room. When writer went in to reassure Resident that she was safe in her room and she was sound asleep. Note: RN (Registered Nurse) writing the above note did not update the NHA (Nursing Home Administrator) or DON (Director of Nursing) regarding this allegation of possible abuse immediately. Note: There is no documentation in R2's chart regarding this incident. On 9/24/25 at 12:40 PM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E if he had received any recent education on abuse or abuse reporting. RN E stated, yes. Surveyor asked RN E when that education occurred. RN E stated this morning. Surveyor asked RN E if R2 has any behaviors. RN E stated, he can be inappropriate verbally but never touch. Surveyor asked RN E if he is aware of any residents R2 is to stay away from. RN E stated, I don't know of anyone R2 is to stay away from.On 9/24/25 at 1:17 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D when she signed the education sheet regarding abuse reporting. CNA D stated, I signed it today. Surveyor asked CNA D if R2 has any behaviors. CNA D stated, R2 can be verbally inappropriate with staff but he has not ever touched anyone that I am aware of. Surveyor asked CNA D if staff are aware of anyone R2 is to be kept away from. CNA D stated I have never been told to keep R2 away from any other residents.On 9/24/25 at 1:30 PM, Surveyor interviewed CNA C. Surveyor asked CNA C when she signed the education sheet regarding abuse reporting. CNA C stated, I signed it this morning between breakfast and lunch. Surveyor asked CNA C if she is aware of any residents R2 is to stay away from. CNA C stated, I have never been told to keep R2 away from any other residents.On 9/24/25 at 12:40 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F if he had received any recent education on abuse or abuse reporting. RN F stated, I have had nothing personally delivered but there is a binder in the breakroom with the facilities policies. Staff are to read and then sign that it was read. Surveyor asked if he is aware of any behaviors that R2 has. RN F stated from what I see he has no behaviors. Nothing that comes to mind. Surveyor asked RN F if he was ever informed to keep R2 aware from any other residents. RN F stated within the last few days I was told to keep R2 away from R1.On 9/24/25 at 1:55 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about the reporting requirements for abuse allegations. DON B stated, it is 24 hours if no immediate danger or physical injury. Police should be notified immediately and if not reported timely re-education to staff on the abuse policy. Surveyor asked DON B when she was educated on abuse reporting requirements. DON B stated, I was verbally educated by the NHA (Nursing Home Administrator) on 9/15/25 but did not sign the education sheet until today.On 9/24/25 at 2:15 PM, Surveyor interviewed NHA A . Surveyor asked NHA A about reporting of abuse allegations. NHA A stated, 2-hour reporting is required if there is serious bodily injury. This report was a unique situation where they approached each other and were hand holding. Surveyor discussed SOM (State Operations Manual) reporting requirements with NHA A. Surveyor asked NHA A about the facility policies indicate 2-hour reporting for serious bodily injury. NHA A stated, this is what our policy states. Surveyor asked NHA A when she started education with staff on the reporting requirements. NHA A stated that she had given education to the RN and DON but did not document that education.The facility failed to report an abuse allegation within 2-hours.

Based on record review and staff interview the facility did not develop and implement a Comprehensive Resident Centered Care Plan for 1 of 4 residents reviewed (R 2). R2's medical record indicated R1 had occasional sexual inappropriate behaviors. R2's comprehensive care plan does not include a care plan for sexual inappropriate behaviors.Evidenced by:The facility's Multidisciplinary Plan of Care Policy, undated, includes in part the following: D. The comprehensive plan of care is maintained in the electronic medical record (EMR) and is updated to reflect the resident's current status and goals. It will be reviewed at minimum quarterly and per resident need. R2 was admitted to the facility 9/12/24. R2's diagnosis include dementia, history of stroke, osteoarthritis and diabetes. R2's most recent MDS (Minimum Data Set) with and ARD (Assessment Reference Date) of 8/28/25, includes, in part, the following: R1 usually understands, is usually understood and has severe cognitive impairment. R1's Interdisciplinary Notes includes, in part, the following:9/11/25, 10:07 AM, Care Plan Conference, What staff attended meeting: Care Plan reviewed by each IDT (Interdisciplinary Team) prior to Care Conference attended by RN G (Registered Nurse), . Annual . FM H (Family Member) apologized for pt's (patient's) occasional sexual inappropriateness .On 9/24/25 at 2:10 PM Surveyor interviewed RN G. RN G stated she was responsible for updating care plans after Care Plan Conferences. Surveyor asked RN G if she had attended R2's Care Plan Conference on 9/11/25. RN G stated yes she did. Surveyor asked RN G if she had updated R2's Care Plan to include the concerns for sexual inappropriateness. RN G and surveyor reviewed R2's Care Plan. RN G stated no she had not updated R1's Care Plan to include concerns of sexual inappropriateness or interventions when R2 was sexually inappropriate. RN G stated she should have updated R2's Care Plan to include the concerns with sexual inappropriateness. RN G stated she would update R2's Care Plan right away.

Based on interview and record review, the facility did not promptly notify and consult with a physician when a resident experienced a potential change in condition for 1 of 3 resident's (R1) reviewed for physician notification.R1 experienced consistently low blood pressure while taking Metoprolol (a beta blocker that lowers blood pressure) and the facility did not notify R1's physician.The Mayo Clinic, Cleveland Clinic, John Hopkins, University of Wisconsin Hospital, [NAME] Health, and the American Heart Association (AHA) define hypotension (low blood pressure) as being below 90/60 mm Hg (milliliters of mercury).According to the Mayo Clinic, Complications of C. difficile infection include: loss of fluids, called dehydration. Severe diarrhea can lead to a serious loss of fluids and minerals called electrolytes. This makes it hard for the body to work as it should. It can cause blood pressure to drop so low as to be dangerous.Pathway INTERACT's (Intervention to Reduce Acute Care Transfers) vital signs criteria for clinician notification states a systolic blood pressure (top/first number in blood pressure reading) of less than 90 should trigger clinician notification.The facility's Notification of Changes policy states, Facility must immediately inform the resident; Consult with the resident's provider; and notify, consistent with the resident's activated healthcare power of attorney, the resident guardian when there is: a.) A significant change in the resident's physical, mental, or psychosocial status, b.) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).R1 was admitted to the facility on [DATE] and had diagnoses that included COPD (Chronic Obstructive Pulmonary Disease) requiring continuous oxygen, hypertension (high blood pressure), and a history of C. diff (Clostridium difficile, a bacterium that causes inflammation in the colon). R1's hospital discharge, dated 7/29/25, indicates R1 had a UTI (urinary tract infection) and had discharge diagnoses of hypertension and transient hypotension (low blood pressure). Additionally, upon discharge, R1's blood pressure was 106/50 which was noted as low. Due to this low blood pressure, the hospital discontinued R1's furosemide (diuretic medication) and lisinopril (used to treat high blood pressure) pending a future reevaluation. Upon admission to the facility, R1 was to continue taking her Metoprolol at 50 mg twice daily.Of note, on 7/30/25 at 9:55 AM, it was noted that R1 had experienced 3 watery, foul-smelling stools. This was reported to R1's physician, MD C (Medical Doctor), who then ordered a C. diff stool test, which came back positive.Initial nursing indicate the facility was to gather R1's blood pressure each shift 9 times (3 days, each of the three shifts).On 9/3/25, the facility provided Surveyors R1's historic vitals from her stay at the facility (7/29/25 thru 8/1/25). The heading for blood pressure reads, Blood Pressure (90/60 - 138/88). R1's documented blood pressures:7/29/25 at 10:58 AM: 110/46 (L - low)7/29/25 at 8:00 PM : 86/41 (L)7/30/25 at 6:44 AM: 96/48 (L)7/30/25 at 10:31 PM: 92/48 (L)7/31/25 at 6:33 AM: 81/44 (L)7/31/25 at 1:57 PM: 94/46 (L)8/1/25 at 4:51 AM: 106/89 (H-high)8/1/25 at 11:00 AM: 128/90 (H)It should be noted that the facility's EHR (Electronic Health Records) system flagged the above blood pressures as either high or low. Additionally, R1's Metoprolol was given consistently twice per day and specifically was given on 7/29/25 at 7:15 PM, on 7/30/25 at 7:31 AM and 8:37 PM, on 7/31/25 at 9:13 AM and 8:25 PM, and on 8/1/25 at 8:22 AM.On 8/1/25 at approximately 3:35 PM, R1's blood pressure registered at 52/40. The facility called a rapid response and R1 was taken to the ED (emergency department) where she was found to be septic.On 9/3/25 at 12:18 PM, Surveyor interviewed MD C who stated that she was familiar with R1 and had been trying to manage her blood pressure for years, even as an outpatient before being at the facility. MD C stated that she had not received any notification from the facility regarding R1's low blood pressures but would have expected notification if her systolic blood pressure had dipped below 100. MD C stated that it is hard to say for sure what would have happened if she had been notified but stated that she could have altered R1's medications or could have potentially discontinued her Metoprolol. MD C also stated that R1's C. diff may have contributed to her low blood pressure. MD C stated there is an opportunity to improve communication.On 9/3/25 at 2:23 PM, Surveyor interviewed DON B (Director of Nursing) who stated that the facility did not have any specific blood pressure parameters for R1 but would expect the nurses to use their nursing judgement as to if a blood pressure was too low or high. DON B stated that their facility's parameters for a low blood pressure is 80 systolic and was unaware that the facility's EHR had 90/60 as the low parameters for blood pressure. DON B was unable to find the additional blood pressure readings as part of R1's nursing order for 3 blood pressure recordings daily for 3 days.The facility was aware R1 was experiencing low blood pressure (both systolic and diastolic), continued to administer metoprolol and did not communicate with R1's physician regarding her low blood pressures.

Based on interview and record review, the facility did not ensure residents maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for nutritional status (R29). R29 experienced a significant weight loss, and the facility did not assess and notify the physician. Findings include. The facility's policy on weights states: *Each resident will be weighed on admission, day after admission and then weekly, unless stated by the physician. Weights will be taken by the certified nursing assistant (CNA) and reported to the team leader who will record them in the residence record. *If weight changes are identified to be significant, nursing will contact the physician for update and possible recommendations. The facilities policy titled Nutrition Risk Program, states: *The registered dietitian, speech pathologist, registered nurse, or other caregiver should identify the resident at nutritional risk during the initial assessment. * Any member of the healthcare team may alert the nutrition risk team to potential nutritional risk situations i.e., observation of poor intake, weight loss, etc. *The nutrition risk team will then determine if the resident meets the outline parameters for their nutrition risk program. *Residents on the nutrition risk program are identified in a few different ways, including a weight loss/gain of 5% or more in the past 30 days or weight loss/gain of 10% or more in the past 180 days. The *Nutrition risk updates will be sent to nursing staff, speech therapy, occupational therapy, physical therapy, and social services as appropriate. The physician will also receive notification that the resident was added to the program. R29 was admitted to the facility on [DATE] and has diagnosis that include dementia. Her most recent MDS (Minimum Data Set), dated 10/11/24, includes a BIMS score (Brief Interview for Mental Status) of 3, indicating R29 has severe cognitive impairment. R29's MNA (Mini Nutritional Assessment), conducted by the facility on 10/4/24, shows a score of 9, indicating R29 is at risk for malnutrition. R29's care plan states, Problem: Health maintenance .Needs: I report that my appetite is poor. Due to my dementia diagnoses, I am at risk for poor meal initiation .Outcome: Maintain nutritional status .I will maintain current body weight without significant weight change. The facility documented the following weights for R29: 10/25/24: 178.5 lbs. 10/29/24: 173 lbs. 11/24/24: 168.6 lbs. 11/26/24: 166.4 lbs. 11/29/24: 168.6 lbs. 12/4/24: 169.7 lbs. On 12/05/24 at 1:31 PM, Surveyor interviewed RD J (Registered Dietician) who stated that CNAs gather weights and the RNs (Registered Nurses) input them into the electronic system. RD J stated that she reviews weights weekly or every couple weeks, but sometimes monthly. RD J stated that if there is a significant change in the resident's weight, it depends on the physician as to who and when they are notified. RD J stated that she had reviewed weights on 11/4/24 and will be putting R29 on the facility's Nutrition at Risk alert for their next meeting on 12/12/24. RD J stated that she had conducted nutritional assessments for R29 on 10/4/24 and 10/18/24 but had not alerted the doctor to any recent weight changes. On 12/05/24, Surveyor interviewed RN G at 2:45 PM and RN H at 2:39 PM, both of whom stated that CNAs gather weights and report them to them (RN, charge nurse, etc.). Nurses then input the weights. RN G and RN H both stated that they look at the previous weight when documenting weights and if the previous weight is a 5-pound difference, they would request a reweight and if the reweight confirms the original weight, then they would conduct an assessment and notify the resident's physician of weight changes. It should be noted that no assessments were provided to Surveyors, nor was any evidence provided of correspondence to R29's physician regarding her weight loss. Additionally, no additional weights were gathered between 10/29/24 and 11/24/24 and no evidence was provided of interventions put into place. On 12/05/24 at 2:02 PM, Surveyor interviewed MD I (Medical Doctor) in person. MD I is also the facility's medical director. MD I stated that he could not recall being notified of R29's weight. While sitting at a computer, MD I searched for any recent contact or correspondence from either facility staff or the Nurse Practitioners (NP) that he oversees and could not see any recent weight notifications. MD I stated R29 was recently visited by an NP on 11/4/29, but there was no mention of weight changes. MD I stated, I did not know. We missed it. I should be much more aware of this and I'm not. MD I also stated that he expects to be notified of any significant weight changes. R29 experienced a significant weight loss of 6.78% in one month and the facility did not assess R29, notify R29's physician or put any additional nutritional interventions in place. The facility was aware that R29 had lost 5 lbs. between weights on 10/25/24 and 10/29/24 and no interventions or additional weights were gathered between then and 11/29/24.

Based on interview and record review the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 2 supplemental residents (R11 and R186) reviewed for antibiotic stewardship. R11 was treated with an antibiotic for an UTI (urinary tract infection) without meeting criteria. R186 was treated with an antibiotic for an UTI and did not meet criteria. Evidenced by: The facility policy, entitled Antimicrobial Stewardship Program, 7/22/24, states, in part: . POLICY: A. (Facility Name) has established and will maintain an antimicrobial stewardship program (AMS). AMS programs promote appropriate antibiotic prescribing practices and play a critical role in reducing antibiotic resistance . C. The Antibiotic Stewardship Team will be responsible for, at a minimum: . b. Ensuring that (Facility Name) follows the Core Elements of Antibiotic Stewardship as recommended by the CDC (Centers for Disease Control) and required by CMS (Centers for Medicare & Medicaid Services) and the Joint Commission . f. Defining and tracking metrics specific to antibiotic stewardship. g. Monitor and report antimicrobial susceptibility trends and communicate these to Healthcare Providers. h. Reporting outcomes, protocol/practice compliance, and opportunities for improvement to providers, our administration, and staff. Monitoring of prescribing practices and adherence to policies and protocols and reporting trends back to the Team and to Healthcare Providers . Example 1 R11 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). R11 is listed on the September Infection Control Line List as having a UTI (Urinary Tract Infection). Symptoms are recorded as 9/14/24- right low back pain. Criteria box is marked with an x to show R11 met criteria. Bacteria: Actinotignum schaalii. Antibiotics: Amoxicillin 250 mg (milligrams) BID (twice a day). Start Date: 9/23/24. Stop Date: 9/30/24. R11's culture dated 9/18/24 shows organism is Actinotignum schaalii with no colony count. R11's culture report dated 9/15/24 shows Organism is gram positive cocci with colony count of 10,000-50,000 CFU (colony forming unit)/mL (Milliliters). Of note: to meet criteria, the colony count must be 100,000 or over. R11's Progress Note dated 9/19/24, states, in part: . Progress Note: A&P (Assessment and Plan) . (3) UTI: . The latest urine showed gram-positive cocci 10 - 50,000 that appears to be contaminant . Patient denies any dysuria. Is not running a fever and she does have a history of back pain much more likely this is related to musculoskeletal pain . R11's Physician order, dated 9/23/24, states, in part: . Amoxicillin 250 mg po (by mouth) BID. Total Doses: 14. Clinical Indication: UTI . Order: 9/23/24. Start: 9/23/24. Stop: 9/30/24. Complete: 9/30/24. Complete Reason: Reached Stop Date . R11's September's MAR (medication administration record) shows R11 received amoxicillin 250 mg x 1 on 9/23/24, bid on 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24 and x 1 on 9/30/24. Example 2 R186 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease Stage 3A (a stage of kidney disease where the kidneys are mildly to moderately damaged and are functioning at 45%-59% of what they should be) and Hypertension (defined as blood pressure above 140/90). R186 is listed on the October Infection Control Line List as having a UTI. Symptoms: strong urine. Type of Infection: UTI. Criteria Met box was left blank. Bacteria: Eschericha coli and Aerococcus species. Antibiotics: Cephalexin 500 mg po BID. Start Date: 10/7/24. Stop Date: 10/10/24. Of Note: Strong urine is not a symptom of McGeers Criteria. R186's culture report dated 10/7/24 shows Organism 1 as Escherichia coli with a colony count of >100,000 CFU/mL and Organism 2 as Aerococcus species with a colony count of >100,000 CFU/ML. Sensitivity show cephalexin is susceptible. R186's Physician Order, dated 10/7/24, states, in part: . Order: Cephalexin 500 mg po BID. Days: 3. Clinical Indication: UTI. Start:10/7/24. Stop: 10/10/24. Complete: 10/10/24. Complete Reason: Reached Stop Date . R186's MAR shows R186 received cephalexin 500 mg on 10/7/24 x 2, 10/8/24- refused, 10/9/24 R186 received x1 and refused x 1, and on 10/10/24 R186 received x 1. On 12/05/24, at 10:17AM, Surveyor interviewed IP E (Infection Preventionist), RN F (Registered Nurse) and ADON C (Assistant Director of Nursing). Surveyor asked what standards of practice the facility uses for infection control and IP E indicated McGeers, CDC (Centers of Disease Control) and DHS (Dept. of Health Services). Surveyor asked if R11 met McGeers criteria to treat with an antibiotic for UTI with symptoms of low back pain and colony count of 10,000-50,000 and ADON C indicated no. Surveyor asked if strong urine is a symptom that meets McGeers Criteria and IP E indicated no. Surveyor asked if R186 met criteria to treat with an antibiotic for UTI with symptoms of strong urine and Escherichia coli with a colony count of >100,000 CFU/mL and Aerococcus species with a colony count of >100,000 CFU/ML. IP E indicated R186 had increased incontinence but was unable to provide supporting documentation. ADON C and IP E indicated R186 did not meet criteria to treat UTI with antibiotics.

Based on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 1 of 1 resident (R10) reviewed for diabetic foot checks. R10 has no documentation of diabetic foot checks. This is evidenced by: Per ADA (American Diabetes Association), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually. Per AMDA (American Medical Director Association), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at-risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer. It is important to note that the facility did not have a policy for diabetic foot checks. Example 1 R10 has a diagnosis of type 2 diabetes mellitus. R10's medical record was reviewed for documentation of diabetic foot checks. R10's medical record does not include any documentation of the facility completing daily diabetic foot checks. On 12/5/24 at 1:44 PM, Surveyor interviewed RN D (Registered Nurse). Surveyor asked RN D what the process is for diabetic foot checks, RN D reported that skin checks were being completed weekly on shower days and that the diabetic foot checks were added to the staff worklist on 12/4/24. On 12/5/24 at 2:16 PM, Surveyor interviewed ADON C (Assistant Director of Nursing). Surveyor asked ADON C where the documentation regarding diabetic foot checks could be found, ADON C reported that they would be on the worklist. Surveyor requested documentation of diabetic foot checks for R10. ADON C reported to Surveyor that the facility had not been completing daily diabetic foot checks but have been doing weekly skin checks on shower days. Surveyor asked ADON C what the standard of practice is for how often diabetic foot checks should be completed, ADON C stated they should be completed daily. On 12/5/24 at 3:35 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were for staff completing diabetic foot checks, DON B stated that they should be done daily.

Based on interview and record review the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 1 of 5 sampled residents (R14) and 3 of 3 supplemental residents (R10, R15, R18) receiving an anticoagulant medication. The facility did not develop a Care Plan for precautions or monitoring related to use of anticoagulation medication for R10, R15, R14 and R18. Evidenced by: (It is important to note the facility did not have a policy related to the use of anticoagulants.) The facility policy, entitled Multidisciplinary Plan of Care, undated, includes, in part: The multidisciplinary plan of care is developed as soon as possible after the resident is admitted . A basic care plan is developed within 48 hours by the Interdisciplinary Team. A comprehensive care is then developed no later than one week after the completion of the comprehensive assessments (within 21 days after admission) . plan of care includes the following: identified resident needs, identified resident goals which are realistic and described in terms that are measurable , related to a reasonable achievement time, or maintenance of highest functional level . approach to meeting identified goals, include care of services that must be provided to meet these goals . frequency of service . Example 1: R10 was admitted to the facility, on 10/11/22, with diagnoses including: Arteriovenous fistula (an abnormal connection between an artery and a vein), presence of prosthetic heart valve, presence of coronary angioplasty implant and graft, peripheral vascular disease, Hypertension (high blood pressure), Atherosclerotic heart disease of native coronary, hypokalemia (low potassium), and paroxysmal atrial fibrillation (irregular heart rhythm). R10's Physician Orders, for 10/2023, include: Warfarin Sodium (Coumadin) . 5 mg (milligrams) . by mouth daily . Review of R10's care plan and CNA (Certified Nursing Assistant) Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Warfarin), such as special precautions and monitoring for/or reporting unusual bruising or bleeding. Example 2: R15 was admitted to the facility, on 2/7/22, with diagnoses including: Chronic pulmonary embolism (one of the pulmonary arteries in the lungs gets blocked by a blood clot), long term use of anticoagulants (blood thinner), and venous insufficiency (blood pools in the veins). R15 Physician Orders, 10/2023, include: Apixiban (Eliquis) 5mg (milligrams) by mouth daily . Review of R15's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Apixiban), such as special precautions and monitoring for/or reporting unusual bruising or bleeding. Example 3: R14 was admitted to the facility on [DATE]. Her diagnoses, include: paroxysmal atrial fibrillation (irregular heart rhythm), hypokalemia (low potassium), and combined systolic and diastolic congestive heart failure (reduced heart pumping ability). R14's Physician Orders, 10/2023, include: Apixaban (Eliquis) 2.5mg (milligrams) by mouth daily . Review of R14's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Apixiban), such as special precautions and monitoring for/or reporting unusual bruising or bleeding. Example 4: R18 was admitted to the facility on [DATE] with diagnoses, including: chronic atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), and nonrheumatic aortic (valve) stenosis (narrowing of the valve). R18's Physician Orders, 10/2023, include: Warfarin Sodium 3mg (milligrams) by mouth Sunday, Tuesday, Thursday, Saturday . Warfarin 2.5mg by mouth Monday, Wednesday, Friday . Review of R18's care plan and CNA Guidelines for Daily Care do not include any reference or interventions related to the use of anticoagulants (Warfarin), such as special precautions and monitoring for/or reporting unusual bruising or bleeding. On 10/5/23 at 9:12 AM Unit Coordinator E indicated the facility does not have interventions, goals, or a monitoring system for residents on anticoagulant medications, but they should have. On 10/5/23 at 9:23 AM RN D (Registered Nurse) indicated the facility does not have anticoagulant care plans or a plan for monitoring residents receiving anticoagulant medications. On 10/5/23 at 9:30 AM DON B (Director of Nursing) indicated there should be a anticoagulant care plan to identify residents at risk for bruising and bleeding and a place for nurses to monitor. On 10/5/23 at 9:39 AM ADON C (Assistant Director of Nursing) indicated R14, R10, R15, and R18 should have goals and interventions related to bruising and/or bleeding due to their use of anticoagulant medications. On 10/05/23 at 12:06 PM RN F stated, I will be adding to R15's, R14's, R10's, and R18's care plan to include goals and interventions related to anticoagulant use/monitoring. R10, R14, R15, R18 were without a care plan to monitor for bruising/bleeding and what interventions should be implemented while receiving an anticoagulant (blood thinner).

Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza and pneumococcal immunization for 1 of 5 residents (R25) reviewed for immunizations. R25 did not receive the pneumococcal vaccine. This is evidenced by: The facility's policy titled Pneumovax Vaccine, no date, states in part: A. On admission to LTC (Long Term Care) and with a MD (Medical Doctor) order, pneumovax vaccine will be encouraged for all resident who have not previously received this vaccine .2. Each resident or resident's legal representative receives education regarding the benefits and potential side effects of immunization .5. Refusal of vaccine will be documented in the resident's medical record. 6. Revaccination will be based on current CDC (Centers for Disease Control) . R25's medical record has no evidence or documentation to show that R25 or their representative was provided education, risks vs. benefits, or side effects regarding the pneumococcal vaccination in order to make an informed choice about receiving/declining the pneumococcal vaccination. There is no evidence of R25 declining the pneumococcal vaccination. On 10/4/23 at 3:13 PM, Surveyor interviewed RN F (Registered Nurse); RN F is also the facility's Infection Preventionist. Surveyor asked RN F if she reviewed R25 for his eligibility for an updated pneumonia vaccine, RN F reviewed her vaccination log and stated that they must have missed him. Surveyor reported to RN F that according to the CDC's (Center for Disease Control and Prevention) PneumoRecs VaxAdvisor, R25's recommendation is for him to receive one dose of PCV20 at least 1 year after PCV13 .or give one dose of PPSV23 at least one year after PCV13, RN F stated that she would look into it. On 10/5/23 at 8:34 AM, Surveyor interviewed MD G (Medical Director). Surveyor asked MD G if he would have expected that R25 would have received an updated pneumonia vaccination, MD G stated that R25 is diabetic, so he would qualify and that he is at an increased risk for pneumonia. R25 did not receive the pneumonia vaccine per the CDC recommended schedule for vaccinations.

Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist for 2 of 5 residents reviewed for unnecessary medications (R33 & R21). R33 did not have a monthly medication review conducted by a pharmacist. R21 did not have a monthly medication review conducted by a pharmacist. Findings include The facility's Consultant Pharmacist policy states, The pharmacist/contracted pharmacy is responsible for conducting a monthly review of all patients' medication regimens. This review must include a review of the resident's medical chart .The pharmacist must report any irregularities to the attending physician and the facilty's medical director and director of nursing, and these reports must be acted upon. R33 was admitted to the facility on [DATE]. Surveyors requested monthly pharmacy reviews for R33 and the facility was unable to provide any documentation that R33's medications and medical chart had been reviewed by a pharmacist since 7/19/23 when a pharmacist documented on R33's IV antibiotic in relation to aspiration pneumonia. On 10/5/23 at 10:18 AM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A confirmed R33 had not had a monthly medication review and also stated that the facility was behind on monthly medication reviews and that facility would conduct an audit to find which resident's medications needed reviewing. 42038 Example 2 R21 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, anxiety disorder, post- traumatic stress disorder, and dissociative identity disorder. Surveyor requested monthly pharmacy reviews for R21. The facility was unable to provide any documentation that R21's medications had been reviewed by a pharmacist since 1/23/23. On 10/5/23 at 11:00 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if she was able to find any monthly pharmacy reviews for R21 since 1/23/23, NHA A stated no, that was the last one and that she spoke with the pharmacist, and he is working on them today.

Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 2 of 3 residents reviewed for pressure injury concerns (R27 and R31) out of a total sample of 14. R27 was at risk for pressure ulcer development due to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor observed wound care performed with R31 using poor hand hygiene practices. Evidenced by: AMDA (American Medical Directors Association) clinical practice guideline entitled 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer [Injury] is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear.Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications.Step 2. Examine the patient's skin thoroughly to identify existing pressure ulcers. Examine the patient's skin upon admission or readmission, .Step 3. Assess the patient's overall physical and psychosocial health and characterize the pressure ulcers. A pressure ulcer should be assessed along with the patient's overall clinical, functional, and cognitive status weekly reassessment and documentation of ulcer characteristics is recommended. More frequent assessment may be necessary for ulcers that are not responding to treatment or are worsening despite treatment.Step 4. Identify factors that can influence ulcer treatment and healing.functional status. Functional factors, including impaired mobility, a self-care deficit, and incontinence (especially fecal incontinence), may influence the severity, duration, and healing of a pressure ulcer.Step 5.Documentation should cover all pertinent characteristics of existing pressure ulcers, including location; size; depth; maceration; color of the ulcer and surrounding tissues; a description of any drainage, eschar, necrosis, odor, tunneling, or undermining; tissue types covering the wound bed; .and a description of the periwound skin .including type and amount of drainage.Step 6. Identifying priorities in managing the ulcer and the patient .Pain control related to the ulcer and any comorbid conditions.The same factors that increase a patient's susceptibility to developing pressure ulcers .may also impair the healing of an existing pressure ulcer . The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's (Pressure Injuries) in the following categories: Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Manufacturer's recommendations for use of the Comfy Splints Multi Podus Boots, dated 2016, include, in part: . Comfy ambulation boot . for use with minimal to moderate ambulation and transferring . upon order of a physician . Example 1 R27 was admitted to the facility on [DATE] with diagnoses, including CMT (Charcot-[NAME] Tooth disease), [CONDITION(S)], and Amputation of left lower extremity below knee. CMT is a spectrum of nerve disorders that damage the nerves in the arms and legs. R27's MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/3/21 indicates R27 is at risk for PI (pressure injury) development and her skin is intact. R27's MDS with ARD of 2/17/22 indicates R27 is at risk for PI development, and she has 2 stage 3 PI, no venous or arterial injuries, and infection of the foot. R27's MDS with ARD of 5/17/22 indicates R27 is at risk for PI development, and she has 2 stage 3 PI, no arterial or venous injuries, and infection of the foot. R27's Comprehensive Care Plan, initiated 10/5/21, includes: start 12/3/21 problem: PI of right foot, heredity of motor and sensory [CONDITION(S)] . transfer me with use of EZ stand and one assist . alternating air flow mattress on bed . pressure redistribution cushion in my wheelchair . encourage me to keep my right foot elevated when I am in my wheelchair, honor my choice to decline . float my heel in bed . use protective boot when I am up in my chair . I require increased protein needs due to wound healing from ulcerations to the right foot . I report times of feeling depressed that I still have not reached my goal of returning home at this time and further infection concerns with my other leg. R27's Medical Record contained the following: 12/6/21 NN (Nurse Note): Resident was found with small pressure areas to her right foot from the use of her new walking shoe. She has 5 areas. Right lateral ankle 0.5cm x 0.5 cm x < 0.1 cm wound bed is dry with light eschar. Right medial foot 0.5cm x 0.5 cm x < 0.1 cm wound bed is dry with light eschar Toes 3rd, 4th, 5th mid phalanges 0.3 cm round white areas to all. R27 had worn her shoes this weekend for transfers, and she has no feeling in her feet. She has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will not place regular shoe on her foot for transfers but will place the Darco boot which is soft with Velcro straps. MD updated and new orders received to dab [MEDICATION(S)] every other day (48 hours) total 5 times. (It is important to note there is no mention of shoes not to be used in R27's Comprehensive Care Plan.) 12/6/22 NN R27's MD was here this afternoon and looked at the sores on R27's right foot. Agreeable to the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Also ordered a consult with podiatry for molding a shoe for the right foot. Sores are dry with no redness . 12/7/22 NN R27 is sitting up in her wheelchair at this time. She had surgical shoe on and informed her that because of the sores on her right foot, MD does not want her wearing any shoes at this time. This writer removed surgical shoe and gripper sock. Area to top of right foot, 3/4/5 toes, and ankle are scabbed and dry . (It is important to note R27 is wearing her shoe again and the intervention is not in R27's Care Plan. It is also important to note there is no wound measurements found from 12/7 to 12/22.) 12/22/21 NN all wounds measured and assessed to right foot. Right lateral ankle measures 0.5cm x 0.8cm with a dry scab, peri wound very light pink Right medial foot measures 0.8cm x 0.9cm with dry scab, peri wound very light pink 3rd digit of right foot measures 1cm x 0.6cm and this is dry, but no scab 4th and 5th digit right foot measures 0.3cm x 0.3cm and these areas are dry . the medial foot and ankle have increased in size. They appear more superficial, and the scabs will fall off with probable healthy tissue underneath . Per MD staff is not to put any shoes on and staff is using gripper socks only which alleviate any pressure . (It is important to note there are no wound measurements found in R27's record from 12/22/21 to 1/12/22) 1/12/22 MD Progress Note: R27 presents from facility with chief complaint of ulcerations on the dorsum of the foot and toes. She is here with her daughter . She comes with a very soiled dressing and states that they have not been doing much for it. Exam: Ulcerations noted to the dorsum of the digital areas on her foot. She has had below the knee amputation of the left lower extremity secondary to ulcer similar-to what she has in the right foot at this time. Also, over the medial cuneiform there is a full thickness ulcer measuring approximately 0.5cm in diameter with necrosis. Surgical debridement elicits some granulation and bleeding. Also, a lesion on the lateral aspect of the right foot measuring approximately 0.5cm in diameter. This too is full thickness, but no probing to bone . At this time, I cleansed all wounds with wound cleanser and applied [MEDICATION(S)] and sterile dressing. I put in orders for a Rooke boot as well as wound care. R27 is allergic to [MEDICATION(S)] so I switched it to [MEDICATION(S)] ointment to be applied twice daily after wound care cleansing and sterile dressings. I also placed R27 on [MEDICATION(S)] 100 mg twice daily for 10 days . Follow up in one-week right foot . 1/12/22 NN R27 saw MD . in regard to the ulcers on her right toes and foot. Order received to apply [MEDICATION(S)] to ulcers on right foot and cover. [MEDICATION(S)] was changed to [MEDICATION(S)] due to sulfa allergy, was started on [MEDICATION(S)] twice daily. 1/13/22 NN R27's foot continues to be red, and wounds appear infected. [MEDICATION(S)] and [MEDICATION(S)] applied. Kerlix, stockinette, and a green foam boot to finish the dressing process. She tolerated well . 1/13/22 NN R27's foot is less red, wounds appear about the same. Old dressing moist with moderate serous drainage . 1/14/22 NN .Foot and lower leg were not red or warm to touch . 1/19/22 MD Progress Note: R27 presents in wheelchair for re-evaluation of right foot ulcerations. I had seen her a week ago and placed her on cleansing of the wounds with utilization of [MEDICATION(S)] ointment. She is also on [MEDICATION(S)] 100mg twice daily. She also has a protective boot which is soaked from the dressings that are soaked also . Exam: Drainage of the [CONDITION(S)] are noted primarily in the midfoot area over the hammertoes 2 through 5 regions. There is no [CONDITION(S)] but again drainage is noted . She has advanced [CONDITION(S)] . At this time, I cleansed the wounds with wound cleanser and applied [MEDICATION(S)] Silver to the site and follow this with sterile 4x4s and a Kling dressing. I wrote orders for the staff to do the same. I will re-evaluate . in 1 week . 1/26/22 MD Progress Note: R27 presents for re-evaluation of ulcerations on her right lower extremity primarily on the dorsum of her right foot. She had similar [CONDITION(S)] previously on her left lower extremity before her below the knee amputation. She is very concerned about losing her right lower extremity at this point. Active problems: [CONDITION(S)], open wound of right foot, pressure ulcer of toe of right foot, pressure ulcer of dorsum of right foot, amputation of left lower extremity below the knee . Exam: Drainage noted from her dressing with yellow discoloration and sloughing on the dorsum of her right foot. There is a slight odor with [CONDITION(S)] localized to the foot itself. There are open sores with [CONDITION(S)], but no sinus tracts noted. Prominent areas on the cuneiforms and lateral ankle show necrotic tissue with ulcerations measuring approximately 0.5cm in diameter. At this time, I cleansed the wounds with wound cleanser and debrided all necrotic and slough tissue. I took a culture interdigitally to be sent for culture and sensitivity. I applied [MEDICATION(S)] Silver to the wounds and follow this with sterile 4x4's and Kerlix dressing. Orders were written for the nursing home to do this treatment twice daily applying [MEDICATION(S)] Silver and sterile dressings. I placed R27 on [MEDICATION(S)] 100mg twice daily for 14 days. Re-evaluate in one week . (It is important to note the facility is not measuring R27's wounds weekly and this is the first measurement recorded since 1/12/22). 1/27/22 NN R27 started on [MEDICATION(S)] for foot infection. 1/28/22 R27 has been taking [MEDICATION(S)] 100mg twice daily and will be starting on [MEDICATION(S)] 500mg twice daily . this evening due to the results from wound culture . Her right foot is reddened and has open areas treated with [MEDICATION(S)] AG with twice daily dressing changes . 1/30/22 NN R27 is resting in bed . No adverse side effects noted from [MEDICATION(S)] or [MEDICATION(S)] which she is receiving for wounds . Dressing . is clean dry and intact and green PR boot is on . continues with slough tissue on inner ankle area . Remains on [MEDICATION(S)] 500mg twice daily and [MEDICATION(S)] 100mg twice daily for pseudomonas in right leg wound . 2/2/22 MD Progress Note: R27 presents for re-evaluation of ulcerations on the dorsum of her foot. Exam: Removal of dressing reveal minimal [CONDITION(S)] and a lot less drainage from last week. Again, the second digit shows an ulceration interdigitally also . I cleansed the wounds and applied [MEDICATION(S)] Silver, [MEDICATION(S)] Sterile 4x4s, and a kerlix dressing. I wrote orders for the nursing staff to continue cleansing twice daily with warm soapy water, applying the [MEDICATION(S)] silver and sterile dressings. 2/8/22 NN: All wounds measured and assessed to right foot. Second digit: 2.2cm x 1.5cm depth undetermined. The wound bed appeared to have small amount of dry yellow slough and pinpoints of granulation tissue. Margins irregular and peri wound pink in color. This wound bed is translucent skin over wound. The other digits have no open areas, . remain very fragile. Dorsum of right foot medial aspect: 1.5cm x 1.6cm x depth undetermined due to thin translucent skin over wound. Margins are regular and noted boney prominent wound bed. No drainage noted. Dorsum of right foot lateral aspect: 1.5cm x 1.8cm x <0.1cm. No drainage noted, but skin is very fragile. Peri-wound is also pink. Lateral aspect of right lower leg: 1.2cm x 0.7cm x undetermined. The wound bed has a thin translucent skin over wound. Wound bed shows 1/2 dry yellow slough and pinpoints of granulation. The right lower leg is all over fragile . heel appeared spongy when palpated . Resident will wear the green boot to alleviate pressure and protect. While in bed the green boot is removed and foot elevated with a chucks when wounds drain . MD aware. (It is important to note the facility is not measuring the wounds weekly and these are the first measurements recorded by MD or nursing staff since 1/26/22). 2/9/22 MD Progress Note: Exam: sloughing and drainage noted on the dorsum of right foot. She has severe contractures of hammertoes and skin slough in these areas. She has a prominent quarter size ulceration on the dorsum of her medial cuneiforms (three bones of midfoot) over the exostosis (bone overgrowth) region. There is no sinus tract no purulent drainage noted . I ordered antibiotics of right lower extremities. 2/9/22 NN: R27 started on Arithromax 500 mg daily for 5 days (antibiotic) . already on [MEDICATION(S)] . MD discontinued [MEDICATION(S)] and started Arithromax . Dressing changed to right foot as dressing was wet with yellow drainage . 2/11/22 NN: . continues to have moderate amount of serosanguineous and yellow colored drainage. Soft green boot in place. 2/12/22 NN: . small amount of yellow drainage. Soft green boot in place. 2/13/22 NN: . right leg continues to have some redness, no increased warmth. R27 has no feeling in her right leg .no drainage noted . 2/15/22 MD Progress Note: R27 presents for re-evaluation of [CONDITION(S)] in ulcerations on her right lower extremity. Exam: Ulcerations noted on the dorsum of the right foot as well as over the medial cuneiform quarter size lesion, on the anterior aspects of right lower extremity, and on the medial malleoli region (ankle). The drainage is less than last week with some necrotic areas. No gangrenous changes noted . At this time, I cleansed the wounds with wound cleanser and applied [MEDICATION(S)] silver, [MEDICATION(S)], sterile 4x4s and a kling compression dressing. Orders were written for nursing staff to continue with the wound care as directed twice daily. She will continue [MEDICATION(S)] as directed. Her ABIs (arterial brachial index- a measure of blood flow to the lower extremities) on the right lower extremity came back normal . 2/17/22 NN: R27 had labs drawn today. MD concerned her with her sed rate as it was 75 which is very high (sign of inflammation) . concerned that the oral antibiotics are not working for the [CONDITION(S)] in her right foot. Order received for [MEDICATION(S)] one time loading dose of 1750mg tonight and then 1250mg twice daily for two weeks . then he will re-evaluate . placed a midline in her antecubital . 2/17/22 MD Progress Note: . Reports new lesion . multiple open wounds right dorsum/lateral malleolus and toes dorsum . and right foot continue [MEDICATION(S)] . MRI (Magnetic Resonance Imaging-type of x-ray) of right foot side and ankle, IV (intravenous) [MEDICATION(S)] .CBC, ESR, CRP, procalcitonin, CMP also to be ordered .(labs used to detect infection) (It is important to note the facility did not provide measurements related to the open sore on knee and has not recorded any measurements since 2/8/22.) 2/19/22 NN: . has open areas from just above the ankle to toes. Due to having high [MEDICATION(S)] trough, (lab to monitor kidney function while receiving [MEDICATION(S)]) her IV for this morning and evening were ordered to be held . moderate amount of sanguineous drainage to prior dressing noted . Green soft boot applied afterward to protect foot . 2/23/22 MD Progress Note: R27 presents for evaluation [CONDITION(S)] to the right lower extremity. She has been undergoing IV . but today . IV line failed . Ulcerations noted on the dorsum of her right foot as well as on the midfoot region quarter size legion as well as on the medial malleolus . slight drainage with [CONDITION(S)] up her leg . 2/23/22 NN: midline in left upper arm was pulled due to not flushing and was halfway out . 3/3/22 MD Progress Note: 1 right mid pretibial ulcer into dermis .2 top of right foot ulcer continues-less red but over bony prominence dorsum foot .3 right lateral malleolus opening red . 4 toes of the 2nd, 3rd,4th digits opening into dermis or extensor toes over prominences . 3/7/22 NN: X ray to right foot shows no [CONDITION(S)] . Pharmacy recommendation discussion of next course of action for open areas on right foot and use of long-term antibiotics . 3/8/22 MD Progress Note: MRI ordered .x-rays are negative for [CONDITION(S)], but MRI is gold standard and need to be ordered to confirm [CONDITION(S)] is not present. 3/9/22 MD Progress Note: . looks a lot better with less [CONDITION(S)] in her right lower extremity and no increased temperature. She still has some ulcerations in the midfoot area as well as on the anterior tibial region . I cleansed wounds with wound cleanser and applied [MEDICATION(S)] and sterile dressings .orders for nursing home . discussed antibiotic use with Pharmacist . continue Vanco IV as directed . 3/10/22 NN: Second digit 0.6cm x 0.9cm x depth undetermined. There are some areas that are covered with scab and slough. Area is often moist; skin is translucent over wound. The other digits have no open areas but remain fragile and moist. Dorsum of right foot medial aspect 1.2cm x 1.4 cm x depth undetermined due to thin translucent skin over wound. Margins are regular and noted boney prominent wound bed. No drainage noted. Dorsum of right foot lateral aspect 1.4cm x 0.8cm x depth undetermined. No drainage noted, scab over wound bed. Skin is fragile. Lateral aspect of right lower leg 0.7cm x 0.2cm x 0.1cm. The wound bed has a thin translucent skin over wound. Wound bed shows yellow slough and is weeping. Skin to right lower extremity is all over fragile and has potential for further skin breakdown. There are areas that are dry and crusty . Areas are cleaned with saline and [MEDICATION(S)] was applied . Resident has her green boot on to alleviate pressure and protect when she is up . (It is important to note these are the first recorded measurements by MD or nursing staff since 2/8/22.) 3/10/22 NN: Dressing to right foot saturated and continues to drain . 3/13/22 MD Progress Note: .daughter unable to take R27 home due to her level of care . multiple wounds right leg that are poorly healing but less red less swollen and has an increased risk of poor healing and bony infection. 3/16/22 MD Progress Note: MRI of the right ankle shows early [CONDITION(S)] despite IV [MEDICATION(S)] and despite oral [MEDICATION(S)] given for [CONDITION(S)] ([CONDITION(S)] Resistant Staph Aureus) and Pseudomonas (bacteria in wound) . there is a good chance R27 may have to have an amputation of her right leg . if does not show improvement . Ulceration noted again on the dorsum with hammering of the digits 2 through 5 on the right foot. [CONDITION(S)] is subsided as well as [CONDITION(S)]. There is no pungent odor. Review of MRI shows possible suspect [CONDITION(S)] to the lateral fibula. At this point there is no ulceration to this area and only small eschar which is healed. She has an ulcer primarily quarter size on the dorsal of the medial cuneiform. There is no bone exposure. I cleansed the wounds . [MEDICATION(S)] silver . I do not feel the MRI warrants any bone biopsy at this point . 3/16/22 NN: MD was here today and reviewed MRI results with R27. MRI results show early [CONDITION(S)] in R27's right ankle . continue IV Vanco for 4 more weeks and restart [MEDICATION(S)] 500mg twice daily for another 10 days . 3/31/22 NN: MD rounded . ordered CT Angiograms (type of diagnostic to check for blockage of arterial system) of both left lower extremity and right lower extremity . 5/4/22 NN: Wound Care 2nd digit 2.0cm x 1.2cm with intact eschar. Noted drainage between 2nd and 3rd digit. No open areas noted. Pink. Toes appear edematous. Dorsum of foot 6.5cm x 11.6cm x <0.1cm. Tissue is very fragile and wound bed has a mixture of slough, granulation tissue, but a film of bioburden. (It is important to note these are the first recorded wound measurements since 3/10/22.) 5/9/22 NN: R27's right lower leg bandage was soaked through . 5/18/22 Wound Care: Dorsum of right foot medial aspect at boney prominence there is an area that measures 1.4cm x 1.9cm. This is intact with thin layer of healing tissue. This area remains very fragile. Dorsum of right foot/large area 12cm x 4cm. This tissue is edematous with much Bioburden. The 2nd,3rd,4th digits are also involved. Heel inspected with no breakdown noted . placed pressure boot to foot . (It is important to note these are the first recorded measurements since 5/4/22.) 5/19/22 NN: Wound culture obtained from dorsum of right foot as ordered. 5/21/22 NN: . wound culture came back Pseudomonas . start [MEDICATION(S)] 750mg two times daily with no stop date at this time . 5/22/22 NN: R27 remains on [MEDICATION(S)] 750 twice daily for a total of 7 days for right foot infection. Noted that her right foot is more swollen than previously seen. The area of slough that was near her inner ankle is healed but the area is now raised. Her great right toe is swollen. Slough bed present across foot base of toes . 5/25/22 NN: writer removed old dressing . old dressing saturated with serous drainage. Wound bed prior to cleansing was very moist drainage. Dorsum wound is larger in size this week. 8.5cm x 17cm x undetermined. In the center of this wound there is a firm yellow slough area that measures 0.5cm x 0.5cm x 0.1cm, Wound bed is light yellow with peri-wound light pink. Will follow up with MD . 5/27/22 NN: dressing saturated . 5/28/22 NN: dressing saturated . 5/29/22 NN: Large amount of yellow fluid on old dressing . Right foot and lower leg are red . Has several areas on lower extremity that are weeping . was started again on [MEDICATION(S)] with no end date to help prevent infection. 5/30/22 NN: . remains on prophylaxis antibiotics . right foot dressing was soaked through kerlix dressing. Noted at base of toes slough bed . Discussed dressing has increased in weeping .needs to be changed 4 times during the day. Boot remains in place . She does not elevate her right leg. 5/31/22 NN: wounds measured . Dorsum R foot medial aspect bony prominence 0.7 x 1 x 0.1 6/1/22 MD Progress Note: R27 presents for evaluation of chronic ulcerations of dorsum of the right foot . The nursing home is continuing to do wound care with cleansing of the wounds and applying [MEDICATION(S)] silver to the wounds . Removal of the [MEDICATION(S)] silver reveals [CONDITION(S)] and slight maceration dorsally. She has severe contractures of the digits 2-5 and ulcerations are noted with drainage noted. Allergies: adhesive tape . 6/8/22 NN: Extensive drainage noted to old dressing. Bony Prominence: 1cm x 1.5cm x <0.1cm. Center . has large patch of a thick dark yellow slough. Right heel: Noted new deep tissue injury. This wound measures 2.5cm x 3.4cm x undetermined depth. Distal edge is open and draining clear drainage. The lower leg is taut with extensive drainage while doing dressing change. The skin is very fragile/friable with erosion appearance. Also found a white macerated band from the lateral aspect of the foot to the medial aspect. This appears to be from a foam dressing that had been placed the last dressing change. Applied [MEDICATION(S)] Ag to wounds and covered with ABDs and wrapped with Kerlix followed by a stockinette dressing to hold in place. We feel the new deep tissue injury may be due to using the EZ stand lift and the heel was not placed correctly to the floor of the lift which could attribute to this injury. (It is important to note the new DTI to the heel and the possible cause recorded here with the EZ stand floor.) 6/8/22 MD Progress Note: reason for visit . follow up right foot open wound and deep tissue injury and [CONDITION(S)] . is on oral [MEDICATION(S)] 100mg twice daily for right lateral malleolar [CONDITION(S)] and is off IV [MEDICATION(S)]. Has macerated right foot and open wound on heel from deep tissue injury . There has been leaking of the tissue fluid through the dressings at night and these have been reinforced and replaced. If appears to be worsening need to order further imaging, see if [CONDITION(S)] is still an issue. Has no significant leg pain but has macerated right leg and open wounds to right leg. Please see RN wound nurse note of 6/8/22. 6/12/22 MD Progress Note: Problems: suspected deep tissue injury of unknown depth . Early [CONDITION(S)] of the right ankle was given IV [MEDICATION(S)] that seem to reduce the redness of the lateral malleolar area that seem to be the issue but whereas the right lateral malleolar area is healed she has a deep tissue injury ulcer on the right heel and burn scalding over some of right foot and plantar surface of right foot and pretibial area. (This can occur from infection.) Will need to restart [MEDICATION(S)] . CBC, CMP, ESR, CRP, Procalcitonin . Patient has significant [CONDITION(S)] of right leg and does not feel pain unless significantly pressure is given to the wound . Suspected Deep Tissue Injury of unknown depth of heel: 3.2cm x 2.0cm right heel. Will see MD on 7/7/22 for recheck .Will be asking nursing to evaluate patient to see about large volume of weeping and redness of the wound if debridement is not going to be necessary for this right foot and leg . 6/14/22 NN: PICC (Peripherally Inserted Central Catheter) line intact and IV antibiotic started . 6/15/22 NN: Dressing to right lower extremity changed as ordered due to saturation from serous drainage . 6/15/22 Wound Assessment: Dorsum R (right) foot medial aspect bony prominence 0.7 x 1.0 x 0.1 Heel 1.8x 3.5 x 0 6/22/22 Wound Assessment: Dorsum R foot medial aspect bony prominence 0.5 x 1.0 x.0.0 Heel 2.5 x 3 x 0.3 - (worsening) 6/24/22 Wound Assessment: Dorsum R foot medial aspect bony prominence 0.5 x 1.0 x.0.0 Heel: 2.5 x 3 x 0.3 (It is important to note these are the last measurements documented in R27's medical record.) 6/28/22 Wound Assessment: Dorsum R foot medial aspect bony prominence 2.1 x 0.6 x 0.0 Heel: No measurements (It is important to note these are the last documented measurements in R27's record the dorsum.) 7/3/22 MD Progress Note: . Right foot is totally and completely macerated significant weeping onto the 4x8s . is on IV antibiotics presently and does not seem to be improving . worsening . on oral [MEDICATION(S)] 500mg twice daily and [MEDICATION(S)] 300mg 3 times daily, will see MD 7/7/22 for evaluation of heel . for further treatment or surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] 7/7/22 MD Progress Note: R27 with daughter for evaluation of her right leg [CONDITION(S)] and infection It has been a chronic condition with Pseudomonas infection and have been on antibiotic IV as well as by month. She has had a below the knee amputation to the left lower extremity secondary to the same type of condition that she has on the right. Exam: Ulceration is noted dorsally where she has severe contractures of the digits 2-5. She has a Charcot-[NAME] foot with [CONDITION(S)] and has no sensation of pain or discomfort. There is [CONDITION(S)] localized to the foot itself with new legion dorsally over the medial cuneiform region. She has necrotic type peeling skin stage 0-I ulcerations with no sinus tract or purulent drainage. There is quite a bit of drainage, but no purulent odor noted . At this time, I cleansed the wound with soapy water and debrided all of the necrotic skin dorsally. I applied [MEDICATION(S)] silver followed by [MEDICATION(S)] followed by sterile 4x4s and a kerlix dressing. An ace wrap was then applied to secure the dressing as well as control some of the [CONDITION(S)] .Possible consult to the UW infectious disease . On 7/11/22 at 10:17 AM Surveyor, RN I (Registered Nurse) and RN J observed R27's wounds. During an interview R27 indicated she was a nurse for many years. R27 stated, My wounds started because I wore a shoe to match my prosthesis and it was too tight. RN I and RN J indicated that is how the wounds started. RN I indicated the heel wound started because R27's heel was not placed correctly on the EZ stand floor. R27 stated, That's right. RN I and R27 indicated R27 did not have boot on during that transfer and she should have to protect her fragile skin. RN I indicated R27 should have a boot on for all EZ stand transfers and while she is up, because R27 has such fragile skin on

Based on observation, interview and record review the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has a potential to affect all 40 (R) residents who reside in the facility. *Surveyor observed 45 individual nectar thickened lemon-flavored waters with expiration dates of [DATE]. *Surveyor observed the sugar and flour bins with no dates. *Surveyor observed 4 individual containers of pureed peaches with use by date of [DATE]. *Surveyor observed a half of pan of blondie bars with use by date of [DATE]. *Surveyor observed a pan of coffee cake with use by date of [DATE]. *Surveyor observed 5 pints of whole milk with an expiration date of [DATE]. *Surveyor observed 1 pint of 1% milk with an expiration date of [DATE]. *Surveyor observed an opened 5-gallon pal of vanilla ice cream with no open date. *Surveyor observed an orange twin popsicle opened with half the popsicle removed and no open date. Surveyor observed a cherry twin popsicle with half the popsicle removed taped shut with no open date. This is evidenced by: The facility policy, entitled Mile Bluff Medical Center-Food Storage and Dating, undated, states, in part: .PURPOSE: To ensure food items are stored and used properly according to national guidelines. PROCEDURE: 1. All food items that are taken out of original packaging must be dated with expiration date from original package .3. All food items in original packaging that are delivered to nourishment centers must contain an opened date and use by date .Staff that open items in the nourishment center must date items with opened date and use by date . The facility policy, entitled Mile Bluff Medical Center- Storage of Food and Supplies, undated, states, in part: POLICY: .12. Food that has passed its expiration date will be discarded . 16. Open food packages/cans will be stored in airtight containers and dated with opened date .PURPOSE: To assure food and nonfood items are stored properly according to National guidelines . On [DATE], at 10:17 AM, Surveyor conducted the initial walk through in the kitchen with DM (Dietary Manager) F finding the following: Surveyor observed 45 individual containers of nectar thickened lemon-flavored water with an expiration date of [DATE] in the dry storage area. Surveyor asked DM F if the nectar thickened lemon-flavored waters were expired and DM F indicated yes. DM F removed all 45 containers of nectar thickened lemon-flavored waters from shelf and disposed of them. Surveyor observed both the sugar and flour bins with no dates. Surveyor asked DM F what the process was for dating the flour and sugar. DM F indicated when the bins get empty the bins are then washed and new bags of flour and/or sugar are added to the bins. Then the date is put on the bins. DM F indicated there were no dates on the sugar or flour bins and should be. Surveyor observed in the freezer 4 individual containers of pureed peaches with use by date of [DATE]. DM F indicated the 4 individual containers of pureed peaches were expired and should not be in circulation. Surveyor observed in the freezer a half pan of blondie bars with a use by date of [DATE] and a pan of coffee cake with a use by date of [DATE]. Surveyor asked DM F if both pans are expired, and DM F indicated yes and disposed the pans. On [DATE], at 10:53 AM, Surveyor observed in the refrigerator in the dining room, with 5 individual pints of whole milk and 1 pint of 1% milk with expiration dates of [DATE]. Surveyor observed in the freezer an opened 5 gallon pal of vanilla ice cream with no open date. Surveyor observed an orange twin popsicle with 1 popsicle left in the package and no open date. Surveyor observed a cherry twin popsicle with 1 popsicle left in the package. The package was taped shut with no open date. On [DATE], at 12:00 PM, Surveyor interviewed CNA (Certified Nursing Assistant) D and asked if the 5 pints of whole milk and 1 pint of 1% milk were expired. CNA D indicated yes and discarded the items. Surveyor asked CNA D if there was an open date on the 5-gallon pal of vanilla ice cream. CNA D indicated no. Surveyor asked CNA D if there was an open date on the orange and cherry twin popsicles. CNA D indicated no and disposed the items. On [DATE], at 3:03 PM, Surveyor had kitchen exit with DD (Dietary Director) G and DM F and explained findings listed above.

Based on interview and record review the facility did not develop a comprehensive person-centered care plan for 6 of 14 sampled Residents (R11, R17, R24, R12, R21, R29) reviewed for person centered care plans. R11 does not have a care plan for the use of an anticoagulant. R17 does not have a care plan for the use of specific [CONDITION(S)] medications. R24 does not have a care plan for pain. R21 does not have a care plan for specific [CONDITION(S)] medications or the use of an anticoagulant. R29 was prescribed an anticoagulant and her comprehensive care plan did not identify her risk with this medication and have interventions and goals in place regarding the use of anticoagulant medication. R12 was prescribed an anticoagulant and her comprehensive care plan did not identify her risk with this medication and have interventions and goals in place regarding the use of anticoagulant medication This is evidenced by: The facility's policy titled, Multidisciplinary Plan of Care, no date, states in part: 1 The multidisciplinary plan of care includes the following: a. Identified resident needs. b. Identified goals which are realistic and described in terms that are measurable, related to a reasonable achievement of time, or maintenance of highest functional level. c. Approach to meeting identified goals . On 7/12/22 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation were for staff when developing a care plan, DON B stated that the care plan should be started on admission and adjust as needed. Surveyor asked DON B if she would expect that a resident who is receiving an anticoagulant, have a care plan for identifying that he/she is on an anticoagulant, DON B stated that she was unsure if anticoagulants are reflected on the care plan and is unsure if she would expect it to be there. Surveyor asked DON B if she would expect a resident who has pain to have a care plan for pain, DON B stated that if the resident has chronic pain, they should have a care plan for it, but if it's acute pain they do not create a care plan for it. Example 1 R11 was admitted to the facility on [DATE]. R11 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R11 is taking the anticoagulant, [MEDICATION(S)], daily. R11's care plan does not address the use of an anti-coagulant or that staff should be monitoring for bruising or bleeding. Example 2 R17 was admitted to the facility on [DATE]. R17 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 was prescribed [MEDICATION(S)] and trazadone for [CONDITION(S)]. R17's care plan does not address [CONDITION(S)], medications used for [CONDITION(S)], side effects to monitor for, or non-pharmacological interventions that have been implemented. Example 3 R24 was admitted to the facility on [DATE]. R24 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24 is prescribed acetaminophen 500 mg (milligrams) scheduled four times a day and PRN (as needed), [MEDICATION(S)]/acetaminophen 5/325 mg scheduled four times per day, and [MEDICATION(S)] immediate release 15 mg every 4 hours as needed. R24's care plan does not address her pain, pain medications, side effects to monitor for, or non-pharmacological interventions that have been implemented. On 7/7/22 at 10:39 AM, Surveyor interviewed R24. Surveyor asked R24 how her pain was, R24 stated that it has been worse the last couple of days, but that she thinks that the facility was doing what they could. Surveyor asked if the facility has tried any non-pharmacological interventions such as a warm compress, ice, or repositioning, R24 stated that she was unsure. Example 4 R21 was admitted to the facility on [DATE]. R21 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21 is currently taking an anticoagulant, [MEDICATION(S)], daily. R21's care plan does not reflect the use of an anticoagulant or how staff should monitor R21 for bruising or bleeding. R21 is currently taking [MEDICATION(S)] for unspecified dementia with behavioral disturbance. R21's care plan does not reflect the use of [MEDICATION(S)], behaviors or interventions put into place for use. On 7/12/22 at 10:10 AM, Surveyor interviewed DON B and asked if R21's care plan should indicate antipsychotic use and interventions. DON B indicated possibly initially. DON B indicated interventions and antipsychotic use could be removed when behaviors no longer exists. Surveyor asked DON B if R21's care plan should indicate anticoagulant use and interventions. DON B indicated she does not know if she would expect interventions and anticoagulant use to be on the care plan. DON B indicated she would look into it. Example 5: R29 was admitted to the facility on [DATE] with diagnoses, including: chronic pulmonary embolism R29 Physician Orders, for July 2022, include: Apixiban for chronic pulmonary embolism R29's Comprehensive Care Plan, initiated 2/7/22, does not identify R29 to be on a high risk anticoagulant medication and does not contain interventions or goals related to the use of an anticoagulant. Example 6: R12 was admitted to the facility on [DATE] with diagnoses, including: Chronic pulmonary embolism and Chronic embolism and [CONDITION(S)] of left popliteal vein. R12's Physician Orders, for July 2022, include: Apixiban for Chronic pulmonary embolism. R12's Comprehensive Care Plan, initiated 4/18/22, does not identify R12 to be on a high risk anticoagulant medication and does not contain interventions or goals related to the use of an anticoagulant. On 7/11/22 at 3:20 PM DON B (Director of Nursing) indicated to Surveyor she was not sure if R29's and R12's Comprehensive Care Plan should include interventions and goals related to their use of an anticoagulants.

Based on interview and record review, the facility did not ensure that a resident's medical record included documentation that indicates the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted, received, or declined the COVID-19 vaccine for 5 of 5 supplemental residents (R31, R8, R189, R28, R25) reviewed for COVID-19 vaccinations. This is evidenced by: The Centers for Medicare and Medicaid Services (CMS) Quality, Safety & Oversight Group (QSO) Memo (Ref: QSO-21-19-NH) released on May 11, 2021, addresses the Interim Final Rule related to COVID-19 Vaccine Immunization Requirements for Residents and Staff, which includes requirements for educating residents or resident representatives and staff regarding the benefits and potential side effects associated with the COVID-19 vaccine, and offering the vaccine. Additionally, the facility must maintain appropriate documentation to reflect that the facility provided the required COVID-19 vaccine education, and whether the resident or staff member received the vaccine. According to the facility's vaccination tracking log, R31, R8, R189, R28, and R25 are unvaccinated for COVID-19. Example 1 R31 was admitted to the facility on [DATE]. R31 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R31 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/15/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status. Example 2 R8 was admitted to the facility on [DATE]. R8 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R8 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 1/28/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status. On 7/12/22 at 9:55AM, Surveyor interviewed R8 of the COVID vaccinations being offered, education provided and signing documentation of refusal. R8 replied there was not much talk of anything, I was asked if I had one, I said no, I was asked if I wanted one, I said no. R8 reports there was not a discussion of education and no handouts or teaching material was provided. R8 does not recall if forms what forms were signed. Example 3 R189 was admitted to the facility on [DATE]. R189 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R189 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 6/10/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status. Example 4 R28 was admitted to the facility on [DATE]. R28 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R28 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 5/17/22 of vaccination refusal and education provided after the Surveyor inquired about it. Example 5 R25 was admitted to the facility on [DATE]. R25 did not have documentation in their medical record indicating COVID 19 vaccination benefits, risks and potential side effects were discussed. R25 had not received any doses of the COVID-19 vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and benefits of the COVID-19 vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/07/22 of vaccination refusal and education provided after the Surveyor inquired about vaccination status. On 7/11/22 at 10:11AM. Surveyor interviewed ICP C (Infection Control Preventionist) and asked where the immunizations are located in the EHR. ICP C reports of sometimes there is a message in the record, and later provided a sample of a message in the EHR and a sample of the education that is provided to residents. ICP C further reported due to the changing of staff she is unsure if they are in a binder or located someplace else. ICP C stated she is trying to pick up where staff have left off.

Based on interview and record review, the facility did not ensure all residents receive treatment and care in accordance with professional standards of practice for 1 of 3 residents sampled for skin integrity (R27) out of a total sample of 14. R27 was at risk for skin breakdown due to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Evidenced by: R27 was admitted to the facility on [DATE] with diagnoses, including CMT (Charcot-[NAME] Tooth disease), [CONDITION(S)], and Amputation of left lower extremity below knee. CMT is a spectrum of nerve disorders that damage the nerves in the arms and legs. R27's Medical Record contained the following: 2/8/22 NN (Nursing Notes): Lateral aspect of right lower leg: 1.2cm x 0.7cm x undetermined. The wound bed has a thin translucent skin over wound. Wound bed shows 1/2 dry yellow slough and pinpoints of granulation. The right lower leg is all over fragile . 2/13/22 NN: . right leg continues to have some redness, no increased warmth. R27 has no feeling in her right leg .no drainage noted . 2/15/22 MD Progress Note: R27 presents for re-evaluation of [CONDITION(S)] in ulcerations on her right lower extremity. 2/17/22 MD Progress Note: . Reports new lesion . pretibial area redness and open sores to knee . Red swelling calf with [NAME] edematous tender calf area questionable heat to area but is swollen and red and tender . continue [MEDICATION(S)] . [It is important to note the facility did not provide measurements related to the open sore on knee and has not recorded any measurements since 2/8/22.] 3/3/22 MD Progress Note: 1 right mid pretibial ulcer into dermis . 3/9/22 MD Progress Note: . looks a lot better with less [CONDITION(S)] in her right lower extremity and no increased temperature. She still has some ulcerations in the midfoot area as well as on the anterior tibial region . I cleansed wounds with wound cleanser and applied [MEDICATION(S)] and sterile dressings .orders for nursing home . discussed antibiotic use with Pharmacist . continue Vanco IV as directed . 3/10/22 NN: Lateral aspect of right lower leg 0.7cm x 0.2cm x 0.1cm. The wound bed has a thin translucent skin over wound. Wound bed shows yellow slough and is weeping. Skin to right lower extremity is all over fragile and has potential for further skin breakdown. There are areas that are dry and crusty . Areas are cleaned with saline and [MEDICATION(S)] was applied . (It is important to note these are the first recorded measurements by MD or nursing staff since 2/8/22.) 5/4/22 NN: Wound Care Right lower shin 1.2cm x 1.4cm x <0.1cm wound bed is 75% yellow slough and 25% beefy red. Peri-wound is pink and intact (It is important to note these are the first recorded wound measurements since 3/10/22.) 5/18/22 Wound Care: Right shin area measures 1cm x 2cm. This is dry intact eschar. (It is important to note these are the first recorded measurements since 5/4/22.) 5/25/22 NN: Shin open area: 0.9cm x 2cm x 0.1cm. 5/29/22 NN: Large amount of yellow fluid on old dressing . Right foot and lower leg are red . Has several areas on lower extremity that are weeping . was started again on [MEDICATION(S)] with no end date to help prevent infection. 5/31/22 NN: wounds measured . Right lower leg shin 2.2 x 2.5 x 0.1 increased 6/8/22 NN: Extensive drainage noted to old dressing. Shin: 2.5cm x 2.5cm with irregular margins .wound bed has 90%moist yellow slough and 10% islands of granulation. Surrounding tissue is crusty moist slough . 6/15/22 Wound Assessment: Right lower leg shin Pressure Injury: 2.2 x 2.5 x 0.1 6/22/22 Wound Assessment: Right lower leg shin: 1x2x0.1 6/24/22 Wound Assessment: Right lower leg shin 2 x 2.5 x 0.1 6/28/22 Wound Assessment: Right lower leg shin 2.2 x 2.0 (It is important to note these are the last documented measurements in R27's record for the shin.) On 7/11/22 at 10:17 AM Surveyor, RN I and RN J indicated R27's wound on her shin is a stasis ulcer and they do not believe it is from pressure. On 7/12/22 at 12:54 PM Surveyor and RN L observed R27's shin wound to not have any tendon or bone showing and was covered in slough. RN L indicated this wound is unstageable and not a stage 4 as NN suggested. RN L measured two shin wounds 5cm x 2.2 and 2cm x 3.2. On 7/12/22 at 2:23 PM. MD O indicated R27 has stasis ulcer on shin/ankle, and he expects staff to do the same for those and measure on a weekly basis per current standards of practice.

Based on interview and record review, the facility did not ensure drug regimens are free from unnecessary [CONDITION(S)] medications for 2 out of 5 residents (R21 and R17) reviewed for unnecessary medications out of a total sample of 14. R21 receives [MEDICATION(S)] for dementia and [MEDICATION(S)] for [CONDITION(S)]. [MEDICATION(S)] is an antipsychotic medication that is used to treat psychotic conditions, such as [CONDITION(S)] and [CONDITION(S)]. R21 was prescribed an antipsychotic medication without documentation of an appropriate diagnosis and targeted behaviors that are persistent and harmful to self and others. R21 was prescribed [MEDICATION(S)] for [CONDITION(S)] without prior sleep monitoring or non-pharmacological interventions attempted. R17 receives [MEDICATION(S)] for [CONDITION(S)]. R17 was prescribed [MEDICATION(S)] for [CONDITION(S)] without prior sleep monitoring or non-pharmacological interventions attempted. This is evidenced by: The facility policy, entitled Administrative Policy- Long Term Care- [CONDITION(S)] Medication, undated, states, in part: POLICY: 1. [CONDITION(S)] medications are any drug used to treat or modify a psychiatric symptom or challenging behavior. 2. A written doctor's order will be obtained to include the Diagnosis or Target Behavior being treated. 5. Residents on [CONDITION(S)] drugs will be assessed each shift for side effects and effectiveness of med. Example1 R21 was admitted to the facility on [DATE] and has diagnoses that include Unspecified Dementia with Behavioral Disturbance, [CONDITION(S)] due to known physiological condition and [CONDITION(S)]. R21's Quarterly MDS (Minimum Data Set) Assessment, dated 5/9/22, indicated that R21 has a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. R21's Care Plan, dated 1/26/22, with a target date of 8/18/22, states, in part: LTC (Long Term Care): Psychosocial Wellbeing Status: Inactive . *LTC: ADL (Activities of Daily Living) .Related to: Unspecified dementia with behavioral disturbance, [CONDITION(S)] d/t known physiological condition, .[CONDITION(S)] .Needs: .For my [CONDITION(S)] I need [CONDITION(S)] medications at this time, with monitoring by nursing .Intervention: .Assist me with my [CONDITION(S)] medication for my sleep and monitor effectiveness . Note: No behaviors or [CONDITION(S)] with interventions regarding antipsychotic use. No indication of non-pharmacological interventions being used prior to medication. R21's Physician Orders state, in part: .[MEDICATION(S)] 1mg [milligram] tablet po [by mouth] BID [two times a day] 84 [at 8 and 4] Scheduled [MEDICATION(S)] HCL [[MEDICATION(S)]] 100mg tablet PO BEDTIME scheduled . Note: No indications for use. R21's Physician Progress Note, dated 6/17/22, states, in part: .Assessment and Plan (1) Dementia: Status: Chronic Assessment and Plan: He continues on [MEDICATION(S)]. Qualifiers: Dementia behavioral disturbance: with behavioral disturbance Dementia type: unspecified type Qualified Code (s): F03.91- Unspecified dementia with behavioral disturbance . R21's Informed Consent for Medication- [MEDICATION(S)], dated 1/31/22, states, in part: .Reason for Use of [CONDITION(S)] Medication .Unspecified Dementia with Behavioral Disturbance . R21's behaviors being monitored are striking out at staff and self-transferring. The month of May 2022 R21 had 7 behaviors documented of striking out at staff. The month of June 2022 R21 had no behaviors documented. From July 1, 2022, to July 11, 2022, R21 had no behaviors documented. This is not indicated as being a harmful and persistent behavior. Note: No [CONDITION(S)] being monitored. On 7/11/22, at 1:54 PM, Surveyor interviewed CNA (Certified Nursing Assistant) D, who indicated R21 sometimes will hit towards staff but does not connect. Surveyor asked CNA D if R21 has behaviors that are persistent and harmful to self or other residents. CNA D indicated no. On 7/11/22, at 1:58 PM, Surveyor interviewed CNA E and asked if R21 has harmful and persistent behaviors to self or other residents. CNA E indicated no, R21 mostly sleeps all the time. On 7/12/22, at 10:10 AM, Surveyor interviewed DON B (Director of Nursing) and asked what diagnosis R21 has for the use of [MEDICATION(S)]. DON B indicated dementia. Surveyor asked DON B if dementia was an appropriate diagnosis for [MEDICATION(S)] and DON B stated, According to the doctor - yes. Surveyor asked DON B if R21 has behaviors and DON B indicated in the past R21 would strike out at staff and self-transfer. Surveyor asked DON B if R21 has behaviors that are harmful and persistent to self or others and DON B indicated no while looking at behavior monitoring. Surveyor asked DON B for sleep monitoring logs and DON B indicated the facility does not have sleep monitoring logs. Surveyor asked DON B if there were non-pharmacological interventions attempted prior [MEDICATION(S)]. DON B indicated they tried non-pharmacological interventions but there is no documentation to show it. Surveyor asked for a sleep assessment for R21 prior to [MEDICATION(S)] and no sleep assessment was provided to Surveyor. Example 2 R17 was admitted to the facility on [DATE]. R17 has diagnoses that include dementia with behavioral disturbance, chronic [CONDITION(S)] with [CONDITION(S)], malignant neoplasm of bilateral lungs, depression, anxiety disorder, and [CONDITION(S)]. R17 was prescribed trazadone 100mg (miligrams) at bedtime PRN (as needed) for [CONDITION(S)] on 1//21/22. R17's care plan does not address [CONDITION(S)], medications prescribed, side effects to monitor, or non-pharmacological interventions. It is important to note that R17 also takes [MEDICATION(S)] 6mg at bedtime for [CONDITION(S)] and [MEDICATION(S)] 0.5mg at bedtime for anxiety/ restlessness. R17's MDS (Minimum Data Set) dated 4/28/22 Section D indicates that R17 has no trouble falling asleep, staying asleep, or sleeping too much. Surveyor requested R17's sleep assessment from DON B (Director of Nursing), and was never provided the information. On 7/12/22, at 10:10 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B for sleep monitoring logs and DON B indicated the facility does not have sleep monitoring logs.

Based on observation and staff interview, the facility did not maintain an infection control program designed to prevent the development and transmission of disease and infection during care observations involving 1 Resident (R11) of 14 sampled residents. Staff did not follow appropriate infection control practices when emptying R11's urinary draining bag (UDB). The Facility is not reviewing their Infection Control Policies and Procedures annually. This is evidenced by: The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the CDC (Centers for Disease Control and Prevention) entitled, Guideline for Hand Hygiene in Health Care Settings, indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The above information can also be found at: https://www.cdc.gov/handhygiene/providers/index.html with the page last reviewed on January 8, 2021. The facility procedure Hand Hygiene (Washing or Decontaminating with Alcohol Products) undated, in part states .2A.1) Alcohol products may be used before and after having direct contact with patients . 07/11/22 09:07 AM Surveyor observed CNA H (Certified Nursing Assistant) empty R11's UDB into a clear plastic urinal. Surveyor followed CNA H entering room. CNA H donned gloves, placed down paper towel barrier, wiped spout with alcohol, drained urine, wiped with alcohol, and replaced UDB under bed. Urine measured and emptied, rinsed with water and placed on side of toilet, gloves removed, washed hands. Surveyor asked CNA H if she should wash per hands prior to procedure, CNA H replied yes and she should have washed her hands. 7/11/22 at 9:55AM Surveyor interviewed ICP C and updated on R11's observation with CNA H. ICP C replied that she was new and had been here a few months and should have washed her hands. The following Infection Control Policies and Procedures are dated further back or not dated than annually for infection control: COVID-19 Testing- no date for reviewed Emergency Mandatory COVID-19 Vaccination Plan During the Pandemic, no date reviewed Pandemic/Emergency Outbreak of Respiratory Illness, no date Isolation of a Resident with a Communicable Disease, Review date 6/12 Epidemic/Infection Prevention, no review date Infection Prevention Surveillance, no review date Standard Precautions, no review date Isolation, no date New Employee Orientation, Infection Control, no date Prevention and Control of [CONDITION(S)] and other Antibiotic Resistant Organisms in the facility, no dates Hand Hygiene, no date Protocol for Administering Pneumococcal Vaccine, approved [DATE], no review date Infection Control Surveillance, no date Optimize the use of antimicrobials for residents of LTC, no date Influenza Immunization, no date Coronavirus/COVID-19 Management Plan, reviewed 08/18/2020 7/13/22 at 4:45PM Surveyor reported polices are procedures are not updated annually. NHA A(Nursing Home Administrator) stated that policies are reviewed online and will provide an update.

Based on record review and interview, the facility did not offer each resident influenza and pneumococcal immunizations, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and potential side effects of the influenza and pneumococcal immunization for 3 of 5 residents (R31, R8, and R28) reviewed for immunizations. R31 refused the influenza and pneumococcal vaccine according to the facility vaccination list. There is no documentation R31 was offered education on the risks and potential side effects of the vaccine. R8 refused the influenza vaccine according to the facility vaccination list. There is no documentation R8 was offered risks and potential side effects of the vaccine. R28 refused the influenza and pneumococcal vaccine according to the facility vaccination list. There is no documentation R28 was offered risks and potential side effects of the vaccine. This is evidenced by: The facility's administrative policy Influenza Immunization undated, documents in part: A. Each resident or resident's legal representative will receive education regarding the benefits and potential side effects of the immunization .C. The resident or the resident's legal representative has the opportunity to refuse immunization. D. The resident's medical record will include documentation, including education that was provided regarding the benefits and potential side effects and if the resident either received the influenza immunization or did not receive due to medical contraindication or refusal . The facility's departmental procedure Protocol for Administering Pneumococcal Vaccine, undated, documents in part: Purpose: To reduce morbidity and mortality from invasive pneumococcal disease by vaccinating all patients who meet criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Pneumococcal vaccine will be offered year-round to MBMC (Mile Bluff Medical Center) patients who meet CDC (Centers of Disease Control) established immunization criteria . Example 1 R31 was admitted to the facility on [DATE]. R31 did not have documentation in their medical record indicating the influenza and pneumococcal vaccination benefits and side effects were discussed. R31 had not received any doses of the influenza and pneumococcal vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and potential side effects of the influenza and pneumococcal vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 2/15/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education. Example 2 R8 was admitted to the facility on [DATE]. R8 did not have documentation in their medical record indicating the influenza vaccination benefits and risks were discussed. R8 had not received any dose of the influenza vaccine, nor was there any documentation in her EHR indicating that the facility had provided education regarding the risks and potential side effects of the influenza vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/11/22 for the date of 1/28/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education. On 7/12/22 at 9:55AM, Surveyor interviewed R8 regarding vaccinations being offered, education provided and signing documentation of refusal. R8 replied there was not much talk of anything, I was asked if I had one, I said no, I was asked if I wanted one, I said no. R8 reports there was not a discussion of education and no handouts or teaching material was provided. R8 does not recall if forms what forms were signed. Example 3 R28 was admitted to the facility on [DATE]. R28 did not have documentation in their medical record indicating influenza and pneumococcal vaccination benefits and risks were discussed. R28 had not received any doses of the influenza and pneumococcal vaccine, nor was there any documentation in her EHR (Electronic Health Record) indicating that the facility had provided education regarding the risks and potential side effects of the influenza and pneumococcal vaccine prior to Surveyors entering the facility. Surveyor was provided a late entry nursing note created 7/12/22 for the date of 5/17/22 of vaccination refusal and education provided after the Surveyor inquired regarding vaccine education. On 7/11/22 at 10:11AM. Surveyor interviewed ICP C (Infection Control Preventionist) and asked where the immunizations are located in the EHR. ICP C reports of sometimes there is a message in the record, and later provided a sample of a message in the EHR and a sample of the education that is provided to residents. ICP C further reported due to the changing of staff she is unsure if they are in a binder or located someplace else. ICP C stated she is trying to pick up where staff have left off.

Based on observation, interview and record review, the facility did not prepare, distribute and serve food in accordance with professional standards for food service safety as the facility served unpasteurized, poached eggs and over easy eggs that were not thoroughly cooked to 2 of 12 sampled residents (R29 and R243). Failure to use pasteurized eggs or to fully cook unpasteurizd eggs before serving created a finding of Immediate Jeopardy (IJ) that started on 5/17/21. The facility NHA (Nursing Home Administrator) was made aware of the findings of the IJ on 5/17/21 at 11:15 AM, which was removed on 5/17/21. The deficiency continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as the facility continues to implement its removal plan and as evidenced by the following: The facility did not check surface temperature of dishes and utensils in a ware washing machine and failed to [MEDICATION(S)] when the TempTaker Disc (non-regressing thermometer- a thermometer that measures the highest or lowest temperature and maintains the temperature point until it is reset) the facility used failed to function. Kitchen staff continued to use the dishwasher and were not testing the dishwasher dish and utensil surface temperature with heat sensitive test strips or another non regressing thermometer. Black plastic cups were wet stacked on a solid plastic tray. Kitchen staff did not wear masks over nose and mouth during food prep. This had the potential to affect all residents. Findings include: Example 1 The facility uses the US Food Code as their kitchen's operational standard of practice. According to the 2017 FDA (Food and Drug Administration) Food Code: 3-302.13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [CONDITION(S)] center, or hospital or nursing home, or nutritional or socialization services such as a senior center. 3-801.11 Pasteurized Foods, Prohibited Re-Service and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; The facility's policy Food and Nutrition Services undated, includes: 15. No raw eggs are to be served i.e.; poached eggs unless patient or resident requests and potential risks are explained and documented in chart, and only pasteurized shell eggs will be used. On 5/16/21 at 8:45 AM, during the initial tour of the facility's kitchen, Surveyor observed one crate of unpasteurized eggs in the kitchen's cooler. On 5/16/21 at 8:55 AM, Surveyor spoke with Co E (Cook). Co E said they serve residents poached or fried eggs on resident request and they have fried eggs on the menu twice a week. Surveyor and Co E walked into the kitchen cooler. Surveyor asked Co E if the eggs in the cooler were pasteurized. Co E said she was sure they were. Co E closely examined the eggs in the cooler and said they aren't marked like pasteurized eggs usually are and the box the eggs are in does not say pasteurized eggs. On 5/16/21, during the initial interview of all the residents, several residents said they frequently ordered and consumed fried or poached eggs. On 5/16/21 at 9:30 AM, R243 said he ate four poached eggs every day. R243's most recent MDS (Minimum Data Set) dated 2/24/21 measures his BIMS (Brief Interview for Mental Status) at 14, which indicates he is cognitively aware. R243 has diagnoses of heart disease, history of COVID-19 and lung disease. On 5/17/21 at 7:15 AM, Surveyors observed R243 eating four poached eggs and had eaten most of the eggs by the time the Surveyor observed him. R29 was served a fried over easy egg, but was stopped from eating the fried egg. None of the eggs were thoroughly cooked and the yolks were runny. R29's MDS dated [DATE] indicated a BIMS score of 4, which indicates R29 is severely cognitively impaired. R29 has diagnoses of lung disease, bowel disease, kidney disease and dementia. On 5/17/21 at 8:50 AM, Surveyor spoke with DM C (Dietary Manager). DM C said she was ServSafe (a food safety certification) certified. Surveyor and DM C examined the unpasteurized eggs in the kitchen cooler. DM C said she was aware the eggs were unpasteurized. DM C said they switched food suppliers on March 1 2021, and the food supplier must have substituted the unpasteurized eggs. Surveyor examined the most recent invoice order for the unpasteurized eggs. The invoice containing the order for the eggs was dated 5/11/21. DM C said they receive the food order 1-2 days after ordering. DM C said the poached and fried eggs were not checked for temperature prior to being served to the residents. Surveyor asked DM C for the most recent invoice for pasteurized eggs. The invoice was dated 2/23/21 and the invoice indicated an order of 15 dozen pasteurized eggs. Surveyor asked DM C what time range that 15 dozen eggs would be used by the kitchen. DM C said that 15 dozen eggs would last around two weeks. DM C said the pasteurized egg order was probably finished around March 9, 2021. The facility had been using unpasteurized eggs since approximately March 9, 2021. According to the Centers for Disease Control and Prevention (CDC), .an egg with a runny yolk still poses a greater risk than a completely cooked egg. Undercooked egg whites and yolks have been associated with outbreaks of Salmonella enteritidis infections. The CDC notes that Salmonella causes 1.2 million cases of illness each year in the United States and 450 deaths. According to Salmonella Enteritidis (Egg Salmonella FAQs), A person infected with the Salmonella enteritidis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization . The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. https://wonder.cdc.gov/wonder/prevguid/p 03/p 03.asp#:~:text=A%20person%20infected%20with%20the,persons%20recover%20without%20antibiotic%20treatment. Serving unpasteurized eggs that were not fully cooked created a finding of IJ. The IJ was removed on 5/17/21, when the facility implemented the following: -On 5/17/21 the facility immediately stopped using unpasteurized eggs for breakfast. -Residents involved (served runny yolk today) will be monitored every shift for 72 hours for signs and symptoms of foodborne illness including fever, abdominal pain and nausea, vomiting and diarrhea. Any sign or symptom of illness will be immediately reported to the physician. -Dietary Manager or designee will educate all dietary staff immediately and prior to their next working shift to ensure all staff are able to identify an unpasteurized egg. All dietary staff will immediately and prior to their next working sift be educated on serving unpasteurized eggs only if fully cooked, no running yolks. The deficient practice continues at a scope/severity of F (potential for more than minimal harm that is not immediate jeopardy/widespread) as evidenced by: Example 2 2017 FDA states: 4-302.13 Temperature Measuring Devices, Manual and Mechanical ware washing (B) in hot water mechanical ware washing operations, an irreversible registering temperature indicator shall be provided and readily accessible for measuring the UTENSIL, surface temperature. 4-501.112 .When surface temperatures of utensils passing through ware washing machines using hot water for sanitizing do not reach the required 160 degrees (F) Fahrenheit, it is important to understand the factors affecting the decreased surface premature. A comparison should be made between the machine manufacturer's operating instructions and the machine's actual wash and rinse temperatures and final rinse pressure. The actual temperatures and rinse pressure should be consistent with the machine manufacturer's operating instructions and within limits specified in sections 4-501.112 and 4-501.113. If either the temperature of pressure of the final rinse spray is higher that the specified upper limit, spray droplets may disperse and begin to vaporize resulting in less heat delivery to utensil surfaces. Temperatures below the specified limit will not convey the needed heat to surfaces. On 5/16/21 at 845 AM, Surveyor spoke with Co E (Cook). Co E said the TempTaker disc had not been working for about a month. Co E said they had been monitoring the dishwasher temperature by the gauge reading on the outside of the dishwasher. Surveyor observed the gauge on the outside of the dishwasher. The temperatures that were displayed on the gauge indicated the correct wash and rinse temperature. The facility's dishwasher temperature logs indicated correct temperatures. On 5/17/21 at 8:50 AM, Surveyor spoke with DM C. DM C said the TempTaker disc had not been working for about a month. DM C said they had been monitoring the dishwasher temperature by observing the gauges outside the dishwasher. DM C said they have not been measuring the internal dish surface temperature with another non regressing thermometer or heat sensitive strips. On 5/17/21 at 9:05 AM, Surveyor spoke with DA D (Dietary Aide). Surveyor asked DA D what she would do if the dishwasher gauge were not displaying the correct temperature for the wash and rinse cycle. DA D said she would notify the dietary manager and if she was not available, she would call maintenance and run the dishwasher without dishes until the dishwasher gauge displayed the correct temperature for the wash and rinse cycle. Example 3 The facility's policy Food and Nutrition Services undated, documents: - 30. Clean dishes must air dry prior to storage to prevent wet nesting. On 5/17/21 at 10:00 AM, Surveyor observed a tray of 15 black plastic cups on a solid plastic tray. The interior of the black plastic cups had droplets of moisture. On 5/18/21 at 9:00 AM, Surveyor spoke with DM C. DM C said all dishware and utensils should be air dried before placing on solid surfaces or stacking. Example 4 The facility Food and Nutrition-Subject COVID -19 Food Service Delivery for Skilled Nursing Facilities undated, includes: - 3. A. All staff are required to wear masks while in the skilled nursing facilities and for all food preparations/serving duties. On 5/16/21, at 8:45 AM, Surveyor observed DA E putting food on plates for resident breakfast. DA E had her mask below her nose and the mask frequently moved to be under DA E's mouth. DA E plated 10 plates of food for resident's breakfast while her mask was worn incorrectly. On 5/17/21 at 11:15 AM, Surveyor observed Co E with her mask strap hanging on her left ear while prepping food tray for residents lunch. Co E prepped 7 food trays while not wearing a mask correctly. Surveyor asked Co E if she should have her mask on. Co E said only when we are on the resident floor. On 5/18/21 at 10:35 AM, Surveyor observed DM C had no mask on her face while prepping food for resident lunch. DM C placed 10 frozen fish filets on a metal tray while not wearing a mask on her face. Surveyor asked DM C when kitchen staff should be wearing a mask. DM C said only when we are on the resident floor.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the ability to affect all 43 residents. The following was observed in the kitchen: Food being cooked under a dusty/dirty hood and dusty/dirty sprinkler pipes & heads 4 refrigerators/freezers without internal thermometers Dirty floors in the walk-in refrigerator and freezer A staff soda in the walk-in refrigerator Evidenced by: On 4/30/19 at 9:26 AM, Surveyor completed an initial tour of the kitchen with CM E (Cafe Manager). Surveyor observed, on the floor, under the shelves, in the walk-in refrigerator, approximately 8 creamers, a pen, dust/dirt, and cardboard pieces. Surveyor notices an opened Pepsi bottle and Dietary Aide F stated that it was hers and she usually did not put her personal items in the kitchen refrigerator. Surveyor observed in the walk-in freezer, on the floor, cardboard pieces and dust/dirt under the shelves. Surveyor also could not find internal thermometers in 4 of the fridges/freezers in the kitchen. Surveyor also noted thick dust on the 4 sprinkler pipes and heads that hung over the stove and cooking area, and the hood also had thick dust hanging from the bottom of the hood in the back, also over the stove where food was being cooked. On 4/30/19 at 11:03 AM, Surveyor observed the same dust on the sprinklers pipes and heads and on the hood with potatoes and meat being cooked on the stove for the noon meal. Cook G stated the hoods were supposed to be cleaned every 6 weeks. On 5/1/19 at 9:58 AM, Surveyor walked through the kitchen with Certified Dietary Manager H. She agreed that each refrigerator and freezer should have a thermometer inside to ensure proper temperatures. She said they check monthly to ensure they are there. She viewed the dirty hood and sprinkler pipes/heads and agreed they were dirty and needed to be cleaned. She said they were last cleaned at the end of March. She also agreed that the floors in the walk-in refrigerator and freezer should be clean.

Based on observation and interview, the facility did not ensure residents with medications in their rooms were assessed for medication self-administration for 2 residents (R190 and R192) of 3 residents reviewed. R190 and R192 had medications at bedside and the facility did not have Physician order [REDACTED]. This is evidenced by: Example 1 R190 was admitted , 4 /15/19, with [DIAGNOSES REDACTED]. R190 is cognitively aware. On 4/30/19 at 10:10 AM, Surveyor observed the following medications on R190's bedside table: [MEDICATION NAME] ointment (antibiotic ointment), [MEDICATION NAME] nasal spray (a steroid nasal spray), Vicks [MEDICATION NAME] (menthol scented ointment), and Ocean Spray (saline nasal spray). R190 did not have Physician order [REDACTED]. On 5/1/19 at 7:20 AM, Surveyor spoke with R190. R190 said the nursing staff was aware of the medications in his room and he used them as he wanted to. R190 said no one had asked him about how to use them or asked questions about how he used the medications. Example 2 R192 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R192 is cognitively aware. On 5/2/19 at 8:45 AM, Surveyor was speaking to R192 in her room. Surveyor observed a spray bottle of sore throat spray at R192's bedside. R192 said she used that frequently, at least several times a day. R192 said the nursing staff knew she had it in her room and that she used it a lot. R192 said no one had asked her about how to use it. R192 did not have an order for [REDACTED]. On 5/2/19 at 12:30 PM, Surveyor spoke to RN I (Registered Nurse). RN I said he knew that some residents had medications in their rooms and used them. RN I was not aware if the residents had Physician order [REDACTED]. On 5/2/19 at 2:00 PM, Surveyor spoke with DON B (Director of Nursing). DON B said she was not aware if R190 and R192 had assessments for self-administration of medications. DON B said an assessment for the residents would be completed right away.

Based on Interviews and Record Review the facility did not ensure Residents received sufficient amounts of fluids based on individual needs for 3 of 7 Residents (R6, R9 & R3) reviewed for Hydration out of a total sample of 11. R6's fluid intakes were not monitored to ensure she received sufficient fluids to meet her needs resulting in dehydration. R3 was hospitalized with dehydration. R3 returned to the facility with orders to drink at least 2 liters per day of fluids. The facility was to keep track of fluid and oral intake and supplement with IV (intravenous fluids) if oral intake was less than 2 liters per day. The facility did not track his total oral intake. R9 was placed on 1500 cc (cubic centimeter) fluid restriction related to [MEDICAL CONDITIONS] and the facility did not fully monitor R9's fluid intake. Only example 1 rises to an actual harm level, the other 2 examples are at a D level. This is evidenced by: The facility policy, entitled Fluid, Hydration and Elimination, states in part: .1. Residents with the following conditions will be screened on admission, readmission, quarterly, annually, significant change, or onset of the listed illnesses for the need to do Intake and Output: Fluid Restriction, Dehydration .intravenous therapy, dehydration risk score of >50, other acute onset of disease process that could potentially cause risk of dehydration i.e.: Nausea, Vomiting, diarrhea, infection .2. I&Os will be collected by the staff during each shift and calculated daily. 3. Totals will be reviewed weekly by a licensed nurse. 4. If the licensed nurse determines that the resident has not consistently met their fluid intake needs and if nursing judgment indicated dehydration, a dietary screen will be sent through and the physician will be updated .9. The value of monitoring fluid intake and output is limited. Intake monitoring may be more accurate in individuals who are completely dependent on staff for fluid needs. Output is often difficult to assess and document accurately. Alternative monitoring indicators may include body weight, laboratory values, and observations of decreased volume of concentrated urine . Example 1 R6 was admitted to the facility on [DATE], and was readmitted on [DATE] and has [DIAGNOSES REDACTED]. R6's Quarterly Minimal Data Set (MDS) assessment, dated 09/12/16, indicates R6 has a BIMS (Brief Interview of Mental Status) of a 7 (severe cognitive impairment). Section G indicated R6 is able to eat independently after set up with meals. R6 incapacitated on 02/17/2014, which indicated R6 is not her own decision maker. R6's Care plan, dated 09/22/16, states in part: CP Dietary provide me with general, low fiber/soft diet w/small portions and w/ extra moisture .provide me with the select menu daily, assist me with meals as needed .I do not tolerate .fruit juice, ice cream .I prefer to drink decaf cola which my daughter brings in for me .I do not like plain water (offer me decaf coffee, hot chocolate, decaf cola) and need encouragement w/ my fluid intakes . R6's CNA (Certified Nursing Assistant) Care sheet, (no date) states in part: Encourage extra fluids .does not like water, Do not throw away warm soda (R6) likes to drink warm fluids .I like decaff soda, hot chocolate, decaff coffee. Feed patient R6's Hydration Risk Review tool, dated 09/12/16 states in part: total score 0 .low risk for dehydration. No problem consuming fluids. Drinks fluids of choice throughout the day as she desires. No difficulty asking for extra fluids as she chooses. She likes to drink coffee during the day. Laboratory values: (BUN (Blood Urea Nitrogen) CRT (Creatinine) NA (Sodium)) 10/26/16 BUN 30, CRT 1.3, NA 136 11/1/16 BUN 37, CRT 1.1, NA 140 11/3/16 BUN40, CRT 1.5, NA 139 11/8/16 Discharge summary/instructions state, Continued medications: [REDACTED].[MEDICATION NAME] 100mg tab by mouth bedtime .[MEDICATION NAME] 50mg tab by mouth daily . R6 Weighed 153 pounds on 10/25/16, on 11/1/16 R6 weighed 154.5 pounds and on 11/15/16 R6 weighed 141 pounds (R6 had a 13.5 pound or 8.73% weight loss in one week). Of note weight loss of this amount in a one week time frame is evidence of lack of fluids and dehydration. November meal intake sheet showed the following: (Please note fluid intakes are not documented in milliliters but as Excellent >75%, Well 75 to 50%, Fair 49 to 25% and Poor <25%, Refused) November 1st through November the 20th (hospitalized [DATE] & 11/7/16 for exacerbation of gout & [MEDICAL CONDITION]) R6's fluid intake was marked poor (<25%) for 13 meals, fair (49 to 25%) for 18 meals, and refused for 3 meals. R6 consumed 49% or less of her fluids for 65% (34 of 52) of meals. 11/18/16 at 4:42PM nurses note states, (R6) cont with poor intakes, recent decline in wts .pt does show decreased mentation in full though process and need for repeated instruction .patient cont with [MEDICATION NAME] every other day order .above updated to (physician). 11/19/16 Laboratory values were BUN 76, CRT 1.3, NA 135 11/20/16 at 3:45AM nurses note states, .continues to tolerate her general, small portion diet w/o difficulties and participates in select menu daily with assist from staff. She eats in her room and staff assist her with her meals . 11/20/16 at 9:30PM nurses note states, .Resident very weak and pale. Daughter .called and updated. She asked for (R6) to be seen in ER for further evaluation. (R6) sent to ER at 9:15PM. 11/20/16 Laboratory values: 11/20/16 BUN 82, CRT 1.5 11/21/16 History and Physical for R6 states, chief complaint: hemoptysis, lethargy, weakness, increasing confusion .also required increased opioid management because of severe discomfort. With that, I think her fluid intake probably has dropped off some and she has become quite dehydrated .she was admitted yesterday for observation .also because her white count has climbed to 16,400 and her BUN had climbed to 82 with a creatinine of 1.5, up from her baseline BUN of 17 and baseline creatinine of 1.1 .Exam: .she is alert but almost incoherent. Her mental acuity is definitely impaired compared to her baseline a few days ago .Assessment: 1. Acute dehydration .Plan: the patient will need at least 2 to 3 days of intravenous fluids and rehydration slowly and carefully . Laboratory values: 11/21/16 BUN 80, CRT 1.6 NA 140 11/22/16 BUN 49 CRT 1.0 11/24/16 physician progress notes [REDACTED].systemically she looks much better as well, probably due to her rehydration. See creatinine and BUN improvement .Assessment: .2.Acute Kidney injury which is now dramatically improved. Her BUN is down to 20, her creatinine is actually down to 0.7giving her an estimated GFR of 80 which is up from 33 on admission . 11/25/16 Discharge Summary states, .Dehydration status: Acute . History of Present Illness more pale and weak appearing in the last few days according to nursing .Sodium Chloride(IV-Sodium Chloride 0.9%) 1,000ml @ 100ml/hr Q 10H (every 10 hours) IV . R6's total Hospital IV fluid intakes from 11/21/16 through 11/23/16 totaled 7,000mL. 11/25/16 at 4:40PM nurses note states, .readmitted from hospital at 1:38PM . R6's Readmit assessment/ Hydration Risk Review tool, dated 11/23/16 states, total score: 20 .(R6) demonstrates adequate hydration and fluid balance, brisk skin turgor, moist membranes, she is alert. Staff to offer and encourage extra fluids. Dietary consult PRN (as needed). Intakes and outputs to be monitored. Is on diuretic, labs monitored per MD orders. Goal is to promote quality of life and remain adequately hydrated. November meal intake sheet showed the following: 11/25/16-11/31/16, R6's fluid intake was marked poor (<25%) for 5 meals, fair (49 to 25%) for 5 meals, and refused for 2 meals. R6 consumed 49% or less of her fluids for 12 of 16 meals. There had been no updates to the care plan for increasing R6's fluid intake even though she had just been hospitalized with dehydration. On 01/30/17 at 4:05PM Surveyor , interviewed Registered Dietitian (RD) J regarding estimated fluid needs. RD J indicated in December, R6 was to have a minimum of 1600mL per day and that R6 was to get 720mL at breakfast and 480mL at lunch and supper. R6's Hydration Risk Review tool, dated 12/6/16 states in part: .Total Score: 15 Remains low risk for dehydration. No problem verbalizing thirst. Able to swallow regular fluids. Takes fluids well both during and in between meals . December meal intake sheet showed the following: 12/1/16 - 12/31/16, R6's fluid intake was marked poor (<25%) for 35 meals, fair (49 to 25%) for 32 meals, and refused for 6 meals. R6 consumed 49% or less of her fluids for 78% of her meals (73 of 93 meals). R6's Significant change MDS assessment, dated 12/09/16, triggered for Dehydration/Fluid Maintenance. CAA states, .Inadequate oral intake r/t increased demand for nutrients and protein for healing and decreased ability to consume sufficient nutrition and protein AEB significant unintentional weight loss of 8.5% in approximately 1 month and open left foot surgical wound .and variable intakes through usually only fair (approximately 25-50%) .fluid intakes fair-good; . R6's Care plan, dated 12/22/16, states, .I prefer to drink decaf cola which my daughter brings in for me .I do not like plain water (offer me decaf coffee, hot chocolate, decaf cola) and need encouragement w/ my fluid intakes Monitor me monthly as part of the nutrition risk program due to weight loss and wound .12/29/16 regular water makes her feel nauseated, 12/29/16 add sugar to water- (R6) likes sugar water 12/29/16 likes sugar on her mac & cheese, 12/29/16 offer anti-nausea med prior to meals, 1/14/17 feed patient. 12/22/16 memorandum to physician states, .Daughter is very concerned about R6 and would like you to meet with them. Concerns are: (decreased) general condition, weaker, more tired, sleeps a lot, (refuses) to get out of bed etc .(decreased) appetite and oral intake eating and drinking <25% . 12/28/16 memorandum to physician states, .general decline in condition: significant wt loss with decrease in appetite and poor fluid intake . 12/28/16 at 1pm nurses note states, .Will update the RD about (R6) not liking water and it makes her feel nauseous so alternative drinks be provided i.e. crystal light in her water .other food/drink alternatives discussed and will be passed to the RD . 12/29/16 physician progress notes [REDACTED].her appetite is dropping off and she is losing weight, perhaps in part because of the inflammation and pain involved in her foot . January meal intake sheet showed the following: 1/1/17 - 1/21/17 (hospitalized [DATE] through 1/6/17), R6's fluid intake was marked poor (<25%) for 20 meals, fair (49 to 25%) for 12 meals, and refused for 12 meals. R6 consumed 49% or less of her fluids for 44 of 45 meals. 01/02/17 at 4:30pm Nurses note states, . order to transfer resident to ER to be evaluated at 1:00PM . (Resident sent due to foot wound/drainage) 01/07/17 at 9:27am nurses note states, .total fluid intake of 30 cc and incontinent of urine x1 .able to hold mug and drink and able to feed herself finger foods . 01/07/17 at 9:06pm nurses note states, . ate fair for all three meals this day, has a weight loss due to this illness . 01/08/17 at 10:10PM nurses note states, .ate poor at supper liquids offered took sips .has been incontinent of urine x2 this shift . 01/16/17 at 1:45PM nurses note states, .Not eating or drinking well . 01/16/17 at 3:24PM nursing note states, . daughter felt she needed emergency care due to lack of interest in taking in fluids/nutrition. 01/16/17 at 11:02PM nursing note states, .Orders for Normal Saline 75cc per hour continuous for 3 days for hydration .refused to eat or drink will continue to monitor. 01/16/17 Physician order [REDACTED].Normal Saline 75cc/hr IV x 3 days for hydration . 01/17/17 at 4:19PM nursing note states, .Resident receiving IV NS at 75ml/hr continuously for dehydration . 01/18/17 at 4:17PM nursing note states, .Resident receiving IV NS at 75ml/hr continuously for dehydration . 01/18/17 at 11:37PM Nursing note states, .not eating sips of liquids. IV [MEDICATION NAME] .normal saline infusing at 75 cc continuous. Will continue to monitor. 01/18/17 Preoperative History and Physical Consultation states, .She is on IV fluids at 75ml an hour and as mentioned above IV [MEDICATION NAME] and IV [MEDICATION NAME] are presently being given to her . 01/19/17 at 1:30PM nursing note states, .was not eating or drinking and was nauseous prior to the antibiotic; that is why she has a PICC (peripheral inserted central catheter) line with hydration fluids running . 01/19/17 Physician order [REDACTED].Continue 0.9% NaCl at 75mL/hr until transfer to ambulance, for dehydration . 1/20/17 at 12:55AM nursing note states, .Normal Saline fluids at 75cc/her (75 cubic centimeters (milliliters) per hour) per pump .did not eat super (sic) void x2. Sips for fluids orally will transfer .1/20/17 for surgery. 01/30/17 at 10:17am, Surveyor interviewed Director of Nursing (DON) B regarding R6 and dehydration. DON B indicated if a [DIAGNOSES REDACTED]. There is a hydration assessment done upon admit and charted for 3 days. Staff are to assess each shift and chart assessment, as well as complete head to toe assessment based on what the resident went into the hospital for. DON B indicated a hydration score of 50 or above indicates a resident is at risk. Surveyor asked DON B how staff would know how many mL a person took in. DON B stated You don't. DON B indicated estimated fluid needs are divided amongst 3 meals whil the medication pass and in room fluids are extra. DON B indicated dietary monitors intakes and directed Surveyor to speak with Registered Dietitian (RD) J. Surveyor asked DON B if one person is responsible for monitoring hydration. DON B stated, No. Surveyor asked if nursing notes should reflect a person's intake. DON B there is a systems break down regarding fluid intakes. DON B indicated if R6 was meeting her fluid needs, she was meeting the minimum and she would refuse fluids. 01/30/17 at 3:10PM Surveyor interviewed RD J regarding R6's fluid intakes. RD J indicated that she looks at I&O's quarterly and as needed if consulted. RD J indicated nurses send a consult if a resident's intake goes way down and then would look at intakes. RD J indicated she placed R6 on nutritional risk in December 2016 for weight loss and wound healing. Surveyor asked RD J if she was aware R6 had a [DIAGNOSES REDACTED]. RD J stated she did not know and she did not have a consult in November for R6. RD J indicated she had a consult beginning of December 2016 related to constipation and protein for wound healing. surveyor asked RD J if R6 had reached met her fluid needs in November and December. RD J indicated R6 had not met her estimated fluid needs. RD J went on to state R6 did not meet her estimated fluid needs between 1/8/17 and 1/16/17 either. RD J indicated staff should be documenting total mL daily if on I&O. RD J indicated if nurses looked at intake using fair, poor, well or excellent instead of mL, it would not prompt nursing to consult her. RD J indicated is a system break down and indicated recent problems with fluid documentation. 01/31/17 at 8:45am & 8:47AM, Surveyor interviewed RN D regarding R6. Surveyor had RN D look at R6's meal/fluid intake sheets for November, December and January. RN D indicated there is no indication of how many mL's R6 took in. RN D indicated fluids should be documented in cc's. RN D stated you really can't tell if R6 is hitting her estimated fluid needs. RN D indicated DON B monitors intake sheets. RN D indicated that R6 hasn't had good intakes for the past few months and that nursing should have contacted dietary. RN D indicated that R6 should have had a RD consult in November based on fluid intakes and [DIAGNOSES REDACTED]. 01/31/17 at 8:50AM, Surveyor interviewed Assistant Director of Nursing (ADON) C regarding R6. ADON C indicated with a [DIAGNOSES REDACTED]. ADON C indicated she would have contacted dietary and put R6 on the board in the report room. ADON C indicated anyone who is readmitted is to be monitored for I&O for 3 days. When asked how many fluids R6 took in, ADON C stated I couldn't tell you. While looking at November 2016 meal intake form, ADON C indicated R6 was doing poor and RD J should have been contacted. ADON C indicated she was unable to tell if R6 was meeting her fluid needs in November, December, or January. On 1/31/17 at 9:55AM Surveyor , interviewed Certified Nursing Assistant (CNA) K regarding R6's fluid intakes. CNA K indicated meals and fluids are documented on a paper located in a folder. CNA K indicated she would report fluids to the nurse at the end of the shift. CNA K indicated she would update the nurse if a resident ate poor or fair, if it was something new, or if the resident refused. CNA K stated that R6 usually only drinks soda that her daughter brings in. CNA K indicated R6's intake is normally poor and does not like water. surveyor asked if R6's poor intakes were ever reported to a nurse. CNA K stated no, because it's her typical. On 01/31/17 10:00AM Surveyor , interviewed CNA L regarding R6 and intakes. CNA L indicated she records intakes as excellent if 100%, Fair if half, poor for not well and R for refuse. CNA L indicated if R6 was on I&O, staff would document cc's/mL's. CNA L indicated she would go to an RN if fluid intake was low, if the resident not eating well, or if the needed help eating. CNA L indicated R6 wouldn't take any fluids, only take a sip or two, but once in a while would be able to get her to drink. Surveyor asked if R6's poor fluid intakes were reported. CNA L stated All the time. CNA L indicated this was not R6's normal behavior and she had declined. 01/31/17 at 10:10AM, Surveyor interviewed CNA I regarding fluid intakes. CNA I indicated she writes down cc's on the intake sheet when a resident is on I&O otherwise uses fair, poor, well and excellent. CNA I stated she reports to nurses when residents didn't eat or drink well or if they refused. CNA I indicated she would set up R6's tray, come back and encourage R6 to eat/drink. CNA I indicated R6 would say she is in too much pain or not feeling well 01/31/17 at 10:20AM, Surveyor interviewed Registered Nurse (RN) M regarding fluid monitoring. RN M indicated he would refer to RD when a resident consumed too little fluids. Surveyor asked if he could tell how many mL's R6 took in by looking at the intake sheet, RN M indicated he could not. Example 2 R3's [DIAGNOSES REDACTED]. R3 is his own decision maker. R3's Hydration Risk Review, dated 9/16/16, included, in part, the following: (R3) continues to take fluids well. He does have a JP (Jackson-Pratt) drain which will drain approx. (approximately) 75 - 90 cc (cubic centimeters) per shift. He recognizes his thirst and has no difficulty communicating this to staff. Low risk. R3's Emergency Service Discharge Instructions, dated 10/7/17, include, in part, the following: Drink at least 2 L (liters) per day of fluids - Gatorade and glucerna. Nursing facility to keep track of fluid and po (oral) intake and supplement with IV fluids if po intake less than 2 L per day. It is important to know that 2000 ml (milliliters) equal 2 L. R3's Cumulative I & O (intake and output) record, includes, in part the following intake totals: 10/7/16 - 630 ml 10/8/16 - 1130 ml 10/9/16 - 1040 ml 10/10/16 - 1530 ml 10/11/16 - 2480 ml 10/12/16 - 1580 ml 10/13/16 - 965 ml 10/14/16 - 500 ml 10/15/16 - 300 ml 10/16/16 - documentation not complete 10/17/16 - 400 ml 10/18/16 - 590 ml 10/19/16 - 1160 ml 10/20/16 - 1220 ml 10/21/16 - 550 ml 10/22/16 - documentation not complete 10/23/16 - 300 ml 10/24/16 - 460 ml 10/25/16 - 910 ml 10/26/16 - documentation not complete 10/27/16 - 300 ml 10/28/16 - 200 ml 10/29/16 - 1280 ml 10/30/16 - 965 ml 10/31/16 - documentation not complete R3's Nursing Notes include, in part, the following: 10/8/16, 01:10 (AM), . Instructions returned from ER (emergency room ) physician stating that is resident is to have 2000 liters per day oral intake and to have supplement with IV if does not have adequate intake.He has Gatorade in room. Discussed with (R3) that he needs to drink 6 of the 10 oz (ounce) mugs a day which is from time he awakens until he goes to sleep for evening. He is aware of need for intake and has taken 300 cc. 10/9/16, 16:58 (4:58 PM) . (R3's physician) informed of po intake remaining decreased. 10/19/16, 16:15 (4:15 PM) Re weight completed with weight loss noted Pt (patient) assessed with [REDACTED]. Note to (R3's physician) regarding and message left for dietician. There is no documentation that R3 ever received any IV fluids or that the physician was informed each day that R3 did not meet the 2 L intake that was ordered to be taken in. On 1/31/16 at 1:20 PM Surveyor interviewed DON (Director of Nursing) B. DON B stated the staff nurses are to monitor the intake and output every shift and assure that they are complete and accurate. DON B stated she would have expected the staff nurses to monitor R3's intakes and assured they were complete and accurate. DON B stated she would have expected R3's physician to be notified when R3 did not meet the 2 L intake per day as ordered by the ER physician to ask if R3 should have the IV fluids to supplement his intake. Example 3 R9 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R9's care plan did not include the need to monitor fluid intake or fluid restriction of 1500 cc per day. R9's physician orders [REDACTED]. Review of R9's Nutritional Flow Sheet for Foods and Fluids shows intakes: -1/29/17, Lunch is documented as G (no key indicated for this) with no documentation of specific fluid intake. Dinner as E (indicating excellent) with no documentation of specific intake. Intake total for this day is 400 cc but does not include specific fluid intake for lunch and dinner. -1/30/17 for breakfast fluids is documented as 520 (cc) and for lunch fluids 300 (cc). Dinner intake is left blank; no monitoring of fluid intake is documented. Intake totals for this date is 1515 cc, but does not include fluids consumed for dinner on this date and this would indicate that R9 exceeded 1500 cc fluid restriction. On 1/31/17 at 10:00 AM Surveyor interviewed DON (Director of Nursing) B about R9's fluid monitoring after returning to the facility on [DATE] following hospitalization for exacerbation of [MEDICAL CONDITION]. DON B stated that R9's care plan was updated on this date (1/31/17) to include fluid restriction and monitoring. After review, DON B stated that R9's fluid intake monitoring was not thoroughly documented and should have been.

Based on interview and record review the facility did not provide appropriate catheter care for 1 of 2 residents reviewed for catheters of 11 sampled residents (R10). The facility failed to follow physician orders [REDACTED]. The facility had no current signed physician orders [REDACTED]. Transcription of R10's catheter care orders were inaccurate and did not follow standards of practice. This is evidenced by: R10 was readmitted to the facility on [DATE]. R10's [DIAGNOSES REDACTED]. R10 has had a SP (suprapubic) foley catheter since 10/28/15 for [MEDICAL CONDITION] Bladder. R10's care plan dated 12/6/16 includes in part: I (R10) am unable to empty my bladder without a suprapubic catheter . Will void without difficulty, I will have adequate output from my catheter each shift. Interventions: I have an indwelling SP catheter. Provide me with catheter care per standard of care .Change SP prn (as needed) . R10's signed physician orders [REDACTED].>1/26/16- SP (suprapubic) foley catheter, use 24 Fr (French) 5cc (cubic centimeter) balloon. 1/12/17 - SP catheter 22 French 10 mL balloon Review of R10's TAR's (Treatment Administration Records) include in part: *8/16: Start date: 1/26/16, SP foley cath change Q (every) 6 weeks and prn, last changed 3/9/16. Due on 8/24/16 to be changed, Use 24 Fr 10 cc balloon is typed in but 10 cc is crossed out with a hand written note of 5cc in place. The TAR indicates that R10's catheter was changed on 8/24/16. *9/16: SP foley cath change . Due on 8/24/16 to be changed. Next (change) is Oct. 5 . Use 24 Fr 10 cc balloon *10/16: SP foley cath change . Due on 8/24/16 to be changed. Next is [DATE]. Use 24 Fr 10 cc balloon is typed in but 10 cc is crossed out with a hand written note of 5cc in place. The TAR indicates that R10's catheter was changed on 10/5/16. *11/16: The facility was unable to provide R10's 11/16 TAR, stating that it could not be found. *12/16: SP foley cath change . Due on [DATE] to be changed. Next is [DATE]. Use 24 french 10cc balloon is typed in (it is important to note that the physician order [REDACTED]. TAR indicates that R10's catheter was changed on 12/26/16 with a hand written note 24 FR 30cc balloon with an arrow to 12/26/16. (12/23/16 box for catheter change was left blank). *1/17: SP foley cath change . Due [DATE] to be changed. Next is March 20. Use 24 french 30 cc balloon is typed in and a hand written note 22 Fr 5cc balloon filled with 10cc saline dated 11/11/17(sic) is written above the typed entry for the size of the foley catheter to be used. The TAR indicates that R10's foley was changed on 1/11/17. Irrigate catheter with sterile water prn with 250-500cc is also documented on each of R 10's TAR's reviewed however there is no start date on this order. It is important to note that upon request, the facility was unable to provide signed physician orders [REDACTED]. On 1/11/17 at 10:30 PM R10's nursing notes indicate: (R10) complained of lower abdominal and penis pain. R10 says he feels like he has to urinate. Foley patent and draining cloudy yellow urine. Had 725 cc out of his foley this shift. Very uncomfortable and feels there is something wrong with him (sic) cath. Attempted to remove cath to place a new one and was unable to remove old cath. (R10) would call out and cry bring knees up to his chest whenever writer pulled gently on the cath. Unable to remove cath. Bladder scan done and showed only 64 cc in the bladder. (R10) very uncomfortable. (10:50 PM) called and spoke with (doctors name) in the ER (emergency room ) and order was received to send (R10) to ER for eval. At (11:00 PM) was sent via cart to ER for eval. 1/11/17 Practitioner Documentation ER notes include in part: History of present illness .complaining tonight of suprapubic catheter causing him discomfort. He shouldn't has a 24 French 30 mL (milliliter) balloon in place and previously had been having a 24 French 10 mL balloon .and he is complaining of significant amount of pain and discomfort .30 mL fluid has been withdrawn but could not remove the catheter tonight without significant pain from the patient .The catheter was cut down but could not be withdrawn without significant pain from the patient (R10) .Clinical Issue Notes: (R10) was given a BNO ([MEDICATION NAME] Alkaloids/[MEDICATION NAME]) suppository and 2 MG (milligram) IM(intramuscular) [MEDICATION NAME] and waited 1 hour and then remove (sic) the 24 French 30 mL deflated balloon catheter and replaced it with a 22 French 10 mL balloon catheter no leaking around the area . (R10) Return back to (facility name) with present suprapubic catheter in place draining a very light pink color urine, follow up by primary care physician (name). 1/12/17 nurses notes at 1:33 AM includes in part: (R10) returned from ER at 1:00 AM with 22 f (French) 10 ml balloon suprapubic catheter clear pink tinges urine output with small specks of red and sediment. (R10) stated he already felt much better. Will continue to monitor . On 1/30/17 at 4:45 PM Surveyor interviewed DON (Director of Nursing) B about R10's current physician orders [REDACTED]. DON B stated there should be orders signed in January. The facility's policy was to have the MD's (medical doctor) reconcile orders every 60 days. R10's MD had not done this, and she would check into this. Surveyor asked DON B about R10's orders for foley catheter care as there were no catheter care orders noted on the 11/1/16 physician orders [REDACTED]. Surveyor asked how often R10's suprapubic catheter should be changed. DON B stated that the facility changes catheters as needed. On 1/31/17 at 8:30 AM DON B showed Surveyor she had a physician reconcile and sign R10's medication orders the night of 1/30/17. Surveyor noted that this did not include R10's suprapubic catheter orders. DON B stated the facility needs to work on this. On 1/31/17 at 9:50 AM Surveyor interviewed RN (Registered Nurse) D and reviewed R10's TAR's related to his suprapubic catheter orders and care. It was noted that R10's current TAR for 1/17 included the order for the nurse to follow: SP foley cath change . Due [DATE] to be changed. Next is March 20. Use 24 french 30 cc balloon is typed in and a hand written note 22 Fr 5cc balloon filled with 10cc saline 11/11/17 (sic) is written above the typed entry for the size of the foley catheter to be used. The TAR indicates that R10's foley was changed on 1/11/17. RN D stated R10's catheter orders were not clear and not transcribed properly. RN D stated the old orders should have been discontinued (yellowed out) and the new orders from 1/11/17 should have entered on the TAR as a separate item and were not. Surveyor and RN D also reviewed R10's TAR's for 8/16, 9/16 (note that 11/16 TAR was not able to be located) and 12/16, noting the discrepancies in what size catheter should be used: 5 cc balloon versus 10 cc balloon and then 30cc in 12/16. RN D showed Surveyor R10's physician order [REDACTED]. Surveyor requested a copy of R10's signed physician orders [REDACTED]. The facility did provide Surveyor with a copy of a foley catheter irrigation order for 100 cc normal saline dated and signed by the physician on 5/1/15 for R10, however this order was not current as R10 had his indwelling catheter changed to a suprapubic catheter on 10/28/15. Surveyor asked RN D about the process for transcribing the TAR from month to month, RN D stated a nurse reviews the TARs monthly to reconcile that orders are current and correct, comparing the previous months TARs to the new month's TAR and reviewing the physician orders [REDACTED]. RN D was unable to find an order. On 1/31/17 at 10:05 AM Surveyor interviewed LPN (Licensed Practical Nurse) E asking if she was the nurse who changed R10's suprapubic catheter on 12/26/16. LPN E stated she had changed R10's catheter on 12/26/16 as it had not been changed on 12/23/16. Surveyor asked LPN E why she used a 24 Fr 30 cc balloon sized catheter rather than the 24 Fr 5cc balloon catheter per the physician orders [REDACTED]. Surveyor asked LPN E if she talked to R10's physician's before using a different size catheter. LPN E stated that she should have consulted with R10's physician and obtained an order from R10's physician before insertion of larger balloon size for R10's suprapubic catheter and did not. On 1/31/17 at about 2:50 PM Surveyor interviewed DON B about the facility's process to assure that resident ancillary orders (non-medication orders, such as catheter orders) were current and accurate. DON B stated the facility would be working on improving this process. Surveyor asked DON B about concerns regarding R10's supra pubic catheter orders. DON B agreed that R10's orders were not clear. DON B indicated she would expect staff to have consulted with a physician if the correct size catheter could not be provided. This was not done and resulted in R10 experiencing significant catheter-associated pain and having to go to theER on [DATE] to have the catheter replaced.

Based on interview and record review the facility did not ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for 1 of 13 sampled residents (Resident 13) and 1 supplemental resident (Resident 14). It was known by the facility that Resident 13 would smoke while wearing liquid oxygen. The tank was on Resident 13's wheelchair and the nasal cannula was on her head with the oxygen running. Resident 14 would also often smoke next to Resident 14 while Resident 13 was smoking with oxygen on. There was no education, evaluation of safety risk or system in place to protect both residents. Contrary to the resident's care plan, staff would not remind Resident 13 to turn off her oxygen. Failure to ensure that Resident 13 and 14's environment remained as free of accident hazards as is possible and that each received adequate supervision to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 10/6/14. Director of Nursing B was officially notified of the immediate jeopardy on 10/22/14. The facility removed the immediate jeopardy on 10/21/14, however, the deficient practice continues at a scope/severity level D (potential for harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan. This is evidenced by the following: The facility's tobacco free policy, revised July 2010, indicates there is no tobacco use in the buildings, vehicles and grounds owned by the facility corporation. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13 is alert and oriented and is able to make her own decisions. Resident 13's most current physician's orders [REDACTED]. Resident 13's care plan, dated 12/2/13, indicates a need related to poor activity tolerance. Resident 13 wants to smoke cigarettes. She received education from staff concerning the consequences to her respiratory status and also knowing the safety risks of smoking near oxygen. Interventions: Encourage me to keep my smoking materials secured in my room and out of reach of other residents. Remind me to remove my oxygen when I smoke. (The latter did not appear on the CNA care plan.) Resident 13's current certified nursing assistant care plan indicates: I can sit off property-smoke by myself. Remind me to keep smoking supplies locked in my drawer in my room. Oxygen at 1.5 liters per minute. Resident 13's Social Service notes include: -5/21/14, Resident 13 expressed desire to smoke cigarettes. Discussed that facility grounds were smoke free and potential health hazards of smoking and chronic oxygen dependency. Agreeable to try nicotine patch. -7/15/14, Resident 13 had another resident's family member assist her off property to smoke. Discussed the potential health hazards of smoking, particularly with oxygen dependence. Resident 13 reports she takes her oxygen tubing off when smoking. -10/8/14, Over the past few months Resident 13 started smoking again despite medical recommendation from physician and staff. She signs herself out and self-propels off campus grounds. She is aware of the consequences and risks of smoking compromising her health. Resident 13's physician progress notes [REDACTED]. She does not care that I know she is smoking. She has her oxygen on the top of her head, with her tank behind her. I counseled her once again regarding smoking with oxygen in place and the dangers to herself and the people around her." Resident 13 did not have a smoking assessment completed to ensure her ability to smoke safely. Resident 14, who would often go out to smoke with Resident 13, did not have a smoking assessment or care plan to address his smoking needs. On 10/21/14, at 2:26 PM, Surveyor interviewed Family Member J. Family Member J expressed concern that Resident 13 smokes outside with her oxygen on. Family Member J stated that she sees Resident 13 smoking by the stop sign at the end of the driveway and that she has had to help Resident 13 get back up the driveway to the facility. On 10/21/14, at 3:38 PM, Surveyor interviewed Resident 13. Resident 13 stated she goes outside to smoke by the stop sign at the end of the driveway twice a day. Resident 13 denied needing any assistance while outside. Resident 13 stated when she was admitted almost a year ago she spoke with Social Worker (SW) H and informed her that she smokes. Resident 13 stated SW H did not make any statements about smoking to her. Resident 13 stated, and showed Surveyor , that she keeps her cigarettes and lighter in her purse in her unlocked drawer in her room. She takes her stuff, signs herself out and goes out to smoke. Resident 13 stated when she gets to the stop sign she takes the oxygen off and smokes 3 cigarettes. Surveyor asked how she takes the oxygen off and Resident 13 stated she removes the nasal cannula out of her nose and puts it on the top of her head. She stated this is how she always did it at home. Resident 13 confirmed she does not turn the oxygen off and the tank stays on the back of her wheelchair. Resident 13 stated she goes out with Resident 14 at times who will usually smokes 1-2 cigarettes. When she is done she replaces her oxygen in her nose and goes back inside. Resident 13 stated the only help she needs from staff is occasionally she will ask them to wrap the oxygen hose around her wheelchair handle if it is too long so it does not drag on the ground when she goes outside to smoke. On 10/21/14, at 4:17 PM, Surveyor interviewed Director of Nursing (DON) B and Assistant Director of Nursing (ADON) L. DON B stated the facility is a no smoking facility. DON B stated there are two residents who sign themselves out and smoke by the stop sign. DON B confirmed the two residents who smoke are Resident 13 and 14. DON B stated that if residents want to smoke they have to keep their smoking materials out of reach of others in a locked drawer or on their person. The resident has to be able to sign themselves out and get out and back in independently. DON B stated she has encouraged them both to wear bright colored clothing and put a flag on their wheelchair, but neither one wants a flag on their wheelchair. DON B stated Resident 13 is her own person and Resident 14's power of attorney says it is okay for Resident 14 to go out and smoke. Surveyor asked about Resident 13 and her oxygen. DON B stated Resident 13 takes her oxygen off and puts it on her head. DON B again stated smoking is not something the facility supports but they allow for resident rights. On 10/22/14, Surveyor reviewed Resident 13 and 14's sign out sheets. The sheets are labeled "Release of responsibility for leave of absence." The form states, "I, the undersigned, do hereby request the privilege of taking the resident, who's name appears below, from the facility premises. I hereby specify the time of departure by affixing my signature I guarantee to assume a responsibility and promise and agree not to hold the facility in anyway responsible or liable in case of accident or any other incident involving this resident while away form (SIC) the facility." Documentation shows Resident 13 signs herself out 1-2 times a day but it does not appear consistent or complete with date and time. She also does not always sign back in. Resident 14 more consistently signs himself in and out at least one time daily. On 10/20/14 Resident 13 signed out at 10:00 AM and Resident 14 signed out at 10:04 AM, but neither have a return sign in time. On 10/22/14, at 9:06 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C stated prior to today, Resident 13 has to sign out in the book to leave the area, go to the end of the drive way to smoke. CNA C stated she was told staff was not allowed to assist her out and that Resident 13 needed to be able to go out and come back in by herself. CNA C stated she was not told to remind Resident 13 to take off her oxygen but she does see Resident 13 put it up on her forehead. CNA C stated Resident 13 did not take the oxygen off her wheelchair before going out to smoke. CNA C stated as of today the unit aides will be going outside with Resident 13 to make sure her oxygen is off and to check her oxygen saturation levels when she returns. On 10/22/14, at 9:12 AM, Surveyor interviewed Unit Coordinator (UC) D. UC D stated prior to today Resident 13 would sign herself out to go smoke. UC D stated on occasion Resident 13 would ask for help wrapping the oxygen tubing around her wheelchair handle so it would not get tangled when she went outside. UC D stated she did not assist Resident 13 with oxygen while smoking but knows that Resident 13 would put the oxygen on her head while she smoked. UC D stated as of today staff are to take the oxygen tank off her wheelchair before she goes outside and someone will help her out and then the oxygen will be checked and replaced when she comes back in. On 10/22/14, Surveyor observed the area where Resident 13 stated she smokes. At the end of the driveway by the facility sign there was a collection of numerous cigarette butts. On 10/22/14, at 1:10 PM, Surveyor interviewed DON B who confirmed Resident 13's oxygen is at 1.5 liters. According to information from OSHA (Occupational Safety and Health Administration), a normal environment is one that is comprised of 16.5 - 23% oxygen. This level changes to one of oxygen-enrichment both around the oxygen tank, because of the venting that occurs, and around the nasal cannula. An oxygen-enriched environment makes the air highly combustible and makes burning more efficient. A spark from a match, a lighter, or a cigarette, could cause lit materials to combust and burn more vigorously. This could cause serious burns to Resident 13, including burns to the resident's throat and lungs had she been inhaling at the time. As a result, various sources advise keeping flames five to six feet away from anyone receiving liquid oxygen. Resident 14 who smoked with Resident 13 was also at risk for burn injuries. Knowing Resident 13 was smoking with oxygen on and at times accompanied by Resident 14 created a finding of immediate jeopardy. The immediacy was removed on 10/21/14 when all working staff and Resident 13 were educated that Resident 13's oxygen was to be removed before going outside to smoke and all on-coming staff will be educated before beginning their shift. Resident 13 was also re-educated on securing her smoking materials in her locked drawer.