Every finding on record at Mercy Manor Transition Center

Based on interview and record review, the facility did not ensure that each resident received, and the facility provided, care and services consistent with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 4 residents (R1) reviewed for change of condition. On [DATE], R1 presented with a change of condition including weakness, abnormal lung sounds, a fever of 102.6, cough, influenza positive, and shortness of breath. As the day progressed, R1 continued to deteriorate with increased symptoms of difficulty breathing and weakness. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician even as R1's condition continued to deteriorate. R1 expired at the facility on [DATE] at 11:58 PM. The facility's failure to complete a comprehensive nursing assessment and notify the physician with a change of condition created a finding of Immediate Jeopardy beginning on [DATE]. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the finding of Immediate Jeopardy on [DATE] at 5:15 PM. The immediacy was removed on [DATE] and continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. This is evidenced by: According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. The facility's policy titled SNF (Skilled Nursing Facility)/Sub-Acute Condition Change Reporting dated ,d+[DATE] states in part: Policy: Communication with the physician is maintained with healthcare professionals, the resident/patient, family, and/or significant other(s) when a change in a resident's/patient's condition affects the current level of his/her care. 1. The physician, resident/patient, and/or family are notified when the resident's physical, communicative, psychosocial, or functional status changes unexpectedly, the resident is injured, or if treatment is significantly altered. 2. If nursing staff is unable to reach the resident's/patient's attending physician, the facility medical director of the physician on-call will be notified. 3. If there is a question by nursing about the appropriateness of physician follow-up, the Director of Nursing and Administrator are notified .5. The resident's/patient's condition and the notification of residents/patients [sic] chosen representative, and physician must be documented in the EMR (Electronic Medical Record) medical record. The facility's policy titled [Facility Name] SNF Assessments dated ,d+[DATE] states in part: .Policy: Assessment will occur prior to an admission, upon admission, quarterly, and upon significant change. Assessment findings will be documented, the attending physician notified as applicable and a plan of care will be initiated or updated to reflect findings .Changes in Resident Condition In the event that a resident's physical, mental, or psychosocial status changes; or if there is a significant change or an injury occurs, the attending physician, other authorized healthcare professionals and family/guardian will be notified. An RN (Registered Nurse) or MD (Medical Doctor) will perform an assessment, and the findings will be documented in the nursing notes. R1 admitted to the facility on [DATE] with diagnoses that include end stage renal disease requiring hemodialysis (a procedure that involves passing blood through a filter to remove waste and extra fluid), congestive heart failure (a chronic condition where the heart can't pump blood well enough to give the body a normal supply), and left ankle fracture. R1's Brief Interview for Mental Status dated [DATE] has a score of 15 indicating R1 is cognitively intact. R1's nursing progress notes state the following: [DATE] at 1:36 AM 0030 (12:30 AM) pt (Patient) up to BR (Bathroom), per CNA (Certified Nursing Assistant) more difficult to transfer than normal, pt c/o (Complained Of) being SOB (Shortness of Breath) with transfer, breathing noted to be regular, even. LUL (Left Upper Lobe), RUL (Right Upper Lobe) CTA (Clear to Auscultation), bilateral lower lobes unable to hear, no cough noted, per pt states she was coughing during day and reports bright yellow sputum. Denies dizziness. Vitals taken, Temp (Temperature) elevated Tylenol last given at 2221 (10:21 PM) for headache, SPO2 (percentage of oxygen in the blood) on 2l (Liters)/via n/c (nasal cannula) was ,d+[DATE]%. O2 (supplemental oxygen) increased to 3l/min for 30min (minutes) SPO2 at 96%, decreased O2 back to 2 liters Secure chat (electronic portal to communicate with physician similar to a direct message on a phone) sent to MD (Medical Doctor). Pt resting quietly in bed at this time with eyes closed, will continue to monitor. Electronically signed by RN G at [DATE] 1:46 AM [DATE] at 8:46 AM - CNA reports to this RN (Registered Nurse) that pt seems off this morning. Pt has wet, productive deep cough and her mental status seems off. She is struggling to answer simple questions, has fever and cough and her functional decline in transfers and ADLs (Activities of Daily Living) has deteriorated since Friday. Temp is elevated at 102 this AM, BP (Blood Pressure) ,d+[DATE] and is currently on 2L of O2. She is weak and lethargic at this time. I know she recently started on Metolazone (medication used to treat high blood pressure and fluid retention). Lungs sounded course and diminished in LLL (Left Lower Lobe), RLL (Right Lower Lobe), LUL (Left Upper Lobe). Chat sent to MD. Electronically signed by RN H at [DATE] 11:33 AM Of note, [DATE] at 8:46 AM is the last documented RN assessment for R1. [DATE] at 9:14 AM - Per protocol COVID swab obtained. Resulted negative. Electronically signed by DON B at [DATE] 9:14 AM [DATE] at 9:16 AM - Per RN staff, patient had difficulty performing a stand pivot transfer wheelchair to toilet on this date due to difficulty following commands. Patient's chart reviewed. Patient sitting in recliner with supplemental oxygen donned and sleeping. Patient awoke enough to state she was feeling lousy but then immediately fell back to sleep and didn't answer any other subsequent questions. Patient mouth breathing and appeared SOB. Discussed concerns with RN [Name] and DON B. Will hold PT (Physical Therapy) treatment session on this date as patient is not medically appropriate and unable to stay alert enough . Electronically signed by PT I (Physical Therapist) at [DATE] 9:26 AM [DATE] at 10:10 AM - VM (Voicemail) and Email sent to [Assisted Living Name] - R1 is not feeling well today so assessment will need to be rescheduled . Electronically signed by SW J (Social Worker) at [DATE] 10:11 AM [DATE] at 12:35 PM - Pt not feeling well this afternoon with temp per nursing. Upon room entry pt also visibly shaking and stated she was not feeling well. Will reattempt to see for skilled OT (Occupational Therapy) services at later date as pt able. Electronically signed by COTA K (Occupational Therapy Assistant) at [DATE] 1:03 PM [DATE] at 1:08 PM - MD notified of critical lab. NOR (New Order) received for CXY (Chest X-ray) and Resp (Respiratory) panel. Electronically signed by RN H at [DATE] 11:38 AM Of note, R1's change in condition started 12.5 hours prior to the first documented consultation with a physician that included interventions. Of note, DON B (Director of Nursing) indicated the critical lab reported was the Influenza A1H3 positive result. [DATE] at 4:25 PM - Critical Lab reported to MD. Resp panel positive for Influenza A1H3 . Electronically signed by RN H (Registered Nurse) [DATE] 4:25 PM [DATE] at 6:30 PM - .Summary of physical status and trends R/T (Related To) skilled service: . Pt. Has had SOB, fever, and crackles to RUL (Right Upper Lobe) and bilat (Bilateral) LL (Lower Lobe) are both diminished. Pt had CXR (Chest X-Ray) and full resp panel. Pt Is pos. (Positive) For Influenza A1H3. Pt. Wheezing bilateral UL (Upper Lobe). Albuterol inhaler (medication used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing and chest tightness) not affective [sic] as pt is SOB and unable to accurately use her inhaler . Electronically signed by LPN L (Licensed Practical Nurse) at [DATE] 7:47 PM [DATE] at 7:08 PM - New set of v/s (Vital Signs) obtained. Spot [sic] 92 2LN/C B/P ,d+[DATE], P100 Temp 102.6 MD notified. Electronically signed by LPN D at [DATE] 5:56 PM On [DATE] at 12:53 PM, Surveyor interviewed LPN D regarding notification of MD. LPN D indicated MD notification was sent via secure chat (an electronic portal to communicate with the physician) and LPN D did not speak to and did not consult with a physician. [DATE] at 9:45 PM - Received a call from the nurse stating patient had developed a fever, seemed to be having more difficulty breathing and weaker. Nurse stated he had called MD [Name] but could not get a hold of him. Writer advised nurse to call NP [Name] (Nurse Practitioner) and update her. Writer received no phone call after that and was not aware that nurse was unable to reach NP [Name]. Electronically signed by RN C at [DATE] 12:54 AM [DATE] at 10:11 PM - Resident noted with temperature of 102.6, increased difficulty breathing, increased weakness. Calls with messages placed to MD [Name] and NP [Name]. Awaiting callback. House supervisor (RN C) aware of change in condition. PRN (As needed) nebulizer (a small machine that turns liquid medicine into a mist that can be inhaled through a mouthpiece or mask) administered as ordered. Medication was effective. Mouth care performed. Resident declined any other medications/cares at this time. Electronically signed by LPN D at [DATE] 10:17 PM [DATE] at 12:01 AM - I went into resident's room (2330hrs) (11:30 PM) to monitor her. It appeared resident's [sic] wasn't breathing, resident's fingers where [sic] blue in color and her mouth was fixed in an open position. I called the house supervisor (RN C) who gave me the on-call Doctor number which, I called. The doctor came up and pronounced the resident at 2358hrs (11:58 PM). Electronically signed by LPN D at [DATE] 6:46 AM [DATE] at 1:16 AM - When I went into resident's room at 2330hrs (11:30 PM) it appeared that resident's [sic] was not breathing, resident was rigged [sic], finger tips where [sic] blue in color and cold on both hands and her mouth was fixed in an open position. I looked for the rise and fall of resident chest and saw no movement. I felt for resident's radial pulse and felt no pulse I spoke with the aide (CNA E) who stated that she had just looked-in-on the resident at 2250hrs (10:50 PM) I then walked back to the nursing station and called the House Supervisor (RN C) who gave me the number for Doctor [Name]. I called Doctor [Name]. Electronically signed by LPN D at [DATE] 1:28 AM On [DATE] at 12:53 PM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R1's change in condition. LPN D gave the following timeline for his shift on [DATE] in regard to R1: 6:30 PM LPN D arrived to the unit. LPN D was unable to get shift report from the LPN L right away, so LPN D printed his resident list and started making rounds. 6:45 PM LPN D entered R1's room and noticed R1 was not doing well. R1 was sweaty, having difficulty breathing, and her words were a light whisper when she spoke. LPN D indicated R1 sounded gurgly like she had phlegm in her mouth. LPN D directed CNA F to obtain vital signs. 7:00 PM LPN D received shift report from the LPN L. LPN D stated LPN L reported R1 had a chest x-ray and respiratory panel completed which indicated R1 was positive for Influenza. LPN D indicated LPN L had received an order for a nebulizer treatment and LPN L was going to enter the order into the electronic medical record. LPN D indicated he received R1's vitals, sent a secure chat to the doctor because of R1's status and contacted the respiratory department to obtain the supplies for the nebulizer. 7:,d+[DATE]:00 PM LPN D indicated he gave R1 the nebulizer treatment, he raised R1's head of the bed and ensured the supplemental oxygen was in place. LPN D said he did not listen to her lungs when he gave the nebulizer treatment. 8:,d+[DATE]:00 PM LPN D offered R1 her bedtime medications and R1 refused. LPN D indicated he called RN C because he was unable to get a hold of the doctor. LPN D indicated RN C gave him the doctor's direct number and told LPN D to call the NP if he was unable to contact the doctor. LPN D indicated he called the doctor and NP and was not able to speak with either of them. LPN D indicated he was calling the doctor because LPN D thought R1 needed a higher level of care than he could provide to address her change in condition. It should be noted at no time did LPN D ask R1 if she wanted to be sent to the emergency room or did LPN D send R1 due to R1's significant change of condition and decline. LPN D continued the timeline for his shift: 11:30 PM LPN D entered R1's room. LPN D stated R1 was not breathing, mouth was fixed in an open position. R1's fingers were blue and cold on both hands. LPN D indicated R1's arm was stiff and rigid when he moved R1's arm to check for a radial pulse. LPN D stated he was unable to obtain a pulse. LPN D stated there was no rise and fall of R1's chest when he checked for respirations. LPN D indicated he called RN C to notify her of R1's passing, and RN C instructed him to call the on-call doctor. LPN D called the on-call doctor for notification of R1's passing. During the interview, LPN D indicated he did not speak to a physician regarding R1's condition and did not have an RN assess R1 prior to R1 passing. On [DATE] at 1:00 PM, Surveyor interviewed CNA F regarding R1's condition on [DATE]. CNA F indicated LPN D asked her to obtain R1's vital signs. CNA F said R1 was having a hard day. CNA F indicated R1 was breathing fast and was too weak to transfer and use the toilet and had to use a bed pan instead and CNA F reported that to the nurse. CNA F stated she obtained the vital signs and gave the results to LPN D. On [DATE] at 4:56 PM, Surveyor interviewed RN C. RN C indicated she is the house coordinator-shift supervisor for the hospital that is connected to the nursing home. RN C indicated she recalls the events related to R1 on [DATE]. RN C stated she received a call from LPN D but did not recall the time. RN C indicated LPN D told her he was unable to get a hold of the doctor and LPN D wanted to let the MD know he had a resident who had a fever and increased difficulty breathing. RN C stated she told LPN D if he was unable to contact the doctor then he should call the NP. RN C indicated she was unaware LPN D did not get a hold of the doctor or NP since LPN D did not call her again regarding this. RN C indicated she did not hear from LPN D again until later that night when LPN D reported he had a resident who passed away and needed to contact a doctor for notification. RN C indicated LPN D did not indicate that these two events were for the same resident. RN C indicated if LPN D would have told her he was unable to get a hold of the doctor or NP, RN C would have called the doctor herself. RN C also stated it is not routine for the house coordinator-shift supervisor to assess residents in the nursing home. RN C indicated she would have gone over to the nursing home and assessed the resident if LPN D would have asked or if there was a sense of urgency. On [DATE] at 2:52 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated the facility has a physician on call 24 hours a day. DON B stated if there is a reason to call the physician between 5:00 PM and 8:00 AM, the facility is supposed to call triage at the hospital and there is always someone to answer the phone. Surveyor asked DON B what the facility does if someone does not answer at triage. DON B indicated the facility could call the house coordinator-shift supervisor. DON B stated she would expect the house coordinator-shift supervisor to suggest the facility utilize the RRT (Rapid Response Team-an interdisciplinary team that will respond to residents with significant changes in condition requiring immediate action) or send the resident to the emergency room . Surveyor asked DON B what a reasonable timeframe would be when the facility calls a physician and is waiting for a call back. DON B indicated the timeframe would depend on the severity of the resident's condition and she would expect staff to use nursing judgment. DON B also indicated if a resident is unstable the facility should use the RRT. Surveyor asked DON B if R1 was assessed by the doctor or NP during LPN D's shift and DON B indicated she is unaware if R1 was assessed. DON B indicated R1 would feel better then worse and appeared to feel better after interventions were implemented like the Tylenol and nebulizer. Of note, an ACLS RN is part of the Rapid Response Team. R1 presented with a respiratory change of condition on [DATE] at 12:30 AM that included weakness, abnormal lung sounds, a fever, and shortness of breath. The last RN assessment was performed at 8:46 AM that included new symptoms of wet, productive cough, decline in functional status, elevated temperature of 102 degrees, and lethargy. The first consultation of a physician with interventions was documented at 1:08 PM, 12.5 hours after R1's change in condition. As the day progressed, R1's condition continued to deteriorate. The facility failed to complete a comprehensive nursing assessment by a registered nurse and failed to consult with a physician resulting in R1 continuing to deteriorate and eventually expiring on [DATE]. The facility's failure to complete a comprehensive nursing assessment and notify the physician with a change in condition created a finding of serious harm, thus leading to an immediate jeopardy situation which began on [DATE]. The facility removed the immediate jeopardy on [DATE] by taking the following actions: The Administrator, Chief Nursing Officer of the Hospital, and Facility Medical Director outlining the steps to contact a physician 24 hours a day, 7 days a week. This became effective as of [DATE] at 7:00 PM. A physician will be available to assess patients 24 hours a day. This process has been communicated to all Hospitalists, Hospital Nurse Practitioners, Hospital RN House Supervisors, Administrator, Administrator Assistant, Director of Nursing, Assistant Director of Nursing, and the [NAME] President of Hospital Operations. All Nursing staff were contacted and immediately educated on this new process. On [DATE], all Nursing staff were contacted and immediately educated to ensure an RN assessment is completed when a resident presents with a change of condition, deterioration in their condition, and/or an immediate MD/NP consultation in needed in order to alter treatment if necessary. The Hospital Chief Nursing Officer also reeducated every RN Hospital House Supervisors immediately to implement the following: Frequent rounding is required in the facility to check on staff and ensure patient safety. If anyone from the facility calls the Nursing Services Office and has questions, are worried about patient safety, or seems that they are unsure what to do they are to immediately go to the facility and assess the situation and assist with calling physicians as needed. When RN House Supervisors are here, they are in charge of the hospital and everyone in it including patients and staff. The Hospitalist Physician assigned to the orange phone will respond to all calls from 7a-7p and the Hospitalist Physician assigned to the black phone will respond to all calls from 7p-7a. On [DATE] the facility Protocol for Condition Changes was revised to include the following; If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. The Director of Nursing has educated all Nursing Staff to the revision. On [DATE], a SNF Change of Condition Notification Protocol was developed to outline the new process of notifying the Physician of any change in a patient's condition as followed. 1. The RN Hospital Shift Supervisors will provide frequent rounding at the facility on all shifts and check in with RN/LPN on shift. 2. RN Hospital Shift Supervisors will provide assistance with any patient at the facility and will come to the unit if the facility Nursing needs immediate assistance. 3. If an LPN is on duty when the DON and/or ADON are not on duty, the RN Hospital Shift Supervisor will be contacted to conduct and document an RN assessment of the patient if there has been a change of condition or if the patient needs immediate assistance. 4. If the facility nurse is unable to reach a physician using the protocol below; the nurse will contact the RN Hospital Shift Supervisor. Physician call tree: o 7a-7p Day Orange Phone [DATE] o 7p-7a Night Black Phone [DATE] 5. If the nurse is unable to reach a physician using the call tree outlined in this protocol, the nurse is to contact the RN Hospital Shift Supervisor back who will then contact the Hospital Chief Nursing Officer for support. 6. RRTs and Code Blues called within the facility will follow the RRT or Code Blue protocols located in the Emergency Management Binder. On [DATE], a SNF Change of Condition Reporting Protocol was revised to include the following. Our facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's condition and/or status. Procedure: 1. The Nurse will notify the resident's attending physician when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental or psychosocial status. c. There is a need to alter the resident's treatment significantly. d. The resident repeatedly refuses treatment or medications. e. The resident is discharged without proper medical authority; and/or f. Deems necessary or appropriate in the best interest of the resident. 2. The nurse will notify the resident's representative when: a. The resident is involved in any injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental or psychosocial status. c. There is a need to alter the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital. 3. Regardless of the resident's mental or physical condition, nursing services will inform residents of any changes in their medical care or nursing treatments. 4. The nurse supervisor will record in the resident's medical record any chances in the resident's medical condition or status. 5. If a significant change in the resident's physical or mental condition occurs, a head-to-toe assessment of the resident's condition will be conducted by the RN on duty or by the MD/NP on call. 6. A representative of administration will verify the address and telephone number of the resident's representative. The Director of Nursing will audit all charts daily for any Change of Condition to ensure an RN, or MD/NP Assessment was completed. This will occur daily for 2 weeks, then weekly for 8 weeks and then monthly for 3 months. The Quality Assurance Performance Improvement Committee will review these audits monthly to ensure compliance. If an occurrence with a change of condition is identified during audits. The Director of Nursing will meet with the Nurses to identify the Root Cause of the occurrence and put appropriate measures in place for that specific occurrence for the next 4 weeks to ensure compliance. On [DATE], the Quality Assurance Performance Improvement Committee will meet to discuss the event and corrective measures to ensure compliance. The Facility Assessment has been updated on [DATE] to include RN Hospital Supervisors as a facility resource. The Facility Assessment has also been updated to reflect the training topic of Identification of patient/resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the State Survey Agency timely and to local law enforcement for 1 of 3 residents reviewed for abuse (R2). R2 voiced an allegation of sexual abuse by CNA N (Certified Nursing Assistant). The facility failed to report the allegation to the State Agency within 2 hours of the allegation being voiced. The facility failed to report the allegation of sexual abuse to the local law enforcement. Findings include: The facility's abuse policy, titled Abuse Policy, and Prevention Program, includes, in part: Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator . Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health or the State of Wisconsin DQA immediately, but not more than two hours after the allegation of abuse . If an allegation of physical sexual contact without penetration is involved: the facility shall immediately contact local law enforcement authorities as required in Section 300.695 in the following situations: intentional sexual touching or fondling, for sexual abuse of a resident by a staff member . R2 was admitted to the facility on [DATE] and has diagnoses that include TIA (Transient Ischemic Attack, mini stroke), HTN (Hypertension, high blood pressure), DM2 (Diabetes Mellitus 2), CVA (Cerebral Vascular Accident, stroke), Persistent Atrial Fibrillation (irregular heartbeat), and chronic kidney disease. His most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 11/8/24 includes a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R2s cognition is intact. R2's MDS also indicates R2 makes himself understood and understands others. On 1/22/25, Surveyor reviewed the Facility Reported Incident involving R2 with the date of occurrence documented 11/24/24 and the time of occurrence documented 5:00 AM. On 11/24/24 at 5:45 AM, RN O (Registered Nurse) called NHA A (Nursing Home Administrator) to report an allegation of sexual abuse. RN O reported that R2 stated upon entering R2's room the male CNA who worked last night (CNA N) asked him if he could go down on him. While RN O was on the phone with NHA A, CNA P told RN O that R2 stated to CNA P the male CNA from last night was playing with his penis, trying to get brown crusty stuff off, tried to go down on him and made him bleed. RN O completed a head-to-toe assessment with CNA P present at 6:10 AM and found no bleeding to penis, rectum, or brief. RN O notified R2's daughter of allegations at 6:30am. CNA N was suspended immediately pending the investigation. R2's daughter and CNA P stayed with R2 at bedside until he transferred to the hospital for evaluation at 2:30 PM due to R2 making suicidal statements and having hallucinations during the day. On 11/24/24 at 10:12 AM, NHA A interviewed CNA N by phone asking about the interaction with R2 on night shift. CNA N stated when he was passing out water on the morning of 11/24/24 at approximately 5:15 AM, he went into R2's room and told him he was going to replace his water. R2 told CNA N he reported him to the RN. CNA N asked R2 what he reported and R2 stated when they were in the bathroom, CNA N asked R2 if he could go down on R2 and R2 told him to get out of his room. CNA N told NHA A he did not say that or do that. The facility conducted their own investigation interviewing staff and residents on 11/24/24 and concluded the incident was not able to be substantiated as abuse. Law enforcement was not notified. (It is important to note the allegation was voiced at 5:15 AM and the initial report to the State Agency was not completed until 4:30 PM). On 1/22/25 at 11:18 AM, Surveyor interviewed NHA A. Surveyor and NHA A reviewed abuse policy together and she stated she did not follow her policy regarding reporting and should have reported to the state agency within 2 hours of abuse allegation being voiced. Surveyor and NHA A reviewed the facility's abuse policy regarding calling the police and she stated she did not call police and did not follow facility policy but should have. On 1/22/25 at 11:40 AM, Surveyor interviewed AA M (Assistant Administrator). Surveyor and AA M reviewed abuse policy together and she indicated the facility should have notified the state agency within two hours and should have notified the police with an allegation of sexual abuse. (It is important to note the facility did not report the allegation of sexual abuse to local law enforcement.)

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 8 residents who reside in the facility. Surveyor observed a box of spoiled lemons in the refrigerator. Surveyor observed undated food in the dry storage area, in freezer (1) and the smaller freezer. Surveyor observed a staff member's personal water bottle in the food prep area. Surveyor observed chunks of rubber missing from ,d+[DATE] spatulas. Surveyor observed the flip tops of 2 garbage cans open and one large garbage can without a lid. Facility staff was observed testing the temperature of the water in the sanitizing sink. The temperature was out of the manufacture's recommendations. Evidenced by: The facility policy, entitled Food & Nutrition Services Policy NO. 5.04 Food Labeling, reviewed date [DATE], states in part. Food items will be labeled with dated produced. A uniform dating system will be used by employees. Each employee will follow practices of safe food handling to check all food items used to be certain they are wholesome. Any item in question will be thrown out. Perishable food items showing an expiration date from the manufacture will be discarded on the date stamped. The guidelines include, the employee will label all opened or post prepared foods. Items will be dated according to the following guide: Date opened and expiration date. The facility policy, entitled Food & Nutrition Services Policy NO. 4.04 Food Labeling/ Leftovers, reviewed date [DATE], states in part. Food items will be received and checked upon arrival for accuracy and damage by the designated Food and Nutrition partner. Items that come in with an expiration date will be followed or within 7 days of opening. Examples - No date opened or expiration date. On [DATE], at 10:16 AM, Surveyor observed an open bag, of baking chips and an open bag of Oreo Cookie pieces with no date opened or expiration date. On [DATE], at 10:16 AM, Surveyor interviewed [NAME] D (Kitchen Office Coordinator) who indicated that baking chips and Oreo Cookie pieces should have a date opened and expiration date. On [DATE], at 10:16 AM, Surveyor observed 2 boxes of expired Graham Crackers and four packages of Graham Crackers with no expiration date. On [DATE], at 10:16 AM, Surveyor interviewed [NAME] D who indicated that the 2 boxes of Graham Crackers are expired and that the four packages of Graham Crackers should have an expiration date. On [DATE], at 10:20 AM, Surveyor observed a bag of frozen waffles with no expiration date. On [DATE], at 10:20 AM, Surveyor interviewed [NAME] D who indicated that frozen waffles should have an expiration date. On [DATE], at 10:27 AM, Surveyor observed a box of spoiled lemons in the refrigerator. On [DATE], at 10:27 AM, Surveyor interviewed [NAME] D who indicated that the entire box of lemons was spoiled and threw them away. On [DATE] at 10:47 AM, Surveyor observed that some of the trays for the salad bar did not have expiration dates. On [DATE], at 10:47 AM, Surveyor interviewed [NAME] D who indicated that all the salad bar trays should have a prepared/open date and an expiration date. Example- Personal items in food prep area. On [DATE] at 10:55 AM, Surveyor observed a staff member's personal water bottle in the food prep area. On [DATE], at 10:55 AM, Surveyor interviewed [NAME] D who indicated that the personal water bottle should not be on the food prep table unless the staff member can take a drink without opening the bottle. [NAME] D asked the staff member to put the water bottle on the lower shelve of the table. Examples - Garbage can lids. On [DATE] at 11:05 AM, Surveyor observed flip top garbage can lids open in the main kitchen and 1 large garbage can uncovered and a plastic bag of trash on the floor. On [DATE], at 11:05 AM, Surveyor interviewed [NAME] D who indicated that the garbage cans should be closed, and that trash should be taken to the trash receptacles and not put on the floor of the kitchen. Examples - Three Compartment Sink On [DATE] at 11:37 AM, Surveyor observed a kitchen staff member test the temperature of the water in the sanitizing sink. The temperature was 92.3 Fahrenheit which is out of range of the manufacture's guidelines of ,d+[DATE] Fahrenheit. On [DATE], at 11:37 AM, Surveyor interviewed SEC C (System Executive Chef) who indicated that the temperature was not with in the manufacture's guidelines. Examples - Defected rubber spatulas On [DATE] at 11:40 AM, Surveyor observed rubber spatulas with chips in the rubber portion of the utensils. On [DATE], at 11:40 AM, Surveyor interviewed [NAME] D who indicated that the rubber spatulas were damaged and needed to be thrown away.

Based on observation, interview, and record review, the facility did not ensure that 1 of 8 residents (R8) reviewed for Activities of Daily Living (ADL) received the necessary services to maintain personal hygiene. R8 voiced concern he did not receive showers as scheduled. Evidenced by: The facility policy, entitled Care Services Provided, last reviewed on 1/2024, states, in part: . General nursing care that will be provided, at a minimum, in addition to the individualized interdisciplinary plan of care is: . Procedure: 5. Hygiene care includes offering bathing (in a shower, trimming of nails weekly, shampooing of hair, application of personal products such as deodorants, etc.) Restorative nursing and psychosocial care will bill be provided continuously. These measures will include, at a minimum, the following: 4. ADL maintenance and retraining: Nursing personnel will encourage and assist residents in maintaining or regaining their ADL abilities. This will include dressing, grooming, bathing, nutrition/hydration, and oral care. R8 was admitted to the facility on [DATE], and has diagnoses that include acute respiratory failure with hypoxia (low blood oxygen levels), non-ST elevation myocardial infarction (heart attack), acute on chronic combined systolic and diastolic heart failure (new exacerbation of chronic heart failure), type 2 diabetes mellitus with diabetic neuropathy (diabetes with nerve damage) R8's Admission Minimum Data Set (MDS) Assessment, dated 4/28/2024 shows that R8 has a Brief Interview of Mental Status (BIMS) score of 14 indicating that R8 is cognitively intact. R8 is a maximal/substantial touch assist for showers or baths. R8 is a tub/shower transfer of 1 person assist with moderate assistance. The assessment also indicates that the resident rates bathing a 2 meaning that R8 considers bathing somewhat important and that he prefers showers. R8's Skilled Nursing Facility Kardex, dated 4/25/2024 shows: Grooming: Total assist Ambulation: 1 Assist with gait belt The Facility's weekly bath schedule indicates that R8 should be receiving baths on Tuesday mornings. The schedule also indicates that the resident may request more showers but that this would be the minimum. R8's Bathing/Showering documentation shows the following: April: - 4/26/2024: R8 received a full bath. - 4/28/2024: R8 received a full bath. - 4/30/2024: R8 received a full bath. - Partial baths received on: 4/26/2024, 4/29/2024, and 4/30/2024 May: - 5/08/2024: R8 received a full bath. - 5/22/2024: R8 received a full bath with the assistance of OT (Occupational Therapist) - 5/23/2024: R8 received a full bath. - 5/28/2024: R8 received a full bath with the assistance of OT - Partial baths received on 5/02/2024, 5/03/2024, 5/07/2024, 5/08/2024, 5/09/2024, 5/13/2024, 5/14/2024, 5/15/2024, 5/21/2024, 5/24/2024, 5/26/2024, 5/27/2024, 5/29/2024, 5/30/2024 Note: R8 did not receive weekly showers or baths as the weekly bath schedule indicates. R8 did not receive a shower the week of 5/13/24. There were several dates where it does not indicate if R8 received a partial bath. On 5/29/2024 at 10:23 AM, Surveyor interviewed R8. R8 indicated he is not getting showers all the time. R8 also stated that some staff don't like doing it. On 5/29/2024 at 1:18 PM, Surveyor interviewed LPN E (Licensed Practical Nurse) who indicated that R8 does not refuse showers. LPN E also indicated that therapy assists R8 with showers and that R8 is scheduled for showers on Tuesday mornings. On 5/29/2024 at 3:06 PM, Surveyor interviewed CNA F (Certified Nursing Assistant) who indicated that they do not know if R8 refuses showers or if he is being offered baths or showers. CNA F indicated that she has not given R8 a shower or bath. On 5/30/2024 at 7:25 AM, Surveyor interviewed R8 who indicated that by the time staff get me up there is no time for a shower before therapy. Surveyor asked R8 who helps him take a shower. R8 states that OT (Occupational Therapy) is the only one who has helped him shower. Surveyor asked R8 if he ever refuses a bath or shower. R8 says he has never refused a bath or shower. Surveyor asked R8 how often he would shower if it was his choice. R8 states he would shower every day. Surveyor asked R8 about what limits him with ambulation and ADLs. R8 indicates that his vision is an issue and uses the example that he can't see the clock from his recliner. R8 also reports that he is on continuous oxygen so that limits his access to walk in the hallway, but he does have enough oxygen tubing to go to the bathroom and get cleaned up. Surveyor asked how R8 ambulates. R8 indicates he has been walking the hallways with a gait belt and staff follow him with a wheelchair. In the past couple of days, it only happens if a nurse is available. If staff are not busy R8 will get a nurse in his room and walk back and forth in his room. R8 believes that the facility is short-staffed and that the staff are worked too thin. On 5/30/2024 at 9:30 AM, Surveyor interviewed PTA H (Physical Therapy Assistant). Surveyor asked PTA H if therapy ever gives residents showers. PTA H indicates that therapy sometimes give showers and if they give a shower it is documented by the therapist and the nurse. PTA H looked through the charting and found no additional shower documentation besides those already listed. On 5/30/2024 at 11:14 AM, Surveyor interviewed CNA G. Surveyor asked CNA G when R8 takes his shower. CNA G states whenever we offer showers, and he is scheduled for a shower on Tuesdays. CNA G also reports that therapy gives him showers at times and that R8 never refuses showers or baths. On 5/30/24 at 2:42 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how R8 takes his showers. DON B states he showers on a shower chair and holds the handheld shower head. Surveyor asked DON B the difference between a partial and complete bath. DON B states that a partial bath involves washing exposed areas and uses the example of washing up his back while on the toilet or his hands and face. A complete bath is hygiene performed from head to toe and is a complete soak. Surveyor asked DON B if a resident refused, would she expect it to be charted. DON B indicated that staff should chart refusals or the reason R8 did not receive a shower if there was a reason. DON B also indicated that the facility needs to provide education to the CNA's to chart refusals if they refuse, and to specifically chart shower for a shower, or full bath for a full bath.

Based on observation, interview, and record review, the facility failed to assess the risk of entrapment, advise of the risk and/or benefits and obtain consent prior to use of bed rail with air mattress for 1 of 2 residents in the facility (R4). The facility failed to assess R4's risk of entrapment, advise of the risk and/or benefits and did not obtain consent prior to installing bed rails. Evidenced by: The facility's Use of Side Rails, last revision date 01/24, includes, in part, the following: It is the policy of (Name of the Facility), that the use of side rails be compliant and consistent with all Federal and State regulatory requirements. It is recognized that, although the reasons for use may differ related to resident-specific needs, side rails are, by definition, a form of restraint and subject to all of the regulatory requirements that currently govern the use of restraints. Residents have the right to be free from any physical (or chemical) restraints including side rails imposed for the purposes of discipline or convenience, and not recognize to treat the resident's medical symptoms. R4 was admitted on [DATE] with diagnoses of Type 1 Diabetes, End Stage Renal Disease, and Diabetic Peripheral Neuropathy. R4 is currently her own decision maker. On 3/12/24 at 11:50 AM, R4 was observed lying in bed. On each side of R4's bed was a quarter rail. There was a 3-inch gap between the rail and the air mattress. On 3/12/24 at 12:40 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and ANHA C (Assistant Nursing Home Administrator). Surveyor asked NHA A and ANHA C about bed rail assessments. NHA A stated we used to do assessments but don't do them anymore. Surveyor asked if they did assessments for residents with air mattress and side rails/grab bar combos. NHA A stated, we don't do any for air mattress or side rail/grab bar combos. We will from here on. On 3/12/24 at 1:10 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor and DON B observed R4 laying in her bed. DON B stated there should not have a gap between the mattress and rail. DON B stated the bed will be swapped out. Surveyor asked DON B if there was evidence that R4 was provided risk and benefits of the side rails or if R4 gave written consent to use the side rails. DON B stated she did talk to R4 about the side rails, but nothing was written down, there was no written evidence of risk and benefits provided, nor was there written consent from R4 for the side rails.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 11 residents. Surveyor observed kitchen staff miss handwashing opportunities while preparing residents' meals. Surveyor observed food in circulation that was opened and undated. Surveyor observed a hair net not properly worn. Surveyor observed a dented can in circulation. Surveyor observed the oven was not cleaned properly. Surveyor observed no temperature logs for the refrigerator/freezer unit in the facility's dining room. This is evidenced by: Hand Washing The facility policy entitled, Hand Hygiene, revised on [DATE], states in part: Policy Statement . the safety of its patients, partners, and visitors as a top priority, and recognizes that hand hygiene is the single most important measure partner can take to reduce the risk of transmitting organisms and spreading disease. All partners will be expected to practice hand hygiene appropriately to prevent healthcare associated infections . I. When to Perform Hand Hygiene . Immediately after glove removal . The facility policy entitled, Dress and Appearance Code-Food and Nutritional Services, reviewed date of ,d+[DATE], states in part: . Glove Use . c. Wash hands after taking gloves off, and before putting gloves on. d. Gloves are NOT a substitute for washing hands. On [DATE] at 12:25 PM Surveyor observed FS F (Food Service) removing her gloves, disposed her gloves, obtained a small black dish that was placed under a bottle of oil on the food preparation table, came around to the other side of the table and obtained a large black steel tray to start to prepare bacon, then applied a new pair of gloves. Surveyor interviewed FS F with the presence of FS Director C and FS F indicated that she should have washed her hands. FS Director C indicated that FS F should have washed her hands. Food Dating/Labeling FDA (Food and Drug Administration) Food Code, 2022, include: . Refrigeration Requirements Refrigeration times and temperatures to inhibit C. botulinum and L. monocytogenes must be based on laboratory inoculation study data or follow one of the ROP methods in Section ,d+[DATE].12 which specifies the time and temperature combinations. The . package must be marked with a use-by date within either the manufacturer's labeled use-by date or as determined by the laboratory data, whichever comes first . Labeling - Use-by date The shelf life of ROP foods is based on storage temperature for a certain time and other intrinsic factors of the food (pH, aw, cured with salt and nitrite, high levels of competing organisms, organic acids, natural antibiotics or bacteriocins, salt, preservatives, etc.). Each package of food in ROP must bear a use-by date. FDA Food Code, 2022 in Section ,d+[DATE].12, states, in part: Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food. The facility policy entitled, Food Storage/Leftovers, reviewed date of ,d+[DATE], states in part: . 11. All items made in house will be labeled with the day the product was made and the expiration date. The date of production is considered the first day . On [DATE] at 12:24 PM, Surveyor observed the following with the presence of FS Director C. Refrigerators: ~ 2-pound bag of shredded cheddar cheese with an expiration date of [DATE], not labeled and opened. FS Director C indicated it was expired and should not have been there and was discarded. A 5-pound jar of sliced jalapenos, opened, no open date or use by date affixed. FS Director C indicated it should be dated and was then discarded. ~ An unlabeled 8-ounce clear cup of liquid with a lid, undated, identified by the FS Director C as thickened water. FS Director C asked FS Team Lead P if she had poured them and indicated she did not and did not know where they are from. FS Director C removed the clear cup of liquid and asked FS Team Lead P to discard. ~ An unlabeled 8-ounce cup of dark liquid with a lid, undated, identified by the FS Director C as soda. FS Director C asked FS Team Lead Q what the substance was and indicated she did not know what it was and that it was not there this morning. FS Director C removed the dark liquid and was discarded. ~ A large bag of brown colored shredded lettuce was opened, not labeled, no open date or use by date affixed. FS Director C identified the item as shredded lettuce and was discarded. ~ Tzatziki sauce with a date affixed of [DATE]. FS Director C indicated she did not know if the date was an expiration date or a use by date and was then discarded. Freezers: ~Texas Toast and a case of pizza crust was observed uncovered, no open or use by date. FS Director C indicated that the food should have been covered and dated. ~ Grilled chicken, Salisbury steak, and diced turkey were observed opened and no open or use by date affixed. ~ A paper bag identified by FS Director C of breakfast potatoes, was observed opened, not labeled and no open or use by date affixed. ~ A bag of fish and a box of fish identified by the FS Director C was observed as not covered, opened, and no open or use by date affixed. On [DATE] at 12:24 PM, Surveyor interviewed FS Director C. Surveyor asked how long an item should be in the freezer after opening the item. FS Director C indicated 6 months and should be dated when the item is opened. Bread ~ An 8 pack of hot dog buns, unopened, hard to touch, no dating affixed. Surveyor lifted the package was stuck to the bread tray. FS Director C indicated the cook would use their judgement and then discarded the buns. ~ 13 rows of bread trays of sliced bread and hamburger buns observed undated, unopened. Surveyor asked FS Director C if the bread was dated, and she indicated that the bread rotates through daily. Surveyor asked FS Director C to provide how bread is dated and she indicated she would follow up with the bread company. ~ 7 opened loaves of sliced bread observed at the deli station, undated. On [DATE] at 2:54 PM, Surveyor interviewed again FS Director C about the bread process. FS Director C indicated she has called twice to the bread company without a response and indicated she will continue to call. Dry Storage ~ Large Sterlite container of butterscotch chips identified by FS Director C. Surveyor observed the container is not labeled, no open or use by dates affixed. ~ Large Sterlite container of sugar identified by FS Director C. Surveyor observed the container is not labeled, no open or use by dates affixed. ~ Large Sterlite container of flour identified by FS Director C. Surveyor observed the container is not labeled with a discard date of [DATE]. ~ Large Sterlite container of graham cracker crumbs identified by FS Director C. Surveyor observed the container is not labeled with a discard date of [DATE]. ~ A bag of sugar, opened, no open or use by date affixed. ~ A bag of pasta fettuccini noodles, opened, no open or use by date affixed. ~ Vanilla wafers identified by FS Director C packed individually in clear plastic bags, placed in a 3-liter container, not labeled, no open or use by date affixed. ~ Saltine cracker identified by FS Director C packed individually in clear plastic bags, placed in a 3-liter container, not labeled, no open or use by date affixed. On [DATE] at 12:24 PM, Surveyor interviewed FS Director C and indicated the items should be labeled and dated, she further indicated that she had a concern. Hair Restraints FDA U.S. Public Health Service Food Code, 2017, includes, in part: ,d+[DATE].11 Hair restraints: . Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food. The facility policy entitled, Dress and Appearance Code-Food and Nutritional Services, reviewed date of ,d+[DATE], states in part: . Grooming . i Food Service Employees are required to wear a hairnet, bouffant nurse cap, or completely black baseball cap in production or serving areas . Personal Hygiene . b. To prepare for work, each employee must wear a clean uniform, cover hair with a hairnet and wear clean shoes . On [DATE] at 2:50 PM, Surveyor observed FS Director C with a hair net on her ponytail only on the back of her head in the food preparation area and walking through with open hamburger being prepared in the kitchen. Surveyor interviewed FS Supervisor D in the presence of FS Director C of the requirements of hair nets in the kitchen. FS Supervisor D indicated that the hairnets are required. FS Director C then pulled her hairnet over her head leaving the front bangs exposed. FS Director C indicated they are not allowed to have the bangs out and her hair net must have slipped back. Dented Can FDA Food Code 2022, section ,d+[DATE].15, includes, in part: Package Integrity. Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants such as Clostridium botulinum may find their way into the food. In anaerobic conditions (lack of oxygen), botulism toxin may be formed. Packaging defects may not be readily apparent. This is particularly the case with low acid canned foods. Close inspection of cans for imperfections or damage may reveal punctures or seam defects. In many cases, suspect packaging may have to be inspected by trained persons using magnifying equipment. Irreversible and even reversible swelling of cans (hard swells and flippers) may indicate can damage or imperfections (lack of an airtight, i.e., hermetic seal). Swollen cans may also indicate that not enough heat was applied during processing (under-processing). Suspect cans must be returned and not offered for sale. The facility policy entitled, Food Storage/Leftovers, reviewed date of ,d+[DATE], states in part: 1. Food items will be received and checked upon arrival for accuracy and damage by the designated Food and Nutrition partner. 2. All food is rotated in the FIFO (first in, first out) basis. Any items damaged or closed to expiration date will be refused and returned to the vendor . On [DATE] at 11:20 AM, Surveyor observed a dented can of 10-pound applesauce in the dry storage area on the canned rack in the first position with FS Director C. Surveyor asked the process of handling dented or damaged cans. FS Director C indicated that dented cans do not go in here, and they are discarded. Surveyor asked FS Director C who is responsible to check the cans, she indicated when the order is put away the staff make sure to check every can. FS Director removed the can from the inventory. Unclean Oven The facility policy entitled, Cleaning Schedules, reviewed date of ,d+[DATE], states in part: Purpose: To maintain the sanitation of the kitchen and meet regulatory requirements. Policy: Schedules for cleaning are established for each piece of equipment as well as for the facility. Procedure/Guidelines: 1. Weekly cleaning schedules are posted for equipment, ceilings, walls, and furnishings. 2. Cleaning is assigned to the employees using the equipment. On [DATE] at 12:05 PM, Surveyor observed 2 double-stacked ovens that had dark stained, brown colored, and burnt particles, on the top and sides of the oven. Surveyor asked FS Director C if the ovens were clean, she indicated that it was dirty, soiled, burnt, and dried up areas. Surveyor asked FS Director C of the cleaning schedule, she indicated that the oven is supposed to be cleaned weekly and they have been short staffed. Surveyor asked FS Director C is she knew that last time the oven was cleaned, and she indicated she did not know. On [DATE] at 2:50 PM, Surveyor observed the inside of the ovens were cleaned and the outside remained unchanged from the previous observation. Surveyor interviewed FS Supervisor D and FS Director C. FS Supervisor D provided a cleaning schedule entitled Weekly Cleaning Chart-Cleaner that lists equipment to be cleaned. Surveyor reviewed the schedule and asked where the oven is listed to cleaned. FS Supervisor D indicated the oven is not on the weekly list because they are in the process of a staff member transitioning to another area. Surveyor asked FS Supervisor D if the oven had previously been on the list, she indicated she did not believe it was. Surveyor asked FS Supervisor D if there was a previous checklist or log to indicate the oven had been cleaned, she indicated she did not. FS Supervisor D provided the Surveyor a note dated ,d+[DATE], entitled Clean Tuesday, that indicates the oven to be cleaned. Surveyor asked FS Supervisor D how to determine if the work was completed, she indicated she did not know as staff do not initial when the work is completed. Temperature logs FDA Food Code 2022, section ,d+[DATE].12, includes, in part: Time/Temperature Control for Safety Food, Slacking. Frozen time/temperature control for safety food that is slacked to moderate the temperature shall be held: (A) Under refrigeration that maintains the food temperature at 5oC (41oF) or less; or (B) At any temperature if the food remains frozen . The facility did not provide a policy for checking temperatures of the dining room unit refrigerator prior to exit. On [DATE] at 10:42 AM, Surveyor observed dining room unit refrigerator with AC E (Activity Coordinator). Surveyor asked AC E if there is a log of the unit refrigerator temperatures and a thermometer. AC E indicated there are not any logs, and if the temperature is not right, somebody calls from maintenance, and they come and adjust it. At 10:58 AM AC E returned to the Surveyor and indicated the electronic probe is monitored by an outside agency. AC E further indicated that she has never been given a log or informed to check temperatures. On [DATE] at 11:06 AM, Surveyor interviewed Maintenance Supervisor G the process of the temperature monitoring with an outside agency. Maintenance Supervisor G demonstrated the probe is remotely monitored and there is not a manual thermostat in the refrigerator. Surveyor asked Maintenance Supervisor G if they come to check the probes manually, he indicated that each individual department would be responsible to check and that it is not the responsibility of the maintenance department. On [DATE] at 5:25 PM, CNO J (Chief Nursing Officer) indicated during exit that she had a thermometer already in place in the unit refrigerator and will begin monitoring.

Based on interview and record review the facility did not establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect 11 of 11 residents (R). Surveyor reviewed staff surveillance/call in list for three months and noted a certified nursing assistant (CNA) called in with symptoms of COVID-19 and returned to work without being tested . Surveyor noted 2 staff members had symptoms of COVID without reporting and turned out to be COVID positive while working. Facility does not provide laundry service for residents' personal laundry. Residents' families transport personal laundry home. Facility does not provide families with safe handling of laundry instructions for residents on contact precautions. This is evidenced by: The facility policy, entitled COVID Infection Prevention Supplement, dated 11/4/22, states, in part: .This policy is intended as a supplement to the facilities infection control policies and procedures as well as (Facility Name) policies and procedures to address the emerging changes with COVID-19 The Core Principles of COVID-19 Infection Prevention . Testing Plan and Response: . It is the practice of (Facility name) skilled nursing facilities to perform a COVID-19 test for any of the following: *Symptomatic residents or staff, even those with mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible . Managing Staff with Covid-19 Infection or Exposure: . *Any staff member who develops fever or symptoms consistent with COVID-19 should immediately self-isolate and contact the Director of Nursing and Employee Health to arrange for medical evaluation and testing . APPENDIX A: SUMMARY TABLES Table 2: COVID-19 Testing Summary Testing Trigger: Symptomatic individual identified Staff (HCP) Health Care Personnel: All staff with signs and symptoms, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible . The facility policy, entitled Linen-Clean Distribution and Soiled Pick-Up, last revision date 5/7/21, states, in part: . Procedure: *All soiled linen (textiles and fabrics) will be handled, transported, stored, and laundered using standard precautions, as if contaminated. *Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons. *Bag or otherwise contain contaminated textiles and fabrics at the point of use. Do not sort or pre-rinse contaminated textiles or fabrics in patient-care areas. Use leak-resistant containment for textiles and fabrics contaminated with blood or body substances. *Identify bags or containers for contaminated textiles and fabrics with labels, color-coding, or other alternative means of communication as appropriate . *Soiled linen must be covered when transported. *Soiled linen will be stored in a soiled holding area . Example 1 Surveyor reviewed 3 months (March-May 2023) of the staff surveillance/call in list and noted a CNA had symptoms of COVID-19 and the facility did not have that CNA test for COVID prior to returning to work. Surveyor noted a registered nurse (RN) worked with symptoms of COVID and did not report symptoms to facility and was found to be COVID positive during outbreak testing. On 5/2/23 the facility's surveillance/call in list shows a CNA called in with symptoms of a sore throat and a headache. The surveillance/call in list indicates symptom onset was 5/1/23 and CNA returned to work on 5/5/23. No indication that CNA was tested for COVID ,even though CNA had symptoms that could be COVID related. On 5/5/23 the facility's surveillance/call in list shows a RN was sent home due to fever of 101.0 (F) Fahrenheit and a sore throat. RN tested positive for COVID on 5/7/23. RN returned to work on 5/13/23. On 6/7/23, at 3:00 PM, Surveyor interviewed DON B and asked if the CNA and RN had worked together on 5/1/23 or prior to that date. DON B indicated the CNA and RN worked together for two hours on 4/28/23 where they could have been in contact with each other. It is important to note CNA and RN worked on 4/28/23 for 2 hours together. On 5/19/23 the facility's surveillance/call in list shows an occupational therapist (OT) tested positive for COVID during outbreak testing at facility. OT had symptoms of a runny nose and allergy symptoms that began on 5/16/23. OT did not report symptoms to facility until tested positive on 5/19/23. OT returned to work on 5/23/23. On 6/7/23, at 10:26 AM, Surveyor interviewed DON B (Director of Nursing) and asked if CNA had been tested prior to returning to work on 5/5/23. DON B indicated no. Surveyor asked if a sore throat and headache are symptoms of COVID and DON B indicated yes. Surveyor asked if CNA should have been tested prior to returning to work and DON B indicated yes. Surveyor and DON B discussed the RN calling in on 5/5/23 and DON B indicated the RN had been working and was sick. The RN spiked a fever of 101.0 F during her night shift and DON B had to come in to replace the RN on the floor. The RN had not reported being sick until she had a fever of 101.0 F. Surveyor asked if symptoms should be reported right away and DON B indicated she would expect staff, even agency, to report to her symptoms, but agency staff generally don't report to her, they report to the agency. DON B indicated OT had tested positive on 5/19/23 through facility outbreak testing. DON B indicated after OT tested positive the OT then reported on 5/16/23 allergy symptoms and a runny nose had begun. OT had not reported the symptoms prior to testing. Example 2 R211 was admitted to the facility on [DATE] and has diagnoses that include Multifocal Pneumonia-Methicillin-Resistant Staphylococcus Aureus (MRSA) and Persistent Bacteremia-MRSA. R211's Kardex (Form for staff to follow on how to care for a patient), dated 5/26/23, states, in part: .Admitting Diagnosis: Pneumonia .On Isolation Precautions: Contact Enhanced Barrier Precautions- MRSA R211's Care Plan, dated 5/26/23, states, in part: .Problem: Contact Isolation: R211 was brought into the ER (emergency room ) 5/15 with abdominal pain and SOB (shortness of breath). R211 underwent thoracentesis (a medical procedure to remove fluid or air from the pleural space) 5/22. R211 was found to be COVID positive and diagnosed with COVID pneumonia . MRSA Bacteremia . Approaches/Interventions: Providers and staff must wear gloves, gown for high-contact resident care .Changing linens . On 6/5/23, at 3:08 PM, Surveyor observed a storage bin outside of R211's room that contained clean gowns and a storage bin was in R211's bathroom for soiled laundry. Surveyor observed a notice on R211's room door indicating R211 is on contact precautions. On 6/6/23, at 1:10 PM, DON B indicated that the residents' families do the personal laundry and linens are sent out with the hospital's laundry to a laundry service outside of the facility. On 6/6/23, at 2:00 PM, Surveyor interviewed DON B. DON B indicated the residents' families wash personal clothing. Surveyor asked DON B if residents do not have family, who washes the residents' clothing and DON B indicated staff will take the laundry home and wash it. Surveyor asked DON B what the process is for completing personal laundry for a resident on isolation such as R211. DON B indicated R211's family takes her laundry home to wash it. DON B indicated the family transports the laundry by plastic grocery bag. Surveyor asked DON B if family has been educated on safe handling of laundry and she indicated no. On 6/7/23, at 2:15 PM, Surveyor interviewed RD I (R211's daughter) and asked who is responsible for R211's laundry and RD I indicated she takes R211's personal laundry home and washes it and transports it back to facility. Surveyor asked what the laundry is contained in during transport and RD I indicated staff put the dirty laundry in a Walmart bag and put the bag in R211's closet for RD I to pick up. RD I indicated the bag is not tied shut. Surveyor asked how long the family has been completing R211's laundry. RD I indicated since R211 was admitted to facility.

Based on observation and interview, the facility did not ensure that each resident was treated with dignity and respect for 1 of 8 sampled residents (R62). R62 expressed concerns regarding CNA H (Certified Nursing Assistant) and requested CNA H not come in her room again. CNA H did not honor R62's request and repeatedly continued to enter R62's room. CNA H did not allow R62 to exercise her rights without interference. As evidenced by: The facility's policy and procedure, SNF (Skilled Nursing Facility)/Sub-Acute Resident Rights and Responsibilities, dated 3/17/23, states, in part, as follows: All staff members at all times recognize the rights of residents, and residents assume their responsibilities to enable personal dignity, well-being, and proper delivery of care. As a resident of a nursing facility, you have extensive rights guaranteed under federal and state law. The rights are reflect by this policy and staff of this nursing facility. You will be permitted respect, privacy, and confidentiality in your medical care. You may refuse to talk with or see anyone, i.e. visitors, community representatives, facility employees . The facility's policy and procedure, Skilled Nursing Facility Sub-Acute Know Your Rights under Federal Nursing Home Regulations, undated, states, in part, as follows: You have the right to exercise your rights as a resident of the facility and as a citizen of the United States, without fear of interference, coercion, discrimination or reprisal. You have the right to be treated with respect and dignity. You have the right to live in the facility and receive services with reasonable accomodation of your needs and preferences . You have the right, and the facility must promote and support your right to make choices about aspects of your life in the facility that are important to you. On 6/5/23 at 11:06 AM, Surveyor spoke with R62. R62 stated on 5/31/23 there was a situation with CNA H (Certified Nursing Assistant) that upset her. R62 stated, she has anxiety and whenever she sees CNA H, she reflects on situation and her muscles get tight and she feels this big (holding up her index finger and thumb indicating 1/2 inch). R62 added, CNA H upset me so bad, I told her to get the hell out of my room! R62 stated, CNA H later came in to apologize and in the same breath said I don't know what I did wrong. R62 stated, she told CNA H to just leave. On 6/5/23 at 11:13 AM and 11:26 AM, Surveyor spoke with DON B (Director of Nursing). DON B stated, CNA H doesn't always come across as soft and indicated concerns with CNA H's demeanor. DON B stated, R62 stated she doesn't want CNA H in her room anymore. DON B added, CNA H was very aware to not go in R62's room. DON B stated, we (indicated CNA H) need to make more effort to not go in R62's room. DON B stated, R62 doesn't want CNA H in her room. Surveyor asked DON B, would you expect R62's preference to be honored. DON B stated, Yes, absolutely. On 6/7/23 at 2:59 PM, Surveyor spoke with CNA H. CNA H stated, I got asked to not go in R62's room again (on 5/31/23). Surveyor asked CNA H if she went in R62's room after R62 requested she not come back in her room. CNA H stated, yes. CNA H stated she went into R62's room multiple times on 6/3/23 and 6/4/23. CNA H stated, on 6/4/23 when she went into R62's room, CNA H stated, Tomorrow is Monday, the special is and R62 stated, Just get out of my room! Surveyor asked CNA H, did R62 look visibly upset. CNA H stated, She (R62) looked disgusted that I was in her room. On 6/07/23 at 3:30 PM, Surveyor spoke with RN L (Registered Nurse). RN L stated on 6/4/23 she worked from 6:30 AM - 11:00 AM. RN L stated she was made aware (after the fact) that CNA H entered R62's room to deliver her breakfast tray. RN L stated, I was not happy about it when I heard. RN L stated, she spoke with R62 and R62 asked if she was going to have to deal with CNA H today. RN L stated, she said no, I will take care of your needs. Surveyor asked RN L, is CNA H supposed to be in R62's room at all. RN L stated, No. RN L stated, CNA H told her she was not supposed to go in R62's room. RN L stated, R62 was visibly upset with CNA H. Surveyor asked RN L, is it your expectation that CNA H stays out of R62's room. RN L stated, Yes.

Based on record review and interview, the facility did not implement their written policy which includes completing background checks for 2 of 8 employees. PTA M (Physical Therapy Assistant) and RN N (Registered Nurse) background checks did not include a BID within the last 4 years. The facility policy Background Check, dated 7/16/20, contains the following information, in part: Procedure: After a conditional job offer for employment has been accepted by an applicant, the background check process will immediately begin. An electronic consent/disclosure (BID) form must be completed by the applicant prior to their start date and at least once every four years post hire . The Human Resources Department will initiate the collection of this electronic data through our background screening vendor. On 6/7/23, Surveyor reviewed eight personnel files. 1) PTA M's date of hire was 6/20/16. PTA M's personnel file did not contain evidence of a BID form completed since 6/18/16, nearly 7 years ago. 2) RN N's date of hire was 9/21/15. RN N's personnel file did not contain evidence of a BID form completed since 9/18/15, nearly 8 years ago. On 6/7/23 a 4:07 PM, Surveyor spoke with CNO J (Chief Nursing Officer). Surveyor asked CNO J, how often are BIDs required to be completed. CNO J stated she verified with Human Resources that BIDs are to be completed prior to hire and every 4 years. Surveyor asked CNO J, should PTA M and RN N's BIDs have been completed every 4 years. CNO J stated, yes. On 6/7/23 at 4:55 PM, Surveyor spoke with HR O (Human Resources). HR O stated the company the facility previously contracted with did not provide the facility with BIDs and she is unable to access their system to obtain the BIDs. HR O stated, she was not aware the facility should retain a copy of employee's BIDs. HR O stated, the facility is currently contacting with a new company and now has access to BIDs moving forward.

Based on interview and record review the facility did not ensure an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use was in place for 2 of 2 supplemental residents (R112 and R113). R112 was treated with antibiotics for a UA C/S (urinalysis culture and sensitivity) that did not meet the facilities SOP (Standard of Practice) (McGeer's) for infection control. R113 was treated with antibiotics for a UA C/S that was contaminated and another UA C/S was not collected. This is evidenced by The facility's Antimicrobial Stewardship policy and procedure dated 3/25/21 documents in part: .II. Principles of Antimicrobial Prescribing and Monitoring .3. Appropriate specimens for culture and sensitivity testing will be obtained, when possible, prior to the first dose of antimicrobial therapy .a. When appropriate, antimicrobial therapy will be promptly stopped or deescalated based on culture and sensitivity results . The facility's SOP for Infection Control is McGeer's criteria. McGeer Criteria for Long Term Care Surveillance Definitions for Infections Updated 2012 documents in part: . At least one of the following sign or symptom criteria: a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate b. Fever or leukocytosis (See Constitutional Criteria Table) and at least one of the following localizing urinary tract subcriteria: i. Acute costovertebral angle pain or tenderness ii. Suprapubic pain iii. Gross hematuria iv. New or marked increase in incontinence v. New or marked increase in urgency vi. New or marked increase in frequency c. In the absence of fever or leukocystosis, then 2 or more of the following subcriteria: i. Suprapubic +pain ii. Gross hematuria iii. New or marked increase in incontinence iv. New or marked increase in urgency v. New or marked increase in frequency Criteria 2 a. At least 105 cfu/mL (colony forming units per milliliter) of no more than 2 species of microorganisms in a voided urine sample . Example 1 Upon review of the facility's Infection Control Line List and supporting documentation, the month of February had R112 treated with antibiotics for a UA C/S that grew 10,000-50,000 CFU/mL. The bacteria that grew was Staphylococcus epidermis. On 4/27/22 at 1:41 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if R112's UA C/S should have been treated with antibiotics based on the results, NHA A was unfamiliar with the organism but stated the DON (whom is no longer there) should have caught this and discussed with R112's provider. Example 2 Upon review of the facility's Infection Control Line List and supporting documentation, the month of January had R113 treated with antibiotics for a UA C/S that grew Staphylococcus simulans but had no CFU/mL present. This bacteria is a common animal pathogen; human infections are rarely reported. This culture report documents they were last resulted on 2/1/22. Surveyor was not given the information from 2/1/22. R113's Culture Urine results dated 2/24/22 documents the following .Culture Result Multiple organisms present, probable contaminants, please repeat culture if clinically indicated . On 4/27/22 at 1:41 PM, Surveyor interviewed CDON D (Consultant Director of Nursing). Surveyor asked CDON D if R113's UA C/S should have been treated with antibiotics based on the results, CDON D said no, it should not have been treated, likely contamination. Surveyor asked CDON D what should occur if a specimen comes back with likely contamination, CDON D stated the UA should be recollected.

Based on interview and record review the facility did not 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 for 3 of 16 sampled residents (R2, R10, and R212) R2 had an observation of multiple breaks in appropriate infection control practice for handwashing and catheter care. R10 was not included on the Infection Control Line List for April and should have been. R212 was not included on the Infection Control Line List for April and should have been. This is evidenced by: The facility's SNF/Sub-Acute Infection Prevention and Surveillance (Skilled Nursing Facility) policy and procedure with a reviewed date of 4/22 documents, in part: .Documentation: Documentation on surveillance logs will occur daily and include monitoring of appropriate infectious symptoms .The Infection Prevention RN [Registered Nurse] will review this data daily and make recommendations as needed in relation to trends and issues if identified. This RN will also trend this data in relation to infection definitions and use this to analyze, and report aggregated data . The facility policy, entitled Hand Hygiene, dated 03/04/22, states, in part: . Policy Statement: Mercyhealth holds the safety of its patients, partners, and visitors as a top priority, and recognizes that hand hygiene is the single most important measure partners can take to reduce the risk of transmitting organisms and spreading disease. All partners will be expected to practice hand hygiene appropriately to prevent healthcare associated infections .Hand Hygiene: Cleaning hands by using either handwashing (soap and water), antiseptic hand wash, antiseptic hand rub (i.e., alcohol-based hand sanitizer including foam or gel), or surgical hand antisepsis .PROCEDURES: I. When to Perform Hand Hygiene .Wash with soap and water .When moving from a contaminated body site to a clean body site during patient care . Example 1 R2 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/27/22, at 1:11 PM, Surveyor observed CNA C (Certified Nursing Assistant) and RN E(Registered Nurse) perform perineal/catheter care on R2. CNA C performed the cleansing portion of the perineal area and the catheter. Without hand hygiene, CNA C began the rinsing portion of perineal care. CNA C went from contaminated body area to clean body area without hand hygiene/glove change. R2 was turned onto left side and CNA C tucked dirty brief under R2 and proceeded with the cleansing portion of R2's bottom. CNA C then performed the rinsing portion of cares followed by drying area with clean towel. CNA C did not perform hand hygiene/glove change in between going from contaminated body area to clean body area. CNA C removed a pair of gloves (CNA C had double gloved prior procedure) and grabbed a clean incontinence product and handed it to RN E without hand hygiene after glove removal. CNA C and RN E proceeded with placing incontinence product on R2. On 04/27/22, at 1:45 PM, Surveyor interviewed CNA C and RN E and asked when hand hygiene should be performed during catheter care/ peri cares. CNA C indicated hand hygiene would be performed before applying gloves and after removal of gloves. RN E indicated before gloves applied and after glove removal, when gloves are soiled and when going from dirty area to clean area. Surveyor asked if hand hygiene should have been completed after going from contaminated area or the cleansing portion of the perineal/catheter cares to the clean area or rinsing portion of the perineal/catheter care. CNA C indicated she removed a pair of gloves. Surveyor asked CNA C if that would be considered hand hygiene and CNA C indicated she was not sure. RN D indicated yes hand hygiene should have been done. On 04/27/22, at 2:34 PM, Surveyor interviewed IDON (Interim Director of Nursing) B and asked when would hand hygiene be expected during perineal/catheter cares. IDON B indicated right before and after cares. Surveyor asked IDON B if at any other times and IDON B indicated just before and after. Surveyor asked if hand hygiene would be expected between going from contaminated area to clean body area and IDON B indicated yes hand hygiene would be expected. Example 2 R10 admitted to the facility on [DATE]. On 4/23/22 R10 had a UA C/S (urinalysis with culture and sensitivity) completed to check for a [CONDITION(S)] (urinary tract infection). R10 received oral antibiotics from 4/23/22 through 5/1/22 to treat [CONDITION(S)]. R10 was not listed on April's Infection Control Line List. Example 3 R212 admitted to the facility on [DATE] on an antibiotic due to recent knee replacement surgery. R212 was not listed on April's Infection Control Line List. On 4/27/22 at 11:25 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if R10 and R212 should be on the Infection Control Line List, NHA A stated yes, they should be tracked on the log.

Based on observation, interview and record review the facility did not ensure that resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 3 of 5 sampled residents (R1, R2, and R3). R1 was noted to be at risk for pressure injury (PI) development; R1 primarily sat up and slept in the recliner. The facility failed to ensure R1 had an intervention in place in the recliner to prevent PI development. R1 developed an unstageable, infected wound to her coccyx. The facility's failure to ensure residents at risk for pressure injuries have interventions in place to prevent development of pressure injuries created a finding of immediate jeopardy that began on 1/17/22. Regional Field Operations Director notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 2/3/22 at 11:55 AM. The immediate jeopardy was removed on 2/3/22; however, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by facility failure to have cushions or air mattresses in place for R2 and R3 who are both at risk for pressure injury development and have pressure injuries. This is evidenced by: The Facility's Policy and Procedure entitled SNF (Skilled Nursing Facility) Pressure Injury Prevention dated 4/21 documents, in part: .1. The responsibility of all caregivers if to prevent, care for and provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing judgement and standards of practice are used to determine what preventive measures are to be sued for each resident. These measures are included in the Patient/Resident Care Plan. 3. Any patient/resident who is considered High Risk will have pressure-relieving devices while in wheel chair and bed .4. It is the policy of this facility to assess all patients/residents for additional factors that place them at risk for developing pressure injuries .Mechanical Loading and Support Surfaces .have been assessed to be at risk for skin breakdown should be repositioned at least every two hours .This repositioning should also take place when residents are in a chair or wheelchair .Limit time in chairs: All patients/residents at risk for skin breakdown should avoid long periods of sitting in a chair without being repositioned .According to the AHRQ (Agency for Healthcare Research Quality) Guidelines, the patient/resident should be repositioned, shifting the points under pressure at least every 2 hours or be place back in bed .Patients/residents who sit too long may be prone to ischial ulceration. Slouching in the chair may cause ulcers of the spine, scapula, or elbow. Chair bound residents should have positioning plans for their wheelchairs as well as in bed .Procedure .5. Patients/residents at risk include the following .3. Patient/residents with alteration in mobility .4. Obese patient/residents .6. Patients/residents with motor or sensory deficits (diabetic .) .9. Patient/residents with alterations in nutrition and fluid balance .Pressure Injury Prevention: institute a plan for any patient/resident who has the potential for developing a pressure injury .1. Turning and repositioning schedules individualized or at least every 2 hours .8. Reduce shearing force by lifting resident rather than sliding when repositioning .11. Provide cushions to patients/residents who are in wheelchair . Example 1 R1 admitted for rehab after two valve replacements (aortic and mitral) and CABG (coronary artery bypass graft- surgical procedure used to treat coronary [CONDITION(S)]) on 1/5/22 with the following sternal restrictions that would inhibit her ability to offload independently: Do not lift more than 8 pounds and Do not push or pull with your arms when moving in bed and getting out of bed. R1 also has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's admission Braden scale on 1/5/22 is scored at a 16 (15-18= mild risk). R1's admission documentation documents her skin was intact without redness upon admit. R1's baseline care plan documents that R1 is identified as High- risk and to initiate care plan. There was no skin care plan implemented or interventions put into place. R1's MDS (Minimum Data Set) dated 1/8/22 indicates she required extensive assist for bed mobility and transfers, is at risk for pressure injury, had no unhealed pressure injuries, and interventions of pressure reducing device in chair and bed. It is important to note that R1 rarely slept in bed, slept in recliner in room, and there was no cushion in recliner. R1 has documented (canned- meaning the writer checks a box on a screen; there is no narrative entry to know if all the skin was observed or just parts) skin checks in Facility's EHR (electronic health record) on 1/8/22, 1/10/22, 1/11/22, 1/15/22, and 1/16/22 with no findings noted. R1's Nurses Notes document the following: 1/5/22 at 1:22 PM- .Skin check completed .skin intact . 1/7/22 at 8:09 AM- Patient requires physical assistance of 1 person for toileting, ADLs (activities of daily living) and functional mobility .R1 has struggles with nausea and has had emesis since admission to our facility .R1 requires physical assistance for transfers due to inability to utilize BUE (bilateral upper extremities) due to cardiac and sternal precautions. R1 only able to tolerate 10 feet of ambulation due to nausea, vomiting, SOB (shortness of breath) and dizziness at initial evaluation . 1/17/22 at 9:00 PM- Patient has 0.5 inch x 0.5 inch reddened area on coccyx. Area is not open. No drainage. Venelex (combination medicine used to treat skin wounds resulting from decreased blood floor or skin grafts) applied. It is important to note the Physician was not updated on this change in R1's skin status or for order for Venelex and the facility did not add an intervention to prevent further skin breakdown. R1's MAR (medication administration record) and TAR (treatment administration record) were reviewed with no evidence of Venelex ointment or foam dressing. 1/18/22 at 8:57 AM- Patient requires physical assistance of 1 person for toileting, ADLs and functional mobility .She is receiving Venelex and a foam dressing to a stage 1 pressure injury to her coccyx daily . It is important to note the Physician had not been consulted for order for Venelex or foam dressing and still the Facility did not add an intervention to prevent further skin breakdown. 1/18/22 at 11:56 AM- .Care Plan changes: none noted . 1/19/22 at 6:51 AM- Writer called in by CNA (Certified Nursing Assistant) to apply dressing to bottom area. Two open spots on bottom. Dressing applied @ this time. Education given to patient on staying off of bottom and lying in bed on her side. Verbalized understanding. Of note- note written by LPN (Licensed Practical Nurse) and Co-signed by DON (Director of Nursing). 1/19/22 at 8:30 AM- CNA called writer into room, pt. (patient) c/o (complained of) bottom hurting and being sore. Upon assessment, pt. does have sores on her bottom. Writer encouraged pt. to get off her bottom and lay on her side in the bed for a bit, pt. states that she cannot lie in the bed, it is not comfortable. Big foam dressing applied to coccyx area @ this time . DON made aware of findings. Of note- note written by LPN and co-signed the following day on 1/20/22 by DON B. 1/19/22 at 11:56 AM- Pt c/o nausea .PRN [MEDICATION(S)] given @ 1054. Chills, fatigue and low grade temp of 98.8. COVID test ordered. COVID test was negative. 1/19/22 at 2:29 PM- Upon assessment of pt.'s coccyx and sacral area, there is distal necrotic area width 3.1 and length 5.5, unstageable. More sacral area whitened area 3 x 2.5, blistered. Both areas are draining and odorous. Secure chat sent to physicians in regards to findings and further assessment. Pt currently in bed, off of bottom. Will continue to monitor. Of note- note written by LPN and co-signed the following day on 1/20/22 by DON B. 1/19/22 at 3:36 PM- OT (Occupational Therapy) asking about seeing pt. for session .OT states that Monday there was a small reddened area on coccyx @ shower time and was reported, see therapy notes. Venelex was ordered and foam dressing applied per .LPN .did see the wound today and states that nothing was opened on Monday during shower and the sores do look different today. Pt in bed laying on right side, resting comfortably. Will continue to monitor. Of note- note written by LPN and co-signed the following day on 1/20/22 by DON B. 1/19/22 at 5:39 PM- New orders for general surgery consult .NP (Nurse Practitioner) contacted regarding coccyx-sacral wound unstageable of unknown etiology. 1/19/22 at 8:46 PM- At shift change patient was reported with having low grade fever, chills and fatigue. Rapid COVID test run this AM was negative. Vitals taken at start of shift Fever 102, HR 106, BP 130/74 and 90% O2 (oxygen saturation level) on room air .NP called. Also explained to NP the extreme progression of patients' pressure ulcer on coccyx. Order to discharge and bring patient to the ED (Emergency Department). R1's ER (emergency room ) documentation contained as follows: 1/19/22 at 8:51 PM- Pt arrives with CC (chief complaint) of fever and sores present on back side. [R1] has been at SNF for past couple of weeks. Facility RN (Registered Nurse) reports that they noticed that she had multiple wounds on back side and pt. had spiked a fever that started today. 1/20/22 at 1:25 AM- Clinical Impression infected decubitus ulcer, unspecified ulcer stage .The patient arrived febrile with [CONDITION(S)] .Concern for [CONDITION(S)] with obvious infection and sacral decubitus ulcer, fever, [CONDITION(S)]. Fluids and antibiotics started. Tylenol given .will plan for admission .Final Impression 1. Infected decubitus ulcer unspecified ulcer stage . R1's Surgical Documentation contained as follows: 1/20/22 at 12:00 AM- Preop Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .pt. admitted yesterday with sacral pain and fever, on exam pt. had some dead skin overlying the sacrum with some foul smelling drainage, operative debridement was recommended, pt. brought urgently to the OR (operating room), pt. was warfarinized (started on anticoagulation therapy) post recent cardiac valve replacement, given oral vitamin K and plan to manage with [MEDICATION(S)] drip postop ([MEDICATION(S)] is an anticoagulant used to prevent blood clots, vitamin K counteracts [MEDICATION(S)]). Necrotic skin was excised using cautery, this revealed a large amount of necrotic subcutaneous tissue, small amount of purulence, cultures sent and specimen sent to pathology . R1' Hospital documentation contained as follows: Encounter 1/19/22: .R1 was admitted with [CONDITION(S)] secondary to infected decubitus ulcer .required surgical debridement on 1/20/22, 2 IV antibiotics and wound vac placement .wound culture grew Staph and Morganella organisms .AKI (Acute Kidney Injury) secondary to [MEDICATION(S)] ([MEDICATION(S)] strong antibiotic to treat serious infections) received in ER and 3rd spacing (movement of bodily fluid from the blood into the spaces between cells- this is caused by too much fluid moving from intravascular space (blood vessels) into the interstitial space) .fluid overload presented as LE (lower extremity) [CONDITION(S)] and weight gain of 20# since admit likely due to IVF (intravenous fluids) and blood [CONDITION(S)] .acute blood loss due to surgery s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Wound documentation after debridement: 1/20/22 at 2:15 PM- base of wound moist slough gray (adipose tissue) .positioned on right side .7 x 8 x 4.2 cm (centimeters) with 1.5 cm undermining (damaged tissue under the skin that can extend in all directions, creating a lip under the edges of a wound) from 11-2 o'clock and 2.5 cm undermining @ 3 o'clock to 6 o'clock . Note from 2/2/22: R1 is still hospitalized (admitted [DATE]) and still receiving 2 IV antibiotics as well as IV [MEDICATION(S)] (strong diuretic used to treat pulmonary and systemic [CONDITION(S)]) and just switched on 1/27/22 from IV drip of [MEDICATION(S)] to oral ([MEDICATION(S)] is an antiarrhythmic medication use to slow the nerve impulses in the heart) due to acute on chronic CHF (congested heart failure). On 2/2/22 at 12:52 PM, Surveyor interviewed CNA C. Surveyor asked CNA C if R1's wound was present on admission, CNA C said no, it was not there on admission. Surveyor asked CNA C what it looked like when it first appeared, CNA C said it was a reddened area on coccyx, topical ointment was applied. Surveyor asked CNA C when R1's wound got worse, CNA C stated it got aggressively worse within 3-4 days. Surveyor asked CNA C if resident slept in bed or recliner, CNA C stated R1 is in recliner 99% of the time. Surveyor asked CNA C if she knew why R1 did not want to lay in the bed. CNA C said R1 said it wasn't comfortable, gave her breathing difficulty. Surveyor asked CNA C if R1 had a cushion in her recliner, CNA C stated I can't say I recall a cushion. Surveyor asked CNA C if R1 was being turned/repositioned, CNA C stated once the wound showed up then we turned/repositioned her every 2 hours. On 2/2/22 at 1:26 PM, Surveyor interviewed LPN D. Surveyor asked LPN D if R1's wound was present on admission, LPN D said no, her skin was intact on admission. Surveyor asked LPN D what it looked like when it first appeared, LPN D explained OT asked for area to be assessed, red blanchable area to coccyx that R1 said hurt, area was tender, about quarter sized. Surveyor asked LPN D what happened next, LPN D said she consulted a RN and they applied Venelex ointment and a foam dressing to cover area. Surveyor asked LPN D where R1 spent most of her time, in bed or recliner; LPN D said she sat in the recliner, didn't like the bed- comfort issue; did sleep in recliner at home as well. Surveyor asked LPN D if R1 was being assisted with turning/repositioning, LPN D said patients on the rehab unit move a lot and she would shift weight quite a bit. Surveyor asked LPN D if they have a wound nurse. LPN D said no but we have access to the hospital's wound nurse. Surveyor asked LPN D if the wound nurse saw R1, LPN D said no, she typically doesn't see our patients unless there's an extensive treatment. Surveyor asked LPN D if R1 had a cushion in her recliner. LPN D stated She probably didn't, Roho's [a specialized pressure relief cushion that redistributes weight to provide skin protection] are few and far between. On 2/2/22 at 2:42 PM, Surveyor interviewed DON B. Surveyor asked DON B what pressure reduction interventions R1 had in place, DON B said all residents have a pressure redistribution mattress on their bed. Surveyor asked DON B if R1 was assessed to be at high risk for pressure injury development, what interventions should be in place for her? DON B replied low air loss mattress cushion, but there's a national shortage of Roho cushions right now. Surveyor asked DON B if R1 should have a specific skin care plan. DON B said yes. Surveyor asked DON B what intervention was put into place once R1 developed the reddened area on 1/17/22. DON B said the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked DON B how wounds are measured. DON B said always in cm. On 2/3/22 at 11:50 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if R1 used a facility recliner or had brought one from home, NHA A stated R1 used a hospital recliner, which is what the facility uses. On 2/2/22 Surveyor made observation of 2 types of recliners used in the facility. One with winged back and one with straight back, both made of vinyl type material. On 2/2/22 at 5:05 PM, Surveyor interviewed R4. Surveyor asked R4 how she likes the recliner she was sitting in, R4 replied I always slide down in it. On 2/2/22 at 5:07 PM, Surveyor interviewed R5. Surveyor asked R5 how she likes the recliner she was sitting in, R5 said I slide down in this one too, constantly. On 2/3/22 at 10:59 AM, Surveyor interviewed Physician E. When Surveyor asked Physician E if he would expect a resident that is assessed at high risk for pressure injury development to have interventions in place to prevent this, Physician E said yes. Surveyor asked Physician E if a resident is sitting and sleeping in a recliner and not the bed, would he expect there to be a cushion in the recliner? Physician E replied yes and daily skin checks. Surveyor asked Physician E once R1's skin was reddened, would he have expected a preventive intervention to be put into place? Physician E said yes. Surveyor asked Physician E if he would've expected to be updated when R1's skin had a change? Physician E said yes and the process for that is typically the nurses update the RNCC (Registered Nurse Care Coordinator) and the RNCC update me or my NP. Surveyor asked Physician E if Venelex ointment and a foam dressing require an order? Physician E stated yes, I give verbal orders for Venelex, we use that often. Surveyor asked Physician E if he is aware of any other etiology besides pressure for R1's wound. Physician E said no. Surveyor asked Physician E if he knew what the pathology report said from the sample the Surgeon sent. Physician E read that wound had an abscess, fat necrosis, and was negative for neoplasm. Facility failure to ensure that interventions were put in place to address R1's risk for pressure injury development (e.g., cushion in the chair where she spent most of her time, assistance with repositioning) and the failure to update the physician when a pressure injury developed led to serious harm for R1, thus creating a finding of immediate jeopardy. The facility removed the jeopardy on 2/3/22, when it had completed the following: 1. The affected resident was sent to the ER for evaluation of [CONDITION(S)] and admitted to the hospital. This was completed on 1/19/2022. 2. The facility performed a house wide sweep of all residents at risk for pressure injuries. All residents at risk had a comprehensive skin assessment completed. 3 residents with wounds were identified and 9 residents were identified at risk for skin breakdown. 3. Care plans were initiated or reviewed to ensure appropriate and aggressive PI prevention and intervention were in place. 4. Beginning 2/3/2022 all staff received education, prior to their next working shift, on the following: The facility educated staff on identifying residents at risk for PI development, creating individualized care plans for PI prevention, implementing interventions to prevent PI development, measurements and assessment of PI once developed, updating the physician with changes of condition. Education included; implementing aggressive PI interventions when redness occurs, daily assessment of pressure areas, including detailed documentation and assessment of PI, interventions implemented and the effectiveness of those interventions. Nurses were trained to complete a thorough assessment, measurement, and to document findings upon identification of a pressure injury. CNA's were educated on performing skin checks during cares and instructed to report skin changes to the nurse immediately. Nursing staff were educated to collaborate with the inter-disciplinary team to identify the root cause and put appropriate measures in place when a pressure injury is identified. 5. The DON reviewed policies and procedures in place related to skin assessment and skin care, and wound assessment and wound care to ensure the policies and procedure meet current standard of practice on 2/3/2022. 6. The DON will review all residents with wounds twice a week to ensure that they have current measurement and that interventions are documented. 7. The DON will round to verify care planned interventions are appropriately in place 3 times per week for 2 weeks, then twice weekly for 4 weeks. 8. The DON will audit each resident twice a week to ensure that all residents that are at high risk for skin breakdown have appropriate interventions care planned. 9. The DON will report all audit findings and corrective actions to the administrator and assistant administrator. 10. The DON will meet with nursing staff and IDT (Interdisciplinary Team) upon identification of a new wound to identify the root cause and put appropriate measures in place for the next 4 weeks to ensure compliance. 11. QA (Quality Assurance) committee will have a meeting to discuss this event and corrective measures on 2/4/2022. The deficient practice continues at a scope/severity of D based on the following examples: Example 2 R2 has DTI (Deep Tissue Injury) to his gluteal and has no cushion in place in wheel chair. R2 was admitted for short term rehab. R2 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Hospital record prior to admission to SNF documents: 1/26/22 at 9:00 PM- Orientation: medial, Location: gluteal .Pressure Injury: deep tissue injury, Present on Hospital Admission: Y (yes), Additional Comments: purple, unblanchable . R2's admission Braden scale on 2/1/22 is scored at a 17 (15-18= mild risk). R2's baseline care plan documents: Skin Risk (Braden on admit) .Wound location .Gluteal . R2's Nursing care plan documents the following: R2 is at risk for pressure injury/skin breakdown due to immobility, dm (diabetes mellitus), obesity and incontinence. He does have .a gluteal DTI. He has an indwelling Foley catheter .R2 will be free from unavoidable pressure injuries during his stay .Assess R2 for skin breakdown routinely. Offer repositioning during rounds or cue to reposition when up in chair. Provide daily wound care to .gluteal area . On 2/2/22 at 11:54 AM, Surveyor observed R2 in bed on back with HOB (head of bed) elevated 30 degrees, no air mattress or cushion noted in wheelchair. Surveyor interviewed R2. Surveyor asked R2 if he was being repositioned, R2 said yes. Surveyor asked R2 what they were doing for the wound on his bottom, R2 said there's a bandage that is changed daily. On 2/2/22 at 2:02 PM, Surveyor interviewed CNA F. Surveyor asked CNA F what interventions are in place for R2's wound to bottom, CNA F stated right now has a cream, no air mattress or cushion. Surveyor asked CNA F if they assist R2 in repositioning, CNA F said he repositions himself. On 2/2/22 at 2:04 PM, Surveyor interviewed LPN D. Surveyor asked LPN D what interventions are in place for R2's wound to bottom, LPN D said he has a wound treatment and he repositions himself. Surveyor asked LPN D if R2 had an air mattress or cushion, LPN D stated he had a hospital bed, no Roho or air mattress. Example 3 R3 has stage I pressure injuries to bilateral areas and has no cushion in place in wheel chair R3 was admitted for short term rehab. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's admission documentation includes: .Side: Left, Orientation: medial, Location: gluteal .Pressure Injury: stage 1, Present on Hospital Admission: Y, Base: red, Tissue Characteristics: fragile, Length: 3 cm, Width: 2 cm, Depth: 0 .Side: Right, Orientation: medial, Location: gluteal .Pressure Injury: stage 1, Present on Hospital Admission: Y, Base: red, Tissue Characteristics: fragile, Length: 4 cm, Width: 3 cm, Depth: 0 . R3's admission Braden scale on 2/1/22 is scored at a 15 (15-18=mild risk). R3's baseline care plan documents that R3 is identified as High- risk-to initiate care plan .Wound location: right ankle unstageable and 2-Gluteal fold stage I . R3's Nursing care plan documents the following: R3 has an unstageable ulcer on her right ankle and stage I ulcers on her right gluteal area and left gluteal areas .R3 will not develop any further skin breakdown throughout her stay .Nursing to perform and document skin check. Encourage proper positioning, and relief on all pressure points. Pressure redistribution mattress, float heels when in bed as she allows . On 2/2/22 at 12:00 PM, Surveyor observed R3 up in wheelchair, no air mattress or heels up on bed or cushion in wheelchair. Surveyor interviewed R3. Surveyor asked R3 what treatments she has for wounds, R3 said there's a treatment daily to her heel. Surveyor asked R3 what they put on her bottom, R3 was unsure about having sores on bottom. On 2/2/22 at 1:54 PM, Surveyor interviewed CNA G. Surveyor asked CNA G what interventions they have in place to prevent skin breakdown for R3, CNA G said they float her heels. Surveyor asked CNA G if R3 has an air mattress on bed or cushion in wheelchair, CNA G stated no cushion in chair and no air mattress. On 2/2/22 at 2:04 PM, Surveyor interviewed LPN D. Surveyor asked LPN D what they are doing to prevent skin breakdown for R3, LPN D replied the reposition her and look at her bottom every shift. Surveyor asked LPN D what interventions R3 has in place, LPN D explained she gets aloe, is repositioned every 2 hours and has heels floated in bed with pillows. Surveyor asked LPN D if she has an air mattress or cushion in her wheelchair, LPN D said no.

Based on record review and interview, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the appropriate agencies for 2 of 5 residents reviewed (R4 and R6). R4 and R6 voiced an allegation of abuse and the facility did not report this to the State Agency. This is evidenced by: The facility policy, SNF - Abuse Policy, with an effective date of 2/1/07 and a revision date of 2/2/21, .Staff shall immediately inform the administrator or acting administrator of the facility and other officials (including to the State Survey Injury and Adult Protective Services where State law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures all reports of potential abuse, neglect, or mistreatment .5. Investigation Components .V. Internal Reporting Requirements and Identification of Allegations .Employee shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or a designee shall initiate an incident investigation. Any allegation of abuse or any incident that results in serious bodily injury will be reported to: Wisconsin Specific: to the Division of Quality Assurance immediately but not more than two hours of the allegation of abuse. {SIC} Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours. Review of a Grievance/Concern Form dated 12/10/20 noted the following: -Summary of Concern: On December 9, 2020, SLP D (Speech and Language Pathologist) reported to NHA A (Nursing Home Administrator) that residents R4 and R6 voiced concerns to another staff member who had told her about the incident today. -NHA A and ANHA F (Assistant Nursing Home Administrator) spoke with both residents on 12/9/20 regarding their concerns with a certified nursing assistant on the evening shift. R6 stated on the evening of 11/29/20 or 11/30/20 she asked CNA C (Certified Nursing Assistant) to go to the bathroom and she needed to have a bowel movement. R6 stated CNA C's response was Just s*** your pants and I will clean you up. R6 reports CNA C had an attitude and was very rude. Additionally, R4 reports CNA C had mistreated her on the same evening, 11/29/20 or 11/30/20. R4 reports she was in pain and CNA C put a blanket on her and R4 informed CNA C she was in pain. CNA C proceeded to turn in her bed and caused her pain .R4 reports during the time CNA C was turning her in bed, she stated to CNA C, you hurt me.R4 explained she and CNA C had words but R4 could not elaborate to what was said . R4 was admitted to the facility on [DATE] with a MDS (Minimum Data Set) assessment, on 11/7/20, indicting a BIM's (Brief Interview of Mental Status) of 15, cognitively intact. Review of a statement from R4 titled, Investigation of Mistreatment Allegation, dated 12/10/20, and notes the following: I felt CNA C was hurrying and treated me rough. I told her it hurted {SIC} and her care didn't change. We had a few words and she left the room. CNA C likes to be in charge. My roommate and I didn't admit it for a long time and when we did we told COTA E (Certified Occupational Therapy Assistant) first. R6 was admitted to the facility on [DATE] with a MDS (Minimum Data Set) assessment, on 11/7/20, indicting a BIM's (Brief Interview of Mental Status) of 14, cognitively intact. Review of a statement from R6 titled, Investigation of Mistreatment Allegation, dated 12/10/20, and notes the following: CNA C the aide always says something smart. Told me once to s*** your pants and I'll clean it up. On 2/25/21 at 12:35 PM, Surveyor interviewed SW G (Social Worker) and asked if the statements made by R4 and R6 could be considered allegations of abuse. SW G stated, yes, they didn't deem it that way, more as miscommunication and staff member being rushed. NHA A was present for interview and was asked if these could be considered allegations of abuse, and she stated, yes. Surveyor asked, NHA A what the policy on reporting abuse is. NHA A stated, they have to be reported immediately. The facility was informed by two separate residents concerning allegations of abuse. These allegations were not reported to the State Agency as required.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the ability to affect all 10 residents. The ice machine's plastic spout inside was observed dirty. Dishes were observed not completely submerged during sanitizing process of the 3 compartment sink. 4 food items were observed opened, but not dated in the facility cooler. The microwave in the facility dining room was observed dirty. Evidenced by: The facility policy Subject: Pot & Pan Procedure, reviewed date of 9/7/17, includes under 'Manual Sanitation' to Place item in sink for at least two minutes. There was also a sign observed above the 3 compartment sink that stated the dishes should be submerged for 1 minute. On 4/23/19 at 8:09 AM, Surveyor entered the kitchen with NHA A (Nursing Home Administrator). FSA C (Food Service Assistant) started the tour with Surveyor as well. Surveyor observed, inside the ice machine, a dark yellow substance along the plastic spout that the ice drops into the bin below. FSA C stated that maintenance staff cleans it quarterly (every 3 months) and does a more thorough cleaning twice a year. Next, Surveyor observed FSA D use the 3 compartment (3C) sink to wash and sanitize the dishes. FSA D did not ensure that 2 items in the sanitizer were completely submerged, a white plastic bucket and a small plastic bin. FSA D then removed them after a few minutes and set them on the tray to dry. Surveyor asked her to test the sanitizer and she did. The manufacturer's direction is to hold the test strip under the water for 10 seconds. FSA D held it only 7 seconds under the water. Surveyor asked FSA D what it showed or tested out as. FSA D stated the green one (there were 4 variations of green on the directions). Surveyor again asked what ppm (particles per million) it showed and FSA D pointed to the 200 ppm green. Surveyor asked what it was supposed to be at and FSA D wasn't sure and then said 200 ppm to 400 ppm. Surveyor asked when FSA D was last observed or had training on using the 3C sink and FSA D could not recall when last observed or trained. Surveyor asked what the plastic bins that were not submerged were used for and Cook G stated they were used for fresh vegetables. Surveyor then observed in the large walk-in cooler, close to the 3C sink, a tuna salad sandwich and bowl of grapes not dated. CM E (Chef Manager) stated they should have a date on them for when they were prepared. Surveyor also found a Colby jack cheese package and jug of fat free milk opened and not dated. CM E agreed they should have an open date on them. On 4/23/19 at 9:08 AM, Surveyor observed the microwave in dining area with food stuck on all surfaces of it. DON B (Director of Nursing) stated he would have someone clean it right away. On 4/24/19 at 7:52 AM, during the follow-up tour of the kitchen with NHA A and CM E, Surveyor again observed the yellow substance on the plastic inside the ice machine. NHA A used her finger and was able to smear the yellow substance and agreed it needed to be cleaned. Then Surveyor observed FSA F use the 3C sink. FSA F put a large metal bowl into the sanitizing compartment, with at least 4 inches of the bowl not submerged, and a plastic bin not submerged. CM E tested the water and it showed 200 ppm and stated it should be between 150 and 400 ppm. FSA F stated they had waited over a minute and put the observed items onto the drying rack. Surveyor asked FSA F if they were completely submerged and FSA F agreed they were not. Surveyor asked when FSA F was most recently observed or trained on how to use the 3C sink. FSA F could not recall either. FSA F also explained that both items that had not been completely submerged were used for salads.

Based on observation, interview, record review and facility policy and procedure review, the facility did not implement professional standards of practice to prevent PIs (pressure injuries) from developing, worsening, or to promote healing. Assessments of PIs were not consistently being completed by a RN (Registered Nurse) for 1 of 1 residents reviewed for PIs out of a sample of 10 residents (R2). R2 was at high risk for PI development and there was no documentation that R2's skin was thoroughly assessed at admission. The facility failed to document a thorough assessment to R2's left heel, until after R2 was found with a ruptured Stage 2 PI with further suspect DTIs (deep tissue injury) to left heel, on 4/1/19, 13 days after admission. The facility knew R2 had a DTI to left heel at admission. R2 continued to wear a diabetic shoe with liner, which did not off-load R2's left heel DTI during weight bearing and transfers. The facility did not implement a Prafo boot (heel offloading boot) to R2's left foot until 4/5/19, 4 days after R2 was found with a ruptured Stage 2 PI with further suspect DTIs to left heel. When the facility identified that R2's admission skin assessment was not documented accurately, the facility did not educate all nurses on admission skin assessments. The facility identified R2's wound to left heel as a diabetic ulcer, even though it presented as a suspect DTI at admission. This is evidenced by: The facility's Skin Assessment policy, dated 6/18, includes, in part: . 1. Upon admission, a registered nurse will complete a head-to-toe assessment of the resident's skin when completing the admission nursing assessment. Residents admitted with skin breakdown will have the skin issues documented in the medical record . 3. RN will perform head-to-toe skin assessment daily on skilled patients. 4. RN will document in medical record the outcome of the head-to-toe skin assessment. These results are documented in the medical record on the skin flowsheet. 5. Any new areas that are found are assessed, measured and documented. Measures are put in place to prevent deterioration and reoccurrence. These measures are documented in the record and placed on the plan of care . Findings: R2 was admitted to the facility, on 3/19/19, with [DIAGNOSES REDACTED]. R2's admission MDS (Minimum Data Set) assessment, on 3/25/19, notes a BIMS (Brief Interview for Mental Status) score of 14, indicating R2 is cognitively intact. Section G of the MDS notes that R2 is dependent on staff for bed mobility. Section M Skin Condition notes R2 is at risk of developing pressure ulcers/injuries. Section M0210: Unhealed Pressure Ulcer/ Injuries - No is marked. Section M1040 Other Ulcers: [MEDICAL CONDITION] is marked. R2's Braden Scale (assessment for development of PI), on 3/19/19, score was 15, indicating high risk; on 4/5/19, R2's Braden score was 15. R2's Comprehensive Care Plan, dated 3/19/19, Risk of skin breakdown, includes, in part: Problem: . (R2) admitted with a blister on left heel . Goal: (R2) is admitted with a blister on left foot: Goal will be to protect blister. Approaches: Pressure relief mattress on bed and pad in W/C (wheelchair), Assist to reposition every 2 hours . Observe for signs of skin breakdown with daily cares. Report irritation/breakdown to the Nurse, Nurse to perform and document weekly skin checks, Offload foot while in bed. On 4/5/19: Care Plan Intervention added: Prafo Boot on at all times. R2's Initial Care Plan notes, in part, the following interventions: 3/19/19 Transfers- Assist of 2 with transfer, heel protectors/ elevate heels 4/2/19 Transfers-EZ Stand 4/4/19 Remove left shoe when sitting and not bearing weight 4/5/19: Prafo Boot on at all times. R2's Physician Orders, on 4/2/19, include: Clean left heel with saline, [MEDICATION NAME] collagen (wound dressing), Aqua Cell Foam, change every 2 days and as needed. Review of R2's medical record, Skin Assessments under Skin Integrity, notes, in part: From 3/19/19-4/1/19, notes include observations of excoriation and bruise to R2's skin. (It is important to note, there is no documentation of R2 having loss of skin integrity to left heel, there is no DTI or blister documented and no measurements are documented.) 4/1/19 other (see comments) 4/2/19 there is no entry for this date 4/3/19 blister(s) 4/4/19-4/23/19: wound(s) (See specific measurements to R2 left heel as noted below) Review of R2's Nursing Progress Notes include, in part: On 3/19/19 at 2:00 PM: . Left lateral heel has ulceration (skin intact) that is being followed by Dr (Doctor's Name- Podiatrist) On 3/24/19 at 1:43 PM: .Skin remains intact On 4/1/19 at 4:18 PM: Therapy reported that patient's gripper sock was wet. Assessment findings of suspected DTI to left heel. Involved left lateral area extending to medial aspect of heel. Large area of loose, unattached white macerated skin and opened blister with underlying skin exposed most deep pink area measuring L (length) 4.5 CM (centimeter) x (by) W (width) 7.2 CM x D (depth) 0.02 CM. Towards the medial aspect of wound is an area deep purple measuring 0.8 CM x 1 CM with another ring of deeper pink approximately 4 CM x 4 CM. Areas cleansed with normal saline. Covered with foam dressing and secured with Kerlix. Heel elevated on pillow Wound Consult made. R2's Summary for PI - 4/1/19- Left medial heel suspected DTI notes: 4/1/19: Length: 4.5 CM x Width: 7.2 CM x Depth: 0.2 CM, purple, moist, pink (It is important to note that this is first documentation of R2's left heel wound measurements/condition on the skin flowsheet.) NP (Nurse Practitioner) Progress Notes SNF (Skilled Nursing Facility) Wound Rounds for R2 notes, in part: On 4/2/19 at 11:57 AM: . (R2) seen at the request of SNF staff for a ruptured blister located R (Right) (sic) heel which began a few days ago a large blister that recently ruptured . Wound Location: L (left) heel . Measurements: 6.0 CM length x 4.5 CM width x 0.1 CM depth . Wound bed: pale, granulating, pink. 2 darkened areas with the wound bed likely DTI's. Granulation tissue: 100% Nursing Progress Notes continue: Late entry on 4/3/19 at 10:00 AM: . Left heel ulceration present on admission, previously noted by (Dr. Name) darkened area measured 1.5 CM x 5.5 CM, skin intact. Plan of care included elevation of heel in bed and off-load pressure. Recliner placed in patient room for purpose of elevating legs and pressure reduction of left heel. On 4/3/19 at 1:00 PM: . Left heel blister followed by wound nurse, dressing to be changed every 48 hours/PRN. Shoe removed while not in therapy to relieve pressure, foot elevated On 4/5/19 at 9:52 AM: . New order for Prafo on LLE (lower left extremity) when in bed and will contact orthotics about insert of left shoe. R2's Summary for PI . Left medial heel suspected DTI notes: On 4/5/19: Wound Measurements: 6.2 CM x 7.2 CM x 0.1 CM cleansed with normal saline, foam dressing, moist drainage, purple NP Progress Notes SNF Wound Rounds for R2 notes, in part: On 4/9/19: Attempted to see patient . Will reattempt as time allows. R2's Summary for PI . Left medial heel suspected DTI notes: On 4/11/19: Wound Measurements: 5 CM x 7 CM x 0.2 CM clean bleeding, cleansed with normal saline foam dressing NP Progress Notes SNF Wound Rounds for R2 notes, in part: On 4/16/19 at 2:53 PM: . L heel, onset 4/2/19, etiology: pressure ulcer. Measurements: 3.5 CM x 1.0 CM x 0.1 CM . Wound condition: wound bed: eschar, firmly adherent with loosening edges . Eschar present: 100% . Stage 2 Pressure Injury L heel with DTI within wound bed . NP Progress Notes SNF Wound Rounds for R2 notes, in part: On 4/23/19 at 1:40 PM . L heel pressure ulcer, Thickness: partial, Wound Condition .Granulation tissue 0%, Sough 40%, Eschar 60%, Stage 2 PI left heel with DTI within wound bed . Procedure completed: Sharps debridement . Amended NP Progress note, on 4/23/19, notes: Granulation tissue: 100% after debridement, Stage 3 PI L heel . R2's Summary for PI .Left medial heel suspected DTI notes: On 4/23/19: Wound measurements: 3 CM x 1 CM x 0.1 cleansed with normal saline, foam dressing, barrier film to peri wound On 4/23/19 at 9:57 AM, Surveyor observed R2 with a Prafo boot in place to left foot. Surveyor interviewed R2 who stated, I had a wound when I came in and it was healing up and got a blister on it, Wound Care Nurse just redressed it. On 4/24/19 at 10:20 AM, Surveyor interviewed RN H (Registered Nurse) about R2's heel. RN H was the nurse who admitted R2 on 3/19/19 and made the late entry on 4/3/19. RN H clearly remembered observing what RN H thought was a suspect DTI to R2's left heel on admission and care planned for R2's left foot to be elevated on pillows to float heel. RN H did not enter an LDA (Lines, Drains, Airway) in the electronic medical record for R2, which would have set up a documentation flow sheet for all nurses to document R2's heel ulceration and RN H should have. RN H stated that the DON (Director of Nursing) had provided RN H with education, on 4/3/19, about this error. On 4/24/19 at 12:07 PM, Surveyor interviewed CNA I (Certified Nursing Assistant) about R2. CNA I stated that staff had been floating R2's heels off the bed before R2 developed the blister on heel. CNA I stated that R2 did fine with using the pillow when in bed. CNA I stated that R2 sometimes wore the diabetic shoe for therapy and transfers and sometimes wore a grippy sock, before the blister opened on heel. CNA I stated that the shoe was no longer used, and the Prafo boot was in place. On 4/24/19 at 1:34 PM, Surveyor interviewed DON B about R2's left heel PI. DON B stated that R2 was admitted with this wound and that it had been previously identified as a Diabetic Ulcer by R2's podiatrist. Surveyor asked if pressure could have contributed to the ulcer developing into a blister, which ruptured on 4/1/19. DON B stated that R2's shoe could have been rubbing on heel in therapy and it opened during therapy. DON B stated that the facility had preventative measures for R2's heel care planned on 3/19/19; staff were floating R2's left heel on a pillow since admission and added the Prafo boot after the blister opened. Surveyor asked if the nurses should have documented measurements and thorough assessments of R2's left heel ulcer starting on 3/19/19. DON B agreed they should have been and were not. Surveyor asked if DON B had immediately educated other nurses besides RN H, on the importance of entering skin integrity concerns into the electronic medical record (LDA), so that the skin flow sheet would be initiated. DON B stated he had not and should have; DON B stated he was going to educate all the nurses at the nurses meeting on 4/25/19. On 4/24/19 at 2:29 PM, Surveyor interviewed MDS RN K about R2's admission MDS Assessment on 3/25/19. Surveyor asked why R2's heel ulcer was coded as a Diabetic Ulcer rather than a PI. MDS RN K stated that's what I was told by DON B. Surveyor asked if MDS RN K directly observed R2's heel before completing the MDS. MDS RN K stated, Most of the time I do a direct observation, but in this case I did not, I should have, I don't recall if I reviewed any documentation, which I should have. On 4/24/19 at 2:45 PM, Surveyor observed RN H complete R2's treatment to R2's left heel. Surveyor observed left heel to have an open area about 3.5 CM x 1.5 CM x 0.1 CM, wound bed with 30% granulation tissue, 10% eschar and 60% with thin layer of white slough. On 4/24/19 at 3:41 PM, Surveyor interviewed NP J about staging R21's PI as a Stage 2 when it was covered with slough and eschar on 4/23/19. NP J stated I should have staged R2's PI as a Stage 3 and would amend the documentation; NP J had debrided R2's wound on 4/23/19.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored and distributed. This has the potential to affect all 20 residents who reside in the facility. During the survey the following were observed in the kitchen: uncovered food in the refrigerator and freezer, expired food items, uncovered garbage receptacles, dirty mixer, scoop in the rice, hair restraints not in place, dish machine temperatures not monitored, not washing hands prior to putting clean dishes away. Evidenced by: Per the facility policy Dress Code-Food and Nutrition Services, with a revision date of [DATE]: It is expected that male employees report to work clean-shaven. A beard guard is required if any facial hair is present. Employees are expected to wear either a hair net, surgical cap or baseball cap that covers hair during working hours. All hair must be covered. The initial tour of the kitchen, on [DATE] at 8:33AM, with DD H (Director of Dietary), Surveyor observed the following items in the various kitchen refrigerators and freezers uncovered: tray of cooked chicken, fajita mix, battered fish, and a pepper and onion mixture. DD H showed us a written protocol for food cooling that stated DO Not Cover - Vent to cool. The NHA A (Nursing Home Administrator) did provide Surveyor information from an in-service provided to staff on [DATE] by DD H to include cooling and covering of food, and dating and discarding of open containers. Education provided that all food items must be covered to prevent possible cross contamination and that during cooling food items must be loosely covered and vented. Surveyor also observed the following with DD H present: Two whipped topping spray cans in a cooler past the use by dates of [DATE] and [DATE]. Two garbage receptacles in the food preparation area that were uncovered. A large mixer with dried on dough like substance near where the beater shaft attaches. DD H was able to scrape off with his fingernail. A bin of rice with a measuring cup inside touching the rice. Facial hair uncovered: DD H during food preparation of a beef and noodle dish and while walking about the kitchen and DA J (Dietary Aide) without a hair net while cleaning dishes DA J moving from dirty side of dish machine to clean without washing hands. Dishwasher temperatures not properly monitored. On [DATE] at 9:12 AM, Surveyor observed DMS I (Dish Machine/Server) working with the clean side of the dish machine. DMS I showed Surveyor temperature gauges for the dish machine and demonstrated how to read them and document on the Temperature Log. DMS I stated the dishwasher should be at the following temperatures: 150 degrees F (Fahrenheit) Wash, 160 degrees F Rinse, 180 degrees F - 194 degrees F Final Rinse. The temperatures taken during the observation were within range, however, were documented on [DATE]. Review of the temperature logs showed no temperature readings for [DATE] and [DATE] prior to the observed documentation today. No internal temperature/minimum surface temperatures were documented on the log for the entire month of June. DMS I was asked to demonstrate internal temperature monitoring and stated they have been unable to locate the thermometer for this. DD H stated that the thermometer had been damaged during use and a new one was ordered. DD H stated that all temperatures should be recorded 3 times a day with meal times. During observation of the dishwashing process a second dietary aide (DA J), was observed without a hair net in place. DA J was also observed moving from the dirty side of the dish machine to the clean side without washing his hands between glove changes. On [DATE] at 1:33 PM, Surveyor returned to the kitchen and observed DD H demonstrate internal surface temperature monitoring. DD H obtained strips for internal monitoring from his EcoLab representative to utilize until the new thermometer arrives. Observation completed and internal surface temperature was recorded at 160 degrees F.

Based on interview and record review, the facility did not ensure that their Antibiotic Stewardship Program included a system to monitor for appropriate antibiotic use, for 1 resident (R2) of 5 reviewed and 2 supplemental residents (R115 and R116) of a total sample of 17. R2, R115 and R116 were placed on broad spectrum antibiotics for UTI (Urinary Tract Infections) without documentation for indication for use of broad spectrum antibiotic use, or evidence that the facility reviewed if a narrower spectrum antibiotic would have been effective, as indicated on the resident's culture and sensitivity reports. This is evidenced by: The facility's Antimicrobial Stewardship policy, dated 10/6/17, includes, in part: Prescriber responsibility .Documentation of diagnosis/indication is required for all antibiotic orders . Appropriate specimens for culture and sensitivity testing will be obtained, when possible, prior to the first dose of antimicrobial therapy . Empiric antimicrobial therapy (the infective pathogen and/or susceptibilities are not known) . When appropriate, antimicrobial therapy will be promptly stopped or deescalated based on culture and sensitivity results . When the infective pathogen is known, antimicrobials will be prescribed according to microbiology results and susceptibilities, when available. Prescribed antimicrobials will be of the narrowest spectrum possible and at the shortest course necessary . Pharmacist-directed prospective audit and feedback . a pharmacist will identify opportunities to streamline, de-escalate, or decrease duration of antimicrobial therapy in an attempt to reduce resistance and adverse events and relay these suggestions to the prescriber. Example 1 R2 was admitted to the facility on [DATE] following a fall at home, secondary to a UTI. Review of R2's Nurse's Notes includes: On 6/27/18 at 12:35 PM, MD (Medical Doctor) was notified that R2 complained of dysuria (painful or difficult urination), and order was received for urine analysis results indicated that R2 might have a UTI, a urine culture was ordered. There was no indication that R2 had a fever. On 6/27/18 at 2:29 PM, a physician's orders [REDACTED]. ([MEDICATION NAME] order was discontinued on 6/27/18 by pharmacy for dose adjustment) to 3.375 GM in [MEDICATION NAME] 50 ML at 100 ml/ hour over 30 minutes. MD Note on 6/27/18 at 11:57 PM notes that R2 reported to be weak, denied chest pain, mildly short of breath . Complicated UTI/Leukopenia-cultures are pending will start on van ([MEDICATION NAME]) and [MEDICATION NAME]. It is also noted that R2's Chest X-ray on 6/26/18 notes Streaky opacities involving the bilateral lower lobes, favored to represent subsegmental atelectasis. Underlying pneumonia cannot be excluded. Trace bilateral pleural effusions. R2's Urine Culture Report results, 6/29/18, notes more than 100,000 colonies of Citrobacter freundii. R2's Urine Culture Antimicrobial Sensitivities Report notes sensitivity to the antibiotics: [MEDICATION NAME], and [MEDICATION NAME]. Resistance was noted for the antibiotics: [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) + Tazobactam. R2 received IV Vanco 1250 MG once and on 6/28/18 the dose was changed to 750 MG receiving the last dose on 6/29/18 and [MEDICATION NAME] 3.375 GM IV every 6 hours on 6/27/18- 6/30/18. Review of the facility's Monthly Infection Control Line Listing for (MONTH) (YEAR) note that R115 and R116 were [MEDICATION NAME] UTI's as follows: Example 2 R115 was admitted to the facility on [DATE] after having surgery to his left hip. R115 was discharged to home on 4/20/18. Review of R115 Nurse's Notes includes: 3/18/18 at 8:00 AM, R115 presented with one loose incontinent stool, a change in behavior including disorientation, demanding to see his doctor, shouting and attempting to get up on his own. The facility called the MD and received orders for labs, stool specimen and UA (urine analysis). (It is important to note that there were no documented localizing symptoms of a UTI for R115.) Review of record notes that R115 is allergic to PCN ([MEDICATION NAME]). The facility's UTI Tracking Tool notes that R115 presented with new onset confusion, visible (gross) hematuria (blood in the urine) and leukocytosis. The facility obtained a urine culture and sensitivity on 3/18/18. On 3/19/18, a physician's orders [REDACTED]. On 3/20/18, R115's urine culture showed greater than 100,000 colonies of E. coli. R115's Urine Culture Antimicrobial Susceptibility Report includes susceptibility to the antibiotics: [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME]/[MEDICATION NAME]. (It is important to note that sensitivity to [MEDICATION NAME] is left blank on R115's culture and sensitivity report.) Example 3 R116 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R116 was discharged to home on 4/7/18. Review of R116 Nurse's Notes includes: On 3/20/18, R116 had blood tinged concentrated urine with complaints of burning with urination, frequency and urgency. The physician was notified and a complete blood count was ordered. On 3/23/18, urine culture is positive, message to physician, awaiting orders. On 3/24/18, physician was notified of urine analysis culture results and new orders were received for Cipro Review of lab results: On 3/21/18, a urine analysis and culture was obtained for R116. On 3/24/18, R116's urine culture final results showed greater than 100,000 colonies of [DIAGNOSES REDACTED] oxytoca. R116's Urine Culture Antimicrobial Susceptibility Report includes susceptibility to the antibiotics: [MEDICATION NAME], and [MEDICATION NAME]/[MEDICATION NAME]. (It is important to note that there is no susceptibility listed to [MEDICATION NAME] on R116's culture and sensitivity report.) On 3/24/18, a physician's orders [REDACTED]. On 7/3/18, at 1:00 PM, Surveyor interviewed DON B (Director of Nursing) and ICP D (Infection Control Practitioner) about the facility's process for review of antibiotic use and the use of broad spectrum antibiotics such [MEDICATION NAME]. ICP D stated that DON B gathers the facility infection information and sends the monthly infection control spreadsheet to the Hospital ICP, which is reviewed, and then verifies if criteria for an infection is met. ICP D stated that pharmacy reviews culture reports and would notify the physician if the antibiotic was resistant. ICP D stated that the facility could close this loop better with documentation. ICP D stated that communication about ATB (Antibiotic) Stewardship between pharmacy and the facility needs to be better. DON B stated that the physician reviewed the preliminary culture and the pharmacy did also. DON B stated that he recalled talking to the physician about R115 and the physician chose the use of Cipro, because R115 had leukocytosis (white blood count was above 14,000), which indicated that R115 might be [MEDICAL CONDITION]; DON B stated that he should have documented this discussion and did not. On 7/3/18 at 2:24 PM, Surveyor interviewed LM E (Lab Manager) asking about why the facility's culture reports do not specify susceptibility's to [MEDICATION NAME]. LM E stated that the lab uses a cascade to follow rules of what antibiotic to use. LM E stated as [MEDICATION NAME] is in the Fluoroquinolone family, and the culture notes sensitivity to [MEDICATION NAME] (a fluoroquinolone) [MEDICATION NAME] be effective. LM E stated that there was no specific policy for the use of the cascade. LM E stated that pharmacy does review the cultures and sensitivities. On 7/3/18 at 2:35 PM, Surveyor interviewed MD C, who is also the facility's Medical Director. Surveyor asked MD C about [MEDICATION NAME] for R115 and R116 and the use of broad spectrum antibiotics. MD C stated that he chooses the antibiotic before the culture. Surveyor asked if he changes the antibiotic after the culture returns. MD C stated maybe we could try to come back and change the antibiotic, but that it doesn't always make sense to come back to change the antibiotic if it is not resistant. MD C stated that pharmacy sees culture results first, they see the results in real time and they call the physician if the antibiotic prescribed is not susceptible. MD C stated that he has reviewed the facility's antibiograms and did not recall resistance [MEDICATION NAME] an issue. On 7/3/18 at 4:50 PM, Surveyor interviewed NHA A, asking about the facility's Antibiotic Stewardship program. NHA A stated that the facility is trying to improve and that if residents do not have symptoms they don't get a culture. NHA A stated that the facility's former Medical Director specialized in infectious disease and wondered if the Hospitalist were driving the use of antibiotics. The facility was not monitoring and analyzing appropriate antibiotic use and addressing the de-escalation of antibiotics. There is no documentation as to why broad spectrum antibiotics were ordered for R2, R115 and R116 when culture results indicate that other antibiotics could be effective.

Based on interview and record review, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice (including, in part, ongoing assessment of the resident's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility; ongoing assessment and oversight of the resident before, during and after [MEDICAL TREATMENT] treatments, including monitoring the resident's condition during treatments, monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices; and ongoing communication and collaboration with the [MEDICAL TREATMENT] facility regarding [MEDICAL TREATMENT] care and services.), the Comprehensive Person-Centered Care Plan, and the residents' goals and preferences for 1 of 1 [MEDICAL TREATMENT] residents (R8) sampled out of a total of 18 sampled residents. The facility did not ensure communication and collaboration with the [MEDICAL TREATMENT] facility was completed for R8. They did not have evidence that the facility communicated regularly with the [MEDICAL TREATMENT] facility or followed-up with the [MEDICAL TREATMENT] facility. Evidenced by: The facility policy with subject [MEDICAL TREATMENT], last revised on 11/2017, states that [MEDICAL TREATMENT] is provided outside of the unit to patients who are dependent on treatment . transportation is set up by an acceptable method prior to admission. The Protocol includes Care Planning: [MEDICAL TREATMENT] time, place of [MEDICAL TREATMENT], method of transportation and specifics of patient needs during [MEDICAL TREATMENT] will be placed on the plan of care. (It is important to note that the policy did not include a central venous catheter (CVC) site in the protocol.) R8 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. She was chronically receiving [MEDICAL TREATMENT] and recently has had a shunt infiltration with arm swelling. To reduce swelling, [MEDICAL TREATMENT] was not accessing the shunt and a CVC (central venous catheter) tunneled catheter was placed for [MEDICAL TREATMENT] access. R8 was receiving [MEDICAL TREATMENT] with a CVC site and goes to off-site [MEDICAL TREATMENT] three times per week. Her care plan, initiated on 6/12/18, included that she had a CVC and had the approach of 1 assist to [MEDICAL TREATMENT] - communicate all changes to [MEDICAL TREATMENT]. Her [MEDICAL TREATMENT] Care Plan includes: Weigh the resident before and after [MEDICAL TREATMENT] procedure according to protocol. Her current care plan also includes that she has a pressure injury to her coccyx. On 7/3/18 at 1:35 PM, CNA F (Certified Nursing Assistant) stated R8's husband has always taken her to [MEDICAL TREATMENT]. She stated if he could not then CNA F would set up transport through the county. She knew the [MEDICAL TREATMENT] center but was not sure where the [MEDICAL TREATMENT] center is located. Surveyor asked what is sent with R8 when she goes to [MEDICAL TREATMENT]. CNA F stated her daily weight and vitals are sent and she eats breakfast before she goes at 8:00 AM or 8:30 AM. CNA F stated she is usually back in time for lunch. Upon R8's return, CNA F would make sure her blood pressure is good and she has had all her mediations. There is a folder that goes with R8 to [MEDICAL TREATMENT]. CNA F states she does take blood pressures, but would not take in the same arm as the CVC. CNA F stated that if the [MEDICAL TREATMENT] site is really puffy she would let R8's nurse know. CNA F stated that R8 is usually really tired upon her return and that R8's husband is here every day to sit with her. CNA F did not know where the protocol for [MEDICAL TREATMENT] was located. Review of communication log between the facility and the [MEDICAL TREATMENT] center. Surveyor was only provided about two weeks of communication. 6/27/18 has note from the [MEDICAL TREATMENT] provider to the facility to ensure a gait belt is sent to [MEDICAL TREATMENT] with R8. 7/2/18 communication sheet filled out by the facility but was completely blank from the [MEDICAL TREATMENT] center. On 7/3/18 at 3:17 PM, Surveyor interviewed DON B (Director of Nursing). He stated, The communication is not what I would expect. He explained that in (MONTH) the person responsible for monitoring the communication log between the facility and [MEDICAL TREATMENT] had left the facility. Surveyor asked who has been monitoring it after that person left. DON B explained the nurse that is assigned to her care sends the form completed. Surveyor asked who does the follow-up upon R8's return. DON B stated the Unit Nurse should do the follow-up. He explained further her weights are supposed to be done at [MEDICAL TREATMENT]. Surveyor asked should the CVC access site be included in the protocol. DON B stated that he has a more current protocol. (It is important to note the newer protocol provided was updated 7/2018 and not provided until after this conversation.) Surveyor asked what the care plan should include, per policy, for care planning (i.e. time, place, and method of transportation for [MEDICAL TREATMENT]). DON B stated, That's what it says and viewed the care plan to see if it included what the policy states; it should include time, place transportation, specific patient needs. DON B stated, I missed it. It may be communicated in the medical record. Surveyor asked how staff would contact the [MEDICAL TREATMENT] center if they had questions as the communication folder did not include the name or contact information of the [MEDICAL TREATMENT] center. DON B stated he could easily look it up on the Internet, but agreed it was not in the folder. Surveyor asked if he knew if the communication from [MEDICAL TREATMENT] to bring a gait belt was followed up on or documented what was done. He stated, I will have to get back with you about that. Surveyor asked if [MEDICAL TREATMENT] was aware of the pressure injury to R8's coccyx and if interventions were communicated to [MEDICAL TREATMENT]. DON B stated they had stated it to the [MEDICAL TREATMENT] center on a global basis. DON B showed he spoke to [MEDICAL TREATMENT] on 4/25/18 about a previous resident regarding checking/changing and repositioning. He did not have evidence that specific communication had been given regarding R8's needs. On 7/3/18 at 4:09 PM, Surveyor followed up with DON B who stated that it is facility protocol to send the gait belt with the patient if they need it for transfer. He said he would have to follow up with R8's husband to see if something had happened to it (the gait belt).

Based on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 4 residents (Resident 4). Resident 4 did not receive assistance with a change of clothes or bathing for two days. This is evidenced by the following: On 11/9/15, at 1:35 PM, Surveyor interviewed Resident 4. Resident 4 stated she generally gets a bed bath every day and prefers to wear a gown as she stays in bed most of the day. Resident 4 stated she received a bath on Friday (11/6/15) and a new gown; however, she did not receive a change of clothes or get washed up on Saturday (11/7/15) or Sunday (11/8/15). Resident 4 stated when staff came in this morning they too noted I was in the same clothes and she gave me a bath and a change of clothes. Resident 4 stated she is able to perform her own oral cares and her husband was visiting so he helped her get the supplies she needed for oral cares. On 11/9/15, Surveyor reviewed Resident 4's Certified Nursing Assistant flow sheet where they document when cares are provided. Resident 4's cares were not signed out on 11/7/15 or 11/8/15. On 11/9/15, at 2:42 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. DON B stated residents receive a bath 1-2 times a week depending on their preference. DON B stated if a resident does not receive a bath on that day they should be washed up in bed. DON B stated all residents should receive a change of clothes daily at least. DON B stated she was not aware Resident 4 did not get washed up or a change of clothes over the weekend and would have to look into it.

Based on record review and interview the facility did not ensure that the assessment was completed accurately for 1 of 8 residents (Resident 2). Resident 2's Minimum Data Set did not reflect Resident 2's wounds. This is evidenced by the following: Resident 2 was admitted to the facility on [DATE]. Resident 2's admission assessment on 4/30/15 indicates the following wounds present on admission: -Left proximal calf 1.5 x 1 x 0.2 cm -Right medial ankle 3 x 1.8 cm -Right lateral calf 11.5 x 2 cm -Left distal calf 2.3 x 1.5 cm -coccyx stage I Resident 2's admission Minimum Data Set (MDS), reference date 5/6/15 indicates there are no pressure ulcers, no venous or arterial ulcers and receiving pressure ulcer care. Theses wounds are all still present at the time of survey. On 5/28/15, at 12:10 PM, Surveyor interviewed Director of Nursing (DON) B about what type of wounds Resident 2's wounds are. DON B stated she recalled speaking with the Medical Director when Resident 2 was admitted because the hospital notes stated there was a pressure ulcer on his leg but she did not feel it was a pressure ulcer. DON B stated that the Medical Director stated the leg wounds were all vascular wounds. On 5/28/15, at 12:36 PM, Surveyor interviewed MDS Coordinator C regarding Resident 2's admission MDS. MDS Coordinator C stated she was not sure what type of wounds Resident 2 had but that they were not pressure ulcers. Then MDS Coordinator C reviewed her notes and charting and stated she did not know why the wounds were not coded on the MDS as vascular wounds. MDS Coordinator C stated it was a mistake and they all should be coded.