Every finding on record at Grace Lutheran Communities - River Pines

Based on interview and record review, the facility did not ensure that appropriate information is communicated to the receiving health care institution or provider for 1 of 1 resident (R22) reviewed for hospitalizations.Facility did not communicate with the hospital emergency department (ED) prior to R22's transfer of the reason R22 needed to be transferred. This is evidenced by:On 05/20/26, Surveyor reviewed R22's medical record. R22's diagnoses include displaced trimalleolar fracture of right lower leg, anemia, congestive heart failure, mild cognitive impairment, COPD, chronic kidney disease stage 3B, restless legs, depression, type 2 diabetes mellitus, and dementia.R22's progress notes documented 05/03/2026 9:25 PM, Health Status Note,Note Text: Pt transferred to ED for evaluation after unresponsive episode. Pt noted to be unresponsive with heart beat and active respirations at 1920 (7:20 PM). Last known well time 18:15 (6:15 PM). POA Updated. Resident was not tracking with eyes, unable to verbalize responses to questions or follow commands.R22's medical record did not document communication with the hospital ED of R22's reason of being transferred to the ED. On 05/21/26 at 11:41 AM, Surveyor interviewed Director of Nursing (DON) B asking if the hospital was notified of R22's reason for transfer. DON B stated DON B was notified of R22 having another unresponsive episode. It was an agency nurse and DON B doesn't have access to that nurse. The nurse no longer works at the facility. There is a packet for discharge, and the nurses will fax the communication sheet to the ED of information of resident and reason for transfer. This is because of the stress of the hospitals from the 2 hospitals closing and staff at the ED are busy and not always able to take verbal report. DON B stated DON B looked in the hospital record system and did not find facility's communication of contact to the hospital of R22's reason of transfer.

Based on interview and record review, the facility did not ensure 3 of 5 (R22, R3 and R4) sampled residents received care and treatment in accordance with assessments and professional standards of practice to ensure their highest practicable physical, mental, and psychosocial well-being. The facility staff did not complete a full assessment when changes in condition occurred, did not assess upon re-admission, and did not coordinate care plans with hospice to ensure consistency and continuity of care. On 05/03/26, the facility did not complete and document a full assessment of R22's change of condition and on 05/04/26 did not complete and document a re-admission assessment. The facility did not coordinate R3's care plans with hospice to ensure consistency and continuity of care. The documentation of R4's cares do not support R4 was receiving a shower twice weekly as care planned. R4 was not placed in the correct Hoyer sling size, and a Hoyer sling size was not documented in the hospice care plan. This is evidenced by: Facility's policy titled Acute Condition Changes – Clinical Protocol dated 05/01/26 documented 5. Before contacting a provider about someone with acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the provider. Phone calls to attending or on-call providers should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. C. Nurses are encouraged to use the SBAR Communication Form and Progress note (Interact Version 4.5) as a tool to help gather and organize information before notifying the provider. Facility's policy titled admission Assessment and follow-up: Role of the Nurse dated 10/10/16 documented Steps in the Procedure.7. Complete a Head to Toe Assessment. 8. Conduct supplemental assessments including, but not limited to: a. Activity level; b. Pain assessment, c. Fall risk assessment, d. Neurological assessment, e. Skin assessment, f. Functional assessment Example 1 R22's diagnoses include displaced trimalleolar fracture of right lower leg, anemia, congestive heart failure, mild cognitive impairment, COPD, chronic kidney disease stage 3B, restless legs, depression, type 2 diabetes mellitus, and dementia. Minimum Data Set (MDS) documented on 05/03/26 a discharge return anticipated submission and on 05/04/26 an entry to the facility submission. R22's progress notes documented 05/03/2026 9:25 PM, Health Status Note,Note Text: Pt transferred to ED for evaluation after unresponsive episode. Pt noted to be unresponsive with heart beat and active respirations at 1920 (7:20 PM). Last known well time 18:15 (6:15 PM). POA Updated. Resident was not tracking with eyes, unable to verbalize responses to questions or follow commands. R22's medical record on 05/03/26 at 7:20 PM did not document a full assessment with vital signs, did not document using the SBAR form, and did not document the provider was updated and if any orders were provided. The medical record did not document R22's diagnosis and admission to the hospital. On 05/04/26, R22 returned from the hospital. R22's medical record did not document a full assessment upon re-admission to the facility and discharge diagnoses. No vitals were entered into the medical record. 05/21/26 at 11:41 AM, Surveyor interviewed Director of Nursing (DON) B asking if assessments of R22 were completed prior to transfer and upon return to facility. DON B stated DON B was notified of R22 having another unresponsive episode. At that time, it was an agency nurse and currently don't have access to that nurse as that nurse no longer works at the facility. DON B stated DON B is unable to find a completed assessment with vitals, provider notification or order, and no SBAR when R22 was transferred to the ED. DON B could not find an assessment of R22 upon re-admission. DON B stated DON B would expect an admission assessment to be completed. Example 2 R3's diagnoses include gangliosidosis, dystonia, respiratory disorder, major depressive disorder, anxiety disorder, respiratory failure, dysphagia, disorder of the autonomic nervous system, contracture of muscle left forearm, immunodeficiency, restless legs syndrome, anemia, psychotic disorder with delusions, aphasia, functional quadriplegia, protein-calorie malnutrition, and phonological neuromuscular. On 03/13/26, MDS documented a Brief Interview of Mental status (BIMS) score of 15/15, meaning intact cognition. R3 is dependent on staff for all activities of daily living. R3's facility's care plan documented:The resident has a terminal prognosis r/t GM1 Date Initiated: 08/26/2025 The resident's comfort will be maintained through the reviewdate. Date Initiated: 08/26/2025 Revision on: 09/09/2025Target Date: 08/27/2026 Work cooperatively with [Name] Hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Date Initiated: 08/26/2025. The care plan did not address R3's choices, preferences and goals when nearing the end of life regarding pain management and symptom control, treatment of acute illness, and choices regarding hospitalization. R3's hospice communication book documented by CNAs of showers given each week and bedding changed. The communication book did not include the hospice care plan for R3. On 05/21/22026 at 11:41 AM, Surveyor interviewed DON B about hospice care plan and coordination of care. DON B stated every Friday DON B goes over any changes with the hospice nurse. This is verbal communication with hospice nurse if there are any changes. We don't go over the care plans to see if they are the same. Hospice gives a weekly calendar for showers and social visits. Example 3 R4 was admitted to the facility on [DATE], with diagnoses including dementia, history of stroke, heart failure, and respiratory failure. R4 was admitted to hospice services on 04/08/26. On 05/20/26, Surveyor reviewed R4's facility and hospice care plans. R4's facility care plan included: Resident has a terminal diagnosis related to hear failure, 04/28/26. Interventions: Adjust activities of daily living to resident's changing abilities. Work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Activities of Daily Living (ADLs), 05/24/23. Interventions: Bathing/showering, check nail length and trim and clean on bath day as necessary, report any changes to the nurse. Resident is totally dependent on mechanical transfer, extra large sling to provide shower weekly and as necessary. R4's hospice Aide Care Plan Report included: Home health aide twice weekly. Bathing task to be completed every visit, two assist with hoyer lift transfer, 04/08/26-07/06/26. Surveyor noted R4's hospice care plan did not indicate the size sling R4 was to use. On 05/20/26, Surveyor reviewed the facility and hospice documentation related to R4's showering tasks. Surveyor noted showering/bathing for the facility was located in the tasks tab of R4's electronic record and options included, Who bathed resident? facility staff, hospice, refused, not applicable (N/A). R4's documentation included the following: 04/11/26-N/A 04/18/26-N/A 04/25/26-N/A 05/02/26-N/A 05/09/26-N/A 05/14/26-HOSPICE 05/16/26-N/A Surveyor noted bathing/showering completed by hospice is documented in the paper hospice binder located at the nurses' station, and included: 04/16/26, hospice aide, showered, dressed, brushed teeth, socialized, brought down for breakfast, cleaned up room. 05/14/26, hospice aide, shower completed. 05/21/26, hospice aide, showered, clean bedding, brought down to breakfast. On 05/20/2026 at 11:51 AM, Surveyor interviewed facility certified nursing assistants (CNAs) D and E. CNAs D and E stated R4 is on hospice and receives a shower on Thursdays when the hospice aide visits. CNA D reported facility CNAs assist hospice aide with R4's shower on Thursdays as R4 requires two staff to transfer with a mechanical lift. CNA D stated hospice aides chart showers in hospice binder and facility CNAs document showers in the task and will indicate who gave the shower, example facility staff or hospice. If the resident refuses, CNAs would document resident refused and tell the nurse. CNA D thinks the nurse is required to document the refusal. On 05/21/2026 at 7:08 AM, Surveyor observed two CNAs from hospice assisting R4 with cares after shower. Surveyor interviewed hospice aides F and G. Hospice aides F and G reported communication with facility staff is verbal, and R4 gets a shower weekly on Thursdays. Hospice aides F and G were not sure if facility staff completed a shower a different day of the week. Hospice aides F and G stated hospice has two aides coming due to R4 being a hoyer lift transfer and hospice aides having to wait for facility staff to assist them, up to 20 minutes. Hospice aides F and were not sure why R4's hospice care plan indicated R4 received a shower every visit, as they only shower/bathe R4 once weekly on Thursdays. On 05/21/2026 at 8:16 AM, Surveyor and CNA I observed R4 was in a size large sling and R4's care plan indicated R4 was measured for an extra large sling. CNA I showed Surveyor the shower room where slings are kept and noted there were extra slings in the room. CNA I was not sure why R4 was in a large sling. On 05/21/2026 at 8:48 AM, Surveyor interviewed hospice Registered Nurse (RN) H. Hospice RN H stated hospice has very good communication with the facility. Hospice RN reported facility and hospice CNAs communicate to her daily, and she has daily communication with the facility's Director of Nursing (DON). Hospice RN stated, I would assume facility staff is giving her a shower, our CNAs come twice a week, one for social once for shower. Yes, communication is verbal. I meet with DON on Fridays to wrap up the week. The aides have not reported concerns to me. Hospice RN H stated she did not realize R4's hospice care plan indicated R4 would receive a shower twice weekly. The facility and hospice documentation of R4's cares do not support R4 was receiving a shower twice weekly as care planned. Hospice aides did not place R4 in the correct hoyer sling size, and a hoyer sling size was not documented in the hospice care plan. The facility did not have a system to communicate what services would be provided to R4 and which provider would complete those services. The hospice and facility staff were unable to report a communication system other than a verbal one.

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice has potential to affect all 46 residents residing in the facility. The facility's Dietary Manager (DM) has been in the position for over 2 years, had enrolled in a course in 8/2022, but did not complete the steps to become certified. The facility does not have a full-time Registered Dietician (RD) at the facility. Findings include: On 2/25/25, at 7:57 AM, Surveyor interviewed Dietary Manager (DM) E. DM E reported that she became the Dietary Manager 2 years ago. When DM E was asked about her qualifications, she stated she was not a certified dietary manager, certified food service manager, nor did she have a related associates degree. DM E stated she was done with the class and took the test last October but had failed. DM E indicated her 90-day wait was about up and she would be rescheduling the exam. DM E stated Registered Dietician (RD) services are contracted and she did not know if the RD was at the facility at least 35 hours per week. DM E did not know if the facility had a waiver for Dietary Management. On 2/25/25, at 3:20 PM Surveyor interviewed Nursing Home Administrator (NHA) A about DM E. NHA A stated that DM E started her position as Dietary Manager a couple years ago. NHA A stated DM E is not certified. NHA A stated that DM E started the course almost right away upon starting as Dietary Manager. NHA A stated she was not sure why the lapse, but DM E had taken the exam in October (2024) and failed. NHA A stated that DM E will be rescheduling the test because DM E's 90-day retake waiting period was up last week or coming up soon. NHA A stated that RD services are contracted. NHA A does not know if RD services are 35 hours per week just for the facility as the RD covers a number of buildings. When asked, NHA A stated the facility did not have a waiver for dietary management. On 2/26/25, at 7:15 AM, NHA A stated the facility did not have 35 hours per week of RD services. NHA A confirmed that DM E started her job as Dietary Manager on 8/15/2022 and has been in her role for almost 2 1/2 years.

Based on interview, record review, and observation, the facility failed to implement correct monitoring of the dish washer for sanitization purposes. This has the potential to affect all 46 residents residing in the facility. The facility did not ensure facility protocol was followed to ensure safe sanitization of dishware via their dishwasher. Findings include: The facility protocol on log sheet: Report if wash Temperature is Less than 110 Report if rinse temp is 120 Report if test strip does not reach between 50-100ppm (parts per million) The Association of Nutrition and Foodservice Professional titled, Know Your Sanitizer states, .If PPM sanitizer solution is too high, it can be considered unsafe and ineffective, potentially leaving harmful chemical residues on surfaces and posing a health risk due to excessive chemical exposures. On 02/26/25, at 10:43 AM, Surveyor interviewed, Culinary Aide (CA) F asking how dishes were cleaned and how temperatures were taken. CA F stated that staff check wash and rinse temps as well as the test strip. CA F demonstrated where test strips are kept, demonstrated how to use test strips, and showed Surveyor the log where staff record results. 0n 02/26/25, at 10:52 AM, Surveyor reviewed the logs for sanitizer ppm and sanitizations levels of the dishwasher in dining area kitchen. The log showed 7 out of 31 days in January and 9 out of our 26 days in February tested out of range with ratings of 150ppm. The range for safe sanitization levels is between 50-100ppm. On 02/26/25, at 10:54 AM, Surveyor interviewed Dietary Manager (DM) E, who stated temperatures and test strips are done every 2 hours while the machine is in use. DM E demonstrated proper use of the test strip during a wash cycle. It tested 150 ppm. DM E was not aware it was testing out of range. Surveyor asked what steps have been taken related to these out-of-range results. DM E stated that she did not know and that she would call the company today and get the situation figured out. Surveyor asked if there were any other steps needed. On 02/26/25, at 11:03 AM, DM E sought out surveyor. DM E stated that she called the company about the dishwasher, and they identified facility staff were not using the right test strips to check sanitizer levels. Surveyor and DM E went back to kitchen where DM E demonstrated proper use of test strips during a wash cycle. The new test result was 50ppm. Chlorine test strips had been switched out to Iodine test strips. Surveyor clarified with DM E that staff were completing the sanitizer level test strips per protocol, but they were using the incorrect strips. The out-of-range levels of sanitizer should have been reported and acted upon.

Based on interviews and record review, the facility did not ensure residents with limited range of motion (ROM) received services to maintain or prevent further reduction in ROM for 1 out of 2 residents (R) (R30). R30's restorative care plan from therapy on 1/24/2025 was not implemented. R30's restorative care plan from therapy on 7/1/2024 was not being followed. Findings include: R30 admitted to the facility on [DATE] with diagnoses to include post polio syndrome, osteoarthritis, and pain in right shoulder. R30's quarterly Minimum Data Set (MDS) assessment dated , 2/7/2025, indicated R30 had no impairment in ROM in both upper extremities and impairment on both lower extremities. R30 needed maximum assist in multiple areas of mobility. R30 had therapy services that were discontinued on 1/21/2025, and a restorative program was ordered on 01/24/2025. Physical therapy orders stated, Patient will benefit from daily seated lower extremity and core home exercise program. Patient needs minimum assist for bilateral lower extremities range of motion especially left lower extremity. Please see handout set up in his room (closet door) per patient's consent. R30's care plan, dated 7/1/2024, did not include the 1/24/2025 restorative order. Related section of the care plan was last updated 7/1/2024. Care plan stated the restorative order from 7/1/24. The order stated, Patient will benefit from bilateral LE AAROM (active assisted range of motion) program on both lower extremities incorporated for AM cares as tolerated (daily) to prevent joint contractures and includes a sheet of exercises. R30's restorative order was not listed in the Treatment Administration Record (TAR) report dated January 2025 and February 2025. No documentation was provided that exercises were being completed. On 2/24/2025, at 9:58 AM, R30 stated that he did not have therapy or a restorative program. R30 stated that facility staff did not do exercises with R30. R30 indicated that R30 did not need them. R30 denied a decline in ADLs. R30 reported he had polio when he was 5 and that he was not going to get any stronger. On 2/25/2025, at 1:01 PM, Surveyor observed the Kardex (CNA plan of care) hanging inside the closet door for R30. The order for LE exercises from 7/1/2024 was under the Resident Care section of the Kardex. On 2/25/2025, at 2:51 PM, Surveyor observed Director of Nursing (DON) B attempt to find documentation of exercises being performed with R30. DON B stated she was unable to find documentation and she would have to get some help to find things. DON B stated that the process is that, when a new order comes in, she transcribes it to the care plan and actions go on the Kardex so CNAs know what to do. DON B stated two copies are printed. One copy is put in the CNA binder and one copy is put on the door of resident's closet. On 2/25/2025, at 3:41 PM, DON B stated she was unable to find documentation. DON B stated it was not being done and she took full responsibility. On 2/26/25, at 11:50 AM, Surveyor interviewed CNA D who stated that CNAs know what to do with each resident because it is on the Kardex. CNA D stated that the Kardex is posted inside the door of each patient room and in the binder at the CNA desk. CNA D stated CNAs do the restorative program. CNA D stated that R30 does not sleep in bed and that it is difficult to do the exercises when R30 is not in bed. When asked if DON B talked to them about doing R30 exercises or if she knew he had them. CNA D said no.

Based on observation, interview, and record review, the facility did not provide assistive devices with meals to prevent accidents for 1 of 6 residents (R)(R2) reviewed for accidents. R2 was assessed and care planned as requiring lids on cups during meals in order to prevent spills. This was not provided for 2 of 2 observed meals. Findings include: R2 admitted to the facility in February of 2024 with diagnoses to include multiple sclerosis, hypertension, paraplegia, and weakness. R2's Minimum Data Set (MDS) assessment, dated 01/10/25, indicated that R2 had limited range of motion on one side of his upper extremities, and required set up assistance for meals. R2's Care Plan, dated 02/24/24, stated Handled cups with lids at meals. R2's Nutrition/dietary note, dated 01/05/25, stated in part, Handled cups with lids and divided plate are provided at meals to support independent eating. Nursing is providing meal set up. On 02/25/25 at 9:00 AM, Surveyor observed R2 having breakfast. R2 had a divided plate and 3 coffee cups with liquids. Surveyor observed that none of the cups had lids on them. Surveyor observed R2's shaking movements while eating independently. On 02/25/25 at 9:29 AM, Surveyor observed R2 eating when he spilled liquids on himself. R2 spilled liquids on R2's right arm and right pant leg. Staff were observed to wipe up the spill and asked R2 if R2 would like to have pants changed. R2 refused and stated that he was okay. Surveyor observed no change in coloration where R2 spilled the coffee on R2's arm. At 9:33 AM, staff refilled R2's coffee cup with coffee per R2's request. The cup did not have a lid. On 02/25/25 at 9:50 AM, Surveyor interviewed R2 and asked about using cups with lids. R2 responded that sometimes R2 used cups with lids. When asked if R2 was okay after spilling coffee, R2 indicated R2 was okay. On 02/25/25 at 12:43 PM, Surveyor observed R2 receive two coffee cups with fluids in at lunch, neither of the cups had lids on them. On 02/25/25 at 12:53 PM, Surveyor interviewed Life Enrichment (LE) G who confirmed that there were no lids on R2's cups. On 02/25/25 at 4:00 PM, Surveyor interviewed Director of Nursing (DON) B who confirmed R2's care plan indicated R2 should utilize handled cups with lids. Surveyor told DON B about the observations above. DON B responded that should not have happened. R2 needed the lid in place to keep from spilling coffee or other fluids on self.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, and administering of drugs and biologicals, for 1 of 6 residents (R)(R11) reviewed for medication administration. The staff did not correctly administer an Advair inhaler for R11. Findings include: Surveyor reviewed instructions from the Michigan Medicine Care Guide titled, How to use your Advair HFA (fluticasone/salmeterol) inhaler last revised 10/2017 which stated, in part: .How to use your Advair HFA: .8. If your doctor has prescribed more than one dose (puff), wait 30 seconds and repeat above . R11 admitted to the facility on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R11 was cognitively intact. R11 had diagnoses of gangliosidosis (a genetic disorder that progressively destroys nerve cells in the brain and spinal cord) and quadriplegia (paralysis that affects all four limbs). On 02/25/25 at 7:42 AM, Surveyor observed Licensed Practical Nurse (LPN) D administer Advair inhaler to R11. LPN D gave R11 one puff of the inhaler and within 10 seconds gave a second puff of the inhaler. Surveyor asked LPN D, Should there be a longer wait time in between puffs? LPN D replied, Yes, but this resident breathes fast. On 02/25/25 at 9:30 AM, Surveyor informed Director of Nursing (DON) B of the observation of LPN D with the Advair inhaler. DON B replied, She (LPN D) should have waited at least 30 seconds before giving the second puff. On 02/26/25 at 7:48 AM, DON B informed Surveyor that it is a 30 second wait time between puffs of the Advair inhaler and provided surveyor with the instructions from Michigan Medicine.

Based on interviews and record review, the facility did not ensure the residents' right to receive mail delivered to the facility. The facility did not have a process to hand out mail on weekends. Mail delivered to the facility on Saturdays was not handed out to the residents until the following Monday. This has the potential to affect all residents in the facility who recieve mail. This is evidenced by: On 09/12/19, Surveyor conducted a group meeting. When asked if the residents received their mail, all stated they did not receive their mail on a regular basis. R33 stated, You cannot tell me they are delivering our mail to us when I don't get mail for days, then they bring me a whole stack. I have insurance information I need to forward to my son. R46 stated, We only get mail on Saturdays and Mondays. All residents stated R46 must have days mixed up since they never receive their mail on Saturdays. R33 stated she has asked the facility activity staff why she was not getting her mail and was told they did not know. Surveyor interviewed Activity Assistant A, who is responsible for mail delivery through the activity program. Activity Assistant A stated, We sign out that the mail is delivered on a clipboard .sometimes it is signed out, sometimes it isn't .There is no way of tracking. On weekends, the receptionist is supposed to deliver the mail. I don't know who is supposed to make sure the mail is delivered .Activities do not have a key to get into the front desk . Surveyor reviewed a sample of residents' mail delivery for September, provided by Activity Assistant [NAME] The columns marked Mail/News were blank for one resident. Another resident received mail on one day, and another resident received newspaper daily, but no mail. Surveyor interviewed Facility Receptionist (FR) B. FR B stated the mail is delivered to the front desk and placed into a container. Then, FR B places the mail into the activity mail box, located at the front desk. FR B stated she has noticed very infrequently that the mail placed in the activity mailbox is not delivered. However, FR B stated she does not work weekends, and the Saturday mail is always at the front desk when she comes to work on Mondays. The reception area is kept locked on the weekends. Activity staff do not have keys. Surveyor interviewed the Nursing Home Administrator (NHA). The NHA stated the activity staff do not have access to the mail on weekends since the reception area is locked. Surveyor reviewed the forms used to sign out mail delivery. The NHA stated the facility did not have a system for tracking to ensure the mail was delivered other than the current forms.

Based on observation, record review, and interview the facility did not prepare, store and distribute food under sanitary conditions. This has the potential to affect all 50 residents. ~Initial tour of the kitchen found equipment stored in a manner that did protect the equipment from contamination. ~DA-C was observed putting away clean dishes without proper hand washing. This is evidenced by: Example #1: On 10/15/18 at 10:46 a.m. during the initial tour of the kitchen the surveyor noted 2 large industrial type mixers both with mixing bowls. The bowls were not covered to protect against contamination. The facility also had a large slicer on the counter that was not in use and not covered. The food contact surfaces were exposed to potential contamination. The surveyor asked the Dietary Manager (DM)-A about the facility practice for storage of the mixers and slicer while not in use. DM-A indicted it is not the facility practice to cover the mixers or slicers while not in use. On 10/17/18 at 1:20 p.m. Surveyor spoke with DM-A and CCD-B (Corporate Culinary Director) and requested the facility's policy regarding storage of clean kitchen equipment. Surveyor received and reviewed the policy titled Employee Sanitary Practices which is not dated. The policy states, .store clean dishes inverted, in enclosed cabinets or storage units. Example2: On 10/17/18 7:20 a.m. Surveyor observed DA-C wash her hands at the hand washing sink. DA-C wet her hands, applied soap and placed her hands under the water flow to rinse. The hand washing process only took 5 seconds. DA-C did not scrub her hands for at least 20 seconds. After drying her hands, DA-C began putting away clean dishes from a cart to the cupboard in the dining room. On 10/17/18 at 7:30 a.m. Surveyor asked Cook-D how the handwashing sink works. Cook-D indicated he does not wash hands at that particular sink, but explained the water does not continue to run unless hands are directly in front of the motion sensor. On 10/17/18 at 8:55 a.m. Surveyor again observed DA-C washing her hands at same sink. Surveyor observed DA-C completed hand washing. The entire process took only 6 seconds. Surveyor asked DA-C about handwashing. DA-C indicated she has been back to work for about 3 weeks and only uses this sink for hand washing. DA-C indicated the water runs in a manner that she cannot wash her hands for the appropriate amount of time for a thorough hand washing. Surveyor asked DA-C if she has reported the concern to anyone. DA-C indicated she had told her co-workers but not the DM. On 10/17/18 at 1:25 p.m. the surveyor spoke with DM-A and CCD-B (Corporate Culinary Director) about hand washing expectations. DM-A indicated staff need to wash and scrub their hands for no less than 20 seconds for a thorough hand washing. The surveyor asked DM-A about the hand washing sink DA-C was observed to use. DM-A responded she was not aware of the sink issue until Surveyors brought it to the attention of kitchen staff. The surveyor requested the facility policy regarding proper hand washing.

Based on observation, record review, and interview the facility did not recognize R4's choice to refuse showering when R4 frequently becomes agitated and yells in anger during the task. The facility has not explored alternative ways to assist him with hygiene and his ADLs (Activities of Daily Living) or discussed his desires and choice with his guardian. This was discovered for 1 of 4 sampled residents. R4 has limited abilities to express his feelings however staff interpret his tone of voice and non-verbal gestures as his expressions of need and desires. Staff continue to give R4 a shower even when he expresses his dislike of how he is showered. R4's legal guardian was not made aware of the extent of R4's aversion to his 3 times a week showers in order to make the best decisions for R4. The facility staff has not explored alternatives to the showers or made consistent attempts to minimize the apparent discomfort R4 is expressing. In addition, observation found his shower was not made tolerable by ensuring basic warmth, privacy, and by asking his permission to proceed. This is evidenced by: R4 has been a resident at the facility since August of 2016. His [DIAGNOSES REDACTED]. A review of his latest MDS (Minimum Data Set) assessment, dated 11/3/17, indicates he needs the physical assistance of 2 staff members and a mechanical lift for transfers and is dependent on the physical assistance of staff for bathing, personal hygiene, and incontinence care. He needs a wheelchair but can propel himself about the facility. He appears to have some short term and long term memory problems. He is able to speak with words, however, he sometimes does not understand others nor do others understand him. A review of his plan of care finds that he continues to attend activities that he chooses to do such as baking, crafts, chapel, magazines, country music. He enjoys talking about trains, his past train trips, and his room full of railroad memorabilia. The care plan states he likes to lay down at least 30 to 60 minutes after meals. It also states staff are (at the direction of his guardian) to shave him, comb his hair, and have clean clothes on him every day, and give him a shower 3 times a week, This is done on the evening shift every on Monday, Wednesday and Saturday. Staff are to use a prescription shampoo. The only direction/intervention for staff helping him with his ADLs is they are to, Assume unhurried manner. Allow ample time for tasks. The care plan outlines that staff are to allow him adequate time to express himself and ask short simple question that can be answered with a yes or no or answered non-verbally when trying to communicate with him. Review of his clinical record finds he is routinely monitored for yelling/expressions of anger. The interventions outlines on the Behavior Tracking Record are to: a) Teach safe spots inside to weather watch b) Assist/supervise outside time, when appropriate c) Give him magazines, train videos, train books, music d) May need personal care if angry e) Offer to help him lay down Review of his physician notes for the last 3 months indicate his medical professionals found him reading, resting, or watching t.v. when they did their examinations. The latest notation dated 10/24/17, states, Patient does not have the ability to fully express needs, but does nod in a manner that seems to express understanding. His mood continues to be pleasant and cooperative. Nursing have no concerns about him. Review of his medications finds he takes [MEDICATION NAME] (antidepressant), and [MEDICATION NAME] (antipsychotic) every day. On 11/20/17 at 2:47 p.m. Surveyor was in the sitting area and overheard yelling coming from R4's closed room. Upon entrance, the surveyor observed R4 in his bathroom naked on a shower chair. CNA-A (Certified Nursing Assistant) turned on a hand held shower nozzle and was testing the water with her hand. The bathroom door was wide open to his bedroom and the shower curtain was not drawn around him. R4 was yelling and repeating,[***] ! CNA-A had the water running and was saying to him This will only take a minute. Over the course of the next few minutes, R4 continually yelled very loudly the repeated phases of[***] ! and I don't care! and You are an[***] ! 36 times. The expression on his face was clear distress and he was emphatically shaking his head and clenching his fists over his groin and yelling. CNA-A completed the shower and washed his hair taking less than 4 minutes in total. The door to his bathroom and the shower curtain were open the entire time to the temperature of the room and he was uncovered without any towels for privacy or warmth. CNA-A announced to R4 she was done and began to towel off his body and his shouting continued with No! No! and God! and God Damn! and I don't care! an additional 11 times while CNA-A put his shirt on. CNA-A told the surveyor That was fun. He does this every time. He only knows 4 phrases. So that's what he always says. He gets a shower 3 times a week. At 3:00 p.m. CNA-B came into the room to assist with the transfer. CNA-B asked R4 is he wanted to lay down in bed and R4 grunted in such a way to mean yes. R4 swore again when staff put on the sling for the lift but became quiet when he was settled into bed and covered up. CNA-B told the surveyor that R4 yells like that every time his gets a shower and when he is even touched. CNA-B stated staff give him a shower 3 times a week on the evening shift. CNA-B stated he is showered more often to control odor. At 3:55 p.m. Surveyor interviewed CNA-A, who had given him the shower earlier. CNA-A stated R4 can only say a few phrases and he says these things even when he is in a good mood. CNA-A stated R4 hates showers and hates taking off his clothes. When asked how the staff are trained to help R4, CNA-A stated staff are told, Just go as fast as you can and get it over with. It happens like that every time. He'll be even madder it it's done after dinner. CNA-A stated R4 did not get laid down for his nap today and that gets him madder still. CNA-A indicated that if R4 is allowed to sleep in and gets his nap, he is a lot more pleasant. When asked what other things had been tried, CNA-A stated R4 likes trains, music, and magazines but these things are not useful in the shower. When asked if the whirlpool tub or bed baths had been tried, CNA-A stated she had been here since the facility opened, over a year and half ago, and she had never heard of anyone trying the whirlpool. CNA-A stated bed baths are not an option as R4 needs his hair shampooed with his special shampoo for his crusty hair and R4 wets his bed every night so he needs a shower to help with the smell and prevent skin breakdown. At 4:35 p.m. Surveyor interviewed RN-C (Registered Nurse) about how staff are to help R4 with his hygiene. RN-C stated staff are trained to Get it over as quickly as possible, as he calms down afterward. RN-C stated the shower, Has to be done. When asked about alternative bathing, RN-C was not aware if any alternatives had ever been tried for R4. RN-C stated a bed bath would need to be done by two staff members and the shower only needs one staff to do it. RN-C indicated R4 swears as it is his only way to communicate and when he swears she tells him that she knows he's upset but, We don't use that word. At 4:05 p.m. Surveyor interviewed HM-D (House Manager) about her expectations of staff should R4 become agitated during a shower or cares. HM-D stated staff are to stop and reattempt or get another staff member to try. HM-D stated R4 reacts the way the surveyor had observed for pretty much every shower. HM-D stated R4 does not communicate very well and he will react and yell during other cares not just showers. HM-D stated the staff should take their direction from R4 himself and let him sleep and lay him down for naps late morning and early afternoon. HM-D stated he gets his showers 3 times a week at the direction of LG-E (Legal Guardian). HM-D stated she had only been on the job for 7 months and she has not had a conversation with R4's guardian personally about how he reacts to the showers but stated the guardian is very much aware of how he reacts. HM-D stated the guardian tells them what she wants the staff to do for R4 and they do it. On 11/21/17 at 10:13 a.m. Surveyor observed CNA-F and CNA-G assist R4 with his morning cares. R4 was very accepting of the staffs' assistance. The CNAs were observed to use multiple interventions and also to ask permission prior to doing each task. R4 reacted with smiles and agreeable vocalizations. Afterwards, the surveyor interviewed both CNAs. CNA-F told the surveyor she has worked at the facility for 7 months. CNA-F stated R4 is not combative at all, but he will not allow her to brush his teeth and doesn't like cold. CNA-F stated she will attempt a foam sponge if he will let her. CNA-F stated he responds best if you get out of his face. At 10:45 a.m. Surveyor interviewed CNA-G. CNA-G has worked at the facility for 2 months and stated she gives R4 his shower sometimes twice a week. CNA-G stated his response to his showers depends on the day. CNA-G stated he is never resistant and she will stop and ask him if what she is doing is o.k. for him. CNA-G stated that is is hard to tell what he wants but you can tell by the tone of his voice if he is ok. CNA-G stated she has to go slow and wring out the cloth and use 3 towels around him to keep him warm. CNA-G stated she always keeps the bathroom door closed so the room is steamy. CNA-G stated she uses a soft voice and makes sure she is connected to him with locked eyes to calm him. She stated she can tell when is he is grumpy and when he will yell. At 10:52 a.m. Surveyor interviewed LG-E about her awareness of R4's intense dislike of showers and if the facility had discussed with her how to work with R4 to lessen his distress. LG-E indicated no staff member had contacted her and informed her of R4's intense reactions to showers until the night before (11/20/17). LG-E indicated she was aware of how he reacts to daily cares but was not aware of his reaction to showers. LG-E stated HM-D had called her the previous night and they discussed reducing the showers to only twice a week if it caused him such distress. LG-E stated also felt that a male caregiver might be better as R4 was always a private individual and never married. LG-E stated she encouraged frequent showering as R4 was always very careful about his appearance and that once a week showers did not cleanse his hair enough.

Based on observation, interview, and record review, the facility did not ensure 1 of 1 sampled residents (R6) receiving [MEDICAL TREATMENT] services was afforded the necessary treatment and services to monitor fluid status. R6 received [MEDICAL TREATMENT]. On 6/6/17 the facility received an order from the [MEDICAL TREATMENT] provider to implement a 1500 cc (cubic centimeter) per 24 hour fluid restriction for R6 due to excess fluid. R6 required an extra treatment on 6/8/17. The facility received multiple requests from the [MEDICAL TREATMENT] provider to monitor R6's fluid intake due to significant weight gain and difficulty breathing. On 6/14/17 R6 again required an extra [MEDICAL TREATMENT] treatment due to excessive weight gain. Despite that, the facility had no system in place to formally monitor R6's intakes. This is evidenced by: R6 had current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) dated 7/26/17 indicated R6 was cognitively intact, and required limited to extensive assistance from staff for all aspects of care except eating. R6's nutritional care plan was dated 12/29/16. The care plan had the following approaches, all of which were undated: ~1500 cc (cubic centimeters) of fluid limit per day. ~Encourage R6 to comply with the fluid restriction. ~Offer R6 ice chips if R6 was exceeding his fluid restriction. Surveyor completed a review of a form titled [MEDICAL TREATMENT] Treatment Information and noted the following: ~6/6/17, R6 returned from a [MEDICAL TREATMENT] treatment with orders for a 1500 cc restriction per day. The information indicated R6 would require an extra [MEDICAL TREATMENT] treatment scheduled on 6/8/17 due to increased fluid. ~6/13/17, R6 returned from a [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] Treatment Information dated 6/13/17 indicated, .Extra treatment tomorrow .Please (underlined once) help monitor fluid intake pt (patient) had a 6.4 kg (kilogram or 14 pounds) of fluid increase . ~7/6/17, R6 returned from a [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] Treatment Information dated 7/6/17 indicated, .was 4.6 kg (or 10.1 pound) over his dry weight this morning prior to his [MEDICAL TREATMENT]. It is very important to watch and limit his fluid intake especially with his breathing issues . ~7/20/17, R6 returned from a [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] Treatment Information dated 7/20/17 indicated, .Please (underlined 3 times) encourage patient to limit fluid intake. He was over his dry weight by 5.9 kilos (kilograms) which is almost 13 pounds! Please offer ice chips versus water whenever possible. This should help improve his breathing . ~7/25/17, R6 returned from a [MEDICAL TREATMENT] treatment. The [MEDICAL TREATMENT] Treatment Information dated 7/25/17 indicated, .6.kg (or 13.2 pounds) over for fluid intake. Please help and encourage him many times to watch fluid intake .very important . According to R6's physician orders, on 6/8/17 a 1500 cc fluid restriction was ordered. This was 2 days after the [MEDICAL TREATMENT] provider requested the fluid restriction. Surveyor completed a review of R6's intakes. Intakes were noted on 2 separate facility forms. The intakes from the 2 forms were not combined/tallied. Surveyor tallied the intakes from both forms and noted the following: ~From 6/8/17 through 6/30/17, 15 of the 22 days had intakes documented for all 3 shifts. Of the 15 days, there was only 1 day that R6 did not exceed the fluid restriction. Surveyor tallied the total intakes for the 15 days and noted an average daily intake of 2110 cc's. This exceeded R6's 1500 cc fluid restriction. There was no indication the facility consulted with the physician or the [MEDICAL TREATMENT] provider regarding R6 consistently exceeding the fluid restriction. ~From 7/1/17 through 7/31/17, 18 of the 31 days had intakes documented on all 3 shifts. On all 18 days, R6 exceeded the fluid restriction. Surveyor tallied the total intakes for the 18 days and noted an average daily intake of 2120 cc's. This again exceeded R6's fluid limit of 1500 cc's. There was no indication the facility consulted with the physician or [MEDICAL TREATMENT] provider regarding R6 consistently exceeding the fluid restriction. ~From 8/1/17 through 8/8/17, 7 of the 8 days had intakes documented on all 3 shifts. On 6 complete days, R6 exceeded the fluid restriction. Surveyor tallied the total intakes for the 6 days and noted an average daily intake of 1890 cc's On 8/11/17 at 11:06 a.m. Surveyor noted R6 had a 240 cc disposable cup on the over-the-bed table. Surveyor spoke with CNA-E (Certified Nursing Assistant) about the observation. CNA-E indicated R6 was on a fluid restriction and should not have water at the bedside. CNA-E was not certain why R6 had water but indicated a staff member had just passed water and thought that staff person had put water in R6's room. On 8/9/17 at 5:00 p.m. Surveyor spoke with RN-A (Registered Nurse) regarding the facility's practice for monitoring fluid intake. RN-A indicated CNAs record fluid intake for every meal in the facility's electronic charting system. RN-A stated the nurses enter any liquids given on the TAR (Treatment Administration Record). Surveyor asked RN-A how the fluid intakes documented were combined/tallied. RN-A indicated she was not sure. On 8/9/17 at 5:20 p.m. Surveyor spoke with RN-B about the facility's practice for monitoring fluid intake. RN-B stated for any resident on a fluid restriction, the dietary department divides out the amount of fluid a resident could have at each meal and with each med pass. RN-B indicated CNAs document fluid intake in their charting system and the nurses documented intake on their TAR. Surveyor asked RN-B where the total intake for a 24 hour period could be found. RN-B stated she was not sure. RN-B stated she thought there was a report the dietary department generated. RN-B stated the dietary department watched intakes closely. On 8/10/17 at 3:00 p.m. Surveyor spoke with the DM (Dietary Manager). The DM indicated she generated a report of fluid intake from CNA documentation of fluid intake at meals. The DM indicated the report was generated for care conferences. The DM did not address the nurses documentation in the TAR. On 8/10/17 at 2:03 p.m. Surveyors spoke with the RD (Registered Dietician). The RD indicated all fluid has not been captured on residents I&O (Intake and Output). The RD indicated as a facility they had recently identified this as problematic. Surveyor asked the RD who was responsible for overseeing I&O. The RD indicated she was not sure, but indicated the DM (Dietary Manager) was not reviewing I&O. On 8/11/17 at 12:00 p.m. Surveyor spoke with the IDON (Interim Director of Nursing). The IDON indicated the facility did not have a system to tally and monitor intake and output. The IDON indicated she was currently working with the facility's IT (Information Technology) team to figure out how to pull all information into one report.

Based on observation, interview and record review, the facility did not ensure 3 (R3, R9, R11) out of 4 sampled residents received the necessary care and treatment to prevent the development and/or promote healing of a pressure injury. R5 has a history of pressure injuries to the coccyx that redeveloped on 1/23/17. Based on the documentation, the pressure injury failed to progress towards healing for 131 days. Observations found R5's care plan was not implemented when there was no repositioning, no incontinence care, and no dressing on the pressure injury for at least 6 hours and 20 minutes. This left R5's wound exposed to urine, increasing the chance of non-healing as well as infection. There were no changes to R5's treatment plan when R5's wound did not progress towards healing. There was no evidence of a weekly assessment of R5's wound. R11 was admitted to the facility at risk for pressure ulcer development. R11 developed DTIs (deep tissue injuries) to both heels on 5/20/17, and a Stage 2 pressure injury to the coccyx on 6/21/17. There is no evidence of a care plan being developed to address risk for or actual pressure injuries until 5/30/17. There was a 1 month delay in having R11 assessed with [REDACTED]. In addition, pressure relieving boots were observed to not be used on multiple observations. R3 has a history of open areas on the buttocks that open and close. On 7/27/17, R3 was admitted from the hospital with Stage 1 and Stage 2 pressure injuries. Surveyor observed no cleansing of the wound prior to dressing change per physician order [REDACTED]. This is evidenced by: Example 1 R5 had current [DIAGNOSES REDACTED]. R5's most current MDS (Minimum Data Set) dated 7/21/17. The MDS indicated R5; ~ Cognitive skills were severely impaired; ~ Required extensive to total assistance of one to two staff persons for all aspects of care; ~ Did not walk; ~ Was at risk for the development of a pressure injury; and ~ Had no pressure injuries. R5's skin care plan was dated 8/2/16. The care plan indicated R5 had the potential for skin breakdown. The care plan did not identify R5's current pressure injury. The care plan had the following undated approaches, .position and toilet approximately q 2 (every two) hours .Keep linens dry and wrinkle free .Observe for any signs and symptoms of skin breakdown .Roho cushion in chair .has recurrent area to her coccyx that may reappear as an open macerated slit. When this occurs .is only up in her wheelchair for meals and church . R5's most current skin risk assessment was dated 7/5/17. The risk assessment indicated R5 was at high risk for the development of a pressure injury. Surveyor received a facility form titled Body Audit Form. Surveyor completed a review of R5's Body Audit Form dated 8/31/16. The form indicated R5's coccyx ulcer was healed. There were no further completed Body Audit Forms received. Surveyor requested all of R5's wound notes since 7/20/16. Surveyor received nursing notes and noted the following. There were no nursing notes describing R5's coccyx pressure injury until 1/23/17. Surveyor was unable to determine when R5's wound as noted from the Body Audit Form developed. ~1/23/17, .0.4cm (0.4 centimeter) slit to coccyx, surrounding skin pink, scar tissue noted to right side of slit . The above nursing note did not include all wound characteristics including the stage of the pressure injury, a description of the wound base, or if there was any drainage. There were no further wound notes noted in the nursing notes until 3/3/17, 62 days later: ~3/30/17, .open area to upper coccyx measuring 1cm long x .3cm wide x .1cm deep (1.0 cm long by 0.3 cm wide by 0.1 cm deep) . The above note did not include all wound characteristics. The measurements indicated R5's coccyx pressure injury had deteriorated since the measurements completed on 1/23/17. The physician was contacted and ordered a [MEDICATION NAME] dressing as well as to reposition R5 every two hours. There were no further wound notes noted in the nursing notes until 5/5/17, 36 days later: ~5/5/17, .0.2x0.2cm open area to coccyx . ~5/16/17, .Area to coccyx open . The above notes do not describe all wound characteristics. There were no further wound notes noted in the nursing notes until 7/31/17, 75 days later: ~7/31/17, .Dressing to coccyx changed .Area remains unchanged in appearance and size .Will continue current wound care protocol . The above nursing note has no wound characteristics documented. Since 1/23/17 to the present survey date of 8/8/17 there has been one change in R5's wound treatment on 3/30/17. There have been no further changes to manage R5's wound to promote healing for the past 131 days. On 8/10/17 beginning at 7:30 a.m. Surveyors made the following observations: ~At 7:30 a.m. R5 was observed seated in a wheel chair on the Cedar unit in the TV lounge. ~At 8:05 a.m. CNA-D (Certified Nursing Assistant) escorted R5 into the dining room. ~At 9:00 a.m. CNA-D escorted R5 to her room. CNA-D indicated to Surveyor she was going to find another staff person to assist her to reposition R5. ~At 9:50 a.m. R5 was escorted by AA-I (Activity Assistant) to the Cypress Unit for an activity, Wheel of Fortune. ~At 11:30 a.m. R5 was escorted by AA-C from the Cypress Unit to the dining room. ~At 12:40 p.m. R5 was escorted by CNA-D to R5's room. ~At 12:45 p.m. CNA-E and CNA-F entered R5's room and indicated they were going to assist R5 to lay down. No staff at any point during the observation repositioned R5. On 8/10/17 at 12:50 p.m. Surveyor observed CNA-E and CNA-F assist R5 into bed. CNA-F removed R5's pants and indicated they were soiled with urine. Both CNA-E and CNA-F turned R5 from side to side to remove an incontinence brief. Surveyor noted the brief was saturated and dripping with urine with urine spilling over and onto a disposable chux. CNA-E completed peri care. Surveyor noted Stage II pressure injury on R5's coccyx the size of a small pea and approximately 0.1 cm deep. The wound base was visible and dull pink in color. The wound was surrounded by approximately 1.0 cm (centimeter) of maceration (softening and breaking down of skin from prolonged exposure to moisture). There was no dressing on R5's pressure injury. CNA-E indicated there had been no dressing on the wound when she and CNA-F assisted R5 with morning cares. Surveyor asked CNA-E if she notified the nurse there was no dressing. CNA-E indicated she had not. CNA-E stated sometimes there was a dressing and sometimes they just put a barrier cream over the area. CNA-E stated she had applied a barrier cream during morning cares. CNA-E also indicated she and CNA-F had assisted R5 into the wheel chair at 6:30 a.m. R5 was seated in a wheel chair and not afforded repositioning from 6:30 a.m. according to CNA-E and CNA-F's account until 12:50 p.m.; a period of 6 hours and 20 minutes. R5 also did not have a dressing on her coccyx wound to protect the wound from urine and feces. On 8/10/17 at 1:05 p.m. Surveyor observed RN-G (Registered Nurse) complete wound care for R5's coccyx pressure injury including the application of a dressing. RN-G measured the coccyx wound at 0.3 cm by 0.2 cm. RN-G then measured the wound including the area of maceration at 1.5 cm by 0.8 cm. On 8/11/17 at 11:08 a.m. Surveyor spoke with CNA-E. CNA-E stated they usually laid R5 down after lunch. CNA-E indicated they did reposition R5 by sliding R5 from side to side while seated in the wheel chair. Sliding from side to side in a wheel chair does not constitute repositioning and off-loading (total pressure reduction). Off-loading is of extreme importance for R5 and a critical component in R5's treatment regimen for wound healing. On 8/11/17 at 7:30 a.m. Surveyor spoke with LPN-H (Licensed Practical Nurse). LPN-H indicated she was the full time nurse on the unit where R5 resides. Surveyor asked LPN-H about the facility's wound management program. LPN-H indicated the nurses on the floor do not do wound rounds. LPN-H indicated the IDON did weekly rounds including wound measurements. LPN-H stated the nurses would call physicians and notify the IDON if there was a decline in a wound. Surveyor asked LPN-H about R5's pressure injury. LPN-H indicated she was not sure why R5's wound kept re-opening. LPN-H stated there was always maceration around the wound. LPN-H also indicated there have been no changes to R5's treatment orders. On 8/11/17 at 12:00 p.m. Surveyor spoke with the IDON (Interim Director of Nursing). Surveyor again requested wound notes for R5. The IDON indicated the wound notes Surveyor received was all there were. The IDON indicated she was not sure why. The IDON indicated the nurses on the floor were to be monitoring and documenting on wounds weekly including wound measurements and characteristics. The IDON indicated she expected all staff to follow care plans for wound management. Example 2 R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11's discharge summary form dated on 5/12/17 indicated R11 was receiving wound care to coccyx. This is indicative that a wound may have been present at some point. The admission MDS (Minimum Data Set) assessment indicated R11 was at risk for pressure injury development, had no healed or unhealed pressure injuries, and required limited assistance with bed mobility. On 5/20/17, an entry in the medical record indicates R11 developed blisters to both heels. The develop of a blister on an area prone to pressure is considered a DTI. On 5/22/17, the Nurse Practitioner ordered an air mattress be placed on R11's bed to assist with pressure reduction. The blisters broke on 5/28/17. There are no measurements or characteristics documented of the areas. R11's Care Plan dated 5/30/17 includes a problem of, Currently has skin breakdown issues R/T (related to) [MEDICAL CONDITION]. Interventions include, If resident uses devices that can cause pressure, such as .Ted hose .splint, assess for redness/irritation .Standard reducing pressure relieving cushion/mattress unless otherwise indicated .Complete wound care per MD order, Float heels on bed to maintain skin integrity, Staff to reposition every two hours and as needed .Air overlay mattress to bed for pressure relief .Wear podus boots per MD order. Surveyor asked for any care plans prior to the one dated 5/30/17. RN-B (Registered Nurse) told Surveyor immediate care plans are not kept. R11's medical record included the following information related to the pressure injury on the right heel. On 6/5/17, the Nurse Practitioner wrote an order for [REDACTED]. Review of the facility wound assessments found an assessment was not completed on a weekly basis. There was no wound assessment or documentation from 5/31/17 through 6/20/17. The entry made on 6/20/17 indicated the pressure injury had some drainage and a foul smell. Because there was no documentation prior to 6/20/17, it can not be determined when the pressure injury began to deteriorate. On 7/3/17, the facility identified eschar (dead tissue) on right heel. The Weekly Wound Documentation stated, Right Heel. Black (eschar) that is moveable but intact, scant serosanguineous drainage, odor noted to area. [MEDICATION NAME] & Gauze. 3.5 cm x 3 cm. Wound bed 75% slough-yellow in color. Moderate amount of drainage. Area cleansed, foam applied covered with [MEDICATION NAME] & Ace bandages. This the first assessment documented including measurements, wound base characteristics, and drainage. 7/5/17, First Wound Care Clinic Visit (30 days after physician order). X-Ray of heel today. Ulcers cleansed this week. New orders: .Dakins 0.5% daily to heel, posey boots to heels. Tubi-grip to legs. 7/12/17 wound clinic notes, Heel ulcer smaller and cleaner .Would like to consider Wound Vac to heel .PT to direct compression therapy. D/C Dakins .[MEDICATION NAME] Blue to heel .Limit Weight bearing to Right foot to toe touch if possible. The physician ordered the wound vac and it was implemented on 7/13/17. On 7/26/17, the wound clinic assesses R11's right heel and notes improvement. The wound vac is put on hold and dressings were restarted. On 8/1/17, weekly wound documentation indicates, Ulcer has deteriorated off the Vac this week; plan to restart. Measurements: 1.6 cm x 2.5 cm x 0.5 cm. On 8/9/17, the wound clinic documents .drainage down so plan to decrease Vac pressure to 100mmHg. Canister not changed d/t (due to) non sent with pt. (patient). Assure current canister not in place > 7 days. [MEDICATION NAME] or short stretch wraps, continue heelboots. Physician Details: .Float heels with Posey boots daily .Heels must be offloaded. Continue offloading measures to heel. On 8/10/17 at 8:18 a.m., Surveyor observed R11 sitting on the edge of the bed with her walker in front of her. There were heel boots on the chair. Surveyor spoke with CNA-O (Certified Nursing Assistant) who stated R11 does not want her boots on at times. There is no evidence that R11 refuses to wear the boots. On 8/11/17 at 7:40 a.m., Surveyor observed R11 in bed. Her heels were not floated and the protective boots were on the chair. R11 told Surveyor, I haven't been to the bathroom all night, usually I just hold it. According to the Care Plan, R11 is to be repositioned every 2 hours and offered toileting every 2 hours. On 8/9/17 at 7:00 a.m., Surveyor spoke with RN-R who stated the night shift tries to reposition residents every 2 hours, But a lot of time we only have 2 CNAs and myself for 2 areas. Right now we have 2 residents that need every 2 hour repositioning and another is repositioned every 3 hours. Surveyor asked which residents require repositioning, RN-R did not name R11. In addition to the pressure injury to the right heel, R11 also developed a pressure injury to her coccyx. On 6/21/17, the pressure injury was first identified. Location: Coccyx. Stage II .0.6 cm x 0.3 cm x 0.0 cm depth superficial. Wound Base 100% Slough. No drainage. No undermining. Wound edges intact and pink. Wound progress/pain Stable and no pain. The coccyx pressure injury was documented as healed on 7/26/17. From 6/21/17 through 7/26/17, there is no evidence of an assessment being completed. The wound clinic notes did not include a complete assessment including measurements, staging, appearance, presence of drainage, etc. to provide staff and the physician with a clear picture of R11's condition. On 8/10/11 at 8:58 a.m., CNA-O was assisting R11 while on the toilet. R11 was incontinent of urine. Surveyor observed a closed 0.5 cm white scar on the coccyx. On 8/11/17 at 6:45 a.m., Surveyor spoke the Director of Nurses (DON) who is also the Certified Wound Care Nurse, regarding R11's pressure injuries. DON stated that R11 developed blisters from [MEDICAL CONDITION], went to the wound care clinic and that the nurses were applying R11's stockings/bandages. There are no weekly wound assessments completed but nursing has been documenting in the clinical notes. Example 3 R3 was admitted to facility on 7/26/17 with [DIAGNOSES REDACTED]. R3's most current MDS (Minimum Data Set) is dated 8/2/17. The MDS indicated: ~Cognitive Intact; ~Extensive assistance with 2 staff for bed mobility, transfers, dressing, hygiene and toilet use; ~Does not walk; ~Frequently incontinent of bowel and bladder; ~Has pain; and ~1 Stage 2 pressure injury which was present upon admission. R3's skin care plan, dated 7/28/16: Problem: .at risk for pressure injury Status: Active (Current). Goal: continue to education .importance of repositioning. Interventions: Staff offer to reposition her approx. every 2 hours while in bed or chair. Assist .with hygiene after incontinence .cushion in recliner and w/c .Nutritional screening . R3's skin care plan, with no date: Problem: .currently has red blanchable area to her coccyx, left ischeal and left gluteal area. Goal: .to not have any pressure injuries. Interventions: Apply barrier product when resident is incontinent or as needed and use brief to manage moisture as needed .assess and document skin for color, moisture, texture, and turgor. Report abnormal findings. Review of Hospital discharge summary, dated 7/26/17 and current physician orders [REDACTED]. ~Use crusting technique for area to coccyx: gently cleanse buttock area, pat dry, to the open areas apply a very thin layer of Stoma powder to the open area (gluteal cleft and ischial tubersity area) dust off excess powder, then apply no sting barrier film allow to dry then repeat the stoma powder and powder and barrier film. Complete daily and as needed when incontinent of stool. Do not try to remove the powder/film each time. On 8/9/17 at 8:15 a.m. CNA-T and CNA-U completed R3's incontinence care. Surveyor observed tissues stuck on the buttock area and noted an open area on the left buttock. On 8/9/17 at 8:35 a.m., Surveyor observed RN-N completing R3 wound care treatment. RN-N removed a piece of tissue from the buttock area. RN-N did not cleanse the wound as ordered and completed the treatment 3 times not 2 times per the physician orders. Surveyor observed 4 discolored areas on the coccyx/buttock area. The nurse did not blanch the areas. Review of RN-N documentation indicated the skin color was within normal limits and was intact. No open areas noted to coccyx/buttock area. Skin prep applied to recent wound area x2 along with stoma powder x2 to provide caking effects . The documentation does not address the discolored areas observed by Surveyor. The documentation also indicates RN-N completed 2 layers of treatment when she actually completed 3. On 8/9/17 at 8:50 p.m., Surveyor interviewed RN-N on the facility procedure with a dressing change. RN-N stated, I know what you're going to say. I know that a wound has to be cleansed prior to treatment. I was told not to cleanse the wound because the wound is not to be disturbed unless soiled with BM. The physician order [REDACTED].

Based on observation, interview, and record review the facility did not ensure 1 of 3 sampled residents (R5) reviewed for weight loss received the necessary care and treatment to improve and/or stabilize weight. R6 had a severe weight loss of 15.4 pounds or 10.8% in 6 months (February 2017 through July 2017). Despite that, the facility did not assess R5 and put interventions in place to assist R5 in maintaining her weight. Additionally, R5's weight loss is not identified on R5's plan of care. This is evidenced by: R5 had current [DIAGNOSES REDACTED]. According to R5's record, R5 has been enrolled in Hospice since 5/26/16. The most current MDS (Minimum Data Set) dated 7/21/17 indicates R5 has severely impaired cognitive skills, requires extensive to total assistance of staff for eating, and has a current weight of 126 pounds. R5's admission MDS dated [DATE] indicated R5's weight was 144 pounds. R5's nutritional care plan was dated 1/27/17. The care plan indicated R5 was at risk for weight loss due to being on Hospice. The care plan had the following undated approaches: ~Allow R5 adequate time to eat. ~Provide food and fluid as R5 desires including snacks. There have been no added interventions to the care plan to address R5's actual weight loss. Surveyor completed a review of a nutritional assessment dated [DATE]. The assessment indicated R5's usual body weight was 140 pounds to 145 pounds, however, the facility R5 previously resided in listed a usual body weight of 157 pounds. Surveyor completed a review of R5's weights and noted the following. All weights are noted in pounds. ~ 8/5/16, 143.4 ~ 9/19/16, 143.6 ~ 10/25/16, 141.8 ~ 11/7/16, 143.8 ~ 12/12/16, 139.4 ~ 1/23/17, 142.0 ~ 2/20/17, 142.2 ~ 3/20/17, 136.6 ~ 4/17/17, 136.0 ~ 5/1/17, 130.8 ~ 6/12/17, 130.6 ~ 7/3/17, 126.8 ~ 8/7/17, 125.4 For the 6 month period of 2/2017 through 7/2017, R5 experienced a 15.4 pound (10.82%) weight loss. R5 continued with weight loss exhibiting an 18.4 pounds since 11/7/16. Based on a usual body weight of 143.0 pounds this was a 12.3% weight loss. There were no changes made to R5's plan of care. Surveyor completed a review of R5's nutritional assessments and noted the following: ~11/17/16, .Receives 4 oz (ounces) of Boost at breakfast. Intakes average 100% at breakfast, 50 - 100% at lunch and 100% at supper .Resident is experiencing nutritional decline. Goal is to make comfortable and allow resident to eat and drink as desires . ~2/1/17, .Food intakes average 75-100% at meals tid (three times a day) .supplements .4 oz Breeze daily . ~5/18/17, .Food intakes average 25-75% at breakfast, 25-50% at lunch, and 50-100% at supper .Weight .exhibits a 7.1% weight loss in 3 mos (months) .expected as resident is enrolled with hospice .Currently offered 4 oz Breeze daily .Care Plan reviewed and remains appropriate . ~7/25/17, .Food intakes average 75-100% at breakfast, 25-50% at lunch, and 75-100% at supper .6# (pound) weight loss since last assessment .Currently offered 4 oz Breeze daily .care plan reviewed and remains appropriate . R5's weight loss was identified by the facility. However, the care plan was not updated to address the actual weight loss and there were no new approaches added to R5's plan of care in an attempt to stabilize or improve R5's weight. On 8/9/17, 8/10/17, and 8/11/17 Surveyor observed R5 during breakfast. R5 required staff assistance for all meals. R5 completed 75-80% of all breakfast meals served. Surveyor noted R5 ate very slowly and staff assisted R5 for approximately 45 minutes to 1 hour. On 8/11/17 at 10:15 a.m. Surveyor spoke with FM-L (Family Member). FM-L indicated R5 had lost a lot of weight however was eating, according to the facility, 65 to 75% of all meals. FM-L indicated R5 loves Hershey chocolate bars. FM-L stated R5 would eat just about anything. FM-L stated R5 likes desserts and would eat those willingly and readily. On 8/10/17 at 2:03 p.m. Surveyors spoke with the RD (Registered Dietician). The RD indicated weights and weight loss were monitored by the DM (Dietary Manager). The RD indicated she evaluates everyone who is identified as nutritionally at risk monthly. The RD also indicated the facility had, in recent past, started a nutrition at risk meeting where residents with weight loss were discussed. Surveyor asked the RD if R5 was discussed during their nutrition at risk meetings. The RD indicated R5 was not discussed at the meetings. The RD indicated the facility had multiple ways to improve caloric intake including Boost, Boost Breeze, Magic Cups, and Bene-protein. The RD indicated whole milk could be substituted for skim milk, residents could receive double meat portions, and there was a fortified hot cereal. Surveyor asked the RD why R5 was not afforded attempts at increasing calories in light of R5's continued weight loss. The RD indicated R5 was on hospice and ate and drank as desired. The RD indicated R5's goals were related to comfort. R5 has a pressure injury to the coccyx. The documentation does not indicate the pressure injury has healed in 131 days. (Refer to F314.) Surveyor asked the RD if she was aware R5 had a pressure injury. The RD indicated she was not aware of R5's pressure injury. Persons with a pressure injury need increased protein and calories to aid in healing of the pressure ulcer.

Based on observation, interview, and record review, the facility did not ensure that 1 out of 3 residents (R3) received necessary care and services to prevent fluid volume deficit. R3 had multiple hospitalization s that included a [DIAGNOSES REDACTED]. status and how staff were to monitor and intervene. The facility did not implement any interventions to monitor and ensure adequate hydration. Review of the facility's intake sheets indicate that R3's fluids are well below her fluid needs to prevent dehydration which subsequently led to 2 more hospitalization s of dehydration. This is evidenced by: R3 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Surveyor completed a review of R3's quarterly nutrition assessment, dated 11/6/16. It indicated, .Weight 121.4# .Total Fluids: 1000-1215 cc (cubic centimeters) per day .Fluids consumed with meals (cc) 675. Percentage of Meals Eaten 50 .Feeding Dependence Independent . According to the American Medical Director's Association, daily fluid needs are calculated by 30 cc's of fluid for each kilogram of weight. R3's weight was 121.4#, which calculates to 55.2 kg. 55.2 kg times 30cc's equals 1656 cc's. According to current standards of practice, Resident #3's correct daily fluid needs were 1656 cc's. Surveyor completed a review of R3's Dehydration Risk Determination, dated 12/5/16. Reason for assessment: Significant change. High Risk Factors . Previous or current [DIAGNOSES REDACTED].Lethargy or Weakness .Sleepy today, reports she didn't sleep well last night .No nausea today and VSS (vital signs). Taking fluids well when offered. Staff are encouraged to offer fluids frequently .Dehydration Risk Total Score: 1 (0-1) is Low Risk . The most current MDS (Minimum Data Set) assessment, dated 8/2/17 indicates R3 is cognitively intact, requires supervision for eating, and weighs 112 pounds. R3's care plan dated 2/7/17 includes a problem of alteration in nutrition/hydration. Interventions include: Encourage food and fluid intakes .Encourage fluids throughout the day .Offer water with each medication pass. Offer beverage of choice at bedside .prefers to drink Mountain Dew vs (versus) water . Surveyor reviewed R3's medical record and noted the following entries: ~3/14/17: Nutritional At Risk: Resident has lost 5.7% body weight in 1 month which is considered significant. Current body weight-115#. Regular diet orders. Poor appetite. Food intakes average-50% at meals tid (three times a day). Fluid intakes average 100-240 cc/meal . Despite the low fluid intake, there is no evidence a dehydration risk assessment was completed. Review of nurses notes dated from 3/6/17 to 4/19/17, do not address any monitoring for fluid needs. ~4/18/17 Nutritional At Risk: Resident has lost 8.4% body weight in 3 mos (months) and has an open area on coccyx .Fluid intakes average 120-240 cc/meal .wt. 109.8# .1500-1750 cc/day fluid needs . On 4/20/17, R3 was admitted to the hospital. The discharge summary dated 4/21/17 indicated that R3 was admitted for AMS (acute mental status) change secondary to Dehydration, UTI, Arrythytmia (second degree heart block and [MEDICAL CONDITION] flutter), Dementia. Brief History: .altered mental status and suspected dehydration. This was apparently something that had occurred on several occasions previously per daughter. She was minimally responsive to sternal rub at presentation and appeared significantly dehydrated .Appears lethargic, does not respond to questions .dry mucus membranes. Hospital Admission Lab Data: WBC (white blood count) 23.7 (high), BUN: (Blood urea nitrogen) 28 (high) and Glucose: 133. Labs at discharge were WBC down to 11.7, BUN: down to 15, and Glucose down to 114. Hospital course: .IV (intravasucular) antibiotics and fluid hydration was given. Within a matter of a few hours she became responsive, was alert and oriented . Hospital Discharge Instructions include, Encourage oral hydration . R3 was started [MEDICATION NAME](antibiotic) for a UTI. The facility should give plenty of fluids to prevent urine crystals while taking Cipro. Upon readmission from the hospital, there was no evidence of a risk assessment for dehydration. There were no changes made to the care plan in order to assist R3 in maintaining fluid status. Surveyor reviewed the Nutrition at Risk assessments completed on 5/6/17, 5/18/17, 5/26/17 and 6/20/17 which addresses protein needs and fluid intake averages. Fluid intake averages were only those fluids consumed at meals, which did not meet R3's needs. However, there is no evidence further interventions were developed by the Interdisciplinary Team to assist R3 in maintaining her fluid needs. Documented fluid intakes for July are as follows: ~7/1/17, 180cc/day. ~7/2/17, 480cc/day. ~7/3/17, 180cc/day. ~7/4/17, no documentation. ~7/5/17, 240cc/day. Went to hospital R3 presented to the emergency room in the evening with some mental status changes with confusion, fever of 101.7, and diarrhea. R3 was hospitalized again. Review of the hospital discharge summary dated 7/7/17, indicated R3 was admitted with [DIAGNOSES REDACTED]. Blood sugar 130. Alk phos elevated at 287. Hemoglobin 11.5 and Hematocrit 37. Urinalysis negative. There was no BUN or creatinine documented. Oropharynx is slightly dry, tacky mucus. Resident was admitted for IV rehydration. She perked up quite well and was able to be discharged home after 24 hours. Treatments consists of IV Hydration. IV placed at 0250 (2:50 a.m.). Discharge labs were completed with BUN at 20 (H) and Glucose 109 (H) rest within normal limits. Despite this being R3's second admission for dehydration, there were no care plan updates to assist R3 in meeting her fluid needs. A nutritional note dated 7/10/17 states, .fluids are to be encouraged and beverage of choice to be offered to resident at bedside Care plan reviewed and updated . Surveyor reviewed the care plan and noted that the problem and goal were updated. There were no changes in interventions. On 7/11/17, Dehydration Risk Determination was completed. No high risk factors for dehydration were documented. Summary and Analysis of Findings: sleep a lot during the day and requires reminders to drink her fluids. When up in her chair she takes fluids well. Skin turgor good and moist mucous membranes present. Dehydration Risk Total Score: 1 (0-1) is LOW Risk. Surveyor reviewed R3 intakes from 7/12/17 through 7/19/17. ~7/12/17, 360 cc/day. ~7/13/17, 580 cc/day. ~7/14/17, 90 cc/day. ~7/15/17, 480 cc/day. ~7/16/17, 300 cc/day. ~7/17/17, 480 cc/day. ~7/18/17, 120 cc/day. ~7/19/17, 300 cc/day. Went to the hospital The hospital record on 7/20/17 states, Altered Mental Status .She was fairly unresponsive when EMS (emergency medical services) transported her. Apparently she received 750 ml of IV fluids in the emergency room . Her altered mental status completely cleared, and she returned to her baseline .B/P has been elevated, most recently 182/100, heart rate 90-100, respirations 20. Temperature on arrival was 101.5 . Lab Evaluation: Reveals her white count to be elevated at 17.2, hemoglobin 12.0, Her lactic acid is 0.7, CRP 8.84 (C-Reactive Protein which is a blood test marker for inflammation in the body. Normal is below 3.0). Chemistry reveals sodium 136, potassium 4.1, BUN 27, creatinine 1.08. Her urine shows large leukocytes, 5 to 10 WBCs and trace bacteria . Assessment: .urinalysis with probable urosepsis and subsequently dehydration with elevated CRP, elevated white count, [MEDICAL CONDITION] and fever. On 7/26/17, Dehydration Risk Determination was completed. Reason: Initial. High Risk Factors: UTI Previous or current [DIAGNOSES REDACTED]. Summary and Analysis of Findings: .is incontinent of urine throughout the day. She needs encouragement to drink a good amount of her fluids. She does takes sips of fluids that are left at bedside. Skin turgor good and moist mucous membranes present. Dehydration Risk total Score: 3 (2-3) is Moderate Risk. A 7/31/17 Annual Nutritional Assessment states, .Able to feed self after tray set up. Resident had recent hospitalization s r/t (related to) dehydration. Latest dehydration assessments rate resident at moderate to high risk. Staff to encourage fluids and offer beverages of choice throughout he day. Fluid intakes since recent admission range from 10 to 240 cc/meal .Goal .1500-1750 cc fluids/day. Care plan reviewed and updated . Dehydration Risk Determinations were completed on 7/30/17, 8/1/17, 8/3/17 8/5/17, 8/6/17 and 8/7/17. Only the 8/3/17 and 8/5/17 assessments indicate low risk with the rest scored at moderate risk. Even though R3 had been hospitalized 3 times with dehydration, the facility put no new interventions in place to monitor R3's fluid intakes, or to assist R3 in reaching her fluid needs. On 8/10/17 at 8:30 a.m., Surveyor interviewed LPN-M (Licensed Practical Nurse) on how the facility monitors residents for dehydration. LPN-M stated she documents the amount of fluids given with medication pass on the TAR (Treatment Administration Record). Surveyor asked if she totals up the fluid amounts. LPN-M stated that the system totals the amounts up and puts it somewhere. LPN-M did not know where or how to retrieve this information. On 8/10/17 at 2:03 p.m., Surveyors spoke with the RD (Registered Dietician) who attends the monthly Nutrition At Risk meeting. RD stated the Dietary Manager was monitoring through June, but since then the RD is reviewing more often. RD discussed recently the facility just starting completing Intake and Outputs for all residents at Nutrition/Dehydration Risk. The facility is now having nursing document the fluid intakes with their medication pass and nurse aides are documenting the amount of fluids taken with and in between meals. RD is unsure who is monitoring the total daily fluid intakes. RD stated the Dietary Manager is not looking at the daily intakes. Surveyor requested the facility policy and procedure related to hydration management. Nothing was received at time of exit. On 8/111/17 at 9:30 a.m., Surveyor spoke with Cypress Unit Manager RN-B. RN-B stated R3 was just readmitted and the facility is pushing and encouraging fluids. RN-B stated there is no monitoring of fluid intakes. The expectation is to review the care plan and update so no further decline in condition occurs. RN-B stated the facility is now completing a lot of dehydration assessments. On 8/11/17 at 6:45 a.m., Surveyor spoke with the Director of Nurses (DON), and the Quality Assurance Nurse Consultant (QANC). The QANC identified a concern with the Hydration program. On 7/31/17 developed a Hydration Plan of Correction which was implemented on 8/3/17. The program was discussed at the 8/3/17 Interdisciplinary Team meeting. The RD area was assessed and the program was implemented on 8/8/17. Surveyor reviewed the meal intakes and nursing intakes starting 8/8/17. ~8/8/17: Meals 360cc, TAR 320 cc. for 680 total. Intake sheet indicates a total of 670 cc total. ~8/9/17: Meals 240 cc, TAR 300 cc. for 540 total. Intake sheet indicates: 1200 cc total. ~8/10/17: TAR 560 cc. Intake sheet indicates 300cc. The totals between the meal intakes and the TARs do not equal the amounts on the intake sheets. In addition, R3 did not meet her fluid needs on all 3 days reviewed. There was no reassessment of her fluid intakes and no evidence the care plan was reviewed and updated to include individualized interventions to assist her in meeting her fluid needs.

Based on observation, interview, and record review the facility did not have an infection prevention program designed to prevent the spread of disease and infection. The facility did not: ~ Have an active system of surveillance to monitor all infections or acute illnesses; ~ Policies and procedures to direct staff on how to manage ESBL (Extended-Spectrum Beta-Lactamases) and CRE (Carbapenem-resistant [MEDICATION NAME]); ~ Identify rates of infections; or ~ Identify or follow appropriate precautions for infections. This had the potential to affect all residents. This is evidenced by: Example 1: On 8/8/17 Surveyor requested the facility's infection prevention policies including policies on ESBL and CRE. None were received. On 8/10/17 at 4:35 p.m. Surveyor spoke with the IDON (Interim Director of Nursing). The IDON indicated she has been employed by the facility since it opened approximately one year ago and has been the primary ICP (Infection Control Practitioner). The IDON stated she has not received any formal training. Surveyor reviewed the facility's surveillance logs with the IDON, noting all residents on the logs were on antibiotics. Surveyor asked how the facility monitors all acute infections including those residents with signs and symptoms of illness but not on an antibiotic. The IDON indicated she was not aware all residents with acute signs and symptoms of illness and not on an antibiotic were to be included on their surveillance log. Surveyor also reviewed information on the surveillance logs which indicated residents with an ARI (Acute Respiratory Infection) were not placed in droplet/contact precautions. The IDON indicated she was not aware until recently ARI's required precautions. Surveyor asked about the facility's rates of infection for both staff and residents. The IDON indicated she had never calculated rates of infection. Surveyor spoke with the IDON regarding surveillance for residents with MDRO's (Multi-drug Resistant Organisms). The IDON indicated she had a list of current residents but not historical. Surveyor questioned the policies for ESBL and CRE. The IDON indicated they did not have policies for either MDRO. Example 2: R3 was readmitted from the hospital with a [DIAGNOSES REDACTED]. The facility did not identify the correct organism (Extended Spectrum Beta-Lactamase-ESBL) which is considered a Multi-Drug Resistant Organism (MDRO). R3 was admitted with a PICC line (a thin, soft, long catheter (tube) that is inserted into a vein. The tip of the catheter is positioned in a large vein that carries blood into the heart) and was receiving IV (Intravenous) antibiotic (Imipenem) i gram IV every 24 hours for 11 additional days. Last dose was 8/7/17. On 8/8/17 at 11:17 a.m., during the initial tour of the facility, Surveyor observed R3 having a small cart outside her room with gowns, gloves and masks, but no sign on the door to alert staff and visitors to speak to a nurse before entering the room. Surveyor asked RN-Y (Registered Nurse) why R3 was on precautions. RN-Y stated contact precautions because MRSA positive in the nares. RN-Y stated she has a PICC line for IV antibiotics related to a bacterial urinary tract infection (UTI). On 8/8/17 at 4:48 p.m., Surveyor observed OT-V (Occupational Therapist) in R3's room sitting on a chair at bedside with no PPE on. OT-V came out of the room and sanitized her hands. OT-V stated she just met R3 today and was unaware that she was on precautions, I just got a history. OT-V then went into the IDON's office. Review of the 8/8/17 OT note indicates that OT-V evaluated R3's current level of function: .is able to pinch with three point pinch 5.6 pound(s) with L hand and 6 obs with R hand. Contact with the resident and environment would be needed to perform this task so PPE should have been on. On 8/9/17 at 7:15 a.m., Surveyor spoke with the night nurse, RN-R who stated R3 has MRSA of the nares and nursing is applying a treatment to the area. RN-R stated the family was here last evening and want to bring in the grandchildren to visit and asked if it was alright. I told them to ensure good handwashing is done. This could be a risk for transmission if R3 is still infectious or even colonized. Gown should be used to protect others. Surveyor asked what type of PPE the night shift use for cares. RN-R stated the staff wash their hands and use gloves, no gowns for the sake of time. On 8/10/17 at 4:35 p.m., Surveyor spoke with the IDON who is also the Infection Control Preventionist (ICP). The DON stated they are aware if anyone should be on precautions upon admission and if suspicious we set up a cart with PPE. The IDON stated R3 is on contact precautions because of MRSA in the nares and lab confirmed positive. Surveyor informed her of observation that staff entered R3 room without putting on PPE and night shift reported they only use gloves with cares. The IDON stated a mask, gloves, and gown are to be used with cares. Surveyor asked the IDON if she was aware that R3 has ESBL in the urine. The IDON stated she was unaware what ESBL is. Even though MRSA and ESBL both require contact precautions, it is vital that the appropriate organism is identified and is on the surveillance log. On 8/11/17 at 8:25 a.m., Surveyor interviewed OT-V who stated she is a casual employee with this company and is working full time to help. Surveyor asked how therapy staff know if a resident is on precautions. OT-V said there is a sign on the door and a cart outside the room. She doesn't recall any sign on the door or the cart outside the door. I normally see the sign on the door then ask the nurse. The facility told me just now that R3 has ESBL and that it is spread through mucous and body fluids. We are to wear gown/glove and a mask even with a evaluation. Example 2: R4 was admitted with a [DIAGNOSES REDACTED]. R4 is on contact precautions for MRSA in the urine and has an indwelling Foley catheter. Contact precautions are to be used for residents who are known to be or suspected of being infected or colonized with infectious agents. On 8/9/17 at 12:00 p.m., Surveyor observed R4 having the Wound Vac dressing changed to his pressure injury. RN-B washed hands, gloved and proceeded to set up a clean barrier and supplies. The IDON, who is also the facility's wound care nurse, was also present for the dressing change. The IDON and RN-B did not use any PPE during the procedure. R4's right buttock area was excoriated with active bleeding during the procedure. On 8/9/17 at 12:50 p.m., Surveyor asked the IDON what the facility practice is for residents who have MRSA and require a dressing change. IDON stated that R4 has a catheter so the urine is contained. The CNAs are to use PPE during catheter care and when emptying for urine bag. DON stated, I'm not coming in contact with the urine. Best scenario, I probably should. On 8/10/17 at 7:30 a.m., Surveyor observed CNA-O, CNA-W and CNA-P in R4 room without PPE on. CNA-A and CNA-W were completing a.m. cares. CNA-O and CNA-W removed their gloves, washed hands and left the room. Both gowned/gloved and came back into the room to empty the catheter bag. During R4 individual interview stated the staff very seldom put on a gown to empty the catheter bag. On 8/11/17 at 9:30 a.m., Surveyor spoke with RN-B who stated PPE should have been used during the dressing change and with a.m. cares because of the body fluids.

Based on interview and record review, the facility did not ensure that 3 of 3 sampled residents (R3, R4, and R9) reviewed for MDRO (Multi Drug Resistant Organisms) infections had a care plan to direct staff on proper management of the specific infection. R3 has a current infection of Extended Spectrum Beta-Lactamase (ESBL) EColi: Bacteremia in the Blood and urine. There was no care plan developed to direct staff on how to manage the infection. R4 has a current infection [MEDICAL CONDITION] in the urine. There was no care plan developed to direct staff on how to manage the infection. R9 was diagnosed with [REDACTED]. R9's care plan did not give staff direction on required personal protective equipment (PPE) required for caring for R9 to prevent the spread of infection. This is evidenced by: Example 1 R3 was readmitted from the hospital on [DATE] with ESBL in the blood and urine. ESBL is an enzyme made by some bacteria. The enzyme prevents certain antibiotics from being able to kill the bacteria. The bacteria then become resistant to antibiotics. R3 was receiving Intravenous Antibiotics through a PICC line (a thin, soft, long catheter that is inserted into the vein in the neck.) Surveyor reviewed R3's care plan. Both the care plan and the CNA (Certified Nursing Assistant) care plan do not identify that R3 has ESBL infection. Throughout the dates of survey, observations and interviews revealed staff were not aware of location of the infection or the type of infection R3 had. In addition, staff did not consistently implement proper precautions when caring for R3. (Refer to F441.) Example 2 R4 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Surveyor reviewed R4's care plan. Both the care plan and the CNA care plan do not identify that R3 [MEDICAL CONDITION] in the urine. Staff indicated R4 [MEDICAL CONDITION] in the urine which is contained in the catheter. There was no care plan to direct staff on how to manage R4's infection [MEDICAL CONDITION]. Observations and interviews with staff throughout the dates of survey, found staff were not aware of the proper precautions to follow when caring for R4. (Refer to F441.) Example 3: Surveyor reviewed R9's medical chart and confirmed a postive culture [MEDICAL CONDITION] of right lower leg wound noted on 5/14/17. Surveyor requested and review R9's CNA care card and care plan. Neither include direction for proper precautions to be followed while providing care toe R9.

Based on observation, interview, and record review the facility did not ensure 7 of 12 sampled residents (R1, R2, R5, R8, R9, R10, and R11) received the necessary care and treatment to promote continence and prevent the development of a urinary tract infection. R5 had a history of [REDACTED]. Prolonged exposure to urine increases the probability of R5 developing another bladder infection. R1, R2, R5, R8, R9, R10, and R11 had bladder incontinence. The facility did not have a bladder management program to identify and assess the incontinence, determine the root cause of the incontinence or develop individualized interventions in an attempt to maintain or restore bladder function. This is evidenced by: Example 1: R5 had current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) dated 7/21/17 indicated R5 had severely impaired cognitive skills, required assistance of 2 staff for all aspects of care, did not walk, and was always incontinent of bladder. R5's care plan for continence management was dated 8/2/16. Undated interventions included, .Assess urinary status and document quarterly .monitor for changes in voiding pattern .has a history of large loose stools after breakfast .offer to toilet after breakfast . R5's CNA (Certified Nursing Assistant) care plan was undated. The care plan indicated R5 was incontinent and to check and change during rounds on the night shift. There were no approaches noted on R5's CNA care plan which directed staff on when to assist R5 to the bathroom during the day hours. The approach as noted on R5's comprehensive care plan to toilet R5 after breakfast was not noted on R5's CNA care plan. Surveyor completed a review of R5's bladder assessments. A bladder assessment dated [DATE] indicated it was an initial assessment. R2 was admitted to the facility on [DATE]. The assessment was completed 2 months after R5 was admitted . There was no bladder diary associated with the bladder assessment. The bladder assessment was incomplete. The assessment indicated R5 was sometimes able to express the need to use the bathroom. The assessment indicated R5 was to be on a check and change program. Surveyor completed a review of a bladder diary dated 10/27/16 through 11/2/16. The dates of the bladder diary were after the date of the bladder assessment. All days of the bladder diary were incomplete. A bladder diary is a log over a 24 hour period that captures incontinent as well as continent episodes on an hourly basis. A complete bladder diary is a critical component of a comprehensive assessment. It is what drives the development of individualized toileting plans as the assessor is able to capture both continent and incontinent patterns. A bladder assessment dated [DATE] noted as a quarterly assessment was incomplete and did not include a bladder diary. A bladder diary completed from 4/23/17 to 4/29/17 was incomplete. A bladder diary completed from 7/15/17 to 7/21/17 was incomplete. None of the bladder diaries correlated with the bladder assessment completed on 6/15/17. It would not be possible to implement an individualized bladder program designed to restore or maintain continence without utilizing a complete comprehensive bladder assessment based on accurate voiding pattern data as found in a bladder diary. On 8/10/17 beginning at 7:30 a.m. Surveyor's made the following observations. ~At 7:30 a.m. R5 was noted seated in a wheel chair on the Cedar unit in the TV lounge. ~At 8:05 a.m. CNA-D (Certified Nursing Assistant) escorted R5 into the dining room. ~At 9:00 a.m. CNA-D escorted R5 to her room. CNA-D indicated to Surveyor she was going to find another staff person to assist her to reposition R5. ~At 9:50 a.m. R5 was escorted by AA-I (Activity Assistant) to the Cypress Unit for an activity, Wheel of Fortune. ~At 11:30 a.m. R5 was escorted by AA-C from the Cypress Unit to the dining room. ~At 12:40 p.m. R5 was escorted by CNA-D to R5's room. ~At 12:45 p.m. CNA-E and CNA-F entered R5's room and indicated they were going to assist R5 to lay down. No staff at any point during the observation offered or assisted R5 with incontinence care. On 8/10/17 at 12:50 p.m. Surveyor observed CNA-E and CNA-F assisted R5 into bed. CNA-F removed R5's pants and indicated they were soiled with urine. Both CNA-E and CNA-F turned R5 from side to side to remove an incontinence brief. Surveyor noted the brief was saturated and dripping with urine with urine spilling over and onto a disposable chux. CNA-E completed peri care. Surveyor noted Stage II pressure injury on R5's coccyx the size of a small pea. The wound was surrounded by approximately 1.0 cm (centimeter) of maceration (softening and breaking down of skin from prolonged exposure to moisture). CNA-E also indicated herself and CNA-F had assisted R5 into the wheel chair a 6:30 a.m. R5 was seated in a wheel chair not afforded assistance with incontinence care from 6:30 a.m. according to CNA-E and CNA-F's account until 12:50 p.m., a period of 6 hours and 20 minutes. Prolonged exposure to urine increased the probability of R5 developing another bladder infection. Additionally, R5's coccyx wound was surrounding by maceration. This indicated R5's wound has been exposed to moisture for long periods of time. On 8/10/17 at 1:15 p.m. Surveyor spoke with CNA-F about the facility's incontinence management program. CNA-F stated the CNAs report off to each other when residents were assisted to the bathroom or assisted with incontinence care. CNA-F stated their practice was to assist all residents every 2 hours. This does not constitute a toileting plan based on a comprehensive assessment that includes a bladder diary in order to develop a care plan which promotes continence. On 8/11/17 at 12:00 p.m. Surveyor spoke with the IDON (Interim Director of Nursing). The IDON indicated there was noone designated to look at a comprehensive bladder assessment including a bladder diary and develop a plan of care to promote continence. Example 2 R10 had current [DIAGNOSES REDACTED]. R10's most current MDS (Minimum Data Set) was dated 7/12/17. The MDS indicated R10 had a moderate cognitive impairment, required the assistance of one staff person for all aspects of care except eating, and was frequently incontinent of bladder. Surveyor completed a review of R10's comprehensive care plan. The care plan did not include a problem or directives to staff on how to manage incontinence. Surveyor completed a review of R10's CNA care plan. Under the heading Toileting the care plan indicated, Incont (Incontinent). There was no care plan developed or directives given to staff on how to manage R10's incontinence. Surveyor completed a review of R10's most current comprehensive bladder assessment dated [DATE]. The assessment was noted as an initial assessment. The assessment indicated R10 woke up at night multiple times to use the bathroom, changing position or coughing caused loss of urine, voided often and in small amount. Under the heading Elimination Patterns it indicated, .No pattern noted . Under the heading Summary and Analysis Of Data is blank. Surveyor completed a review of R10's voiding diary dated 6/29/17 to 7/4/17. For the 24 hour period on 6/29/17, there was one entry. All the rest of the days were blank. Both R10's comprehensive bladder assessment and voiding diary were incomplete. It would be impossible to develop a toileting program designed to promote continence based on the information contained in the comprehensive bladder assessment and voiding diary. On 8/10/17 at 1:15 p.m. Surveyor spoke with CNA-F about the facility's incontinence management program. CNA-F stated the CNAs report off to each other when residents were assisted to the bathroom or assisted with incontinence care. CNA-F stated their practice was to assist all residents every 2 hours. This does not constitute a toileting plan based on a comprehensive assessment that includes a bladder diary in order to develop a care plan which promote continence. On 3/11/17 at 12:00 p.m. Surveyor spoke with the IDON (Interim Director of Nursing). The IDON indicated there was no-one designated to look at a comprehensive bladder assessment including a bladder diary and develop a plan of care to promote continence. Example 3: R11 was admitted to the facility and has a [DIAGNOSES REDACTED]. R11's admission Minimum Data Set (MDS) assessment dated [DATE] indicates R11 requires assist of 1 staff for toileting and is occasionally incontinent of bladder. R11's care plan for continence management, dated 6/15/17, includes interventions of .will be offered the toilet approximately every 2 hours . Care Area Assessment (CAA) dated 5/25/17, indicates that R11 is incontinent of urine and currently on an antibiotic for UTI. There are no individualized interventions to assist R11 with maintaining or improving continence status. On 8/10/17 at 8:34 a.m., R11 had the call light on to get assistance with going into the bathroom. After 3 minutes, R11 disconnected the wound vac and transferred herself onto the toilet. R11 put the call light on again. 5 minutes later, LPN-M (Licensed Practical Nurse) answered the call light, shut the alarm off, and went to get a CNA to help. 12 minutes later, R11 put on the bathroom call light. 2 minutes later CNA-O came into the room to help her. The wound vac was sounding and she went to get the nurse. At 9:00 a.m., CNA-O and CNA-W came into to the room to assist R11. Surveyor asked R11 how she got into the bathroom. R11 said, I walked to the bathroom by myself. I tore the pad off, I was soaked. On 8/11/17 at 7:40 a.m., Surveyor observed R11 room door closed with the call light on. A CNA entered the room and said, I will be right back. R11 told this surveyor that she feels so discouraged. I haven't been to the bathroom all night, usually I just hold it. Review of the bladder diary dated 5/15/17 through 5/21/17. All days of the bladder diary were incomplete. Surveyor completed a review of R11's bladder assessment dated [DATE], 23 days after the last day of the bladder diary. The bladder assessment is incomplete. The assessment indicated R11 sometimes could identify the need or urge to void. R11 is able to use the call light. Incontinent episodes with changing positions, coughing, exercising, laughing and sneezing. Sometimes wakes up at night to void and this varies nightly. Concerns with leaky urine. R11 had incontinence of urine prior to admission. Dribbles constantly and after voiding. Mixed (combination of both urge and stress) incontinence. There is a pattern of urinary incontinence. Elimination Plan: Scheduled/Habit toileting plan (Scheduled toileting at regular intervals on a planned basis to match voiding habits). Will schedule toileting to be approximately every 2 hours. On 8/11/17 at 7:50 a.m., Surveyor spoke with CNA-O regarding if R11 was on a toileting program. CNA-O stated R11 usually tells us if she has to go. Example 4: R1's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated R1 was dependent on staff for toilet use; requires staff assistance for transfer, ambulation and personal hygiene; and is frequently incontinent of bladder. The quarterly MDS completed 6/30/17 shows R1 is now occasionally incontinent of urine. Surveyor requested all bladder assessments conducted for R1 since her admission on 12/26/16. The 6/14/17 assessment indicates R1 shows no pattern of incontinence, has functional incontinence, and requires assistance with toileting and ambulation. The assessment does not provide an individualized plan to manage R1's incontinence, A Seven Day Bowel and Bladder screening was to be recorded 6/28/17 through 7/04/17 (after the assessment had been completed). Of the possible 168 hourly entries, only 23 were complete. The lack of documentation makes it impossible to determine a pattern to develop an individualized toileting plan to maintain or improve R1's urinary incontinence. Surveyor reviewed R1's care card that directs staff in her care. The care card states only, incontinent at times. The care card does not direct staff on R1's toileting needs or plan. Surveyor reviewed R1's care plan and noted the facility did not address R1's toileting needs to maintain or improve her urinary incontinence on her care plan. On 8/10/17 at approximately 4:30 p.m. Surveyor spoke with CNA-J. CNA-J works full time on the p.m. shift and is responsible for R1's care. Surveyor asked CNA-J about R1's toileting plan. CNA-J indicated R1 is occasionally incontinent of urine. CNA-J further expressed staff do not ask R1 to use the toilet; the wait for her to alert them of her need to go to the bathroom. On 8/11/17 at 7:15 a.m. Surveyor spoke with CNA-K who routinely cares for R1. CNA-K indicated R1 is not on a toileting plan, staff offer R1 toileting when she gets up in the morning otherwise they wait for her to alert them of her toileting needs. Example 5: R2's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated R2 is dependent on staff for toileting and is frequently incontinent of bladder. The quarterly MDS completed 6/10/17 reflects the same information. Surveyor requested R2's bladder assessments since admission on 10/07/16. The facility provided an assessment dated [DATE]. The assessment indicate R2 showed no pattern of incontinence, had functional incontinence, and R2 can make her needs known for bathroom usage. There is no plan identified to maintain or improve R2's incontinence. The facility provided Surveyor with a Seven Day Bowel and Bladder screening which was conducted 3/09/17 through 3/15/17. This does not correspond with any bladder assessment. The voiding pattern data collection was incomplete with only 40 of the 168 possible entries being completed. The lack of documentation makes it impossible to determine a pattern to develop an individualized toileting plan to maintain or improve R2's urinary incontinence. A second Seven-Day Bowel & Bladder Screening was conducted 6/04/17 through 6/10/17. This does not correspond with any bladder assessment. Again, the assessment is incomplete with only 4 of the 168 possible entries being completed. The lack of documentation makes it impossible to determine a pattern to develop an individualized toileting plan to maintain or improve R2's urinary incontinence. The surveyor reviewed R2's care card that directs staff in her care. The care card notes the following regarding R2's toileting needs: Toileting: incontinent at times. The care card does not direct staff on R2's toileting needs or plan. R2's care plan includes a problem of impaired urinary elimination related to overactive bladder and occasional incontinence. Interventions include [MEDICATION NAME] as ordered, Encourage and assist resident with toileting upon rising, before meals and naps, and at bedtime. check resident approximately every 2 hours at night, provide peri-care after episodes of incontinence .monitor for signs and symptoms of urinary tract infections [MEDICAL CONDITION], Notify MD if skin impairment occurs or signs and symptoms of uti. Even though R2 has a care plan for toileting, it does not include individualized interventions meant to maintain and/or improve her bladder continence. On 8/10/17 at 4:30 p.m. Surveyor spoke with CNA-J. CNA-J works full time on the p.m. shift and is responsible for R2's care. The surveyor asked CNA-J about R2's toileting plan. CNA-J indicated R2 is both continent and incontinent of urine. CNA-J further expressed staff transfer R2 to the toilet at night before bed. At no other times do staff ask or prompt R2 to the toilet. Example 6: Surveyor reviewed R8's medical record. R8's [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicates R8 requires staff assistance for personal hygiene and toilet use; and is occasionally incontinent of bladder Surveyor requested all bladder assessments conducted for R8 since her admission on 6/14/17. The facility provided Surveyor with an assessment dated [DATE]. The assessment indicated R8 shows pattern of urinary incontinence. No other information including the type of incontinence or an elimination plan were documented. R8's Seven-Day Bowel & Bladder Screening beginning 6/20/17. The data collection began after the assessment was completed. The data is incomplete with only 12 of the possible 168 entries being completed. The lack of documentation makes it impossible to determine if and when R8 is incontinent and if there is a pattern of her voiding. Surveyor reviewed R8's care card that directs staff in her care. The care card notes the following regarding R8's toileting needs: Toileting: incontinent. The care card does not direct staff on R8's toileting needs or plan. R8's care plan included a problem of risk for incontinence. Interventions include, anticipate toileting needs ., check for incontinence .remind and/or assist to go to the bathroom/toilet approximately every 2-3 hours, before or after meals and activities, and as needed, use incontinent product .If incontinent provide peri-care .If resident is awake at night, assist to toilet or commode . Although R8 has a toileting care plan, it does not include individualized interventions. Example 7: R9's [DIAGNOSES REDACTED]. The MDS dated [DATE] indicates R9 is dependent on staff for toilet use and personal hygiene and is frequently incontinent of bladder. The quarterly MDS completed 7/16/17 notes R9 is now occasionally incontinent of bladder. Surveyor requested all bladder assessments conducted for R9 since her admission on 7/28/16. The facility provided the surveyor with an assessment dated [DATE]. The assessment indicates R9 shows no pattern of incontinence, has functional incontinence, and the plan was for prompted voiding. The Seven Day Bowel and Bladder screening for R9 which was conducted 7/28/16 (the day the assessment was completed) through 8/03/16 was incomplete. Only 31 of 168 possible entries were completed. The Seven Day Bowel and Bladder screening for R9 which was conducted 4/23/17 through 4/29/17 (with no corresponding assessment) was incomplete. Only 22 of the 168 possible entries were completed. The Seven-Day Bowel & Bladder Screening conducted 7/15/17 through 7/21/17 (with no corresponding assessment) was incomplete. Only 19 of the 168 possible entries were completed. The lack of documentation makes it impossible to determine a pattern to develop an individualized toileting plan to maintain or improve R9's urinary incontinence. Surveyor reviewed R9's care card that directs staff in her care. The care card indicates R9 is continent, even though the assessment completed 6/13/17 indicates R9 has functional incontinence. The care card does not direct staff on R9's toileting needs or plan. The Bladder screening conducted show R9 has episodes on incontinence. Surveyor reviewed R9's care plan and noted urinary incontinence is not addressed. the Care plan provides no direction to staff on R9's toileting needs. On 8/10/17 at 11:55 a.m. Surveyor spoke with the IDON regarding the facility's process for resident bladder management. The IDON indicated bladder assessments and bladder dairies are supposed to be completed by the floor nurse or the MDS Nurse upon admission and with the MDS. The IDON further expressed she was not sure why the assessments are not done as indicated or why the diaries are incomplete. Surveyor asked the DON what staff are to use for a guide for implementing individualized toileting plans for the residents. Again the DON responded she was not sure if the information is on resident care plans or care cards to direct staff. Surveyor requested the facility's policy on resident bladder management. On 8/11/17 the DON informed the surveyor the facility does not have a policy related to resident bladder management.

Based on record review and interview the facility did not ensure 2 (R3, R11) of 12 residents were free from significant medication errors. R3 receives the blood thinner [MEDICATION NAME]. On 3 different occasions, staff either provided the incorrect dose or administered the medication when it was to be held. These errors placed R3 at risk for either blood clot development or excessive bleeding. R11 was to received 6 doses of [MEDICATION NAME] over the course of 3 days. R11 only received 3 doses over the course of 4 days. The physician had to reorder the Ceforoxime acetil, 6 doses in 3 days. However, R11 received 9 doses in 7 days. This is evidenced by: Example 1: R3 was admitted to the facility with a [DIAGNOSES REDACTED]. Surveyor completed a review of R3's clinical record and noted the following: R3's lab report dated 8/31/16 indicated and INR (International Normalization Rate) of 1.4, with 2.0-3.0 being normal range. On 8/31/16 the physician order [REDACTED]. ~3 mg (milligrams) on Monday, Wednesday, Thursday, Friday, and Sunday. ~2 mg on Tuesday and Saturday Then recheck INR in 1 week. Surveyor reviewed the September 2016 Medication Record (MAR). On 9/1/16, a Thursday, R3 received [MEDICATION NAME] 2 mg dose instead of the ordered 3 mg dose. Example 2: R3's lab report dated 3/6/17 revealed an INR of 3.7 with a normal range of 2.0 to 3.0. In response to R3's high INR, the physician ordered [MEDICATION NAME] to be held on 3/6/17 and 3/7/17, then administer 1 mg daily beginning 3/8/17 with a recheck of the INR in 2 weeks. Review of the March 2017 MAR indicated [REDACTED]. On 8/10/17 at 4:35 p.m., Surveyor spoke with the IDON (Interim Director of Nurses) who stated she did not complete a medication error investigation to determine why these errors occurred. Example 3: R11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R11 had a physician's orders [REDACTED]. Review of the May 2017 MAR indicated [REDACTED] ~1 dose on 5/12/17 ~0 doses on 5/13/17 ~1 dose on 5/14/17 ~1 dose on 5/15/17 This equated to only 3 doses and not the 6 prescribed by the physician. On 5/16/17, the physician wrote another script for [MEDICATION NAME] 250 mg two times a day for 3 days. R11 received a total of 9 doses over 7 days. The first errors caused R11 to have to go through a second round of antibiotic treatment with the second round resulting in the administration of 3 extra doses. Increased use of antibiotics could lead to development of antibiotic resistance or development of ,[MEDICAL CONDITION].-difficile. On 8/10/17 at 4:35 p.m., Surveyor spoke with the IDON. The IDON indicated there was a problem requesting a hard script for the antibiotic. The nurse faxed to the physician requesting orders but didn't specify the need for a hard script. The physician then wrote new orders and once received the nurses thought it was a new order. It was entered and processed. The doses that were initially given were pulled out of our contingency before the pharmacy let us know of the need for a script.

Based on interview and record review the facility did not ensure 2 of 5 sampled and supplemental sampled residents (R6 and R13) were up to date with immunizations. R6 was eligible however never received the Pneumococcal Conjugate Vaccine (PCV13). R13 was eligible however never received the Pneumococcal [MEDICATION NAME] Vaccine (PPSV23). Both the PCV13 and PPSV23 are important to protect against pneumococcal disease. This is evidenced by: Pneumococcal disease is caused by a bacteria spread from person to person. It can cause ear infections, pneumonia, blood infection, and brain and spinal cord infections. Surveyor completed a review of R6's immunizations and noted R6 was never administered PCV13. Surveyor completed a review of R13's immunizations and noted R13 never received PPSV23. On 8/10/17 at 5:10 p.m. Surveyor spoke with the IDON (Interim Director of Nursing) regarding R6 and R13's immunization status. The IDON indicated there was no record of R6 or R13 ever receiving the respective immunization. The IDON stated she was not sure why. On 8/11/17 at 12:00 p.m. Surveyor spoke with the IDON. The IDON indicated obtaining immunization status was a part of their admission process. The IDON stated the admitting nurse should be checking each resident's immunization status and then scheduling those immunizations the resident needs to receive.

Based on observation, interview and record review, the facility did not ensure that each resident received the appropriate assistance devices to prevent accidents for one of four residents reviewed for safety (Resident #4). Resident #4 did not have a scoop mattress on the bed or Dycem (a non-slip material) in the wheelchair. The scoop mattress and Dycem were both listed on the care plan as fall prevention interventions. This is evidenced by: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4's Care Plan states: (Resident #4's nickname) is at risk for falls R/T (related to) CVA (Cerebral Vascular Accident or a stroke) with residuals Interventions include in part: Dycem in wheelchair and scoop mattress. Status is listed as active. Resident #4's Fall Risk Assessment, dated 07/15/16, indicated Resident #4 was a high fall risk. On 07/20/16 at 9:15 a.m., Surveyor observed Certified Nursing Assistant (CNA) A assist Resident #4 with morning personal cares. Resident #4 did not have a scoop mattress on the bed. There was no Dycem observed in Resident #4's wheelchair prior to CNA A transferring Resident #4 into the wheelchair. CNA A told Surveyor that there was not Dycem in the wheelchair and that she has not seen Dycem in the wheelchair since Resident #4's admission. CNA A examined Resident #4's bed with Surveyor . CNA A agreed the mattress was not a scoop mattress. On 07/20/16 at 10:00 a.m., Surveyor interviewed the Director of Nursing (DON) about the above observation and what was on the care plan. The DON indicated that Resident #4's fall interventions were current on the care plan. At approximately 11:00 am, the DON informed Surveyor that the Nursing Home Administrator retrieved a scoop mattress and Dycem from the previous facility for Resident #4 and they were now in place.