Every finding on record at Marinuka Manor

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 33 of 33 residents reviewed. Observations were made of laundry and nursing staff not performing hand hygiene with delivery of linens to residents. Registered Nurse (RN) D did not wear appropriate PPE during wound care for R4; staff did not use the proper technique by putting a barrier under R4's foot during wound care to ensure that R4 would be free from the spread of infection. Certified Nursing Assistant (CNA) C did not complete proper hand hygiene when providing personal cares to R13. Proper signage was not used for R4 who is on precautions due to Methicillin-resistant Staphylococcus aureus (MRSA) in the urine. Findings include: Example 1 The facility policy entitled, Water Management Program, states in part: Identify building water systems that need Legionella control measures, review diagrams, determine proper control measures to avoid infections. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system using a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. - Include a water management team that reviews processes. The section of the policy entitled, Identify building water systems that need Legionella control measures, contained: see water flow diagrams, review water systems when changes or remodeling occurs, and infection control nurse will review annual water quality reports from the city of Galesville. Surveyor noted the flow diagram was generic and does not specify any distinguished locations or areas where Legionella could grow, spread, or any measures to control the possible spread. The section of the policy entitled, Determine proper control measures to avoid Legionella infections contained: Night shift staff will run sinks in empty rooms for two minutes weekly, ensure water heaters are maintained at appropriate temperatures, surfaces that may contain biofilm are cleansed, document any changes in interventions as needed. Surveyor noted the above four control measures-weekly night shift checks, water heaters maintained, surfaces with biofilm cleansed, and documenting any changes in interventions-were the only risk hazards/control measures documented in the facility's WMP. Surveyor noted the facility's WMP did not document specific names, contact information or assignments of the individuals on the team, and the plan did not contain all the control points or measures taken to reduce Legionella. The above policy/WMP did not address dead legs throughout the facility. On 10/31/23 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)/Infection Preventionist (IP) B about water management plan. DON B indicated that the facility policy is not really detailed, and they do not have a formal diagram pertaining to exactly where they are preventing the risk of Legionella in the water systems. DON B indicated that they do not have the best system in place. Example 2 The facility policy entitled, Hand Hygiene, states in part: Handwashing required after removing gloves, between residents, and before leaving a resident's room. On 10/30/23 at 11:33 AM, Surveyor observed Laundry Aide (LA) J go into R6's room and deliver clean linen into the linen drawer behind the door. LA J exited room, went to linen cart, pulled out all clean linens and entered R11's room without performing hand hygiene. LA J entered R10's room without performing hand hygiene and delivered clean linen into drawer. LA J touched drawer surfaces, exited back out of room and went to clean linen cart without performing hand hygiene. LA J was observed entering and exiting R29, R13, and R23's room without hand hygiene. On 10/30/23 at 11:36 AM, Surveyor observed LA J exit R23's room and go to clean linen cart to grab clean bath towels and deliver to bathroom without performing hand hygiene. On 10/30/23 at 11:39 AM, LA J stocked clean linen cart on hall 100 with clean linens. No hand hygiene was performed. LA J went to Hall 200 and delivered clean linens down the hall. On 10/30/23 at 11:43 AM, Surveyor interviewed LA J and asked process for preventing infection when delivering clean linens to residents' rooms. LA J indicated that LA J was unsure how to answer the question, but the facility makes sure that we have clean hands before delivering linens. Surveyor asked how to prevent infection when going in and out of resident's rooms and touching their drawers when delivering linens. LA J indicated that there isn't anything else we do, and there isn't much else we can do. On 10/31/23 at 7:55 AM, Surveyor completed tour of laundry services with LA J. LA J indicated that laundry gathers dirty linen from the hall 100 and hall 200 and separates into personal linens in one sink and regular linens such as towels, bedspreads, and wash cloths in the other sink. Surveyor asked how isolation linens are handled. LA J stated that they are handled the same as regular dirty linen because the chemicals sanitize clothes in the washer. LA J indicated she uses gloves for all linens, but she does not need to use PPE in the handling process of isolation linens. On 10/31/23 at 8:15 AM, Surveyor observed LA J collect dirty linens from hall 100. LA J reached into cart and pulled out dirty linens and dirty linen brushed across LA J's scrubs in the front. On 10/31/23 at 8:19 AM, Surveyor observed LA J collect dirty linens from hall 200. LA J reached into cart and pulled out dirty linens and dirty linens brushed against LA J's scrubs in the front. LA J emptied garbage out and picked the bag up and rested the trash across LA J's abdomen on scrubs and brought out to the back dumpster. LA J entered facility with same gloves on and started sorting dirty linens into the two sinks in the laundry area. Once completed, LA J took gloves off and walked into the clean linen side and began pulling the clean linen cart over to sort clean linens. LA J did not perform hand hygiene. On 10/31/23 at 8:30 AM, Surveyor interviewed LA J and asked process for after handling dirty linens when sorting them into sink and taking gloves off. Surveyor asked if LA J completed hand hygiene and LA J indicated no, I just reapply a new pair of gloves before handling clean linens. Surveyor asked if LA J uses a gown to protect scrubs while handing isolated dirty linens and LA J indicated no. On 10/31/23 at 8:40 AM, Surveyor observed LA J apply new pair of gloves while handling clean linens out of dryer. LA J dropped a clean sock on ground, picked it up and placed it back into clean linen pile in bin. LA J proceeded to washer and took handfuls of clean linens, held it against body onto scrubs and placed into dryer. LA J then went to dirty linens, grabbed dirty linens and placed into washer. LA J took off gloves and went straight into the clean linen area. LA J did not perform hand hygiene between dirty linens and clean linens. On 10/31/23 at 8:45 AM, Surveyor interviewed DON B and asked the process and expectations for handling linens and isolation linens from staff. DON B indicated that staff is supposed to utilize gloves when handling dirty linens and keep dirty linens away from scrubs or clothes when handling. DON B indicated staff should sanitize after completing handling of dirty linens. DON B indicated when handling clean linens, washing or sanitizing hands is expected. DON B stated laundry staff should be using gloves and a gown when handling dirty isolation linens to make sure that clothes are not touching scrubs and laundry staff is expected to sanitize or wash hands if soiled after handling dirty linens and before handling clean linens. DON B also indicated that if any clean linen falls on the ground it is considered automatically dirty and needs to be rewashed in the chemical sanitizing process in washer. DON B indicated she is unaware that laundry staff does not have personal protective equipment (PPE) stored in the laundry area. On 10/30/23 at 2:05 PM, Surveyor observed Certified Nursing Assistant (CNA) L deliver clean linens to R30's room. CNA L touched bathroom doorknob to put into bathroom and exited R30's room. CNA L walked over to clean linen cart and pulled more linens out. CNA L did not perform hand hygiene before or after delivering clean linens. On 10/30/23 at 2:07 PM, Surveyor observed CNA L enter R32's room and deliver clean linens to drawer. CNA L then walked into bathroom and placed clean linens on bathroom bar. CNA L exited R32's room and did not perform hand hygiene. On 10/30/23 at 2:11 PM, Surveyor observed CNA L enter R24's room holding clean linens against body on scrubs then delivered into bathroom. CNA L opened bathroom door and placed towels on the bathroom bar. CNA L exited R24's room and proceeded to clean linen cart without hand hygiene performed. On 10/30/23 at 2:15 PM, Surveyor observed CNA L enter R31's room to deliver clean linens. CNA L had clean linens held against body of scrubs while walking down the hallway and into R31's room. CNA L delivered socks to R31's drawer and hand towels delivered to bathroom. Surveyor did not observe hand hygiene performed before or after. On 10/30/23 at 2:27 PM, Surveyor interviewed CNA L and asked what process for minimizing infection spread between residents when delivering clean linens? CNA L indicated that we usually sanitize hands before entering rooms and after exiting rooms. Surveyor asked if CNA L completed hand hygiene before and after entering and exiting residents' room, and CNA L indicated she did not perform hand hygiene. 31086 Example 3 R4 was admitted to the facility on [DATE] and has a diagnosis that includes Methicillin-resistant Staphylococcus aureus (MRSA) in the urine, stage 2 pressure ulcer, and a catheter. On 10/31/23 at 9:36 AM, Surveyor observed Registered Nurse (RN) D performing wound care for R4's pressure ulcer on the right foot. RN D did perform hand hygiene before starting to work on R4's wound. During the observation, RN D cleaned the wound with presumably dirty gloves and reached into the clean bandage box before changing gloves. RN D grabbed a clean bandage and completed the dressing change. During the dressing change, RN D did not place a barrier under R4's foot initially while the old bandage was off, allowing R4's foot to rest on the dirty bed linens to perform the dressing change. On 10/31/23 at 2:30 PM, Surveyor observed a sign outside of R4's door which indicated contact precautions. Surveyor observed RN D provide wound care for R4. RN D entered R4's room to set up supplies and did not apply a gown. Surveyor observed RN D's clothing was touching R4's bed while providing wound treatment to R4's buttocks. Surveyor interviewed RN D asking about the location of MRSA infection. RN D indicated the MRSA is located in R4's bladder and has a suprapubic catheter that does not leak and is a closed system. On 11/01/23 at 10:40 AM, Surveyor interviewed Director of Nursing (DON) B asking about use of personal protection equipment during wound care for R4 and what precautions are implemented. DON B indicated contact precautions are used when providing cares to the infected area and staff are to wear gown, gloves, and mask. Surveyor asked what standards of practice are followed for contact precautions. DON B indicated the facility follows the Centers of Disease Control (CDC). Surveyor reviewed with DON B the observation of staff not wearing PPE during wound care and the facility policy does not follow CDC contact precaution guidance. DON B indicated the policies will be reviewed and updated and staff education will be provided. Example 4 On 10/31/23 at 10:03 AM, Surveyor observed CNA C provide R13 with personal cares. With gloved hands, CNA C cleansed buttocks of stool and removed gloves and washed hands. CNA C, after washing hands, used a paper towel to turn the faucet off and with the same paper towel dried hands. CNA C applied clean gloves and placed a clean brief on R13. CNA C emptied the wash basin into the toilet and dried the basin. CNA C removed gloves, washed hands, and turned the faucet off with clean hands and applied gloves. CNA C applied R13's shoes and combed R13's hair and removed gloves. CNA C gathered the garbage from the garbage can and without hand hygiene touched R13's water mug and held the straw for R13 to drink. On 10/31/23 at 1:24 p.m., Surveyor interviewed CNA C, asking the procedure for proper hand hygiene and when it should be completed. CNA C explained hand hygiene appropriately. Surveyor asked when observed turning the faucet off with paper towel should you use the same paper towel to continue to dry hands? CNA C stated she did use the same paper towel and should not have. CNA C stated she did turn the faucet off with her clean hand and should not have. CNA C stated she should have washed her hands after touching the garbage. Surveyor asked if the facility provides education on proper hand hygiene. CNA C indicated training is provided yearly and competencies are checked off. On 11/01/23 at 10:40 AM, Surveyor interviewed DON B asking about hand hygiene during resident cares. DON B indicated proper hand hygiene is to use clean paper towel to dry hands and not use the same paper towel that was used to turn off the faucet. A different dry towel is to be used to turn off the faucet. Education will be provided to staff. 47807 Example 5 The facility policy, entitled Infection Control - MRSA or other MDROs, date revised June, 2023, states in part: When MRSA or other MDROs are identified, contact precautions should be considered and implemented . b. Contact Precautions . ii. Wear gloves when entering the room. During the course of providing care for a resident changes gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal matter and wound drainage). Remove gloves before leaving the resident's room and wash hands immediately with an antimicrobial agent After glove removal and hand washing, ensure that hands do not touch potentially contaminated environment surfaces or items in the resident's room to avoid the transfer of microorganisms to other residents and environments iii. Wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent or has diarrhea, an ostomy or wound drainage not contained by a dressing. The Center for Disease Control and Prevention (CDC) standard of practice, entitled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 07/12/22, states, Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions On 10/30/23 at 1:41 PM, Surveyor observed that R4 had a sign next to their door that said, Stop contact precautions and indicated that any providers entering the room must: Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. On 10/31/23 at 7:59 AM, Surveyor interviewed Director of Nursing (DON) B regarding their expectations regarding PPE during cares for R4. DON B said that R4 is under contact precautions due to the MRSA in their urine. DON B's expectation is that anyone who is doing direct care with R4's catheter, anything with R4's urine, and cleaning their restroom would wear gown, mask, and gloves and use hand hygiene before and after. If staff were to only be in the room working with low-risk items, then they would only need to use hand hygiene before and after leaving. On 10/31/23 at 9:28 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O about the contact precautions. CNA O said they only needed to wear the full PPE listed on the sign when working with R4's urine or anything the urine would touch. CNA O did wear full PPE in R4's room due to entering to empty R4's catheter. CNA O said they get told what to do for any resident on precautions in the morning meetings, which is how they knew what to do for R4. On 10/31/23 at 9:36 AM, Surveyor observed RN D setting up in R4's room to perform wound care. RN D was only wearing gloves at the time of observation; they did not have plans to have contact with R4 at the time per the interview with RN D. On 10/31/23 at 9:48 AM, RN D performed wound care for R4 for a pressure ulcer on their feet. RN D only wore gloves during the process. Surveyor interviewed RN D regarding the lack of other PPE, and they said that due to not working with his urine, they did not believe they needed to have the full PPE on. When asked how they get their information, RN D said they get it during the morning meeting or from the memos that the facility sends out. RN D also said that if they have any changes, they usually go to an Inter-Disciplinary Team (IDT) meeting, which then sends out a memo to all staff highlighting any changes for residents. On 11/01/23 at 7:35 AM, Surveyor interviewed CNA G regarding what the precautions sign outside R4's door said. After reading the sign posted outside R4's door, CNA G said that it did read that anytime a staff member would enter the room, they should put on a gown, mask, gloves, and use hand hygiene. On 11/01/23 at 7:53 AM, Surveyor interviewed DON B, asking who is responsible for putting up the signs for residents who are under precautions. DON B said they are the person responsible for placing the signs and setting up a resident under contact precautions. When asked about the difference between what the precautions sign read and what staff are saying the procedure is to work with R4, DON B said the sign does not reflect exactly what staff are being told to do. On 11/01/23 at 2:38 PM, Surveyor interviewed DON B about their expectations regarding using the proper precautions sign for someone with a Multi-Drug Resistant Organism (MDRO). DON B said that they should be using an enhanced barrier precautions sign as it reflects their policy better and that the enhanced barrier sign would give visitors or new providers the proper information they would need at the door to work with R4.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 33 of 33 residents residing in the facility. Dietary Supervisor (DS) M and Dietary Aide (DA) N did not use a hair restraint over their beards while preparing, serving, and operating in the kitchen. Findings include: The facility policy, entitled Infection Control - Dress Code 2.4, not dated, states in part: A. All staff must have their hair restrained in a hairnet Men should be clean shaven or they will be required to wear a beard net. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with DS M. The Surveyor observed that DS M had a noticeable beard approximately 1/2 in long protruding from behind the mask they wore. The mask did not cover all the beard, only around the mouth area. The surveyor also observed that DA N had a noticeable beard that protruded from behind the surgical mask that they wore. Both individuals had full beards that traveled from ear to ear. On 10/30/23 at 11:38 AM, Surveyor observed lunch being prepared for the facility. DA N was cooking and taking temperatures for all foods, including pureed foods. DA N did not have a beard net at this time and did have a full beard, as described in the previous observation. DS M entered the kitchen at this time to supervise as the food was being prepared and served. DS M also did not have a beard net and still had a full beard, as described previously. On 11/01/23 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the lack of hair restraints used. NHA A would expect they follow the policy and be clean shaven or use a beard net.

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 could potentially affect all 33 residents residing in the facility. The facility does not have a director of food and nutrition services with the minimum requirements or a full time registered dietitian on site. Findings include: On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. Surveyor asked DS M what qualifications they held that allowed them to assume the role of Dietary Supervisor. DS M said they had ServSafe certification, and they were working on completing a course that would qualify them as a Certified Dietary Manager. On 10/31/23 at 1:59 PM, Surveyor interviewed DS M regarding the oversight of a registered dietitian. DS M said they have a registered dietitian they work with, and they come only on Monday to complete the tasks required of a registered dietitian. The registered dietitian is also available by phone every day of the week. The facility did not provide evidence that the registered dietitian was monitoring the kitchen for oversight of all kitchen operations. On 10/31/23 at 2:17 PM, Surveyor interviewed DS M regarding their current qualifications to perform director of food and nutrition services for the facility. DS M said they do have the ServSafe qualification but have not yet finished their courses to become a certified dietary manager. DS M has no other certification besides ServSafe related to food and nutrition services. DS M is working on a four-year degree from the University of North Dakota, which is not yet completed. Record review revealed that DS M was hired on 10/08/23. On 11/01/23 at 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the lack of certification for DS M and the oversight of the registered dietitian. NHA A said they were still hiring for a Dietary Manager, and that DS M was the dietary supervisor. They required the dietary manager to have the necessary qualifications but have not been able to hire someone; they still have a job position posted. At this time, NHA A and DS M worked together with the registered dietitian to make sure everything was covered. Surveyor asked what qualifications NHA A had related to dietary services, and NHA A replied none; NHA A did say they have a four-year degree in business administration. The facility hopes to move DS M into the dietary manager position once they receive the qualifications. Surveyor then asked about the expectations that NHA A has regarding the qualifications of the director of food services, and they replied they would expect them to have the proper certifications. They are still hiring to try and find someone as soon as possible.

Based on observation, interview, and policy review, the facility failed to dispose of garbage and refuse properly. This has the potential to affect all 33 of 33 residents residing in the facility. The facility did not ensure the garbage dumpster lids were closed; this was observed multiple times during the survey. This is evidenced by: The facility policy, entitled Pest Control, not dated, states: Ongoing measures are taken to prevent, contain, and eradicate household pests such as roaches, ants, mosquitoes, flies, mice and rats All state and local regulations are followed. On 10/30/23 at 9:30 AM, Surveyor performed the initial walkthrough of the kitchen with Dietary Supervisor (DS) M. When looking at the garbage dumpsters, Surveyor observed them to be open. On 10/31/23 at 8:52 AM, Surveyor observed the large blue dumpster located outside, near the dietary employee entrance and the outdoor freezer, was open and not covered. On 10/31/23 at 1:59 PM, Surveyor observed that the large blue garbage dumpster was not covered and was open. On 11/01/23 at approximately 1:35 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the open dumpsters. NHA A said they would expect them to be closed to prevent attracting pests that may get into the building. 48793 Example 2 On 10/31/23 at 8:19 AM, Surveyor observed Laundry Aide (LA) J collect garbage from hall 200. LA J gathered garbage from small trash can on hall 200. LA J picked the trash bag up, resting on scrubs across abdomen, and brought it out to the back dumpster. Surveyor observed the dumpster lid open, and LA J threw garbage into dumpster and left the lid open. On 10/31/23 at 8:25 AM, Surveyor interviewed LA J and asked about the garbage dumpster being left open. LA J stated that the dumpster lid is always open.

Based on observations and interviews, the facility did not ensure personal protection of resident medical records for 1 of 1 resident (R2). Licensed Practical Nurse (LPN) F did not ensure personal protection of R2's medical records when leaving the medication cart in the hallway unattended and the computer screen open. Findings include: The facility's policy entitled, Medication Administration, reads in part Any personal information must be hidden when not in use (cover report sheets, minimize or close computer screen). On 10/31/23 at 7:21 AM, Surveyor observed a medication cart in the 200-hallway unattended. When Surveyor walked past the medication cart the computer screen was opened. R2's information was up on the computer screen so anyone walking by could see the information. Approximately 3 - 5 minutes later, LPN F returned to the medication cart. On 11/01/23 at 8:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) and Medical Assistant (MA) G and asked what their process was when leaving medication cart. CNA/MA G indicated they lock the cart, cover up any papers with identifiable names on them, pull the screen down on their computer for privacy and make sure there are no medications left on the cart. On 11/01/23 at 8:06 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the practice is before a nurse leaves their medication cart. DON B indicated locking cart, computer screen down or locked, and covering papers with any names on them.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was last obtained on 09/17/18. Findings include: The facility policy, entitled Allegations of mistreatment/neglect/abuse/injuries of unknown source, misappropriation of resident property, exploitation, and resident to resident altercations, revised, November 2018 states in part The BID, IBIS, OIG and DOJ checks are completed every four years by the Human Resources Department. On 10/31/23, Surveyor reviewed 8 random staff Background Information Disclosures (BID) as part of the caregiver program compliance check. Surveyor was reviewing a BID for Certified Nursing Assistant (CNA) H; the form was dated 09/17/18. Surveyor reviewed the Department of Justice report that was attached, and it had the date of 09/17/18 indicating that is the date the BID was completed. On 10/31/23 at about 1:30 PM, Surveyor interviewed Business Administration Assistant (BAA) E and asked if they had an updated BID for CNA H. BAA E looked through CNA H's personnel file and said, I guess not. On 10/31/23 at 3:06 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and told her the BID for CNA H was last done on 09/17/18 asked if they thought the BID was up to date. NHA A indicated with what Surveyor was telling NHA A, if BAA E cannot find another one then it is not up to date.

Based on observation, interview, and record review, the facility did not provide appropriate care and treatment for 1 of 2 sampled residents (R) (R13) who were at risk for pressure injuries. R13 was observed in bed in a supine position without being repositioned and without heels being elevated for 4 hours. Findings include: The facility policy entitled, Repositioning, dated 6/2022, states in part: Staff will ensure resident is repositioned per the resident plan of care or Kardex, residents will be given pressure relieving devices for impaired or risk of impaired skin integrity. Guidelines from the National Pressure Injury Advisory Panel (NPIAP) 2016, Pressure Injury Prevention Points, accessed 02, November 2023, Prevention Points | National Pressure Ulcer Advisory Panel (npiap.com), states in part: Turn and reposition all individuals at risk for pressure injury, turn the individual into a 30-degree side lying position and use your hand to determine if the sacrum is off the bed, ensure that the heels are free from the bed, use heel offloading devices for high risk pressure injuries. R13 was admitted on [DATE] and current diagnoses, in part: non-Alzheimer's dementia, Huntington's disease, and arthritis. Surveyor completed record review of the Minimum Data Set assessment (MDS), dated [DATE], which indicates the resident's most recent Brief Interview for Mental Status (BIMS) score was an 11 out of 15 total points. According to the BIMS assessment, a score of 11 indicates the resident has moderately impaired cognition. The MDS documents R13 being at risk of pressure injury, always incontinent of bladder and frequently incontinent of bowels. R13 is dependent on staff for activities of daily living and maximum assist of staff to roll in bed. Nurse notes indicated through assessments that Braden scale was conducted for R13 with a score of 10. Braden scale is utilized to measure pressure sore at risk and 10-12 is considered high risk. Care plan from 10/05/23 indicates that R13 needs assistance with cares and repositioning. A pressure redistribution mattress, use pillows to position comfortably, float heels for offloading and apply Roho wheelchair cushion. R13 needs help to move. Physician orders from 08/18/21 indicate ensure that Dycem cushion is under resident when in wheelchair. On 10/30/23 at 10:04 AM, Surveyor observed R13 lying in bed on back in the dark. On 10/31/23 at 7:10 AM, Surveyor observed R13 sleeping while lying in bed on back, heels on bed and not elevated. On 10/31/23 at 8:41 AM, Surveyor observed R13 sleeping while lying in bed on back and covers on. On 10/31/23 at 9:15 AM, Surveyor observed R13 sleeping while lying in bed on back. R13 continues to be sleeping in same position. On 10/31/23 at 10:00 AM, Surveyor observed R13 sleeping while lying in bed on back. On 10/31/23 at 10:03 AM, Surveyor observed Certified Nursing Assistant (CNA) C provide personal cares. Surveyor observed R13's both heels directly resting on the bed with no offloading device. Surveyor asked CNA C if anything is used to off-load heels. CNA C indicated the foot of the bed is angled down. Surveyor observed a foam cushion with Dycem in Broda chair. The foam cushion is not a Roho cushion. The care plan directed a wheelchair Roho cushion be applied. On 10/31/23 at 1:03 PM, Surveyor interviewed R13 and asked about repositioning and how often R13 gets repositioned. Surveyor also asked R13 about floating heels to prevent skin breakdown and how R13 feels about having her feet elevated. R13 indicated that R13 is ok with her cares and that R13 doesn't like to be repositioned with legs elevated. On 11/01/23 at 6:57 AM, Surveyor observed R13 sleeping while lying in bed on back. On 11/01/23 at 7:51 AM, Surveyor observed R13 sleeping while lying in bed on back. On 11/01/23 at 7:54 AM, Surveyor interviewed CNA K and asked process for repositioning R13 and when the last time R13 was repositioned this morning. CNA K stated that usually we go in and try to reposition often but there are times where R13 doesn't want to be repositioned. CNA K indicated that night shift gave report that rounds were completed around 4:00 AM on 11/01/23, but that CNA K was unsure if that is when R13 was repositioned. Surveyor asked CNA K if CNA K had repositioned R13 or when will CNA K will be going in R13's room to reposition. CNA K stated CNA K has not yet gone in this morning, but usually will go in before breakfast to reposition. CNA K indicated R13's comprehensive care plan does state offload on heels so with any residents we use pillows to prop feet up. CNA K indicated to have never seen R13 to have a pillow in room to float heels. R13 may not want to have feet up. CNA K indicated we follow care plan in R13's room for what interventions to perform per care daily. On 11/01/23 at 8:05 AM, Surveyor reviewed CNA care plan for R13 with CNA K, and it states in part, for repositioning that R13 needs assistance with repositioning. CNA K indicated the care plan was very vague. On 11/01/23 at 8:09 AM, Surveyor observed CNA K enter R13's room, and then exit with trash. Surveyor interviewed CNA K who indicated that R13 had an incontinent episode and CNA K changed her. Surveyor observed R13 in supine position and sleeping again. On 11/01/23 at 12:10 PM, Surveyor interviewed DON B asked expectations of CNAs and repositioning residents who are totally dependent on staff to reposition. DON B indicated that facility knows on R13's reposition and care plan interventions are not adequate. DON B indicated due to the at risk for skin issues it is expected that CNAs reposition residents often and that waiting over a couple hours is too long before needing repositioning.

Based on observation, interview and record review, the facility did not ensure pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 2 residents (R) observed receiving insulin. (R4) Staff did not follow current standard of practice of priming the insulin pen prior to setting the dose to be administered to ensure the insulin pen and needle are working and the air was removed to ensure the correct amount of insulin would be administered. Findings include: Facility policy entitled, Insulin Administration stated in part, .If using an insulin pen, cleanse hub then, prime pen with 2 units .: On 10/31/23 at 7:55 AM, Surveyor observed Licensed Practical Nurse (LPN) F prepare two insulin pens (Lispro and Humulin) for administration to R4. LPN F took two insulin pens out of medication drawer and verified medication labels with medication orders on the Medication Administration Record. LPN F removed the cap from the Humulin insulin pen and wiped tip of the pen with alcohol pad. LPN F attached a needle to the pen and dialed the pen to the ordered dose of 11 units. LPN F did not prime the needle with 2 units prior to dialing pen to the ordered dose. LPN F removed cap from the Lispro pen and wiped the tip with an alcohol pad. LPN F attached a needle and dialed the pen to the ordered dose of 5 units. LPN F did not prime the needle with 2 units prior to dialing the pen to the ordered dose. LPN F administered both insulin doses to R4. Immediately after the procedure, Surveyor asked LPN F if they primed the needles on the insulin pens prior to dialing the pens to the ordered dose to ensure the pen was in working order and the air was removed to ensure the correct amount of insulin would be administered. LPN F stated they were never taught to do that, and they did not usually prime insulin pens with 2 units prior to dialing pen to the ordered dose. On 10/31/23 at 12:19 PM, Surveyor interviewed Director of Nursing (DON) B about the observation of LPN F drawing up 2 insulin pens to the ordered dose without priming the needle first for R4. DON B stated staff were supposed to prime the needle on insulin pens prior to dialing the pen to the ordered dose of insulin to ensure the resident received the correct dose of insulin.

Based on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman of hospital transfers for 2 residents (R27 and R11) of 2 residents reviewed for hospitalization in the sample of 14. The facility failed to have a system in place to ensure notifying the State Long-Term Care Ombudsman of hospital transfers. This had the potential to affect all 33 residents that reside in the facility. R27 was hospitalized from 09/10/23 through 09/12/23 and the Ombudsman was not notified of that transfer to the hospital. R11 was hospitalized from 03/19/23 through 03/20/23 and the Ombudsman was not notified of that transfer to the hospital. Findings include: Example 1 R27 was admitted to the facility on [DATE] with diagnoses, in part, of chronic kidney disease stage 3, heart failure, and vascular dementia. Record review identified R27 was cognitively impaired and had an activated Power of Attorney for Health Care (POAHC). R27's son was the POAHC. Record review identified R27 was transferred to the hospital on 09/10/23 due to an exacerbation of heart failure. Surveyor reviewed a notice of bed hold policy and notice of transfer form that was issued to R27's POAHC at the time of the transfer to the hospital. On 10/31/23 at 8:32 AM, Surveyor interviewed Social Worker (SW) I, and asked if the Ombudsman was notified of R27's transfer to the hospital on 09/10/23. SW I stated they did not notify the Ombudsman of that transfer, and they did not routinely notify Ombudsman of hospital transfers. SW I stated they did notify the Ombudsman of all discharges from the facility or if a resident was not allowed back in the facility after a hospitalization . SW I stated they did not notify the Ombudsman of residents who transferred to the hospital if they were readmitted to the facility after the hospitalization . SW I did not know that was required and stated they had never done that for any residents who were transferred to the hospital. 48793 Example 2 R11 was admitted to the facility on [DATE] with diagnoses, in part, of diaphragmatic hernia without obstruction or gangrene, hypertensive kidney disease, major depressive disorder, anxiety disorder, and bilateral osteoarthritis of knee. Record review identified R11 was transferred to the hospital on 03/19/23 due to severe abdominal pain with emesis and pain 8 out of 10. Surveyor reviewed a notice of bed hold transfer form that was issued to R11 at the time of transfer to the hospital. On 11/01/23 at 11:56 AM, Surveyor interviewed Social Worker (SW) I, and asked if Ombudsman was notified of R11's transfer to the hospital on 03/19/23. SW I stated they did not notify the Ombudsman of that transfer, and they did not routinely notify Ombudsman of hospital transfers.

The facility did not ensure they designated a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. This had the potential to affect all 32 residents. The DON was named as the Nursing Home Administrator (NHA) on 7/23/22, leaving the DON position open since 7/23/22. This is evidenced by: On 09/26/22 at 9:26 AM, Surveyor conducted an entrance conference with DON B. When asked if there was an NHA, DON B told Surveyor that she was the acting NHA and had been working in that capacity. Surveyor asked her how long she has been the acting NHA. DON B indicated it has been since June. Surveyor asked DON B when she was informed of the change. DON B indicated she had an email and she would look for it. Surveyor asked if another staff member had been assigned to fill the DON role. DON B indicated there had not been anyone else assigned to the DON role. On 09/26/22 at 11:28 AM, Surveyor interviewed the previous NHA C and asked if there is anyone that helps with the vacant NHA position. NHA C indicated that a new NHA is starting on Monday. NHA C indicated that herself, along with another NHA from a sister facility, and the VP from corporate have been coming 1 time a week to assist with the NHA vacancy. Surveyor asked NHA C how long the NHA position has been vacant. NHA C indicated it has been vacant since 07/23/22. NHA C provided Surveyor with Nursing Home Notice of Change for Administrator or Director of Nursing Form: Type of change Administrator. The form listed the previous NHA of record and the new administrator of record to be DON B, date position began 07/23/22, work status Acting (Unlicensed). Surveyor also received the email to review that was received from the State of Wisconsin Licensing/Certification Program Coordinator which indicated they were in receipt of the form. The letter reads in part: .facility must have a licensed NHA no later than November 20, 2022. Surveyor asked NHA C if there was another staff that took over the DON position. NHA C indicated no. Surveyor asked NHA C if the facility had a waiver for not having a full time DON. NHA C indicated no.

Based on observation and interview, the facility failed to ensure food was handled and served in accordance with professional standards for food service safety. This has the potential to affect all 33 residents in the event of a foodborne illness outbreak. Staff observed touching ready to eat foods with contaminated gloves during observation of meal service. Findings include: Facility policy entitled Food Service Safety last revised on May 8, 2018, stated in part, .ii. Food handlers must wear single use gloves when handling ready to eat food. iii. Food can be handled with spatulas, tongs, deli sheets or other utensils . 09/27/22 12:18 PM Surveyor observed Cook E clean hands with alcohol based hand rub, apply single use glove to right hand. Cook E touched the plates, plate covers and was using that hand to lean on the counter that the food was served from. Cook E picked up biscuits with the same contaminated right gloved hand. 09/27/22 1:15 PM Surveyor interviewed Cook E and asked what is your policy regarding using your gloved hand touching ready to eat foods like a biscuit for instance, after that same gloved hand has touched everything else. Cook E responded we should be using tongs when we pick up ready to eat food. 09/27/22 1:25 PM Surveyor interviewed Dietary Manager (DM) D and asked what is your policy regarding using your gloved hand touching ready to eat foods like a biscuit for instance after that same gloved hand has touched everything else. DM D responded that you should use tongs to serve the biscuit. Surveyor requested a policy about gloved hands touching ready to eat foods and DM D was not sure that they had one and will check. 09/27/22 1:30 PM DM D presented Surveyor with a food service policy. 09/28/22 8:11 AM Surveyor observed Cook E using tongs to pick up ready to eat foods for breakfast.

Based on interview and record review, the facility did not provide necessary care and services in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 2 of 3 sampled residents being reviewed for following physician orders, Resident (R) R1 and R2. R1 had physician orders [REDACTED]. The facility did not contact the physician when the weight was greater than 3 pounds and did not continue to monitor weights. R1 continued to have an increase in weight and leg [MEDICAL CONDITION]. When treatment of [REDACTED]. R2 had a physician order [REDACTED]. This is evidenced by: Review of R1's current [DIAGNOSES REDACTED]. Review of R1's physician orders [REDACTED].>3 # (greater than 3 pounds) in 24 hours call provider to restart diuretics. Review of nurse's notes document in part: 11/05/20 at 1:32 p.m., New Admission: .[MEDICAL CONDITION]: Resident wears [MEDICATION NAME], non [MEDICAL CONDITION] present bilaterally . 11/06/20 at 2:05 a.m., Medicare progress note: .Legs with non [MEDICAL CONDITION] bilaterally . 11/08/20 11:29 p.m., Medicare progress note: .Legs with non[MEDICAL CONDITION] bilaterally . 11/10/20 at 2:07 p.m., Medicare progress note: .continues to have BLE (Bilateral Lower Extremity) [MEDICAL CONDITION]. non pitting at this time . 11/11/20 at 11:40 p.m., Medicare progress note: .Legs with non[MEDICAL CONDITION] bilaterally . 11/13/20 at 5:28 p.m., Medicare progress note: .Legs with non-[MEDICAL CONDITION] bilaterally . 11/14/20 at 2:57 p.m., Medicare progress note: .LE [MEDICAL CONDITION] noted . 11/16/20 at 10:26 p.m., Medicare progress note: .Has 2+ [MEDICAL CONDITION] to LE (Lower Extremities) . The physician was not notified with the increase of [MEDICAL CONDITION]. No further documentation of assessments for bilateral lower extremity [MEDICAL CONDITION] until 12/03/20 when a noted increase in [MEDICAL CONDITION] with a weight increase. Review of weights documented daily from 11/06/20 to 11/17/20. On 11/16/20, documented a weight of 188.6 pounds and on 11/17/20 documented 192 pounds. This is a 3.4 pound increase in 24 hours and the physician was not updated. On 11/18/20, R1 was diagnosed with [REDACTED]. On 12/03/20, documented R1 weighed 204.2 pounds; this is an increase of 12.2 pounds since 11/17/20. The physician was updated and on 12/03/20 therapy ordered comprillian wraps to bilateral legs. On 12/03/20 at 10:37 p.m., nurse's notes document in part: Resident has a fluid filled blister noted to her right heel. Resident was just started on Comprillian wraps today and there was no blister noted to her heel this AM. Writer informed family that this blister is likely a result from the fluid shift from the new comprillian wraps . 12/04/20 at 8:54 a.m., Area 1: right heel 3.1cmx3.1cmx0cm .Area assessed and noted intact fluid filled blister . On 12/04/20, physician ordered [MEDICATION NAME] (diuretic) 2 mg twice a day for [MEDICAL CONDITION]. On 01/25/21, Surveyor interviewed Registered Nurse (RN) C and RN D about how often weights are obtained and when would notification to the physician be required. Both RN C and RN D indicated weights are obtained with the weekly shower or how prescribed by the physician. Would update the physician if there would be a three pound increase or how it is prescribed for a resident. On 01/25/21 at 3:07 p.m., Surveyor interviewed Director of Nursing (DON) B about R1's missing weights. DON B indicated during the COVID-19 outbreak the Medical Director (MD) said not to bring anyone out to be weighed. Surveyor asked where the scale would be located. DON B indicated the scale is in the short hallway not near any resident rooms and residents would have to travel out of their hallway to get to the scale. Surveyor asked if there was another type of scale that could have been used. DON B indicated on 11/27/20 there was a different scale brought in to have one on each hallway. Surveyor asked why R1 was not weighed on 11/27/20 when R1 was not showing any symptoms of COVID-19. Surveyor asked why the physician was not updated on 11/17/20 when the weight was increased over 3 pounds. DON B indicated she was unable to determine if R1's primary physician was updated with weights not being taken daily as prescribed. Review of R2's medical record documented current [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. This order was discontinued on 12/18/20. On 11/25/20, an order for [REDACTED]. Review of R2's weights document a weight on 11/16/20 with the next weight obtained on 12/07/20. The facility did not weigh R2 on 12/08/20. Review of R2's documentation did not identify the physician was updated with R2 not being weighed as prescribed. On 01/25/21 at 3:30 p.m., Surveyor interviewed DON B about R2's missing weights. DON B indicated this was during the COVID-19 outbreak. Surveyor referred to previous interview of the scale for the hall being obtained on 11/27/20. R2's order was obtained on 11/25/20 and was not followed. R2 did not test positive for COVID-19 until 12/18/20. DON B indicated she will look to see if there is Certified Nursing Assistant charting of weights. At 3:55 p.m., DON B indicated there was no additional information of weights for R2. Surveyor reviewed with DON B and Nursing Home Administrator (NHA) A the missing weights for R1 and R2 that does not follow their physician orders. With the increase in weight and [MEDICAL CONDITION] R1 inccurred and delayed treatment resulted in a deep tissue injury to the heel.

Based on observations, interviews and record reviews, the facility did not complete assessments for risk of entrapment or obtain consents for the use of side rails for 4 of 14 Residents (R): R5, R39, R40 and R32. R5, R39, R40 and R32's beds contained side rails as observed by Surveyors. The facility did not ensure appropriate alternatives for side rails, assess for risk for entrapment with the use of side rails, or obtain informed consent prior to use. This is evidenced by: 1. On 06/17/19 at 9:45 a.m., Surveyor observed R5. R5 was sleeping in bed. Two half side rails were in place. Surveyor reviewed R5's Minimum Data Set ((MDS) dated [DATE]. The MDS indicated R5 has not experienced falls in the facility. The MDS indicated R5 requires supervision with bed mobility. R5's Brief Interview for Mental Status (BIMS) was 12, indicating mild cognitive impairment. Surveyor reviewed a document entitled Side rail assessment--Evaluation dated 06/07/19. The document stated, in part: Reason for use: Request of resident. Reason for recommendation: Bed mobility. Mental status: Alert/oriented x3, not confused at night. Good mobility/sitting up: Yes. When are side rails used: Aid with independence with mobility and repositioning. Team Recommends: At all times in bed. Ability to release rails: No. There was no information indicating the facility assessed for the risk of entrapment related to side rail use. There was no indication the facility attempted less restrictive measures. There was no documentation the facility provided R5 with information regarding the risk/benefits of the use of side rails, or signed consent indicating R5 wished to continue side rail use after understanding the risk/benefits of use. On 06/19/19 at 10:30 a.m., Surveyor interviewed Registered Nurse (RN) C and Nursing Home Administrator (NHA). RN C and the NHA agreed the facility did not attempt least restrictive measures prior to side rail use, did not assess for risk of entrapment and did not obtain a risk/benefit statement from the resident/Power of Attorney Health Care, prior to side rails use. 2. R39's [DIAGNOSES REDACTED]. On 06/17/19 at 9:30 a.m., Surveyor observed R39. R39 was sleeping in a recliner, with lower extremities elevated. R39's bed showed half side rails on both sides of the bed. On 06/19/19 at 8:59 a.m., Surveyor reviewed R39's clinical record. Surveyor reviewed a document entitled Side rail assessment--Evaluation dated 05/22/19. The document stated, in part: Reason for use: Resident wants side rails. Reason for recommendation: Bed mobility. Mental status: Sometimes confused, especially at night. Good mobility/sitting up: Yes. When are side rails used: Aid with independence with mobility and repositioning. Team Recommends: At all times in bed. Ability to release rails: No. Surveyor reviewed R39's MDS dated [DATE]. The MDS showed R39's BIMS was 10, indicating cognitive impairment. The MDS indicated R39 requires extensive one person assistance with bed mobility. There was no information indicating the facility assessed for the risk of entrapment related to side rail use. There was no indication the facility attempted less restrictive measures. There was no documentation the facility provided R39 with information regarding the risk/benefits of the use of side rails, or signed consent indicating R39 wished to continue side rail use after understanding the risk/benefits of use. On 06/19/19 at 10:30 a.m., Surveyor interviewed RN C and NHA. RN C and NHA agreed the facility did not attempt least restrictive measures prior to side rail use, did not assess for risk of entrapment and did not obtain a risk/benefit statement from the resident/Power of Attorney Health Care, prior to side rails use. 3. R40's [DIAGNOSES REDACTED]. On 06/16/19 at 9:30 a.m., Surveyor observed R40. R40 was sitting in a broda chair in her room, and was asleep. R40's bed contained two half side rails. On 06/19/19, Surveyor reviewed R40's MDS. The MDS, dated [DATE], showed R40 requires two person extensive assistance for bed mobility. R40's BIMS was 12, indicating moderate cognitive impairment. Surveyor reviewed a document entitled Side rail assessment--Evaluation dated 05/23/19. The document stated, in part: Reason for use: Resident wants side rails, request of resident family. Reason for recommendation: Bed mobility. Mental status: Alert/oriented during the day, sometimes confused at night. Good mobility/sitting up: Yes. When are side rails used: Bed mobility and repositioning. Team Recommends: At all times in bed. Ability to release rails: No. There was no information indicating the facility assessed for the risk of entrapment related to side rail use. There was no indication the facility attempted less restrictive measures. There was no documentation that the facility provided R40 with information regarding the risk/benefits of the use of side rails, or signed consent indicating R40 wished to continue side rail use after understanding the risk/benefits of use. On 06/19/19 at 10:30 a.m., Surveyor interviewed RN C and NHA. RN C and NHA agreed the facility did not attempt least restrictive measures prior to side rail use, did not assess for risk of entrapment and did not obtain a risk/benefit statement from the resident/Power of Attorney Health Care, prior to side rails use. 4. R32 was admitted on [DATE], with history of a recent fall and [MEDICAL CONDITION] that required surgery. R32 has [DIAGNOSES REDACTED]. BIMS score on 05/15/19 is an 11, meaning R32 has some cognitive impairment. R32 has a history of three falls, two occurring in her room when she fell out of bed. Surveyor observed two upper half bed rails on R32's bed during the initial tour 06/17/19 at 9:15 a.m. Surveyor reviewed medical record and noted an assessment dated [DATE] that identifies R32 can not release her bed rail. The assessment does not assess for the risk for entrapment. The record did not contain a consent for the use of the bed rails. The bed rails were initiated on 04/19/19, the date of R32's admission. Care plans in part, I have the potential to feel confused and forgetful, .my memory and cognition vary .my cognition does not fluctuate due to dementia.I have the potential to fall down .I am unable to understand that I am unable to transfer myself, please place my w/c at bedside when I am sleeping so if I decide to transfer myself I may I may do so in the safest manner to prevent injury. Nurses notes in part, 05/12/19 Resident noted to be crawling out of bed . 06/01/19 Resident noted to have her legs out of bed .resident was attempting to self transfer 06/02/19 Resident .was self transferring on an off . 06/03/19 Resident was noted to be crawling out of bed . 06/11/19 Resident self transferred several times from w/c (wheelchair) to bed . 06/17/19 Self transferred many times from w/c to bed and to toilet . On 06/18/19 at 10:14 a.m., Surveyor interviewed the Director of Nursing (DON) to ask about consents. The DON indicated they have no consents for the bed rails. On 06/19/19 at 10:20 a.m., Surveyor interviewed RN [NAME] about any other alternatives tried that were less restrictive prior to the bed rails. RN [NAME] indicated no other alternatives were tried. Surveyor asked if the risk for entrapment had been assessed for R32. RN [NAME] indicated that is not part of the assessment they completed. On 06/19/19 at 10:35 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and RN C about the above concerns. Surveyor asked if R32 was at a risk for entrapment in the bed rails with the attempts at self transfers and crawling out of bed. The NHA indicated R32 is at risk and the facility is implementing a policy and making changes to the assessment.

Based on observation, interview and record review, the facility did not ensure nursing staff possess the competency necessary to provide emergency medical needs safely for 1 of 14 residents (R) R25 whose medications were reviewed. Staff were not knowledgeable as to where [MEDICATION NAME] (a medication used to treat anaphalaxis--a medical emergency) was kept, the form of the medication available, how to administer the medication or why epinepherine was listed on the physician orders [REDACTED]. This is evidenced by: On 06/18/19 at 2:47 PM, Surveyor did an inspection of the medication storage room and medication cart with Licensed Practical Nurse (LPN) F. At approximately 2:55 p.m., Surveyor reviewed the medication cart for the 100 hall for R25's [MEDICATION NAME] supply. The order had been noted during medications pass task. Surveyor asked LPN J, who was working the evening shift for the 100 hall, where the [MEDICATION NAME] supply was kept. LPN J stated she did not know where it was. LPN F stated, It's not in the cart. It is in contingency supply in the emergency box identified as the red box. LPN F held the red box, and then stated, That is wrong it is in the other box, the gray box. Surveyor asked LPN J why R32 needs the [MEDICATION NAME] order. LPN J was not sure. Surveyor asked if it is prescribed in the form of an epi-pen or an injection. LPN J did not know. Surveyor looked in the med cart and in the fridge, locating no epi-pen. LPN F reviewed the Back up Med Reference book for guidance, and the guide stated there were 3 [MEDICATION NAME] of [MEDICATION NAME] ([MEDICATION NAME]) in the emergency box. LPN F then searched through the gray contingency box and could not locate the [MEDICATION NAME] of [MEDICATION NAME]. At approximately 3:03 PM, LPN F found 3 [MEDICATION NAME] that were located in the top shelf. Surveyor asked how LPN F would administer this medication from the [MEDICATION NAME]. LPN F stated, I'm not sure. Surveyor asked if there are any special considerations. LPN F stated, I do not know. Surveyor did not observe any filtered needles or instructions with the [MEDICATION NAME] of [MEDICATION NAME]. On 06/18/19 at 3:30 p.m., Surveyor interviewed the Director of Nursing (DON) to ask about the process for using [MEDICATION NAME] for [MEDICATION NAME]. The DON said she would look, she did not know if the facility has a policy or procedure. Surveyor asked what allergies [REDACTED]. Surveyor reviewed orders noting R25 has allergies [REDACTED]. At 3:45 p.m., Surveyor interviewed R25 who has a Brief Interview for Mental Status (BIMS) score of 10. R25 stated she has allergies [REDACTED]. R25 stated yes all fish and shellfish. Surveyor asked what symptoms R25 has if she eats fish. R25 stated, I puff up, as she pointed to her mouth and face. On 06/19/19 at 7:54 am., Surveyor asked Registered Nurse (RN) H to describe emergency procedures for a resident experiencing anaphylactic shock. RN H stated she would go to emergency box and get out the epi-pen. Surveyor asked if they used a pen, RN H indicated, I think so, let me check. It should be a pen as that would be the most practical way with the right dose. RN H went to the med room and went to the emergency box and looked at the back up book to look for [MEDICATION NAME]. The book stated [MEDICATION NAME] (3) for [MEDICATION NAME] ([MEDICATION NAME]). Surveyor asked if they use [MEDICATION NAME]. RN H said, I guess so. Surveyor asked if there are any special protocols to drawing up the [MEDICATION NAME]. RN H said, Draw it up and give it IM, nothing else that I know of. Procedure for drawing medication from an [MEDICATION NAME] (an [MEDICATION NAME] is a glass container containing liquid medication) -Using a clean piece of gauze, or a new alcohol wipe, grasp the neck of the [MEDICATION NAME] and quickly snap the top off directing away from you -Remove the syringe from its package and attach the filter needle to the syringe, securing snuggly (the filter needle prevent fragments of glass from being drawn up) -Using a clean piece of gauze, or a new alcohol wipe, grasp the neck of the [MEDICATION NAME] and quickly snap the top off directing away from you. Place on a flat surface -Remove the cap of the needle and, tilting the [MEDICATION NAME] gently, place the tip of the needle inside the [MEDICATION NAME] to withdraw the medication into the syringe -Remove the filter needle -Attach the non-filter needle to the end of the syringe and secure tightly. At 7:59 a.m., Surveyor interviewed Nurse Tech (NT) I, Surveyor asked NT I her status. She indicated she is a graduate nurse, and will be taking her boards soon. Surveyor asked process for using [MEDICATION NAME] for emergency. NT I indicated the staff get it from back up supply, but was not sure what form the medication was available (an epi-pen or [MEDICATION NAME]). Surveyor asked the process for drawing medication from an [MEDICATION NAME]. NT I did not know. Surveyor asked if NT is working the 100 hall where R25 resides. NT I said, Yes. Surveyor asked if there are any residents that have orders for [MEDICATION NAME] in case of an anaphylactic reaction on that hall. NT I stated, No. At 8:05 a.m., Surveyor interviewed RN C about [MEDICATION NAME] use and processes for emergencies. RN C indicated that the Back Up Med Reference Book did not contain the correct information. The box did contain an epi kit, on the 3rd shelf, but it was turned upside down so the nurses could not see the label. The kit contains an [MEDICATION NAME], a filter needle, and a regular needle. The kit also contains instructions. RN C indicated the pharmacy will be coming to review and relabel the box today and add additional instructions for the correct administration of the [MEDICATION NAME]. The pharmacy will be providing an epi-pen for R25, so the emergency supply is available on the medication cart for R25. Surveyor asked if the facility has done any education or competency evaluations for the use of [MEDICATION NAME]. RN C indicated there has been no training. Surveyor asked if R25 has had any allergic reactions since her admission. RN C indicated R25 has not, and stated the facility does not serve shellfish. R25 has not been served fish as the dietary card was correct. Surveyor asked if there are any other residents in the building that have orders for emergency [MEDICATION NAME] treatment with [MEDICATION NAME]. RN C stated there are no other residents. Surveyor shared concerns about a lack of competency and knowledge staff have regarding the location of epinepherine, what form it is in (epi-pen or [MEDICATION NAME]), how to administer the [MEDICATION NAME], (using a filtered needle to draw and then change to another needle), and the correct dose to administer should an emergency occur. Surveyor shared the interviews with staff conveying that the staff did not know what residents have orders for [MEDICATION NAME], or why they would need it. RN C indicated the facility will be doing all staff training on emergency situations in which epinepherine is used. At 10:00 a.m., Surveyor requested a policy and procedure for the use of the [MEDICATION NAME] or [MEDICATION NAME] for emergencies. The NHA indicated the facility does not have a policy or procedure for this. The current medication policy was reviewed and contains no specific information related to the above.

Based on interviews and record review, residents were not allowed to choose wake times for 2 of 14 Residents (R), R10 and R18. R10 and R18 indicated staff awaken them in the morning to tell them it is time to get up, not allowing them to decide for themselves when they would like to get out of bed in the mornings. This is evidenced by: 1. R10's [DIAGNOSES REDACTED]. R10's Brief Interveiw for Mental Status (BIMS) was 04 on 3/20/19, indicating cognitive impairment. On 06/18/19 at 9:00 a.m., Surveyor conducted a group meeting. During the meeting, R10 stated, I am awakened every morning and told it is time to get up. I've told them I would rather sleep but they will not let me I don't want to get up so early .they wake me up and tell me it's time to get up . On 06/19/18 at 9:45 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) A, who is primarily responsible for assisting R10 with Activities of Daily Living (ADLs). CNA A stated, R10 is usually awake. It is very seldom that we have to wake her up .yes, we do have to wake her up if she's not awake . Surveyor reviewed R10's Minimum Data Set (MDS). The MDS, dated [DATE], indicated R10 has no problem falling asleep. Surveyor reviewed a document entitled Sleep Assessment. The document indicated R10 has normal sleep patterns. Surveyor reviewed R10's plan of care. The nursing care plan, dated 03/22/19, read: Potential to feel sad and anxious . I need the aides to .give me choices and honor preferences . On 06/19/19 at 11:10 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) and Registered Nurse (RN) C. The NHA and RN C stated the facility staff should not awaken residents to ask them if they want to get up or sleep longer. 2. R18's [DIAGNOSES REDACTED]. R18's BIMS was 15, indicating cognitively intact, on 05/04/19. On 06/17/19, Surveyor conducted an interview with R18. When asked about choices, R18 stated, I don't want to get up so early sometimes. They wake me up and tell me I have to get up. On 06/19/19 at 8:02 a.m., Surveyor interviewed R18. R18 stated, Yes, they (the staff) have woken me up and told me it's time to get up on 06/17/19 and 06/18/19. Surveyor interviewed CNA A. CNA A stated, We let them (the residents) sleep unless it gets closer to breakfast, then we wake them up . Surveyor interviewed CNA B. CNA B stated, No we don't make them get up, but we do go in the rooms and rub them gently on the shoulder and say, 'Would you like to get up? Or sleep for another 1/2, 1 hour?' We give them their preference. CNA B agreed staff are waking residents up and asking them if they would like to sleep longer. Surveyor reviewed R18's MDS. The MDS, dated [DATE], indicated R18 has no problem falling asleep. Surveyor reviewed a document entitled Sleep Assessment. The document indicated R18 has normal sleep patterns. Surveyor reviewed R18's plan of care. The plan of care does not outline desired wake times. On 06/19/19 at 11:10 a.m., Surveyor interviewed the NHA and RN C. The NHA and RN C stated the facility staff should not awaken residents to ask them if they want to get up or sleep longer.

Based on observation, interview and record review, the facility did not ensure residents were treated with dignity for 1 of 16 (R32) residents observed on three days of survey. R32 was upset about facility staff not assisting with facial hair removal, since R32 was not able to do this independently. Findings: Resident was admitted [DATE], after a fall and [MEDICAL CONDITION] at home. R32 required surgery and then was admitted to the facility for rehabilitation. Brief Interview for Mental Status (BIMS) score on 05/18/19 is 11, indicating R32 has some cognitive deficits. On 06/17/19 at 9:22 AM, Surveyor observed multiple white whiskers on R32's chin and face. On 06/17/19 at 12:14 PM, Surveyor observed facial hair is still present while resident is seated at the dining table for lunch. Whiskers are approximately 1/4 inch long. On 06/17/19 at 3:55 p.m., whiskers still present on resident's face. On 06/18/19 at 6:52 AM, whiskers still present on face. Resident is in hallway, going to the dining room for breakfast. On 06/18/19 at 12:20 p.m., R32 is at lunch. Whiskers present on face and chin, greater than 1/4 inch long. On 06/18/19 at 2:10 p.m., Surveyor interviewed R32 about facial hair. When asked if R32 is bothered by the facial hair, R32 stated, I would like to have them shaved off, it's been too darn long. I don't like it. I don't think I have anything to shave them with. When I was at home I took care of it myself. Surveyor asked if R32 has asked for help. R32 indicated she has told some of the girls she would like them shaved. R32 then stated, I look like a man. On 06/19/19 at 7:10 a.m., Surveyor went to R32's room to observe morning cares. Surveyor interviewed Certified Nursing Assistant (CNA) A about the facial hair. CNA A stated it must have been overlooked. Surveyor asked if R32 has her own razor CNA A said, No. CNA A indicated they will get one from the beauty shop and take care of it. Surveyor asked if R32 can do on her own personal hygiene and grooming. CNA stated, No, she needs assist for all personal cares. The CNA care plan in part: I can't complete cares on my own .I do hygiene/grooming with the help of 1 person . On 06/19/19 at 7:20 a.m., Surveyor interviewed the Nursing Home Administrator (NHA) about the observations and resident dignity concerns with unshaven facial hair. The NHA stated she would take care of it.

Based on interview and record review, the facility failed to ensure the medical record for 1 of 16 (R25) residents was complete and accurately documented for known allergies [REDACTED].>R25 was admitted with a known fish allergy. This was not documented on the physician orders [REDACTED]. Findings: R25 was admitted on [DATE]. The physician orders [REDACTED]. Surveyor observed medication pass for R25 on 06/18/19 at 7:30 a.m. and noted an order for [REDACTED]. The order does not specify what allergen would cause the [MEDICATION NAME] reaction. At 3:45 p.m., Surveyor interviewed R25 who has a Brief Interview for Mental Status (BIMS) score of 10. R25 stated she has allergies [REDACTED]. R25 stated yes all fish and shellfish. Surveyor asked what symptoms R25 has if she eats fish. R25 stated, I puff up, as she pointed to her mouth and face. The fish is not listed on the Physician order [REDACTED]. At 3:55 p.m., interviewed the Director of Nursing (DON) about conflict in listed allergies [REDACTED]. At 4:00 p.m., Surveyor interviewed the DON and Nursing Home Administrator (NHA) about the documentation from the dietary card, and interview with R25 not being consistent with the physician orders. The NHA stated they would clarify allergies [REDACTED]. On 06/19/19 at 7:20 a.m., Surveyor interviewed the NHA, about the conflicting allergy from physician orders [REDACTED]. The allergy list will be updated. Surveyor interviewed Director Of Nutritional Services I, who stated she believes fish was identified on admit 4/25/18 as the allergy from the first dietary assessment. Surveyor reviewed the admit initial assessment 4/25/18 that identifies fish as the allergy, but does not identify shellfish. On 06/19/19 at 10:30 a.m., Surveyor interviewed Registered Nurse (RN) C and the NHA. Surveyor asked if the medical record had correctly documented R25's allergies [REDACTED]. RN C stated the allergies [REDACTED].

Based on observation, interview, medical record review and policy review, the facility did not ensure that an infection prevention and control program was implemented to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of infections for 2 of 3 residents (R36 and R3) observed during wound care and 1 of 6 residents (R30) observed during medication pass. Staff did not perform hand hygiene after opening a sterile dressing prior to applying the dressing to a ulcer when performing wound care on R36. Staff did not wash their hands for 20 seconds and did not perform hand hygiene when indicated during wound care observation on R3. Staff did not perform hand hygiene after picking a glove off the floor before administering insulin to R30. This is evidenced by: The facility's policy entitled Handwashing Policy dated 08/18/17 states in part, Purpose: To prevent the spread of infection- Handwashing Required: Always wash hands before doing cares on resident, after cares, after removing gloves, before leaving room and when visibly soiled. Procedure: Handwashing: Wash all parts of hands for 20 seconds. ~Wound Care 1. On 06/04/18 at 2:00 p.m., Surveyor reviewed R36's medical record. R36 has a venous stasis ulcer on the right shin. The physician ordered the following treatment on 05/23/18, Cleanse ulcer to right lateral aspect of shin with normal saline and pat dry. Apply collagen to wound bed, then alginate. Cover areas with ABD pad and secure with rolled gauze and tape. Change daily PM and as needed for dislodgement/saturation until healed. On 06/04/18 at 2:55 p.m., Surveyor observed a dressing change on R36 performed by Registered Nurse (RN) A who is a wound care nurse. RN A removed the soiled dressing, performed hand hygiene and regloved. RN A cleansed the ulcer. Resident's ulcer is 1.5 inches in diameter and open. RN A regloved and opened a sterile package of collagen dressing. RN A did not change the contaminated gloves. RN A picked up the sterile dressing with contaminated gloves and applied the dressing to the open ulcer. RN A degloved and used hand sanitizer and completed the dressing change. On 06/06/18 at 7:30 a.m., Surveyor interviewed RN F who is the infection control nurse and staff educator. Surveyor discussed the wound treatment observation on R36 performed by RN A. Surveyor asked RN F what would be her expectation. RN F stated RN A should have changed her gloves prior to applying the collagen dressing. RN F stated she performs audits of nurses performing wound care and handwashing. On 06/06/18 at 8:15 a.m., Surveyor discussed the wound care observation with the Director of Nursing (DON). Surveyor asked the DON what she would expect staff to do. The DON stated she would expect RN A to change her gloves and perform hand hygiene before placing the clean dressing on the wound. 2. On 06/05/18 at 10:00 a.m., Surveyor reviewed R3's medical record. R3 has a [DIAGNOSES REDACTED]. On 04/13/18, the physician ordered [MEDICATION NAME] 2% ointment topical applied three times per day to the upper left lip until healed and cover with a bandaid. On 06/05/18 at 8:05 a.m., Surveyor observed Licensed Practical Nurse (LPN) C perform wound care on R3. LPN C washed her hands 8 seconds and wet a washcloth with water. LPN C gloved. LPN C removed the soiled bandaid. LPN C did not change her gloves and perform hand hygiene. LPN C washed R3's left lip with wet washcloth and dried area. LPN C degloved, pulling glove off inside out over soiled washcloth. LPN C then placed the glove containing the washcloth on the resident's recliner. LPN C washed hands for 8 seconds. LPN C regloved, opened a bandaid and applied [MEDICATION NAME] to the bandaid. LPN C then applied the bandaid to resident's left lip. R3 has a 1/2 inch open area on the left upper lip. LPN C did not change her gloves and perform hand hygiene. LPN C, with same gloves on, picked up the dirty glove with the washcloth inside it, a bag containing eye drops and a bag containing nasal spray and left R3's room. LPN C unlocked the medication room with the contaminated gloves, entered the medication room and placed the bag with eye drops and the bag with the nasal spray on the counter. LPN C left the med room with the same contaminated gloves on and opened the door to the soiled utility room. LPN C disposed of the washcloth and the dirty glove, degloved and washed her hands for 20 seconds. On 06/06/18 at 7:30 a.m., Surveyor interviewed RN F who is the Infection Control nurse and staff educator. Surveyor discussed the observation of wound care provided to R3 by LPN C. Surveyor asked what RN F would expect LPN C to do. RN F stated LPN C should have washed her hands for 20 seconds. RN F stated the facility policy is to wash hands for 20 seconds. RN F stated LPN C should have performed hand hygiene before cleaning the ulcer and after the dressing change. RN F stated LPN C should have done the following: put the dirty washcloth in a bag, degloved and performed hand hygiene in the resident's room, then put meds away in med cart, then go back and remove dirty washcloth from the room. RN F stated she performs dressing change audits on nurses. RN F stated RN A does audits of dressing changes on the p.m. shift. On 06/06/18 at 8:15 a.m., Surveyor interviewed the DON). Surveyor discussed the wound care observation on R3 by LPN C. Surveyor asked what the DON's expectation would be. The DON stated she would expect LPN C should have performed hand washing for 20 seconds. The DON stated the facility policy is to wash hands for 20 seconds. The DON stated LPN C should have performed hand hygiene after removing the soiled bandaid and before leaving the room. ~Medication Pass On 06/05/18 at 10:15 a.m., Surveyor reviewed R30's medical record. R3 has a [DIAGNOSES REDACTED]. On 06/05/18 at 8:30 a.m., Surveyor observed RN B draw up [MEDICATION NAME]for R3. RN B grabbed a handful of gloves and dropped one glove on the floor. RN B picked up the glove off the floor and disposed of the glove in the garbage on the med cart. RN B did not perform hand hygiene. RN B went to R30's room to administer the insulin. RN B did not perform hand hygiene. RN donned gloves and administered the insulin to R30. RN B asked Surveyor how she did. Surveyor informed RN B of not washing her hands after picking the glove off the floor and prior to giving the insulin. RN B stated, I should have washed my hands or used hand sanitizer before giving the insulin. On 06/06/18 at 7:30 a.m., Surveyor discussed the medication observation by RN B. Surveyor asked RN F what she would expect. RN F stated she expected RN B would have washed her hands or use hand sanitizer after picking the glove off the floor. RN F stated she performs audits of nurses during medication pass and handwashing. RN F stated RN A performed audits of nurses with handwashing and med pass on the p.m. shift. On 06/06/18 at 8:15 a.m., Surveyor interviewed the DON. Surveyor discussed the medication observation by RN B. Surveyor asked the DON what her expectation would be. The DON stated RN B should have performed hand hygiene after touching the floor.

Based on observation, interview and record review, the facility did not ensure the accurate administering of drugs to meet the needs of 3 of 6 residents (R14, R35 and R3) observed during medication pass. Two of three nursing staff did not perform three checks of the 5 rights to ensure the accurate administration of medications to R14, R35 and R3. This is evidenced by: On 06/04/18 at 12:00 p.m., Surveyor observed Nurse Technician (NT) D administer medication to R14. NT D performed one check when dishing up the medications. NT D administered the following medications: [REDACTED]. On 06/04/18 at 12:05 p.m., Surveyor observed NT D administer medication to R35. NT D performed one check when dishing up the medications. NT D administered the following medications: [REDACTED]. On 06/05/18 at 8:05 a.m., Surveyor observed Licensed Practical Nurse (LPN) C administer medication to R3. LPN C performed two checks during the medication pass before and during the dishing of medication. LPN C administered the following medications: [REDACTED]. On 06/06/18 at 7:30 a.m., Surveyor interviewed Registered Nurse (RN) F who is in charge of infection prevention and staff education. Surveyor discussed the med pass observations of NT D and LPN C. Surveyor asked RN F how many checks are the nursing staff to do when administering medication. RN F stated one check. RN F stated she checks the medication versus the Medication Administration Record [REDACTED]. On 06/06/18 at 8:15 a.m., Surveyor interviewed the Director of Nursing (DON). Surveyor discussed the medication pass observation of two nurses who did not complete three checks during the medication pass. Surveyor asked the DON how many checks are the nursing staff to complete when administering medication. The DON stated staff are to perform three checks during medication pass; check before, during and after administering the medication. On 06/06/18 at 8:45 a.m., RN F told Surveyor she spoke wrong. RN F stated the facility policy is to do three checks during med pass.

Based on observation, interview and record review, the facility did not ensure pain management was provided to residents who require such services, and did not include in the comprehensive care plan. This occurred for one of twelve residents (Resident (R) 23) who were reviewed for pain. R23 has a wound to the right, upper arm, and the resident experiences pain during dressing changes and when the wound is touched. There is no documentation pain medication is being offered prior to dressing changes. The resident's care plan does not identify the resident's wound pain, nor individualized interventions related to pain management. This is evidenced by: On 06/04/18, Surveyor reviewed R23's medical record. The resident has [DIAGNOSES REDACTED]. The resident is [AGE] years of age. The resident's most recent Brief Interview for Mental Status (BIMS) score, dated 04/19/18, was a 10 out of a possible 15 points. According to the BIMS assessment, a score of 10 indicates the resident has moderately impaired cognition. The resident has an order for [REDACTED]. The resident does not have any scheduled pain medication. R23 has an order which states the following, in part, Ask resident if they have pain. Offer PRN (as needed) pain medication if they are having pain. Was pain medication accepted or declined .AM PM. This has been ordered, since 10/25/16. The resident has an open wound on the right, upper arm from a skin biopsy. An order, dated 05/31/18, identifies the wound should be cleansed and changed twice a day. Prior to 05/31/18, the resident had a dressing change once a day. The resident's Minimum Data sets (MDS'), from 01/25/18 and 04/23/18, indicates R23 has not received scheduled or as needed pain medications within the previous seven days and has not reported any pain within the previous seven days. Surveyor reviewed R23's nurse's notes, from 03/01/18 to 06/05/18. The notes state the following, in part: -03/01/18: A rough patch was identified on the resident's right, upper arm; from a previous skin biopsy. -04/01/18: The resident continues to have a large, rough hard callous to the right, upper arm. The note states R23 complains of stinging pain when this area is touched. -05/13/18: The notes identify an old wound dressing was removed from the resident's right, upper arm, and the resident reported this area is tender to the touch. -05/14/18: The dressing to the resident's right arm was changed. The notes state the resident complained of pain during the treatment. -05/15/18: During the dressing change, the resident complained the wound to the right arm is very tender to the touch. The facility sent a fax to the resident's physician, on 05/16/18, with an update on the condition of the arm wound. The fax states the following, in part, .Pain noted with cleansing of area . The physician referred R23 to surgery. A physician progress notes [REDACTED].has a [MEDICAL CONDITION] on her right upper arm. It is over the biceps. Did see Dermatology and had a biopsy done .This was done several months ago. The [MEDICAL CONDITION] has not healed. It is mildly tender. It is fairly large. It is raised on the right upper arm . The resident's nurses' notes state, in part: -05/17/18: old dressing removed .resident c/o (complained of) pain throughout tx (treatment) stating it hurts when being cleansed/being touched in general . -05/18/18: The resident's right, upper arm wound was cleansed and the dressing was changed. The note identifies the resident reported the wound was painful. -05/19/18: Dressing change done to the right, upper arm wound, the note states the resident reported pain. -05/20/18: (Arm wound) Cleansed with saline; very tender to touch; resident hollers out 'ow' during tx . -05/24/18: old dressing removed. area cleansed with normal saline and patted dry, which was painful for resident .resident complains of pain throughout treatment process, but refuses any intervention, including pain meds (medications) . This is the first time it is documented in R23's medical record the as needed pain medication was offered. The resident's nurses' notes continue, in part, -05/25/18: Skin tx done per order .The area is moist, red, swollen and painful . -05/27/18: Old dressing removed .Slight redness also noted around stitches .Did grimace when open areas were cleansed and dried . -05/29/18: Removed old dressing from right upper arm incision .Complaints of pain noted with palpation of area . -05/31/18: old gauze removed .resident c/o pain during tx, but only while cleansing . -06/01/18: Dressing changed on the right arm wound. The note states the resident reports pain when the wound is touched. -06/03/18: Dressing change to the right arm wound. The note identifies the resident had pain when the wound is touched. -06/04/18: old dressing removed .PA (Physician's Assistant) removed stitches .resident c/o pain during cleaning and stitch removal . Surveyor reviewed R23's care plan, which states the following, in part: 04/23/18 .I NEED to be asked if I'm in pain BECAUSE I .gouty arthritis that will flare up at times .I need my nurses to---ask me if I hurt, offer me pain medication and administer my medications as ordered. Nurses will assess if any pain medications that were given were effective and monitor for side effects. Nurses will notify provider if I should develop increased complaints of pain or discomfort .MY GOAL IS TO: I will continue to be pain free with no gouty flare ups causing pain or discomfort . 05/31/18 .I have fragile skin BECAUSE I am a diabetic, have kidney disease, have poor tissue perfusion related to [MEDICAL CONDITION] and venous stasis disease. Biopsy [MEDICAL CONDITION] to right upper arm. [MEDICAL CONDITION] removed 05/21/18 and have surgical incision (incision dehisced 05/29/18) .MY GOAL IS TO: keep my skin healthy and intact . The care plan does not identify R23 has pain from the right arm wound, nor does it identify individualized interventions in order to alleviate the resident's pain. On 06/04/18 at 12:33 p.m., Surveyor observed R23's room door closed. At this time, PA G entered the resident's room. At 12:35 p.m., Surveyor heard the resident yell, Ouch, ouch! from the hallway, outside of the resident's closed room door. At 12:36 p.m., Surveyor heard the resident yell, Ouch! from the hallway, outside of the resident's closed room door. At 12:37 p.m., Surveyor heard a staff member say, Thank you, and I'm sorry if I hurt you. This was heard from the hallway, outside of the resident's closed room door. At 12:39 p.m., Surveyor observed PA G exit R23's room. The PA stated a facility nurse was still located inside of the resident's room, completing the dressing change on the resident's right arm wound. On 06/05/18 at 7:32 a.m., Surveyor interviewed R23. Surveyor asked if the resident has pain in the right arm wound. The resident stated she was not currently having any pain in the right arm but stated the wound hurt before and will hurt sometimes. The resident further stated staff asks if the resident needs any Tylenol, but did not specify when/what time of the day staff ask the resident. On 06/05/18 at 2:49 p.m., Surveyor observed R23's wound care on the resident's right, upper arm. At this time, the resident was sitting up in a wheelchair, in the resident's room, and Surveyor observed Registered Nurse (RN) A complete wound care. During the observation, RN A was observed to dab triple-antibiotic ointment, via a sterile swab, onto R23's open wound. At this time, Surveyor observed the resident look away from the resident's wound, and the resident was observed to have facial grimacing, and a furrowed brow. At approximately 2:58 p.m., when the dressing change was completed, Surveyor asked R23 if the resident experienced any pain during the treatment. The resident replied she could feel it. Surveyor asked if the resident felt any discomfort in the resident's right arm, to which R23 replied, Yes. At 3:03 p.m., Surveyor interviewed RN A. Surveyor asked if the RN offered R23 Tylenol prior to completing the dressing change. RN A replied she had not offered or administered R23 with Tylenol prior to the dressing change. The RN stated she usually completes the resident's dressing changes every Wednesday, and the hall nurses change the dressings other days. Surveyor asked if RN A offers R23 Tylenol prior to dressing changes on Wednesdays, to which RN A replied, No. The RN stated the resident's right arm was painful, last week. RN A further stated R23 would report having pain when the wound is touched. On 06/06/18 at 7:30 a.m., Surveyor received and reviewed R23's list of as needed medications, which have been administered to the resident, from 04/01/18 to 06/05/18. The following dates are when R23 received the as needed Tylenol, since 04/01/18: -05/22/18: Given for a headache -05/25/18: Given for right arm pain. The medication was documented as being effective in treating the resident's pain. -06/06/18: Given for a fever. On 06/06/18 at 9:53 a.m., Surveyor interviewed Licensed Practical Nurse (LPN) E, who has completed dressing changes to R23's right, upper arm wound. The LPN stated she tries to offer R23 Tylenol prior to the dressing changes, but the resident refuses the pain medication. LPN E further stated the resident is [AGE] years old and is very hard of hearing. Surveyor asked the LPN if the resident shows any signs of pain during dressing changes, to which LPN E replied the resident doesn't moan, doesn't holler out and has never complained of pain. LPN E indicated she has documented in the resident's medical record when the LPN has offered, and when the resident has refused Tylenol prior to dressing changes. At 9:58 a.m., Surveyor interviewed Nurse Tech (NT) D, who has completed R23's dressing changes. The NT stated she has offered the resident Tylenol prior to dressing changes, but the resident usually refuses. NT D stated she generally documents in the resident's nurses' notes when the resident refuses Tylenol. NT D stated before the section of the resident's arm was biopsied (where the current wound is located), the resident's upper, right arm always bothered R23, and it hurt when it was touched. Surveyor asked the NT if the resident shows any signs of pain during dressing changes. The NT stated there are times in which the gauze would stick to the resident's wound, and the resident would fidget a little when the gauze was removed. During the continued interview, NT D indicated on 06/04/18, PA G removed a few stitches from R23's wound, and this NT was present when this occurred. Surveyor asked if NT D offered R23 Tylenol prior to the PA's visit and the dressing change the afternoon of 06/04/18. NT D replied she offered the resident Tylenol prior to the dressing change/stitches being removed, but R23 refused. Surveyor asked if the resident had any pain when the stitches were removed, and NT D replied the resident was saying, Ow, and was jerking her arm. Surveyor asked NT D if the PA or NT stopped the procedure and offered R23 Tylenol before additional stitches were removed. NT replied she nor the PA stopped the procedure, and did not offer any Tylenol to the resident when the stitches were removed. There is no documentation in R23's medical record if nursing staff have offered Tylenol prior to completing dressing changes or if the resident refuses the Tylenol. At 10:05 a.m., Surveyor interviewed the Director of Nursing (DON) and the above interviews and observations were discussed. The DON stated the nurses ask R23 if the resident has pain, and this is done every shift throughout the day, everyday. The DON stated the nurses should be documenting in the nurses' note if Tylenol was offered and if the resident refused this pain medication, prior to any dressing changes. The DON stated she would expect the nurses to be documenting when the nurses are offering Tylenol and if the resident is refusing, prior to any dressing changes. Surveyor asked if the facility has asked the physician if R23 could have a scheduled pain medication, prior to dressing changes. The DON replied she has not seen any requests for scheduled pain medications from a physician. Surveyor discussed the resident's care plan, which the DON reviewed. The DON stated the care plan needs to be updated to reflect the resident is having pain in the wound.