Every finding on record at Morrow Memorial Home

Based on observation, interview and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness. This has the potential to affect all to 65 residents. The dry storage area and kitchen cooler contained multiple open food items not labeled with open or use-by dates. Personal beverage stored in kitchen cooler. Culinary Aide (CA) C was not wearing hair restraint on facial hair while assisting with meal service in kitchen. Findings include: Facility policy titled, Food Storage, dated 07/23, states in part: All food items will be stored, thawed and prepared in accordance with proper sanitary practices .Dry goods .5. All open products must be stored in clean air-tight containers. 6. Label and date all storage containers. Facility policy titled, Open Food Discard Policy, dated 07/23, states in part: Any Non-Potentially Hazardous food item that is opened for use in the kitchen but not used in its entirety will be labeled, dated and properly stored .foods include, but are not limited to, boxed mixes .bulk cereals .pasta. Wisconsin Food Code, dated 2020, states in part: Food employees are required to wear hair restraints such as hair nets, hats, and beard nets that are effective in keeping hair under control .Personal items must be kept away from food processing and food storage area .Employees must eat, drink or use tobacco only in designated areas where contamination of food, equipment, utensils, linens, and single-service and single-use articles cannot occur. Example 1 On 06/02/25 at 8:34 AM, Surveyor toured kitchen area and dry storage area with Assistant Dietary Manager (ADM) D. Surveyor observed in dry storage area open bags of corn flakes, honey-nut cheerios, and rice crispies bulk cereal that were re-closed with a twist tie. Surveyor observed no open or expiration dates on bulk cereal packages. On the shelving adjacent to the bulk cereal, Surveyor observed a box of rice pilaf sealed with clear tape and with writing stating, 1/2 box. Surveyor observed the rice pilaf box did not have an open date or expiration date. Surveyor asked ADM D the process for dating and labeling food items. ADM D stated that all food items should have dates when opened. Surveyor asked ADM D about the rice pilaf box. ADM D stated that ADM D then removed all open cereal bags and rice pilaf box and discarded in trash. On 06/02/25 at 8:38 AM, Surveyor observed the inside of kitchen prep cooler. There were 2 metal steam compartment bins, 1 containing cooked bacon and 1 containing cooked pancakes and French toast. Both containers did not have a prepared or serve-by date. Surveyor observed an open package of cooked eggs closed with a twist-tie without a prepared or use-by date on package. Surveyor observed 4 half sandwiches in plastic bags without prepared or use-by dates. As Surveyor was observing these items with missing dates, ADM D removed items from cooler and stated that all of them should be dated, then placed all undated items in trash. Surveyor observed 1 closed bottle of ICE sparkling water. Surveyor asked ADM D if this was for resident consumption or a personal drink. ADM D stated that it was a personal drink. Surveyor asked ADM D if it was an acceptable practice for kitchen staff to store personal food and drink items in the kitchen area. ADM D stated no and removed the drink from the cooler. Example 2 On 06/02/25 at 11:21 AM, Surveyor observed kitchen staff preparing lunch meal. Surveyor observed CA C with facial hair around mouth, chin, and jawline assisting with meal service in kitchen. No facial hair restraint in place. Surveyor observed CA C placing resident meal plates and beverages on trays. On 06/02/25 at 11:23 AM, Surveyor interviewed ADM D regarding use of hair restraints. ADM D stated that all staff are required to wear hair restraints in the kitchen, including facial hair restraints. Surveyor relayed observation of CA C in kitchen not wearing facial hair restraint. ADM D stated that CA C should be wearing a facial hair restraint and would educate on this expectation.

Based on observations, interview and record review, the facility did not treat each resident with respect and dignity and care for each resident in a manner that promotes their quality of life. Resident (R) R44 was not provided privacy of the window shade being closed during cares when lying in bed not fully clothed. This occurred for 1 of 17 sampled residents (R44). This is evidenced by: R44 was admitted to the facility on [DATE]. R44's current diagnoses include chronic obstructive pulmonary disease, chronic kidney disease, Parkinsonism, reduced mobility, major depressive disorder, and anxiety. Minimum data set (MDS) assessment dated [DATE] documents R44 has a Brief Interview for Mental Status (BIMS) score of 2/15, meaning R44 has severe cognitive impairment. R44 has impairment to one side of upper and lower extremities and requires moderate assistance with upper body dressing and personal cares. R44 has a urinary catheter. Review of R44's activities of daily living care plan documented for hygiene and grooming R44 needs 1 helper providing more than half the effort to complete. On 06/03/25 at 7:30 AM, Surveyor observed Certified Nursing Assistant (CNA) F provide morning personal cares for R44. R44 resides on first floor ground level with a view of a sidewalk and a grass open area that is like a park setting. Surveyor observed a person on a riding lawn [NAME] mowing the grass area beyond the sidewalk. CNA F applied personal protective equipment of a gown then entered R44's room. CNA F gathered supplies for cares, turned on the room light and gathered R44's clothes. R44 was in bed and CNA F removed additional bed coverings and pillows. CNA F did not close the window shade. While R44 was in bed CNA F applied lotion to R44's feet and compression socks then washed R44's face and removed t-shirt. CNA F removed brief and completed peri care front and back. CNA F dressed R44 with pants and shoes. CNA F assisted R44 to sit at edge of bed and transferred with sit to stand lift to get R44's weight. This took place in front of the window. Anyone outside the window could view R44. R44 was not wearing a shirt. CNA F transferred R44 to the recliner and washed R44's back and underarms. CNA F assisted R44 to apply a clean t-shirt. On 06/03/25 at 8:04 AM, Surveyor interviewed CNA F asking if closing blinds during cares would be appropriate. CNA F stated she normally does close the blinds and did not think of it. On 06/04/25 at 1:14 PM, Surveyor interviewed Director of Nursing (DON) B about privacy during personal cares. Surveyor shared the observation of CNA F not closing window shade when providing R44 personal cares including peri care. DON B indicated it is the expectation to close the window shade to provide privacy.

The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (R) R41, observed during personal cares. CNA did not perform hand hygiene before resident contact. Findings: Facility policy titled, Hand Hygiene revised on 6/24, stated in part: .Hand hygiene must always be performed before and after direct patient contact .The following is a list of some situations that require hand hygiene: . Before and after any resident contact . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting . Before and after wearing gloves . On 06/04/25 at 9:00 AM, Surveyor did not observe Certified Nursing Assistant (CNA) E perform hand hygiene upon entering R41's room. CNA E placed gait belt on R41, entered the bathroom, indicated that they are running short of gloves in this room, put on gloves and brought over the front wheeled walker and oxygen. The remaining observation of this care was performed appropriately. On 06/04/25 at 9:19 AM, Surveyor interviewed CNA E, asking if there was hand hygiene prior to resident contact and cares. CNA replied, Oh, yes, I know that I am supposed to perform hand hygiene. On 06/04/25 at 10:12 AM, Surveyor interviewed infection preventionist Registered Nurse (RN) G about the observation of no hand hygiene. RN G replied, Oh shoot that CNA is one of our best. She should have performed hand hygiene prior to resident contact and glove use. On 06/04/25 at 10:22 AM, Surveyor asked Director of Nursing (DON) B what the expectation is of hand hygiene before resident contact. DON B replied, It should be done.

Based on interview and record review, the facility did not promptly notify and consult with a resident's physician when there was deterioration in a resident's clinical condition. This occurred for 1 of 2 residents (R39) reviewed for physician notification and consultation. R39 presented with new symptoms of cardio-respiratory complications in addition to a significant weight gain. Staff did not immediately notify R39's provider of this occurrence resulting in R39 being admitted to the hospital 4/30 - 5/4/23, one week after the start of these symptoms, with a diagnosis of heart failure and atrial fibrillation with RVR (rapid ventricular rate). Findings include: The facility policy, entitled Notification of Change, revision date 7/21, states: .Significant changes in a resident's condition or treatment are promptly .reported to the attending physician or designee .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident .Requirement of notification of resident's physician: .A significant change in the resident's physical, mental or psychosocial status in either life-threatening conditions or clinical complications .The nurse will notify the resident's physician for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician (utilize Interact 4.0 guidelines and nursing judgement) . The Interact Version 4.0 states: Change in condition: When to report to the MD/NP/PA (Provider) Immediate Notification: Any symptoms, sign or apparent discomfort that is: acute or sudden in onset, and: a marked change (i.e. more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Non-Immediate Notification: new or worsening symptoms that do not meet above criteria . R39 was admitted to the facility on [DATE] with diagnoses that included in part, Crohn's disease, major depressive disorder, hyperlipidemia, Alzheimer's, vascular dementia, cerebrovascular disease, paroxysmal atrial fibrillation post-surgery resolved (2016). 5/4/23: acute pulmonary edema, acute/chronic heart failure (CHF), atrial fibrillation with RVR. R39's provider orders: Prior to 4/30/23 - Aspirin 81mg daily for anticoagulant therapy. R39's provider notes in part: 3/27/23 Primary provider note indicated nursing staff do not report any acute concerns. No recent hospitalization s or ER visits in last year. Patient's weight is stable at 208 pounds. R39's nurse progress notes in part: 4/17/23 weight 205 pounds standing scale. 4/23/23 at 2:04 AM [R39] came up to the nursing station complaining of not feeling well. Skin is cool, moist and pale. She is able to talk and seems anxious and restless. Hands fly in the air when she tries to say exactly how she feels. Blood pressure elevated 160/93, pulse 95, O2 sat 95% RA, Temp 96.9 with hair wet from sweating. Respiratory rate 28. Given Tylenol and melatonin as she complains she can't sleep. Assisted back to her room and laid down with HOB (head of bead) slight elevated. She [R39] is now fast asleep. Unsure what the cause was. Denies chest pain but did say heavy. Pulse fast but regular. If she woke from a bad dream, anxiety, worry, dementia, unsure will monitor. *Note no provider notification completed. 4/24/23 at 12:55 AM The past two nights, [R39] has talked with the nursing staff about feeling restless and out of sorts. States I am tired but cannot sleep. Note occasional nonproductive cough, fine crackles in upper lung fields. Temperature 96.8, oxygen saturation 94% on room air. Sat at nursing station for 20 minutes. Gave her Tylenol and melatonin to help her rest. Will continue to monitor. Respirations audible wheezing, lung sounds crackles heard upon auscultation upper bilateral lobes, nonproductive cough. Continue to observe, encourage coughing and deep breathing, head of bed elevated, repositioned, encouraged to rest. Covid 19 test done: negative results. *Note no provider notification completed. 4/24/23 at 6:48 AM weight 212 pounds (weekly) standing scale - weighed x 2. *Note a 7-pound weight gain over one week along with two nights of new symptoms of cardio-respiratory complications. No provider notification completed. 4/24/23 at 10:43 AM Pulse 100, respiratory rate 24 and shallow, respiratory findings: shortness of breath or trouble breathing when sitting at rest (on room air), lung sounds: no wheezing noted. Resident on her way to activities like she does every day. I don't know why I am short of breath. *Note no provider notification completed. 4/24/23 at 11:24 PM Shortness of breath noted when talking and when self-propelling in hall. *Note no provider notification completed. 4/29/23 at 12:15 AM [R39] was escorted to nursing station this NOC (night shift) with complaints of chest heaviness and hard time breathing. Patient is being monitored. Blood pressure (b/p) 156/106, pulse 113, temp 96.8, respiratory rate 27. 4/29/23 at 12:25 AM feeling better, [R39] said she felt hot with shortness of breath. b/p 157/94, pulse 120, oxygen saturation 94% on room air. 4/29/23 at 12:35 AM b/p 151/94, pulse 121. 4/29/23 at 12:50 AM b/p 130/88, pulse 111. [R39] feeling better, back to her room with escort. Will monitor. *Note no provider notification completed. 4/29/23 at 11:48 PM b/p 137/83, pulse 121, respiratory rate 22, oxygen saturation 92% on room air. Patient requested to see RN (registered nurse), heaviness on chest while laying down and again when up right in her wheelchair. Lung sounds with wheezing bilateral upper lobes. Called on call provider: ordered on time Albuterol nebulizer treatment, if not effective to send to ER (emergency room ). After treatment, [R39] stated feeling better, decreased wheezing on auscultation. Will monitor. 4/30/23 at 11:18 AM b/p 142/72, pulse 91, respiratory rate 22. [R39] was coughing quite a bit with breakfast. Dose sound audibly wheezy. Crackles in upper lungs. Denied shortness of breath. Did give her a prn (as needed) dose of cough medication with improved results. Weight is 214 pounds. Bilateral lower extremities with 2-3 + edema. 4/30/23 weight 214 pounds standing scale. Weight gain of 9 pounds from weight on 4/17/23. *Note no provider notification completed. 4/30/23 at 8:43 PM Writer was passing by [R39]'s room this evening and heard resident shouting, Someone help me, I can't breathe. Found resident to be visibly short of breath, resident skin was clammy, and hair was damp. Oxygen at 2 liters per minute started per nursing measure. b/p 183/133, pulse 150, oxygen saturation 97% (taken after oxygen applied), respirations 28. Resident is a full code. Dispatch notified and resident sent to the hospital. Provider and guardian notified. R39 was admitted to the hospital from 4/30/23 through 5/4/23 with a new diagnosis of congestive heart failure and atrial fibrillation with RVR. 4/30/23 Emergency department note indicated R39 was admitted to the hospital with a diagnosis of CHF and atrial fibrillation with RVR. R39 was started on a Cardizem infusion [to control the atrial fibrillation rate], and Lasix [to help remove excess fluid the heart was unable to pump out] injection. Chest Xray indicated central vascular congestion secondary to pulmonary edema with small right sided effusion. BNP (lab test for heart failure) level was 8,386. EKG indicated atrial fibrillation with RVR. 5/1/23 Hospital history and physical note indicated R39's significantly elevated BNP and pulmonary edema are indicative of heart failure likely secondary to her atrial fibrillation. Will continue further evaluation of her ejection fraction via TTE (transthoracic echocardiogram) in the morning and continue to pull off fluid with Lasix for now. 5/4/23 Hospital discharge summary note indicated R39's TTE result stated: the left ventricular internal cavity size was mildly increased. Concentric left ventricular hypertrophy. Moderately decreased left ventricular ejection fraction. Normal right ventricular size and ejection fraction. Left atrium appears severely dilated. Ejection Fraction of 33% and global hypokinesis. Weight at discharge 205 pounds 8 ounces. R39's physician orders post hospitalization on [DATE]: Eliquis 5mg twice per day for cerebrovascular accident prophylaxis, Digoxin 125mcg daily for atrial fibrillation RVR hold for pulse less than 60, Lasix 20mg daily for chronic heart failure with reduced ejection fraction, Metoprolol ER 100mg twice per day for atrial fibrillation. On 3/26/24 at 1:40 PM, Surveyor interviewed Licensed Practical Nurse (LPN) K and asked what the process for resident weights was if there was a weight increase. LPN K said some of the residents have orders to notify provider if 3 pounds in one day or 5 pounds in one week. Other residents have if the weight was increased, we would re-weigh the resident. If the weight was increased, we would do an assessment to look for edema and lung sounds and notify the provider and my supervisor. Surveyor asked if a resident complained of chest heaviness, restless, vital signs off what would you do. LPN K said she would think cardiac and would assess the resident, get vital signs, and notify the provider and my supervisor. On 3/26/24 at 2:15 PM, Surveyor interviewed RN J and RN H and asked if a resident had an increase in weight, what would be the process. Both RNs said we would reweigh the resident, assess the resident, start the fluid volume overload protocol, and notify the provider to see what to do for the resident. Surveyor asked RN J and H if a resident stated they had chest heaviness, restlessness, and elevated vital signs, what would you do. RN J said she would assess the resident and it all depends on the situation. If it was cardiac or anxiety. If it was only one time and the resident calmed down, there would not be an immediate notification to the provider but notify in the provider notification book. If the symptoms continued, then I would for sure notify the provider. Surveyor asked if R39 had a diagnosis of anxiety. RN J looked at R39's chart and RN H looked at R39's electronic record. Both RNs said R39 did not have a diagnosis of anxiety. On 3/26/24 at 4:11 PM, Surveyor interviewed Director of Nursing (DON) B and asked if a resident had an increase in weight what would be the process if the resident does not have a congestive heart failure (CHF) diagnosis. DON B said we would at least do a routine notify to provider about the weight gain every Monday. DON B looked up to see if this was done for R39 when R39's weight increased from 205 to 212 pounds. DON B said there was no notification to R39's provider. Surveyor and DON B looked at R39's nurse progress notes from 4/23/23 through 4/30/23. Surveyor asked DON B if provider should have been notified based on R39's signs and symptoms and weight gain. DON B said the expectation to notify provider was for the nurse to use their judgement. On 3/26/24 at 4:38 PM, DON B provided Surveyor with the policies and documentation requested. DON B said the only time R39's provider was notified was on 4/29/23 at 11:48 PM when they received an order for an Albuterol nebulizer treatment and again on 4/30/23 at 8:43 PM when R39 was sent to the hospital. On 4/1/24 at 10:40 AM, Surveyor interviewed R39's Medical Doctor (MD) P and explained the weight gain along with the signs and symptoms R39 developed from 4/23/23 through 4/30/23. Surveyor interviewed MD P asking what the expectation was for staff to notify the provider due to weight gain and new cardiac symptoms. MD P said with these symptoms and weight gain we would be concerned about heart attack, heart failure, or atrial fibrillation. When the heart rate was above 100, that would be concerning of atrial fibrillation. Weight gain is tricky, but with the combination of the weight gain and acute symptoms, I would expect the facility to notify the provider right away. MD P said she was not sure why the facility did not notify her or the nurse practitioner who visits the facility regularly concerning R39's weight gain along with acute symptoms. Surveyor asked MD P what you would have done if notified earlier of R39's weight gain and symptoms. MD P said anything concerning chest pain/heaviness and shortness of breath, we would send the resident out to be evaluated at the emergency department for possibility of heart attack, heart failure, or atrial fibrillation. MD P said she should have been notified when the symptoms started on 4/23/23 and would have sent R39 to the emergency department. Surveyor asked MD P would an earlier notification to you with earlier interventions for R39 result in less damage to the heart. MD P said this was hard to predict because it sounds like a gradual worsening onset. Also, what started first the atrial fibrillation or the heart failure. Atrial fibrillation puts a person at risk for stroke. Surveyor asked MD P how R39's cardiovascular status was now compared to before the hospitalization at the end of April 2023. MD P stated now R39 was prescribed Digoxin and Metoprolol (to control the atrial fibrillation rate), Lasix (to help remove excess fluid the heart was unable to pump out), and Eliquis (a blood thinner to prevent blood clots formed while the heart is in atrial fibrillation as there is a risk for stroke). MD P said R39 continued to be in the atrial fibrillation rhythm but does not currently have any edema or shortness of breath. R39's symptoms were well controlled on the current medications. MD P said she was surprised the facility did not notify her about this and allowed the symptoms to go on for that long. That was unusual for this facility.

Based on observation and interviews, the facility did not ensure residents (R) were treated with dignity and respect and cared for in a manner to enhance their quality of life during dining. This occurred for 4 (R4, R1, R6 and R40) out of 60 residents. Findings: On 03/27/24 at 8:11 AM, Surveyor observed Registered Nurse (RN) D wipe egg yolk from R4 with the clothing protector. On 03/27/24 at 8:24 AM, Surveyor observed Certified Nursing Assistant (CNA) F standing over R1, feeding R1 applesauce then eggs and talking with CNA G across the table during breakfast meal. On 03/27/24 at 12:08 PM, Surveyor observed CNA E and CNA G sitting and assisting residents with eating during lunch time. CNA G assisted R6 with feeding. CNA E assisted R40 with feeding. CNA G and CNA E were talking across the table with each other instead of the residents they were assisting. On 03/27/24 at 1:35 PM, Surveyor asked CNA F, Is it okay to stand while assisting a resident in the dining room? CNA F replied, Sometimes I stand, I guess I was never told not to. Surveyor asked, Is it ok to talk across the table to other staff while assisting residents in the dining room? CNA F replied, Normally I talk to whoever I am feeding. Surveyor asked, How about using the resident's clothing protector as a napkin if the resident has something like egg yolk or mashed potato on their cheek? CNA F replied, Yes, I usually use the clothing protector to wipe their face clean. On 03/27/24 at 1:38 PM, Surveyor asked CNA E, Is it okay to stand while assisting a resident in the dining room? CNA E replied, Not all of the time sometimes it is. Surveyor asked, Is it ok to talk across the table to another staff member while assisting residents in the dining room? CNA E replied, Yes, it is appropriate. Surveyor asked, How about using the resident's clothing protector to wipe off egg yolk or mashed potato to wipe their face clean? CNA E replied, At first I use a clothing protector because it's right there. On 03/27/24 at 1:41 PM, Surveyor asked CNA G, Is it okay to stand while assisting a resident in the dining room? CNA G replied, No I don't. Surveyor asked, Is it ok to talk across the table to another staff member while assisting residents in the dining room? CNA G replied, Yes, that's ok. On 03/28/24 at 8:00 AM, Surveyor conducted an interview with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding the observations below. 1) Staff wipe resident's mouth with clothing protector 2) Staff conversing across the table with each other not focusing on the residents 3) Staff standing over the resident while assisting with feeding. NHA A acknowledged this was not dignified treatment of residents. On 03/28/24 at 8:00 AM, Surveyor asked, What is the expectation for staff when assisting residents with meals. DON B stated, The staff should be treating the residents with dignity and respect and not be standing over the resident.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one of one resident reviewed for pressure injuries (R40). R40 developed an unavoidable stage 3 pressure injury while at the facility. Observations of poor infection control occurred during wound care. Findings include: The facility policy, entitled Nursing Skin Protocol, revision date 7/23, states: .Keep bed clean, dry, smooth, and free of [NAME] .The use of clean technique will be assumed for all dressing changes that are not specifically ordered as requiring sterile technique . The facility policy, entitled Hand Hygiene, revision date 7/23, states: .The following is a list of some situations that require hand hygiene: before and after changing a dressing .after contact with a resident's mucous membranes and body fluids or excretions . R40 had diagnoses that include in part dementia, chronic kidney disease (CKD) stage 4, anemia, diabetes, osteoarthritis, gout, hypothyroid, low back pain, pressure ulcer of right heel (upon admit), pressure ulcer of coccyx, chronic obstructive pulmonary disease (COPD), asthma, heart failure, and edema. R40's Minimum Data Set (MDS) assessment, dated 1/24/24, indicated that R40's mobility was substantial/maximal assistance - helper does more than half the effort. R40's Brief Interview for Mental Status (BIMS) score of 00 indicating severe impairment. R40's Care Plan, dated 1/17/24, states: I have a skin injury on my heel upon admission because I am a diabetic, have poor tissue perfusion, have trouble feeling certain sensations, sometimes get confused or can't remember things, can't move around well on my won, lose my balance sometimes and can fall or bump into things. Interventions include: -reduce pressure and friction between myself and my bed or chair, -elevate my heels when I'm lying in bed, -check my skin with cares, -provide me with wound care, -utilize a pressure redistribution cushion on any surface that I sit on, -provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface, -place an air mattress on my bed 1/29/24 Intervention added: pressure redistribution boot to my RLE (right lower extremity) on at all times except for hygienic cares, skin checks and transfers. 3/20/24 Intervention added: lay me down in bed between meals to offload pressure. Upon entrance to the facility on [DATE], Surveyor observed R40 to have proactive air plus air mattress, air cushion for Broda chair, right heel pressure redistribution boot on at all times with heels elevated with heel lift cushion, and R40 was only up in the Broda chair during meals otherwise R40 was lying in bed offloaded from the coccyx wound and repositioned right to left side at least every two hours. R40's Braden assessments completed upon admit and weekly indicated R40 was high to moderate risk for skin breakdown. R40 was admitted to the facility with a stage 3 pressure injury to the right heel with initial measurement of 6.5 cm (centimeters) x 5.4 cm x 0 with 100% yellow slough with copious amounts of serous and slough like drainage present with scant [NAME] bleeding present, odor noted. Now, on 3/26/24, the right heel pressure injury measured 0.8 cm x 0.8 cm x <0.1 cm a great improvement. R40's general skin condition note dated 1/17/24 stated R40 was admitted to the facility with no open area to coccyx. R40 does have an old scar on the coccyx where she did have an open area at one time. R40 had in place pressure reducing device for chair and bed, receives turning/reposition program, ointments/meds applied, continue to observe, encourage to rest, and reposition. R40's weekly wound assessments were completed at the facility by the wound care nurse for both the right heel and coccyx pressure injuries. These assessments included measurements, description, education provided, interventions, provider, and Power of Attorney (POA) updated, and treatments were updated/changed per the provider orders. R40's had norovirus in Februray causing continuous loose stools, and the need to sit up to prevent aspiration while vomiting. On 2/22/24 an open area noted to coccyx 2 cm x 0.5 cm yellow slough observed to wound bed, no redness/drainage or odor noted. Foam border patch applied, and provider and family notified. With slough present, this wound would be unstageable. Weekly assessments, and frequent physician notification with wound care order changes have been done. On 3/27/24 at 10:35 AM, Surveyor observed Registered Nurse (RN) D and Licensed Practical Nurse (LPN) K perform wound care to R40's coccyx and right heel pressure injuries. RN D performed the care and LPN K helped to hold R40. Both RN D and LPN K used hand hygiene before donning a gown and gloves. RN D and LPN K then helped to roll R40 onto her left side while LPN K held R40 in position. RN D unsecured R40's brief, laying the brief flat on bed without providing a clean barrier under the wound. R40 at this time had a small amount of soft stool in the brief. The stool was not in the wound, but it was approximately less than two inches away from the coccyx wound. The stool was not cleaned prior to R40's wound care to the coccyx and the brief remained on R40 during the wound care to the coccyx. With the same gloves on, RN D removed the old dressing of Dakin's gauze and foam border dressing, threw this away in the garbage and removed gloves. RN D used hand sanitizer and donned new gloves. The wound to the coccyx was open and appeared dark inside with the peri wound (wound edges) red. The old gauze was covered with brown/gray slough. There was an odor, and RN D said this odor was from the wound. RN D with new gloves on, sprayed wound cleanser inside the wound and used a clean gauze to clean out the wound. RN D threw the gauze away but did not change gloves. RN D then grabbed new gauze and poured Dakin's solution on it, wringed it out and packed the Dakin's-soaked gauze into the wound, with contaminated gloves. RN D then took border foam dressing and applied over the wound. RN D did not change gloves. RN D then started to clean the stool and RN D and LPN K helped to remove the old brief and apply a new one. When completed with cleaning R40, RN D and LPN K removed gloves and gown and performed hand hygiene. On 3/27/24 at 11:05 AM, RN D left the room to get pain medication. On 3/27/24 at 11:10 AM, RN D returned to the room, hand hygiene performed, gown and gloves donned. RN D then gave R40 oral Tramadol for pain. RN D did not remove the gloves she was wearing and then went right away to the right heel and removed the heel protector boot with same gloves on, took scissors and cut the kerlix off, removed the old dressing and threw away. RN D threw away gloves, hand hygiene and new gloves applied. RN D sprayed wound cleanser on the right heel wound and wiped with gauze and threw in garbage. RN D then took the scissors to the sink to cleaned them with soap and water, dried with paper towel and with same contaminated gloves, RN D took the scissors, and cut the needed size calcium alginate with silver and applied to R40's right heel with ABD pad and kerlix. RN D did not change gloves. RN D with the same gloves on, placed tubi-grip (compression sock) to R40's right leg and placed the heel protector back on. RN D then removed gloves and performed hand hygiene. On 3/28/24 at 7:30 AM, Surveyor interviewed Certified Nursing Assistant (CNA) N and asked about what kind of repositioning was done for R40 before the development of the coccyx wound. CNA N said we would reposition R40 at least every two hours before the coccyx wound and after the wound developed, we would offload R40 from the coccyx by laying her down in bed rotating each side keeping R40 off the back. On 3/28/24 at 7:47 AM, Surveyor interviewed RN J and asked if coccyx wound care needed to be done and stool was present, what should be done about the stool. RN J said the stool would need to be cleaned first before doing the wound care. On 3/28/24 at 8:17 AM, Surveyor interviewed RN I and asked if stool was present when going to do a coccyx wound care what would you do. RN I said clean the stool first. On 3/28/24 at 8:49 AM, Surveyor spoke with RN D and asked about the stool present during the wound care yesterday and what should have been done. RN D said the dressing was starting to fall off, so I wanted to get the new one on before cleaning the stool. RN D said she wanted the wound to be cleaned and covered before cleaning the stool. On 3/28/24 at 9:00 AM, Surveyor asked DON B how the coccyx wound started for R40. DON B said the coccyx wound started due to the norovirus outbreak we had in February. R40 had multiple incontinent episodes of loose stools and urine, needed to be upright due to vomiting with risk of aspiration and her health status of being unhealthy, low hemoglobin, diabetes, poor perfusion, and progressive dementia. Surveyor asked DON B if the coccyx wound was avoidable. DON B said based on the clinical condition of R40, R40's coccyx wound was unavoidable. We started interventions immediately upon admit for R40 to include air mattress, air Broda chair cushion, toilet plan, reposition every 2 hours and then added offload coccyx area once the wound started. The family/POA wanted comfort cares for R40 and not to be sent out for treatments and to treat only for comfort. We provided education to the family and offered hospice, but they wanted the staff here to treat R40. The provider and POA discussed foley placement to help with wound healing of coccyx and the POA agreed, so we added this for R40. Surveyor advised DON B what observations were seen during the wound care treatment for R40 concerning the glove changes, and stool present during wound care. DON B said the glove changes should have been completed after cleaning the dirty area and applying the clean dressing. DON B said she will need to look at the standards of practice to verify this. DON B asked Surveyor if the observation of RN D with the same glove change process followed for the coccyx wound and the heel wound was observed. Surveyor said yes, the same process was followed. DON B said R40's heel wound has greatly improved even if that process was followed. DON B said concerning the stool present during the wound care that R40 was incontinent of stool and there was no way to prevent stool in a wound of an incontinent resident. On 3/28/24 at 10:00 AM, Surveyor interviewed R40's provider, Nurse Practitioner (NP) M, and the Infection Preventionist RN L. Surveyor asked about the history of R40's coccyx wound. NP M said she believes R40 had a coccyx wound before but would have to look at the records to see. The POA/family have been well educated about risk versus benefits of treatment for R40's coccyx wound, and they understand that they want comfort care. NP M said we did offer hospice care, but R40's POA/family would rather the staff here to care for R40. Surveyor asked how R40 developed the coccyx wound and if the wound was avoidable. NP M and RN L both said R40 developed the coccyx wound due to the norovirus that occurred at the facility in February. R40 had multiple incontinent stool and urine episodes, and R40 needed to be elevated due to vomiting with risk of aspiration. NP M said the coccyx wound was unavoidable due to R40's clinical condition of failing dementia, poor perfusion, diabetes, poor intake, and norovirus. R40 had all the interventions in place with standards of practice followed prior to and after development. We also discussed with POA about foley catheter placement to help with wound healing if okay with the POA. POA agreed, so we implemented this. NP M said R40 was very at risk for pressure injuries. Surveyor advised NP M and RN L what observations were seen during the wound care treatment for R40 concerning the glove changes. RN L said concerning the glove changes that staff should have removed the old dressing, cleaned the wound out and then performed hand hygiene and get a new pair of gloves to apply the new dressing.

Based on observation, interview and record reviews, the facility failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical wellbeing for 1 (R40) of 1 resident reviewed for pain. R40 had verbal (moaning, crying out) and non-verbal expressions of pain during wound care. Staff continued to perform the wound care treatment without doing an adequate pain assessment and waiting for the pain medication to be effective. Findings include: The facility policy, entitled Nursing Skin Protocol, revision date 7/23, states: .Pain levels should be determined during dressing changes and discuss offering resident pain medication prior to dressing changes and update MD (medical doctor) as needed. Nursing and therapy staff may offer non-pharmacologic measures like e-stim, distraction, individualized comfort approaches . The facility policy, entitled Pain Assessment and Management, revision date 7/23, states: .Evaluate if the resident is able to effectively communicate discomfort. If there are concerns with communication or comprehension, look for nonverbal indicators of pain such as: a. Crying, whining, gasping, moaning, or groaning b. Verbalizations of pain (that hurts, ouch, stop) c. Grimacing, wincing, wrinkled forehead, furrowed brow, clenched teeth or jaw d. Bracing, guarding, or massaging a body part e. Clutching or holding a body part during movement .Ensure scheduled or prn (as needed) analgesia is offered prior to potentially painful activities (i.e. wound care, ADLs (activity of daily living), transfers). Prior to administering analgesics, discuss and offer nonpharmacological pain relief interventions to resident if applicable . R40 was admitted to the facility on [DATE], and had diagnoses that include in part dementia, chronic kidney disease (CKD) stage 4, anemia, diabetes, osteoarthritis, gout, hypothyroid, low back pain, pressure ulcer of right heel, pressure ulcer of coccyx, chronic obstructive pulmonary disease (COPD), asthma, heart failure, and edema. R40's Minimum Data Set (MDS) assessment, dated 1/24/24, indicated that R40's mobility was substantial/maximal assistance - helper does more than half the effort. R40's Brief Interview for Mental Status (BIMS) score of 00 indicating severe impairment. R40's pain management stated the following: Should pain assessment interview be conducted? Yes, was selected; No (resident is rarely/never understood) was the other option. Pain assessment interview: Pain presence? No was selected; Yes, and unable to answer were the other options. No further questions about pain were answered. R40's Provider Orders: Tramadol 50mg 1 tab daily for pain and 50mg twice a day as needed for pain start date 1/17/24. Acetaminophen 1000mg twice per day for pain start date 1/17/24. R40's care plan, dated 1/17/24, states: I need to be comfortable because I sometimes hurt and get aches and pains, have arthritis. I show this by grimacing or showing nonverbal signs of pain, becoming impatient/irritable. I need my nurses to ask me if I hurt, distract me with conversation. I need all staff to provide the Standard of Cares for pain. My goal is to maintain a level of comfort that allows me to participate in the activities I want to. Goal date 4/30/24. R40's pain assessments were completed weekly and indicated resident receives scheduled Ultram (Tramadol) daily and twice daily Tylenol. Has chronic pain in her extremities. Has dementia and not able to make her needs known so staff monitor for nonverbal signs of pain. Will note moaning and grimacing with transfers or repositioning. Once settled in bed or recliner or Broda chair she is quiet and does appear comfortable. Review of R40's PRN (as needed) pain medication given the past month indicated the following: *3/17/24 at 11:18 AM Tramadol 50mg given for pain restless, moaning - per son visiting, pain level 3-4, location all over, non-pharmacological intervention attempted: yes. *3/21/24 at 9:33 PM Tramadol 50mg given for pain level 5/10, non-pharmacological intervention attempted: yes repositioning. 10:45 PM med effective. *3/27/24 at 11:25 AM Tramadol 50mg given for pain all over. 2:09 PM med effective resolved no further crying. *3/27/24 at 9:07 PM Tramadol 50mg given before treatment. 9:41PM med effective. *3/28/24 at 10:36 AM Tramadol 50mg given for pain and pretreatment to make her comfortable. 11:40 AM med effective resting. R40's provider note dated 3/27/24 stated, .Staff report she has been crying out in pain with transfers or dressing changes of her sacral ulcer. Pain seems transient and she quickly settles back to normal. Current pain regimen is 50mg Tramadol every morning and 2 times daily as needed. They are giving this 2 times with dressing changes . On 3/27/24 at 10:35 AM, Surveyor observed Registered Nurse (RN) D and Licensed Practical Nurse (LPN) K perform wound care to R40's coccyx and right heel pressure injuries. RN D performed the care and LPN K helped to hold R40. R40 started to whimper and sounded like she was in pain. R40 was unable to verbalize needs. Surveyor asked RN D if R40 had any pain medication today. RN D said she had given R40 pain medication during morning med pass. RN D continued with the wound care. LPN K spoke with R40 to help calm her down and to notify of what was going on, but R40 continued to increase her moaning and crying out. (Review of R40's Medication Administration Record (MAR), Tramadol and Tylenol were given at 9:00 AM before the wound care treatment.) Once the wound care to the coccyx was complete, RN D then started to clean the stool. R40 continued to cry and make sounds that she was in pain. RN D and LPN K helped to remove the old brief and applied a new one. R40 started to cry out even more and her face was with mouth frowned and she appeared in much pain with tense body. LPN K suggested to RN D, let's let R40 rest as it was close to lunch time, and we can do the heel wound later because R40 was crying in pain. RN D said no, I want to finish the heel wound dressing change because the surveyor was here to see it and wants to see it done and we are here ready to do it. Surveyor told RN D that we can do the heel wound at a later time to let R40 rest. RN D said no we need to get it done. LPN K said again to RN D we should let R40 rest, and that the Surveyor was willing to wait to see the dressing change to R40's heel at a later time. Surveyor again said to RN D we can wait as R40 was in pain. RN D then said, I will get R40 some pain medication and RN D left the room at 11:05 AM. LPN K attempted to console R40 as she was crying out with visible facial grimacing noted. At 11:10 AM, RN D returned to the room with the PRN pain medication tramadol and then gave R40 the oral tramadol for pain. RN D then went right away to the right heel and removed the heel protector boot, cut the kerlix off, removed the old dressing and started with the wound care. R40 was making noise in pain, moaning, and crying during this procedure with tense body and facial grimacing. RN D said to R40 you just had a pain pill you will be okay. After a moment, RN D asked if R40 would like lunch. RN D stated lunch will be here soon. After another moment, RN D asked R40 what's the matter, what can I do for you. Remember I gave you an extra pain pill. RN D then placed tubi-grip (compression sock) to R40's right leg and placed the heel protector back on. R40 continued to moan, grimace, and cry out in pain during all of this. When RN D was completed working with R40 at 11:20 AM, Surveyor asked RN D if R40 was in pain during the wound care changes. RN D said R40 was more in pain than normal so that's why she went to get the PRN pain medication. Surveyor asked RN D if R40 was able to verbalize her pain by speaking. RN D said no, R40 was unable to verbalize pain, but does makes noises or facial grimaces to indicate pain. On 3/27/24 at 1:35 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F and asked if they had witnessed R40's response during wound dressing changes. CNA F said R40 tenses up and sometimes tries to roll back while holding her. On 3/27/24 at 1:38 PM, Surveyor interviewed CNA E and asked if they had witnessed R40's response during wound dressing changes. CNA E said it looks painful. On 3/28/24 at 7:30 AM, Surveyor interviewed CNA N and asked if R40 had any pain during wound care treatments. CNA N said yes R40 had pain with any movement but with wound care it was worse, you can really tell a difference between regular pain compared to wound care pain. Surveyor asked what the nurses did when they saw R40 in pain during wound care. CNA N said some nurses will make sure the pain medication was given, some will wait and be gentle, others will just get the wound care done and not stop to address R40's pain. Surveyor asked CNA N what RN D did for pain when doing wound care for R40. CNA N said RN D was the worst at this. CNA N said RN D does not stop and just continues to work through the wound care while R40 was crying out in pain during the wound care treatments. On 3/28/24 at 7:47 AM, Surveyor interviewed RN J about what pain scale the facility used for nonverbal residents. RN J said we use the FACES pain scale. Surveyor asked RN J what you would do if a resident who was nonverbal appeared to be in much pain with calling out and facial grimacing during a coccyx wound change that was completed and still needed to do heel wound care. RN J said she would see if a PRN pain medication could be given and allow time for it to work, give resident a rest and help comfort her and then come back to the other wound once pain was under control and medication working. On 3/28/24 at 8:17 AM, Surveyor interviewed RN I and asked if a resident was nonverbal in pain after wound care and another wound needs to be completed, what would you do. RN I said they would give resident a break and help her to be comfortable before doing another wound care. On 3/28/24 at 8:49 AM, Surveyor spoke with RN D and asked what pain level used for nonverbal resident. RN D said FACES pain scale. Surveyor asked RN D what level R40's pain was at yesterday during the wound care Surveyor observed. RN D said I would say at least a 6. RN D said she spoke with the provider yesterday who said it was okay for R40 to have a PRN pain medication before the wound treatment and that was what RN D will do today for the wound care. On 3/28/24 at 9:00 AM, Surveyor interviewed Director of Nursing (DON) B concerning what pain scale was used for a resident who was non-verbal. DON B said they would use FACES pain scale. Surveyor advised DON B what observations were seen during the wound care treatment for R40 concerning pain. DON B said R40 was getting scheduled tramadol for pain as R40 doesn't swallow well and that small amounts of scheduled medications would be better than having PRN medications also. R40's provider visited and said it was okay to give PRN pain medication prior to wound care. DON B said the resident's pain should have been addressed and not complete the wound care just for the surveyor to observe. Surveyor reiterated that yes, residents come first and that was why Surveyor agreed with LPN K that the wound care of the heel could wait. Surveyor asked DON B when does oral tramadol start to work. DON B said she would have to look it up to be exact, but a good rule of 30-60 minutes for it to start to be effective. On 3/28/24 at 10:00 AM, Surveyor interviewed R40's provider, Nurse Practitioner (NP) M, and the Infection Preventionist RN L. Surveyor advised NP M and RN L what observations were seen during the wound care treatment for R40 concerning pain. NP M asked if R40 was consistently being in pain during wound care treatments and was wondering if a short acting pain medication would better suit this situation. NP M thanked the surveyor for bringing this to her attention and will look into and discuss with R40's POA (power of attorney) the possibility of trying a different medication for comfort. Surveyor asked when tramadol would start to take effect. RN L looked up tramadol in the medicine nurse handbook and stated the onset time was one hour and peak at two hours. On 3/28/24 at 12:15PM, Surveyor spoke with NP M after assessing R40. NP M said she had written an order to start Ativan and Morphine for R40 if it was okay with R40's POA. The creator of the Wong-Baker FACES pain scale states, This self-assessment tool must be understood by the patient, so they are able to choose the face that best illustrates the physical pain they are experiencing. It is not a tool to be used by a third person, parents, healthcare professionals, or caregivers, to assess the patient's pain. There are other tools for those purposes. The facility utilized this scale for R40's pain. Pain Assessment in Advanced Dementia (PAINAD) scale is a tool used to determine pain by having the nurse assess the resident concerning five categories: breathing independent of vocalization, negative vocalization, facial expression, body language and consolability. This assessment was more appropriate to be used to assess R40's pain but was not utilized by the facility to determine more accurate pain assessments for R40.

Based on interview and record review, the facility did not ensure 1 of 3 residents (R) R5's drug regime was free from unnecessary medication use without adequate indications for use for an antibiotic. Findings include: R5 was admitted to the facility on [DATE], with diagnoses that include pneumonia, acute and chronic respiratory failure, and hyperthyroidism. Record review reveals a doctor's order on 12/15/22 for Nitrofuration Monohyd Macro (an antibiotic)100 mg cap by mouth daily 0800 for uninary tract infection (UTI) prophylaxis. On 03/28/24, Surveyor reviewed R5's chart and could not find a rationale for the indication for use of a prophylactic antibiotic or that the pharmacists had made any recommendations on the long term use of the antibiotic stating this medication was needed. The physician progress notes were reviewed and include information that R5 is on comfort cares, with comfort focused treatment. The physician documents medications were reviewed and reconciled. The physician progress notes do not include a detailed evaluation of mental, physical, functional, psychosocial benefit, or comorbid conditions that describe adequate indication for the continued use of the antibiotic. On 03/28/24 at 11:55 AM, Surveyor interviewed Registered Nurse (RN) D and asked if R5 took a prophylactic antibiotic. RN D indicated that R5 has been taking the antibiotic for as long as RN D has been working with R5. Surveyor asked if the facility had ever looked at removing the antibiotic. RN D indicated that R5 does not like change. On 03/28/24 at 1:10 PM, Surveyor interviewed RN L and asked if there was a clinical rationale for R5 to be on a prophylaxis antibiotic. RN L indicated that R5 had a hysterectomy, ovarian cyctectomy and has urogenital implants. Surveyor asked if the facility ever considered discontinuing the antibiotic. RN L indicated, no. RN L stated the facility emailed the pharmacists today about reviewing the antibiotic as there is no evidence the medication is needed.

Based on random observation, 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 help to prevent the development and transmission of communicable diseases and infections for 2 residents (R) (R60 and R21) Example 1 Facility policy titled, Hand Hygiene, reviewed 07/2023, The following is a list of some situations that require hand hygiene: .Before and after wearing gloves . On 03/26/24 at 6:49 AM, Surveyor observed Certified Nursing Assistant (CNA) C, provide incontinence care for R60. CNA C conducted hand hygiene and donned a pair of clean gloves, removed incontinent product, provided incontinence care and proceeded to do the following: apply barrier cream to abdominal folds, apply clean brief, placed mechanical sling under R60, applied deodorant, picked up a emery board off of floor, positioned lift towards resident, hooked sling to lift and using controls turned on and positioned resident to recliner, unhooked and removed sling. No observation of changing gloves and conducting hand hygiene was observed as CNA C moved task to task with contaminated gloves. On 03/28/24 at 8:58 AM, Surveyor interviewed CNA C regarding expectation of hand hygiene between glove changes. CNA C stated training did not include hand hygiene between glove changes. 46694 Example 2 On 03/26/24 at 6:41 AM, Surveyor observed CNA E and CNA G perform morning cares on R21. Proper hand hygiene was performed, and Personal Protective Equipment (PPE) was donned, as this resident has a catheter and is on transmission-based precautions. CNA E cleaned R21's upper body without any issues. R21's pants were removed and catheter pulled through the pant leg by CNA E. CNA G put the catheter through the new pant leg. CNA E cleaned the peri area with new washcloth and then dried. R21's attends tucked, and resident rolled onto the right side. Dirty attends taken out from under R21. R21's buttocks were cleaned and dried. CNA E removed the dirty gloves, put on new gloves without using hand hygiene between glove changes. CNA E then applied skin barrier cream on R21's buttocks, put on a new incontinent product, pulled up R21's sweatpants, while rolling R21 to the left side. CNA E then placed the Hoyer sling under the resident. CNA E removed the dirty gloves and put on new gloves without performing hand hygiene between glove changes. CNA G brought the Hoyer lift to the resident's bedside. Hoyer sling attached to the Hoyer and both CNAs assisted R21 into the wheelchair. CNA E removed gloves and put on new gloves without hand hygiene between glove changes. CNA E then wiped left down with sanitizer wipes. Both CNAs performed hand hygiene after removing their gloves and exiting the room. On 03/28/24 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B, explaining the observations made during morning cares on R21 with no hand hygiene between gloves changes. DON B stated, This should not be. The staff should all know that hand hygiene is the standard of care. On 03/28/24 at 8:47 AM, Surveyor asked CNA F, What do you do just before putting on gloves or immediately after taking off your gloves? CNA F replied, I would use hand sanitizer.

Based on observation, interview and record review, the facility did not ensure foods were stored at safe ranges to prevent spoilage by not consistently checking refrigerator and freezer temperatures in accordance with professional standards for food service safety. This has the potential to affect all 60 residents in the facility. Findings include: 02/13/23 09:43 AM Initial tour of the kitchen and kitchenettes with Registered Dietician (RD) H. Temperature logs for February missing temperatures: Cold storage in kitchen missing Feb. 11 and 12th. Freezer temperature in kitchen missing Feb. 11 and 12th Kitchenette Rehab refrigerator missing Feb. 10, 11, and 12. Kitchenette Day room refrigerator missing Feb. 10, 11, and 12. On 2/14/23 at 10:20 AM, Surveyor asked RD H for a copy of the policy and procedures for logging temperatures on refrigerators and freezers. On 2/14/23 at 12:05 PM, Surveyor interviewed RD H regarding staff who are to complete these logs. She replied she had the new employee that worked this weekend come in last night and he received education on logging temperatures of these devices. On 02/15/23 at 11:42 AM, Surveyor received Policy and procedures title Refrigerator and Freezer Temperature Logs from RD H. Policy: All cooling units (both refrigerator and freezers) within the food service operation will be temped once per day, every day, by a designated culinary staff member. Temperatures of the cooling units will be recorded daily to ensure that proper cold holding temperatures are being met. Procedures: 1. Upon starting the morning shift, the designated culinary aide must observe and record temperatures of all cooling units. 2. Staff member will record the temperature of each cooling unit onto the corresponding log located in close proximity of the fridge or freezer . .5. During normal job functions, staff who enter the cooler/freezer should periodically check the temperature and log as needed .6. In the event the designated culinary aide is unable to accomplish this task it is the responsibility of the person in charge to ensure the task gets accomplished.

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure all staff sanitized mechanical lifts between use with multiple residents. This had the potential to effect 12 residents, who require transfers with a mechanical lift, out of 19 residents residing on the north wing of the second floor. The facility did not ensure all staff handled soiled linens properly. Four staff were observed holding soiled linens against uniforms when carrying to dirty linen bins in hallway. This has the potential to affect all 19 residents on the north wing of the second floor Findings include: Facility Policy entitled Cleaning of Mechanical Lifts, last updated 06/2022, stated in part: .After any mechanical lift usage, disinfect lift using provided disinfection cleaning product . According to CDC guidance for Routine Handling of Contaminated Laundry in Health Care Facilities: Staff should .Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons, and bag or otherwise contain contaminated textiles and fabrics at the point of use . https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html#g On 02/14/23 at 7:51 AM, Surveyor observed Certified Nursing Assistant (CNA) D bring a mechanical lift out of R16's room and place it at the end of the hall. Surveyor did not observe CNA D wipe down the lift prior to walking away from the lift. Surveyor interviewed CNA D who stated they sometimes wiped down the handles of the lift with Clorox wipes after use. Surveyor asked if the lift was just used in R16's room and CNA D stated yes. Surveyor asked if CNA D wiped the lift with sanitizer wipes before leaving it in the hallway. CNA D stated no. CNA D stated they were a new employee at the facility and was not entirely sure of the process for disinfecting the lifts after use. On 02/14/23 at 10:13 AM, Surveyor observed CNA E bring a mechanical lift out of R21's room and placed it in the hallway. Surveyor did not observe CNA E wipe down the lift prior to walking away. On 02/14/23 at 10:40 AM, Surveyor interviewed CNA E about the facility policy for cleaning and sanitizing mechanical lifts. CNA E stated staff wipe down the lifts or multi-use equipment with bleach wipes every evening. Surveyor asked to clarify if using a lift in a resident room, do they sanitize the lift after each use. CNA E stated no they were cleaned by the evening or night shift staff. On 02/14/23 at 1:32 PM, Surveyor observed CNA D bring a mechanical lift out of R41's room. Surveyor did not observe CNA D sanitize the lift prior to bring it into another resident room on the same hallway. On 02/16/23 at 10:05 AM, Surveyor asked Registered Nurse (RN) C, who was responsible for infection prevention and control, if staff were expected to sanitize multi-use equipment between residents. RN C stated staff should wipe down lifts or any multi-use equipment with Clorox hydrogen peroxide wipes that are kept on all lifts. RN C stated all staff had been educated on that process. Surveyor reviewed the above observations of CNA D and CNA E not sanitizing the lifts between use. Surveyor informed RN C during interviews with the two staff members, they indicated they did not know the correct facility procedure. RN C stated they should have sanitized the lifts between use and they will re-educate staff about this procedure. On 02/14/23 at 10:24 AM, Surveyor observed CNA E come out of R23's room carrying a used hand towel and other linen. The dirty linen was not in a bag and CNA E was not wearing gloves and was observed holding the dirty linen against CNA E's uniform prior to placing it in a covered bin in the hallway. On 02/14/23 at 11:21 AM, Surveyor observed CNA D carry dirty linen from a resident room and carry it down the hall to the dirty linen room. The dirty linen was not in a bag and CNA D was not wearing gloves and was observed holding the dirty linen against their uniform. On 02/15/23 at 6:37 AM, Surveyor observed CNA F exit a resident room carrying used towels and linens in their hands. CNA F carried the dirty linens down the hall and placed them in a dirty linen hamper. CNA F was not wearing gloves. The linens were not in a bag and Surveyor observed CNA F hold the dirty linens against their uniform. On 02/15/23 at 7:32 AM, Surveyor observed CNA G carry soiled towels and linen out of R54's room and place it in a dirty linen hamper in the hallway. The linen was not in bag and Surveyor observed some of the dirty linen hanging down against CNA G's clothing. On 02/16/23 at 10:05 AM, Surveyor interviewed RN C and asked how staff should handle soiled linens when they carry them out of resident rooms to be placed in linen hampers in halls or in the soiled utility room. RN C stated staff should wear gloves when handling soiled linens, but they do not require staff to place soiled linens in bags prior to carrying to a soiled linen hamper. Surveyor explained the above observations of staff not wearing gloves and holding the soiled linens against their uniforms. RN C stated the staff should not have been holding the dirty linens against their uniforms. RN C did not know if they had a written policy on handling of linens, but would look into it and would re-educate staff.

Based on record review and interview, the facility did not submit Minimum Data Set (MDS) data to Centers for Medicare and Medicaid Services (CMS) within the required timeframe for 1 Resident (R) of 18 Residents reviewed. (R7) R7 was discharged from the facility on 10/06/22. As of 02/14/23 the discharge MDS was not completed or submitted to CMS. Findings include: R7 was admitted to the facility for a short term rehabilitation stay on 10/04/22. Review of R7's medical record identified the following MDS assessments: Entry MDS with a target date 10/04/22, completed date 10/05/22, status accepted. Not OBRA- 5-day PPS Discharge MDS: target date 10/06/22, completed dated 10/10/22, status accepted. A nursing progress note, dated 10/06/22, stated R7 discharged home on that date. Surveyor did not identify a Discharge Return Not Anticipated MDS assessment on the medical record. On 02/14/23 at 9:19 AM, Surveyor interviewed Director of Nursing (DON) B, who stated DON B was not the MDS coordinator at the time of the MDS assessment in question. DON B stated R7 was in the facility very briefly and the final MDS assessment should have been a discharge return not anticipated assessment. DON B will review R7's MDS assessments that were completed and submitted to CMS. On 02/14/23 at 10:03 AM, DON B reported R7's Discharge MDS assessment was not completed or submitted to CMS. DON B submitted the discharge MDS assessment for R7 to CMS.

Based on interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments accurately reflected resident's current status for 3 residents (R) of 17 reviewed. (R42, R21, R39) *R42 was listed as a female on the admission and quarterly MDS assessments. R42 was listed as a male on the most recent MDS assessment. This created two residents in the CMS system. *R21's most recent MDS assessment listed a fall with major injury. R21 did not have a fall with major injury since previous MDS assessment. *R39's MDS assessments documented R39 had a Urinary Tract Infection (UTI) in the past 30 days prior to the assessment. R39 did not have a UTI in the past 30 days prior to the assessment. Findings include: Example 1: R42, a male resident, was admitted to the facility on [DATE]. Record review identified an admission MDS assessment, dated 07/07/22, that identified R42 as a female. The quarterly MDS assessment, dated 10/06/22, identified R42 as a female. The quarterly MDS assessment, dated 01/03/23, identified R42 as a male resident. This discrepancy caused R42 to be entered into the Centers for Medicare and Medicaid Services (CMS) system as two separate residents. On 02/14/23 at 9:19 AM, Surveyor interviewed Director of Nursing (DON) B, who was not the MDS coordinator at the time of the MDS assessments in question, but was currently responsible for completing the MDS assessments for the facility. Surveyor informed DON B of the MDS assessments completed for R42 which listed R42's gender as female. DON B reported the MDS assessments were completed and submitted to CMS incorrectly. DON B stated they would correct the demographic information on the incorrect MDS assessments and re-submit them to CMS. Example 2: The Long Term Care Survey Process (LTCSP) listed an MDS indicator of a fall with major injury for R21. On 02/13/23 at 11:28 AM, Surveyor interviewed R21, who stated they had not had any falls recently. The CMS-802 Matrix for Providers form, received on 02/13/23, was not marked for falls for R21. Surveyor reviewed R21's medical record and found no documentation of a fall with injury. Surveyor reviewed the MDS assessments and identified the following. The most recent MDS assessment, dated 01/05/23, was marked for a fall with major injury since the previous assessment. A PPS discharge MDS, dated [DATE], was marked for a fall with major injury since previous assessment. A significant change MDS, dated [DATE], was marked for a fall with major injury since the previous assessment. The quarterly MDS, dated [DATE], identified no falls since previous assessment. Surveyor reviewed R21's medical record for fall incident documentation from July through present date and identified a note dated 09/13/22: 01:16 PM Was reported that in route to dialysis she slid out of her w/c to the foot pedals . On 02/14/23 at 9:19 AM, Surveyor interviewed DON B, who stated R21 did not sustain a fall in the facility, so it was not documented or investigated as a fall. The transport van was in a motor vehicle accident when R21 was being transported to dialysis. R21 slid out of the wheelchair in the accident and suffered a fractured leg. The facility did submit a self-report to the state about this incident at the time of the incident. Surveyor asked DON B if each subsequent MDS assessment should be marked that R21 had a with a fall with major injury. DON B stated only the MDS assessment immediately after the fall should have fall with major injury checked. DON B stated if R21 did not have a fall since the previous assessment, fall with major injury should not be checked on subsequent MDS assessments. On 02/14/23 at 10:03 AM, DON B reported after review of R21's medical record, they determined R21 did not have any falls since the incident in the transport van in September. DON B stated the MDS assessments completed after the significant change MDS were completed in error. Example 3: The LTCSP listed an MDS indicator of Urinary Tract Infection (UTI) for R39. On 02/13/23 at 1:26 PM, Surveyor interviewed R39 and her husband, who stated R39 had not had any UTIs in a long time as far as they were aware. The CMS-802 Matrix for Providers form, received on 02/13/23, was not marked for UTI for R39. Surveyor reviewed R39's medical record and found no documentation of a UTI in the past 30 days and resident was not currently or recently on any antibiotics for infection. R39's quarterly MDS assessment, dated 12/22/22, had UTI checked in the diagnosis section. This indicated R39 had a UTI in the last 30 days prior to the assessment. The MDS assessment, dated 09/29/22, had UTI checked in the diagnosis section. On 02/14/23 at 9:19 AM, Surveyor interviewed DON B and asked if R39 had a UTI in the recent past as indicated by the last two MDS assessments. DON B stated their understanding of the MDS assessments was if UTI was checked, it meant the resident had a UTI in the previous 30 days prior to the assessment. DON B would check R39's medical record to determine if these assessments were completed accurately. On 02/14/23 at 10:03 AM, DON B reported R39 did not have any recent UTIs and the MDS assessments were completed incorrectly.

Based on observation, record review and interview, the facility did not ensure acceptable parameters of nutritional status to maintain usual body weight. This occurred for 1 of 7 residents reviewed for nutritional status. Resident (R) R61. R61 was not weighed weekly to assess if he was maintaining his usual body weight. R61 had significant weight loss and weight gain that were not assessed when weights were obtained. This is evidenced by: R61 was admitted to the facility on [DATE], and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The last 7 weights charted are: 08/11/21 260 pounds 08/31/21 260 pounds (Resident not weighed for over 3 weeks) 09/07/21 251 pounds, 09/21/21 256 pounds, (Resident not weighed for 2 weeks) 10/12/21 246 pounds (Resident not weighed for 3 weeks and has a 10 pound weight loss that is not addressed) 10/19/21 266 pounds, (Resident has a 20 pound weight gain 10.83% gain with no assessment) 11/02/21 260 pounds (Resident has not been weighed for 13 days) Surveyor interviewed Dietician D and asked if she was notified of the significant weight gain or loss noted above, Dietician D stated, I have not noted that. Review of the facility's policy and procedure manual for Weights Monitoring read in part objective: to ensure appropriate tracking and monitoring of resident's weight and fluctuations so appropriate referrals can be made to the medical provider, nursing providers and culinary team. R61 was having significant weight gain, 10/12/21 - 10/19/21. R61 had a 20 pound weight gain, no physician notification, nursing notes or culinary team referrals were in the file when there was a significant weight fluctuation.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that assure accurate administering of all drugs and biologicals. This occurred for 1 Resident (R) of 1 resident observed for medication administration with insulin pen. R35 received 40 units of BASAGLAR® KwikPen® Insulin [MEDICATION(S)] by using an injectable pen that a safety check was not completed on to ensure the injectable pen was dispensing insulin before administration. This is evidenced by: R35's Physician Orders dated 02/20/2021 reads: [BASAGLAR® KwikPen®] Insulin [MEDICATION(S)] 100unit/ml Solution Pen-Injector Dose: 40 units Subcutaneous daily at 07:30 a.m. for type 2 Diabetes. On 11/03/21 at 7:41 a.m., Surveyor observed Licensed Practical Nurse (LPN) C prepare R35's medications. When LPN C prepared the insulin pen of insulin [MEDICATION(S)] with 40 units of insulin, LPN C did not perform the safety check of priming 2 units of insulin to observe the insulin being ejected from the needle before administering to R35. Surveyor asked LPN C if she would prime or discard insulin when using an insulin pen. LPN C responded that she does not. On 11/03/21 at 11:14 a.m., Surveyor reviewed manufacturer's guidelines and Instructions for Use 2021 Eli Lilly and Company, read in part: Priming your Pen Prime before each injection. Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps. Small air bubbles are normal and will not affect your dose. Reviewed facility Policy and Procedure Manual Nursing Insulin Administration and documentation, dated 07/20. No specific directions regarding insulin pens except for #14 which states, Pre-drawn insulin should include the resident's name, date, insulin type and dosage. Reviewed facility Insulin Administration with Vial/Syringe Employee Competency Check Off. This document did not contain any directions regarding insulin pens. Reviewed facility Policy and Procedure Manual Medication Pass Audit Nursing, no date. Document states, in part Does the nurse use the proper technique for administering subcutaneous injections, using an appropriate site and cleansing that site with alcohol prior to the medication administration? On 11/03/21 at 2:19 p.m., Surveyor interviewed Director of Nursing (DON) B and asked if staff administering injections are trained to prime insulin pens prior to administering insulin. DON B responded that she did not think that was their practice. The facility did not ensure that medication was administered in accordance with manufacturer's specifications and with standards of practice.

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (R) reviewed for treatment and prevention of pressure ulcers (R2). R2 had a significant change of condition placing R2 at increased risk for pressure injury (PI) development. The facility failed to revise R2's care plan or implement interventions to prevent PI. R2 developed bilateral PI's to the heel and worsened to a Stage 3 PI. R2 did not have a heel lift device in place or heels floated when in bed. There is also documentation that R2 attended a clinic visit for her wounds and a dressing was not in place as ordered at the time of that visit. Evidenced by: The facility policy entitled Nursing Procedures/Skin Care Protocols states in part; Standard Protocol for Skin Care: 1. Skin Inspection and Assessment: a. all residents will be assessed on admission, quarterly and with a change in resident's condition for risk factors. Minimize Skin Exposure and Injuries: h. Use pillows, foam wedges etc., to keep bony prominences (knees, ankles) from contat with one another. According to the National Pressure Ulcer Advisory Panel (NPUAP) standard of practice, .Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that heels are free of the surface of the bed Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf . (NPUAP Heel Pressure Ulcers: 2014 International Pressure Ulcer Prevention & Treatment Guidelines, 2014). R2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. MDS assessments were as follows: - Annual assessment on 12/12/19 indicated R2 was independent with no set up with bed mobility. - A Quarterly assessment on 3/12/20 revealed R2 was at risk for developing pressure injuries, but had no unhealed pressure injuries or other skin or foot problems. - A Significant Change MDS assessment on 4/13/20 indicated R2 was at risk for developing pressure injuries, but had no unhealed pressure injuries or other skin or foot problems. - A Significant Change MDS assessment on 5/7/2020 indicated R2 had two stage two pressure injuries. - Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R2 had one Stage 3 pressure injury (PI) at the time the assessment. R2 also had a BIMS (Brief Interview of Mental Status) score of 9, indicating moderately impaired cognition. It is important to note that R2 was hospitalized with pneumonia on 4/4/2020 and returned to the facility on [DATE]. According to R2's Significant Change MDS assessment on 4/13/20, R2 now required extensive assistance of one staff with bed mobility. It is also important to note that when R2 returned from the hospital with decreased bed mobility and an increased risk for developing pressure injuries, the facility did not implement any new interventions to prevent PIs from developing. R2 did develop PIs on bilateral heels, the right heel worsening to a Stage 3. Interventions to prevent PI to the heels were not put into place until after R2 developed a PI. The weekly skin assessment done on 4/23/2020 indicated at that time, R2 has had no foot problems. A review of the Nurse's Notes indicates the facility discovered R2 had developed bilateral heel blisters on 4/28/2020. Nurse's Notes on 4/28/2020 regarding right heel blister reads, 5cm round, boggy. Red with areas of grey and black, intact. The left heel blister was noted as, 2.5cm round, grey, boggy, intact. On 4/29/2020, R2's Care Plan was updated with the intervention to Provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface. R2's Care Plan also states, Know that I am independent with bed mobility and have decided not to utilize the heel lift, place an air mattress on my bed, utilize a pressure redistribution cushion on any surface I sit on, despite the Significant Change MDS done on 4/13/20 that shows, R2 required extensive assistance of one staff with bed mobility. R2 has utilized an air mattress in bed since prior to 2020. The Care Plan was updated again on 5/10/2020 to add I often decline my heel lift knowing the risks. Offer me pillows as an alternative. Encourage use. There is no evidence in the record to indicate that R2 was educated on the risks and benefits of refusing to use a heel lift or that she was indeed offered to have one in place. On 5/4/2020, R2 had a telehealth visit with provider. Visit notes written by the Nurse Practitioner (NP), read, She is sitting more which has caused bilateral heel pressure sores with skin that is currently intact. Staff have implemented treatment measures with floating her heels and offloading pressure. Nurse's Notes on 5/4/20 note the right heel to have a 4 cm x 5 cm brown dry soft blister and the left heel to have a 2 cm x 2 cm soft blister. Nurse's Notes indicate R2, does now float her heels. On 5/11/2020, Skin Assessment Nurse's Notes describe the right heel as a 4 cm x 4 cm blister and a small open area of 1 cm x 1 cm x 0.1 cm with small serosanguineous drainage. The left heel is described as 08.0 cm x 03 cm and a 0.5 cm round flesh colored bump noted. The note states left heel fluid has reabsorbed and heel is soft in the area around the bump. The Nurse's Notes states, in part . She is to be floating her heels in her chair and in bed with heel lift cushion . Floating heels is important. There is no indication that resident has refused to float heels. On 5/18/2020, there are no measurements on the heels. The right heel is described as black in color with tiny pinpoint area stuck to [MEDICATION NAME] and bed one drop of bright red blood. Left heel has a discolored area that is soft and has no fluid in it. Skin intact . can be OTA (open to air) just keep it floating . She does lay down more in bed and is now using the heel lift cushion in bed as her heels do bother her some. She is frequently repositioned by staff as she doesn't move much on her own anymore. On 5/26/2020, Skin Assessment Nurse's Notes describe R2's left heel as a 5 cm x 5 cm dark brown area dry, 1.5 cm x 1.5 cm thicker dark scab almost black in color, 0.5 cm x 2 cm pink area wet with some serous fluid, tender. R2's left heel is described as dark brown dry thicker skin 1.5 cm x 1.5 cm, OTA. Nurse's Notes state, She does float her heels on the heel lift cushion. On 6/1/2020, R2's Skin Assessment Nurse's Notes state, Right heel as a 3 cm x 3 cm dried skin area that looks like it is peeling off slowly. This is OTA and resident denied any pain here. Left heel has a 2.5 cm x 2 cm dark brown area in the center of the wound bed. This portion is dry. Around this area is a red ring with a 0.5 cm white macerated ring around the entire area. Almost involves the whole heel. The rest of the skin around it is red but not swollen or hot. Area is very wet . provider was notified and request for order change to [MEDICATION NAME] suggested. Left heel tender. Notes indicate, She lays does (sic) in bed on an air mattress in bed and floats her heels on the heel lift cushion. On 6/3/2020, R2 was seen in the general surgery clinic for possible abscess of buttock and wound of right heel. Under physical examination notes from the visit, the provider documents, Right foot heel posterior aspect there is a 4 by 3 cm stable eschar that is present today there is tenderness to palpation. Underlying tissue does not feel boggy. There is no surrounding [DIAGNOSES REDACTED]. There is no discharge . The provider notes in the Assessment and Plan an unstageable pressure injury of right heel and that it is Important to keep pressure off the right posterior heel. Patient should be utilizing offloading . On 6/8/2020, R2 had a follow up visit which consisted partly of debridement of the right heel, along with treatment for [REDACTED]. Assessment and plan from this visit indicate R2 has a Pressure injury of right heel, Stage 3 and orders to monitor for infection, daily dressing changes, continue offloading the right heel, float heels when in bed, and follow up in one week. Skin Assessment Nurse's Notes on this day state, The right heel has a 1.5 cm x 1.4 cm black eschar area noted. Around this area from 2:00 o'clock to 10:00 o'clock is an open ring measuring 0.5 cm wide rim around the eschar. This area is pink and moist. The left heel is noted as healed with dry skin. Notes indicate R2 does lay in bed on an air mattress in bed and floats her heels on the heel lift cushion. On 6/15/2020, the Skin Assessment Nurse's Notes read, Late entry for 6/14/2020 Did assess her skin last pm at 1900 . On her right heel she had a 1 cm round eschar area and a rim of red tissue 0.5 cm at the weidest part around the edge of the eschar. Today (wound clinic physician's assistant) did debride it and cleaned it with NS and applied skin prep and [MEDICATION NAME] and covered with a foam patch . She does float her heels on the heel lift cushion. On 6/23/2020, Skin Assessment Nurse's Notes describe the right heel as having A 3 cm by 3 cm open area on the back of the right heel. In the center is a layer of white tissue and is adhered yet. Around the island is pink tissue and it is moist. Surrounding skin intact . lays on ain air mattress at night. She is using the heel lift cushion as well to float heels at night. On 6/26/2020, R2 had follow up visit with general surgery clinic. Provider notes reads Still have concern that she is putting pressure on her heel. It has been ordered that the (sic) float the heels to keep pressure off these areas. Notes under physical examination today read Skin: Right heel wound there is no dressing in place today there is only the patient's sock to protect the wound there is the 2.5 x 3 x 0.2 cm wound with a 70% slough 30% granulation tissue. Slough will be debrided today. Assessment and plan notes for the Pressure injury of right heel, stage three states, Discussed the importance of off-loading the heel, discussed floating the heel. Current treatment and dressing order at the time of this visit when no dressing was in place reads, Cleanse right heel wound w/safeclens or similar and pat dry. Apply [MEDICATION NAME] to wound bed and skin prep to edges. Cover with 10 x 10 [MEDICATION NAME] or similar daily until healed. On 6/29/2020, the Skin Assessment Nurse's Notes indicate R2's right heel has a 3 cm x 3 cm open area yet. Most of this is white fibrous tissue with some black in the center. No mention of heel lift, floating heels, or refusals. On 7/6/2020, R2's clinic visit notes state, Vital to keep pressure offloading the heel. Important to float the heels. Nurse's skin assessment notes on this day describe the right heel as open area 1 cm x 1 cm x <0.1 cm and is pink and healing. Moist. No undermining, tunneling, odor, little pain, and not draining. Edges are defined and attached. Surrounding skin is intact. No mention of heel lift, floating heels, or refusals. On 7/13/2020, R2 was seen in the clinic. Clinic documentation states the right heel has a 1 x 1.2 x 0.2 cm wound with 90% healthy granulation tissue. There is some slough in the superior aspect at the 12 o'clock position that will be debrided today. There is no tunneling or undermining. There is no significant periwound [DIAGNOSES REDACTED]. There is no induration. There is no significant tenderness to palpitation. Skin Assessment Nurse's Notes indicated the treatment was not done tonight, as it was done by the provider in the clinic this afternoon. Will try to get it done later in the week. No mention of heel lift, floating heels, or refusals. On 7/22/2020, Skin Assessment Nurse's Notes read, Did get to see this resident's wounds tonight. The right heel measures 2.2 cm x 2 cm x 0.4 cm wound bed is pink and wet 75% of wound and the other 25% on the upper edge is firmly adhered yellow slough. No undermining or tunneling. Very wet with some yellow to brown drainage. No odor, wound edge is yellow and wet. Surrounding skin intact . She lays in bed on an air mattress. She does float her heels with heel lift cushion. On 7/27/2020, Skin Assessment Nurse's Notes indicate R2's right heel to have a 2 cm x 1.5 cm x 0.2 cm open area with pink wound bed that looks a bit dry. Note states, She sits on a cushion and lays in bed at night and is floating heels and is laying side to side . On 8/3/2020, Skin Assessment Nurse's Notes states the right heel wound measures 1.4 cm x 1.6 cm x 0.2 cm. Wound bed is pink with a small island of firmly adhered slough noted. No undermining, or tunneling is seen. On odor, and there is a small amount of yellow drainage but some of that is probably warm medi honey. It is still tender to touch. Edges are defined and attached. Surrounding skin intact. Little macerated around the edges . She does lay on an air mattress and float her heels on the heel lift cushion. On 8/10/2020, R2 was seen again in the clinic, with clinic visit notes stating, Continue offloading buttock and heel. Measurements of right heel at clinic were 0.9 x 1.2 x 0.1 cm with 100% granulation tissue. There is no tunneling or undermining. No periwound [DIAGNOSES REDACTED], induration, tenderness to palpation, or calor. The wound was cleansed using SAF-Clens and then blotted dry. [MEDICATION NAME] was placed in the base of the wound. Skin prep was placed on the periwound, then a [MEDICATION NAME] 10 x 10 cm dressing was placed, followed by roll gauze to secure the dressing and then a compression stocking and sock were replaced. Skin Assessment Nurse's Notes on this day read, . On her right heel this area appears to have been debrided today too as the drainage on the dressing was light pink in color. Measures 1.4 cm x 1.3 cm x 0.2 cm. Wound bed is pink in color and moist. Cleaned with NS and blotted dry. Applied [MEDICATION NAME] and [MEDICATION NAME] and covered with a foam dressing and kling wrap. This is changed daily . She does float her heels on heel lift cushion in bed. Does not mention use of heel lift in recliner or refusals to use heel lift in recliner. On 8/17/2020, Skin Assessment Nurse's Notes indicate R2's right heel wound is 1 cm x 1 cm and covered with a thin layer of light yellow slough and a scant amount of brown drainage in the old dressing. Note states, She does float her heels on heel lift cushion in bed. On 8/19/2020 at 11:48 AM, Surveyor observed R2 resting in bed. Resident was covered with blanket, but legs and feet did not appear to have anything between mattress and legs - heels did not appear to be floated. At 12:07 PM, Surveyor observed CNA C deliver meal tray to R2's room. CNA C assisted R2 from bed to wheelchair. Surveyor did not observe any heel lift or pillows in place on bed for use in floating heels. R2 was wearing gripper socks and appeared to have dressing under right gripper sock. On 8/19/2020 at 12:15, Surveyor spoke with CNA C regarding interventions used with R2 to reduce pressure. CNA C stated that for R2's heels, she uses a blue cushion when in the chair or in the bed. Surveyor asked if she had it in place this morning. CNA C stated she thought it might have needed washing. Surveyor asked CNA C what is usually done when a resident has a heel lift that is temporarily unavailable, and she stated, We would use a pillow or something until it is back. CNA C stated she thought R2 should have a pillow in bed for her heels since the blue heel lift was not available, but stated there were no pillows or pressure relieving devices in use for R2 while in bed prior to lunch today. Surveyor made another observation of bed and floor and did not note any pillows in the vicinity other than what was used at R2's head. Surveyor asked CNA C how to know what R2's pressure relieving device needs are, and CNA C showed Surveyor the CNA care card, which indicated Provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface. I often decline my heel lift knowing the risks. Offer me pillows as an alternative. Encourage use. Surveyor asked if R2 had heels floated while in bed prior to lunch today, and CNA C stated, No. Surveyor asked if R2 should have had her heels floated while in bed, and CNA C stated, Yes. On 8/19/2020 at 4:12 PM, Surveyor spoke with DON B and NHA A. Surveyor asked DON B what would be a key intervention she would expect to see for a resident with pressure injuries or risk for pressure injuries on the heels. DON B replied, The standard of care is a heel lift cushion. DON B stated that R2 had a heel lift cushion available up until last night as far as she can tell and was not sure if it got sent to laundry overnight. Surveyor asked what would be expected in a situation such as that when the pressure relieving device is unavailable, and DON B stated, Float heels with pillow. Surveyor was unable to locate, nor did the facility provide, any documentation of refusal or education on risks and benefits of refusal to using heel lift in R2's medical record.

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 76 residents who reside in the facility. Facility's ice machine spout was observed to be covered in a thick white substance. CDM G (Certified Dietary Manager) indicated the substance was lime build up. A staff member's opened Diet Pepsi was being stored in the facility walk-in refrigerator. A dented can was observed in circulation and CDM G indicated that a can with minimal damage can remain in circulation. Facility's equipment was observed stored and speckled with old food particles, including two mixers and a meat slicer. Microwave was observed spattered with food particles on the top inside and inside sides of microwave. A damaged spatula was observed in circulation. This is evidenced by: Ice machine: Facility policy entitled Ice Machines includes, in part: . Sanitize Interior: Sanitize Interior of ice machine per manufacturer's instructions. Clean out and sanitize ice bin . Clean Exterior: Clean and wipe down exterior . Manufacturer's guidelines entitled Ice Machine Cleaning and Sanitizing, dated 2/26/18, includes, in part: . in bad water conditions a more thorough soaking may be required. Turn off power supply, clean all items in a solution of 5 ounces of scale away per gallon of warm water . Using a nylon scouring pad, nylon brushes, and cleaning solution scrub the storage bin, bin top, agitator, drip ring, spouts A and B, ice chute, and drain pan . Soak the parts removed in sanitizing solution for 15 minutes. Rinse all parts thoroughly with clean water . Ice machine should be cleaned and sanitized at least once a year . On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed a white substance coating the entire inside of the spout where the ice machine pushes out ice cubes. DM G indicated that it is limed up and she has contacted the Maintenance Department about this several times, but they haven't cleaned it yet. CDM G indicated she would call the company and see if they can come clean it. CDM G also indicated the ice machine is used to serve fresh cold water to the entire house. On 10/31/19 at 8:26 AM, during an interview, CDM G indicated Maintenance cleans the ice machine every 6 months, but due to hard water maybe maintenance needs to clean more often. CDM G and Surveyor reviewed a Maintenance request that was filled out by CDM G, on 9/30/19, for ice machine to be cleaned and CDM G indicated she is still waiting for this request to be filled. Dented Cans: Facility policy entitled Guide to Evaluating Dented Cans, undated, includes, in part: . there are many pictures of safe, minor defect cans, and pictures of unsafe, critical or major defect cans. The critical and major defect cans are labeled with red arrows and the minor defect cans are labeled with green arrows . you should have a good idea of what cans have only minor defects and are safe and which cans have critical and major defects making them unsafe. FDA Public Health Service Food Code, (YEAR), includes, in part: 3-202.15 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 ,[MEDICAL CONDITION]. botulinum may find their way into the food. In anaerobic conditions (lack of oxygen), [DIAGNOSES REDACTED] 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 may indicate can damage . Suspect cans must be returned and not offered . (It is important to note the discrepancy with the Food Code and the facility policy.) On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed a dented can of bread and butter pickles. CDM G indicated that the facility uses a picture guideline to decide if the can is safe to use after it has been compromised from its original condition. CDM G and Surveyor reviewed this. On 10/31/19 at 8:26 AM, during an interview, CDM G indicated she will be educating staff on throwing out dented cans and removing her picture guidelines. Unclean equipment: Facility policy entitled Microwave, dated 5/19, includes, in part: . use hot soapy water, clean wash cloth, bucket, and sanitizer . when: Tuesdays 10:15 . wipe down inside of microwave . inside door and top of microwave . Facility policy entitled Mixers, dated 3/18, includes, in part: .when: Fridays 5:00 . Use: hot soapy water, clean wash cloth, bucket, and sanitizer . Procedure: wipe down each mixer, getting all exposed areas, especially where the attachment attaches to the motor . Spray down with sanitizer when done washing . On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed a small mixer to be speckled with two different colors of food particles underneath the top of mixer head. Surveyor also observed a large mixer to be spattered with food particles underneath the mixer head. CDM G indicated that these two pieces of equipment were cleaned and being stored. Surveyor asked CDM G to bend down and look up underneath the mixer head and she did. CDM G indicated the mixers were not properly cleaned before stored and should have been. Surveyor asked if there was potential for these speckles to fall into the bowl if used without cleaning. CDM G indicated there was the potential. On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed a meat slicer in the main kitchen that was covered with cloth linen. CDM G indicated the meat slicer was cleaned and being stored. CDM G uncovered the meat slicer, Surveyor and CDM G observed dried food particles on handle, blade, and sliding platform. CDM G indicated it looked like dried meat and should have been thoroughly cleaned before storing. On 10/31/19 at 8:26 AM, during an interview, CDM G indicated she will be educating staff on cleaning of equipment and that the mixers, meat slicers, and microwaves should be cleaned after every use. Opened personal food item in resident food area: On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed an open Diet Pepsi in the walk in refrigerator. CDM G indicated that it belongs to a staff member and she should know better than to store this with resident food as she has been talked to previously about this. On 10/31/19 at 8:26 AM, during an interview, CDM G indicated she will be educating staff on where to keep their personal food items. Compromised utensils: On 10/28/19 at 10:15 AM, during initial tour of kitchen, Surveyor observed a spatula in the utensil drawer to have a pea sized piece of the rubber end missing. CDM G indicated that the spatula should not be used and should have been tossed in the garbage. On 10/31/19 at 8:26 AM, during an interview, CDM G indicated that she will be educating staff on throwing out compromised equipment, such as nicked spatulas.

Based on observation, interview, and record review, the facility did not develop and implement a Comprehensive Person-Centered Care Plan for 2 of 21 residents reviewed (R40 and R41). R40 was observed without care plan interventions in place. R41 did not have a care plan related to his use of an anti-coagulant (high risk) medication. R41 was prescribed an anticoagulant medication and the facility did not develop a care plan to identify R41 to be at a higher risk for bruising and bleeding or have a system in place for monitoring R41 for bleeding and or bruising related to his anticoagulant usage. This is evidenced by: R40 was admitted to the facility, on 8/16/19, with [DIAGNOSES REDACTED]. Facility policy entitled Management of the resident on anticoagulant therapy, updated 7/19, includes, in part: . Residents . will be monitored for signs and symptoms of uncontrolled bleeding, including: severe bruising, blood in emesis, blood in stool, black or tarry stools, altered cognition/mental status, unexplained decrease in hemoglobin . Licensed staff will monitor for signs and symptoms of bleeding including bruising, bleeding from gums during teeth brushing, blood in stool, sudden onset of confusion that may indicate bleeding in brain, or recent changes in breathing patterns or sounds that may indicate bleeding in lungs . Example 1 R40's Significant Change Minimum Data Set (MDS) assessment, dated 9/16/19, indicates resident is at risk for pressure injuries has a current unhealed pressure injury Stage 2, and has no foot problems. Current skin and ulcer/injury treatments, marked on MDS, include pressure reducing device for chair, pressure reducing device for bed, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet. R40's care plan, dated 9/25/19, with a target date of 12/31/19, states: I: have a skin injury and fragile skin; Because I: have poor tissue perfusion, sometimes get confused or can't remember things, can't move around well on my own, health decline; I show this by: having an existing skin injury - right coccyx. Interventions include providing heel lift cushion in bed/recliner/chair when heels may potentially come in contact with any surface, gripper socks on feet at all times except with transfers, shoes on for transfers only. On 10/29/19, the care plan was updated to include right outer foot open area. Interventions were updated to include blue redistribution boots on at all times except with EZ Stand transfer, and then use shoes for the transfer only. On 10/30/19, the care plan was updated to include existing skin injury to left toes and right ball of foot open area under callous. Interventions were not changed at this time. Hospice charting, on 8/30/19, reads: His feet are prone to wounds and they are documented above as well as a wound on his coccyx. R40's Braden Scale Assessment, completed 9/18/19, showed a score of 13, which indicated a moderate risk for pressure injury development. On 10/28/19 at 1:37 PM, Surveyor observed R40 sitting in room in Broda chair. R40's right foot had shoe on, left shoe had fallen off and was lying on the floor, and heel lift cushion was not in place in chair nor observed near resident at this time. On 10/29/19 at 12:47 PM, Surveyor observed CNA D (Certified Nursing Assistant) assist R40 with transfer and cares. CNA D prepared to transfer resident with EZ Stand and noted to Surveyor resident had gripper socks on his feet. CNA D transferred resident from Broda chair to commode, left resident in room with call light, returned to room at 12:54 PM, assisted resident with cares, and used EZ Stand to transfer R40 back to Broda chair wearing gripper socks. On 10/30/19 at 10:39 AM, Surveyor observed resident on commode in room with shoes on. CNA D and LPN C (Licensed Practical Nurse) in room for transfer back to Broda chair and dressing change performed by LPN C. After completing standing dressing change, R40's right leg had come off of the EZ Stand platform and shoe had fallen off in the process. CNA D lowered resident to seated position to reposition resident for completion of transfer. LPN C suggested they try using the leg strap on the lift to keep R40's legs in position, which they did, but R40 was transferred to Broda chair with only one shoe. Once in Broda chair, blue boots were placed on R40's feet and heel lift was put into place. On 10/30/19 at 10:30 AM, Surveyor spoke with CNA D asking how staff knew how to transfer a resident and what interventions they should have in place. CNA D stated that all information was in the Care Plan Card at the foot of a resident's bed so that anyone providing care could find it there. On 10/31/19 at 12:15 PM, Surveyor spoke with CNA D regarding R40's transfers. CNA D indicated R40 is to have shoes on with all transfers. Surveyor asked if he should have had shoes on instead of gripper socks for the transfer observed on 10/29/19 at 12:47 PM. CNA D stated, He probably should have, but half the time they come off anyway. CNA D indicated she probably should have started the transfer with shoes on and thought that resident only wore shoes during transfers for protection and that He came in with sores on his toes and feet. Surveyor discussed the use of the heel lift cushion with CNA D who stated, I was on vacation for eight days and when I came back he didn't have his heel cushion, so I thought maybe it was discontinued, but I asked and found out he was still supposed to have it. On 10/31/19 at 1:22 PM, Surveyor discussed observations of R40 with DON B (Director of Nursing). She stated, It's unfortunate that his interventions for one issue are counterintuitive for another, since he is also at risk for falls. Example 2 R41 was admitted to the facility, on 3/11/19, with [DIAGNOSES REDACTED]. R41's Physician order [REDACTED]. Dose: 1 tablet by mouth daily 4:00 PM for [MEDICAL CONDITION]. R41's Comprehensive Care Plan, initiated 3/12/19, does not include a need/preference to identify R41 as taking a high risk anticoagulant medication, a goal for R41 related to anticoagulant use, or interventions for monitoring R41 related to anticoagulant usage. R41's Plan of Care Summary, printed 10/30/19, does not indicate R41 is at high risk for bleeding or bruising. It also does not have interventions for monitoring R41 related to anticoagulant usage. R41's Medication Administration Record [REDACTED]. On 10/31/19 at 7:55 AM, during an interview, DON B indicated R41 has had quite a few falls this year, including one the previous night (10/30/19). DON B indicated it is her expectation that staff would be able to identify residents on anticoagulants as high risk for bleeding/bruising and that they would monitor residents daily for bleeding and/or bruising related to anticoagulant use. DON B indicated staff would find information in the care plan and would monitor on resident's MAR/TAR. DON B indicated she does not know why R41's care plan does not include anticoagulant use and monitoring and it should. DON B also indicated R41's MAR/TAR should also have a place for staff to be monitoring and does not.

Based on observation, interview, and record review, the facility did not ensure safe and secure storage, including limited access and mechanisms, to minimize loss or diversion for Scheduled medications in 1 of 2 medication rooms and proper labeling of medication in 1 of 27 medication pass observations for R59 (Resident). A contingency supply of two 2mg/ml (milligram/milliliter) - 30 ml bottles of liquid [MEDICATION NAME], a Schedule IV medication, were stored in an unlocked refrigerator in the first floor medication room. A medication label on a vial of [MEDICATION NAME]for R59 did not reflect the current dosage ordered by the provider. This is evidenced by: The (Facility Name) Policy and Procedure Manual, Nursing, Medication Storage and Labeling, Policy: Medications for resident use will be stored to maintain the integrity of the medications, with a revised date of 7/19, states, in part: .3. Controlled substances must be separately locked and secured in the narcotics box on each medication cart or the locked drawer in the med room. a. These must be double locked at all times. b. Examples of double locking include locking the narcotics box and either the medication cart or the medication room .5. Medications requiring refrigeration must be kept in the refrigerator in the locked medication room .7. Medications will be accessible only to the registered nurse or designee. 8. Prescription medications must be labeled with the following information a. The expiration date of the medication .g. The full name of the resident. h. The name and strength of the prescribed drug dispensed . On 10/30/19 at 2:14 PM, Surveyor requested a Medication Administration Policy. DON B (Director of Nursing) stated the facility does not have a Medication Administration Policy. They utilize their Medication Pass Observation form. DON B stated this form shows the expectations of the nurse during med pass. The form is labeled (Facility Name) Policy and Procedure Manual Medication Pass Audit Nursing, and is not dated. The Observation Checklist states, in part, .Does the nurse complete the 5 rights and 3 checks? . Example 1 On 10/28/19 at 12:50 PM, Surveyor and RN [NAME] (Registered Nurse) conducted an observation of the first floor medication room. Surveyor observed 2 multi-dose bottles of liquid [MEDICATION NAME] concentrate in an unlocked refrigerator. The refrigerator observed was inside the medication room. Surveyor asked RN [NAME] if she was aware of what the facility policy is on locking of liquid [MEDICATION NAME]. RN [NAME] stated, No, we don't double lock the liquid. On 10/30/19 at 2:14 PM, Surveyor interviewed DON B. Surveyor asked DON B what the process is for storage of Scheduled medications. DON B stated they are either stored in the locked drawer in the medication carts or, if they are Scheduled II meds that have to be refrigerated, they are in the box in the refrigerator. Surveyor asked DON B if the multi-dose bottles of liquid [MEDICATION NAME] should be double locked. DON B stated it is not required to be double locked. Surveyor asked DON B why it did not require double locking. DON B stated she had spoken with their pharmacy and was told it didn't require a double lock. Surveyor asked DON B if she had documentation of this conversation. DON B stated, no, it was at least 2 years ago. Example 2 On 10/29/19 at 4:03 PM, Surveyor observed RN F (Registered Nurse) during medication pass. RN F prepped 8 units of [MEDICATION NAME] Insulin for R59. Prior to RN F administering the insulin, Surveyor showed RN F the label on the [MEDICATION NAME] vial that stated to inject 4 units SQ (subcutaneously) three times a day. RN F stated that the new order is for 8 units; however, they do not have a new label. Review of the routine monthly printed orders, signed on 9/29/19 and 8/27/19, show the [MEDICATION NAME] order as 8 units. Surveyor asked RN F what the process is when she has a label on the medication that does not match the MAR. RN F stated, I'm not sure exactly. It may be in this case that pharmacy did not get the new order to make a new label. Surveyor asked RN F what she does if she notices a discrepancy. RN F stated she would ensure the expiration date, that the medication is correct and use the dose on the MAR (Medication Administration Record), as that is the most up to date. DATE TIME Surveyor asked DON B what her expectation of the nurses is when the label on the medication does not match the MAR. DON B stated if the label doesn't match the MAR, they would need to follow the MAR for dosing. Surveyor asked DON B, is it correct then that you would not expect the nurse to check the order, they can just use the MAR? DON B stated, Correct, our pharmacy doesn't re-label medications. Surveyor asked DON B how the new dosage get put on the label when a change is made. DON B did not respond. Surveyor asked if the label would be updated when the medication comes for the next month. DON B stated, That would make sense. Surveyor asked DON B if that's the process. DON B indicated she couldn't say that definitively, but that would make sense. DON B could contact the pharmacy. Surveyor asked DON B, in relation to the Medication Pass Observation form, where it states, Does the nurse complete the 5 rights and 3 checks?, what would need to be completed for the nurse to be checked off as competent. DON B stated looking to make sure the nurse was verifying the name, dose. Surveyor asked where the nurse would verify the dose. DON B stated on the MAR. DON B stated she would look for them to verify the right patient, correct time, and the 3 checks. Surveyor asked what the 3 checks are. DON B stated check the name of the medication, strength of the medication, check the MAR for the order and dose and give them to the patient and verify that all the meds were given. Surveyor informed DON B of the observation during med pass of the [MEDICATION NAME] label not matching the MAR and that the order for 8 units had been in place since at least back to August. Surveyor asked DON B if she felt it was acceptable to have a label with the incorrect dosage for that length of time. DON B stated, I think it is most important that the nurse gave the correct dosage. Surveyor asked DON B how a new order gets sent to the pharmacy so they know there is a dosage change. DON B stated once a new order is taken, that order gets faxed that day to the pharmacy. Surveyor asked if there is a double check that the pharmacy received the order. DON B stated the pharmacy sends our fax back to us showing a check mark that they received it, but we don't keep those. Surveyor asked DON B, overall, how do you check that the labels are correct? DON B stated when we check in medications, I guess the ones that really get checked are the narcotics for the labels. Surveyor asked DON B, at this time, are you saying you don't have a process for checking that the dosage change is on the new medication label when it comes. DON B stated, I feel like we have a good process in place during our end of month review. Surveyor asked DON B what that review includes. DON B stated it includes checking the actual medication container/blister pack, the orders and MAR, This one must have gotten missed.

Based on observation, interview, and record review, the facility did not ensure to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 20 hand hygiene observations (R40, R30, and R10). R40 was observed during personal care and wound care and staff did not perform hand hygiene according to facility policy and professional standard of practice. R30 was observed during wound care and staff did not perform hand hygiene according to facility policy and professional standard of practice. Surveyor observed CNA H (Certified Nursing Assistant) use gloved hands to wipe R10's nose and then assist R10 with her meal without a glove change or handwashing. This was observed several times throughout meal. CNA H used the same napkin to wipe R10's nose and her face/mouth throughout meal service. This is evidenced by: The facility policy titled Hand Hygiene, last reviewed 6/19, states, in part: Staff are required to perform hand hygiene after each direct resident contact, and whenever hands are contaminated with potentially contaminated materials for which hand hygiene is indicated by accepted professional practice. Alcohol based hand sanitizer is the preferred method of hand hygiene over soap and water in most cases. The purpose states it is to, in part . prevent the spread of infection . Hand hygiene continues to be the primary means of preventing the transmission of infection. The policy indicates staff are to Utilize the 5 moments for Hand Hygiene, which include before touching the patient, before a clean or aseptic procedure, after touching a patient, after body fluid exposure risk, and after touching patient surroundings. In addition, the policy contains a list of situations which require hand hygiene, including, in part: . - Before and after any resident contact - Before and after assisting a resident with meals - Before and after assisting a resident with personal cares - Before and after changing a dressing - When coming in contact with and after contact with a resident's intact skin - Before and after assisting a resident with toileting - After blowing or wiping nose - After contact with a resident's mucous membranes and body fluids or excretions - Before and after wearing gloves. When toileting a resident, wash or sanitize hands as soon as the resident has been place (sic) on a secure surface. - This is not a complete list. Example 1 On 10/30/19 at 10:39 AM, Surveyor observed dressing change on R40 performed by LPN C (Licensed Practical Nurse). R40 was on commode in room. LPN C entered with dressings and put on gloves. Surveyor did not observe hand hygiene at this time. CNA D assisted R40 to standing position with mechanical lift and LPN C wiped R40's peri area. LPN C then removed her gloves and asked CNA D for a new pair. LPN C did not wash her hands with soap and water or use an alcohol based hand sanitizer. LPN C put on gloves and proceeded with dressing change to resident's coccyx for a Stage 2 pressure injury that was present on admission. LPN C removed the current dressing, used wound cleaner to spray wound and patted it dry, still wearing same gloves. Without changing gloves or performing hand hygiene, LPN C then opened new dressing and placed over R40's coccyx wound. R40 also had preventative dressing over left buttock, which LPN C pealed back partially for skin observation without glove change and hand hygiene. On 10/31/19 at 10:04 AM, Surveyor spoke to LPN C to inquire if she had been observed or audit checked performing hand hygiene. LPN C indicated she thought she had been observed, but could not recall when. Discussed recent hand hygiene education and learning opportunities with LPN C, who states the facility sends out frequent memos and notifications through the electronic charting system or emails. She also recalled a mandatory in-service in (MONTH) that included hand hygiene, as well as a display set up earlier in the month of (MONTH) for Infection Control Week with statistics about bacteria and handwashing information. On 10/31/19 at 1:20 PM, Surveyor spoke with DON B (Director of Nursing) regarding hand hygiene with dressing changes. DON B stated, Yes, she would expect a nurse doing a dressing change to wash hands or perform hand hygiene in between glove changes. Example 2 On 10/29/19 at 10:07, Surveyor observed LPN C provide cares to R30. (It is important to note that R30 was in contact isolation for a [MEDICAL CONDITIONS] infection.) Surveyor observed LPN C properly don appropriate PPE (personal protective equipment) prior to entering resident's room. Surveyor observed LPN C turn R30 for observation of coccyx area to check for any current pressure injuries. At that time, R30 was noted to have stool present. Surveyor observed LPN C clean up stool, check skin and apply barrier cream. LPN C then removed her gloves, applied an alcohol based hand rub and applied new gloves. LPN C then proceeded to perform a dressing change to a surgical wound on the resident's foot. LPN C removed the old dressing and then began cleansing the wound with a spray wound cleanser and fresh gauze. There was no glove change between removal of the old dressing and cleansing of the wound. After cleansing the wound, LPN C removed her gloves and donned new gloves and applied the new dressing. No hand hygiene was observed between this glove change. After cares were completed, Surveyor asked LPN C if she completed hand hygiene after she finished cleaning up the stool and prior to performing the surgical wound care on his foot. LPN C stated she changed her gloves. Surveyor asked, Did you perform hand hygiene? LPN C stated she did use hand sanitizer. Surveyor asked LPN C if hand sanitizer is an acceptable hand hygiene agent when assisting a resident with [MEDICAL CONDITION] infection. LPN C stated, No. Surveyor asked LPN C if hand hygiene should be performed between glove changes. LPN C stated, Yes. Surveyor asked LPN C if she should have changed her gloves and performed hand hygiene after removing the old dressing and before beginning to cleanse the wound. LPN C stated, Yes. Surveyor asked LPN C, prior to putting on the clean dressing, you changed your gloves; did you perform hand hygiene? LPN C stated, No. Surveyor asked LPN C if she should have and she stated, Yes. Example 3 On 10/28/19 at 11:20 AM, during dining observation, Surveyor observed CNA H wipe off R10's nose that was running and her oxygen tubing with R10's napkin. CNA H continued to assist R10 with her meal, wiping R10's face with same napkin when food fell from R10's mouth. CNA H again assisted R10 with her runny nose, using the same napkin she used on R10's nose and mouth. CNA H did not exchange gloves or wash her hands throughout the meal service. On 10/31/19 at 8:11 AM, during an interview, DON B (Director of Nursing) indicated it is not facility policy to wear gloves while assisting residents with meal service. DON B indicated CNA H should have washed her hands after assisting R10 with her nose. DON B also indicated CNA H should have changed her gloves after assisting R10 with her runny nose, oxygen tubing, or any other personal needs before continuing to assist R10 with her meal. On 10/31/19 at 1:47 PM, during an interview, CNA H indicated she just put gloves on in case she would need to touch any food and she had gotten them out of her pocket, where she keeps gloves. CNA H indicated she is supposed to wash her hands when she removes her gloves. CNA H indicated she should remove her gloves after assisting with personal needs, such as blowing a resident's nose. CNA H indicated she did not remove her gloves or wash her hands while assisting R10 with her meal and she should have. When asked if wearing gloves to assist a resident with meal is providing a homelike environment for resident, CNA H indicated it is not.

Based on observation, interview, and record review, the facility did not ensure that residents who entered the facility without a pressure injury (PI) does not develop a PI, and a resident who has a PI receives the necessary treatment and services to promote healing, prevent infection, and prevent new PIs from developing, for 2 (R81 and R79) of 7 out of 31 sampled residents. R81 was admitted to the facility without a PI and was identified to be at risk for PI development. R81 developed several stage 2 PIs while in the facility. The facility did not notify physician when PI worsened or for a change in treatment to promote healing. R81 was observed to be on a low air loss mattress with the pump powered off and to have several layers between her and her pressure reduction mattress and pressure reduction chair cushion. R79 was admitted to the facility without a PI and was identified to be at risk for PI development. R79 developed an in-house stage 2 PI and was observed without care planned interventions in place. Evidenced by: Facility Policy entitled Wound Care Standing Orders, revised 6/17, includes, in part: . These are facility standing orders; Physicians may order alternative treatments as appropriate. Medical Doctor (MD) must be notified for all new wounds, significant changes, and non-healing wounds . Update MD per AMDA (The Society for Post-Acute and Long-Term Care Medicine) guidelines related to skin problem and current treatment and progress . Facility Policy entitled Skin Protocol, revised 4/14, includes, in part: Skin inspection: open areas will be reported to the nurse . appropriate intervention and treatment will be instituted immediately upon identification based on the Wound Care Standing Orders . The Wound Care Certified Nurse will assess the wound and evaluate the appropriateness of current treatment plan . Pressure redistribution mattresses will be utilized as directed by Wound Care Certified Nurse or Assistant Director of Nursing . Relieve heel pressure by keeping heels totally off of bed . Nurses: .pressure areas .observe for symptoms of infection: . purulent drainage . report symptoms . Example 1: R81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R81's Braden (skin assessment), dated 6/8/18, scored 12, indicating high risk of skin breakdown. R81's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/14/18, Brief Interview for Mental Status (BIMS) scored a 03, indicating R81 is severely cognitively impaired. Section G110 - A. Bed mobility: Indicates R79 requires extensive physical assistance with one staff for bed mobility. B. Transfer: Indicates R81 is totally dependent on physical assistance by two or more staff for transfers. Section M0150 indicates R81 is at risk for PI. Section M0210 indicates R81 does not have an unhealed PI. R81's Care Area Assessment (CAA), associated with R44's MDS, dated [DATE], includes, in part: Triggers: R81 requires extensive assistance. R81 is at risk of PI development. R81's Baseline Care Plan, dated 6/8/18, includes, in part: I have fragile skin, have surgical wound, and bruise easily, because I have poor tissue perfusion, have trouble feeling certain sensations, had surgery, lose control of my bladder and/or bowels, and can't move around well on my own. I show this by: Having a surgical incision and bruises. I need my nurses to . Place an air mattress on my bed with a pump. My goal is have my skin heal and avoid infection. Goal date: 9/30/18. *It is important to note that R81 is care planned to have air mattress with a pump. R81's Comprehensive Care Plan, dated 8/6/18, includes, in part: I have fragile skin, have surgical wound, and bruise easily because: I have poor tissue perfusion, have trouble feeling certain sensations, had surgery, lose control of my bladder and/or bowels, and can't move around well on my own. I show this by: Bruises, PI to buttock stage 2 . I need my nurses to . place an air mattress on my bed with a pump. My goal is have my skin heal and avoid infection. Goal date: 11/30/18. *It is important to note R81 is care planned to have an air mattress on bed with a pump. R81's Kardex (medical information system), entitled Guidelines for Daily Care, dated 1/1/2018 - 8/30/2018, includes, in part: .Skin Care: - Utilize a pressure redistribution cushion on any surface that I sit on . - Provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface . - Place air mattress on my bed with a pump . *It is important to note R81 is care planned to have an air mattress with a pump. R81's Nurse Notes (NN) include, in part: . -6/9/18 10:42 AM: Admission body check completed . bottom is clean, dry, and intact, blanchable redness noted on coccyx . Skin treatments: Receives turning and repositioning program, ointment/medications (other than feet). -7/7/18 10:48 PM: Skin: Resident has a new PI on right upper gluteal. Area is 1.3 x 1.3 cm (centimeter). It appears pink and moist. Area was cleansed and Allevyn patch applied. Staff was educated to reposition resident every 2 hours. Will continue to monitor . -7/9/18 11:20 AM: Physician Visit: Nurse Practitioner (NP) here and saw resident today for special visit. She was updated on . bladder scans . labs . cast issues .pharmacy recommendations (on pain management) . *It is important to note this note does not include information related to PI. -7/10/18 6:00 PM: Physician/NP Contact: . ortho consult but will need a right hip and wrist x-ray . *It is important to note this note does not include information related to PI. -7/11/18 10:02 PM: Skin Assessment: This nurse has tried to do skin assessment on her bottom on both Monday (7/9) and Tuesday (7/10). She declined both PM shifts. She yelled, Get out and leave me alone. -7/11/18 10:10 PM: General Skin Condition: Skin issues noted, open area right gluteal irregularly round with redness surrounding and white spot in center. Cleansed and [MEDICATION NAME] 3 x 3 applied. Will notify NP as indicated, continue to monitor. Position changes hourly . -7/12/18 1:56 PM: Weekly Skin Assessment/General Skin Condition: Skin issues noted, 2 x 2 round pressure area just right of her gluteal fold. Wound bed is yellow surrounded by healthy pink tissue . Area cleansed and Allevyn patch applied to area. Call out to NP about appropriate treatment . -7/12/18 7:14 PM: Pressure Injury: Has partial thickness loss of skin layers that presents as an abrasion or blister /PI stage 2 . Coccyx . Tissue type: partial thickness skin loss very superficial in nature . Wound tissue: whitish-yellow pink . Initial stage: Stage 2 .Wound shape: round/oval .no tunneling . no undermining .Exudate type: serosanguinous, pink, thin, scant, no odor . 1.0 x 1.0 x less than 0.1 . Interventions: Support surfaces for bed: mattress: low air loss; Support surfaces for wheelchair: Cushion: fluid filled or gel cushions, combination cushions; Other support surfaces: heel lifts or heel suspension device, positioning pillows/wedges, turning and proper positioning; Turning schedule . Physician notified and gave orders for Allevyn foam patches to heal and protect this area. Can change every five days or as needed . R81's Physician Orders, dated 7/12/18, include, in part: Treatment: Skin: cleanse right buttock open area, then apply Allevyn dressing daily . first date: 7/12/18 *It is important to note that facility provided no evidence that R81'S MD was notified about new PI or an order was received until 7/12/18, 5 days after PI was discovered. R81's Wound Follow-Up Assessments include, in part: -7/16/18 Has partial thickness loss of skin layers that presents as an abrasion or blister /PI stage 2 . Coccyx . Tissue type: partial thickness skin loss very superficial in nature . Wound tissue: granulation pink, bright, beefy red; 75 -100% of wound filled and/or tissue overgrowth .[MEDICATION NAME]: no [MEDICATION NAME] present .Wound shape: round/oval . Wound edges: distinct, outline clearly visible, attached, even with wound base . no tunneling . no undermining .Exudate type: serous, clear, thin, scant, no odor . 1.0 x 1.0 x less than 0.1 . Interventions: Support surfaces for bed: mattress: low air loss; Support surfaces for wheelchair: cushion: fluid filled or gel cushions, combination cushions; Other support surfaces: Heel lifts or heel suspension device, positioning pillows/wedges, turning and proper positioning; Turning schedule . -7/23/18 One larger open area and some has filled in and left three smaller open areas. Two of them are pink and have granulation tissue noted. One small area is yellow in the center . [MEDICATION NAME]: Noted around the open areas as last week that area was open as well . Necrotic tissue: loosely adherent yellow slough in one area . Wound shape: round/oval . Wound edges: distinct, outline clearly visible, attached, even with wound base in two pink wounds and can't see it in the yellow centered area . no tunneling . no undermining .Exudate type: serous, clear, thin, scant, no odor Healing progress: Improving in some ways and the yellow area may be worsening .0.5 x 0.2 x 0.1 the yellow area is . 1.0 x 0.4 *It is important to note that this note indicates this wound may be worsening and facility did not provide evidence that R81's MD was notified of this change. -7/30/18 PI: Has partial thickness loss of skin layers that presents as an abrasion or blister/pressure stage 2 . -Area 1: Coccyx . initial stage 2 now advanced . Tissue type: slough . Wound tissue: yellow . Necrotic tissue: loosely adherent yellow slough, 75 - 100% wound covered . Wound shape: round/oval . Wound edges: well defined, not attached to base . Exudate type: foul purulent, color yellow, odor moderate foul, consistency watery, amount small/minimal - wound tissues are very moist or wet; drainage covers less than 25% of the dressing moist . Healing progress: worsened stage 2 PI . Measurement: 3 x 2 inside this area are two smaller yellow areas that are moist. With a rim of redness around to be included in this measurement. Area 2: Coccyx . initial stage 2 . Tissue type: slough . wound tissue: yellow . Necrotic tissue: loosely adherent yellow slough, 75 - 100% wound covered . Wound shape: round/oval . Wound edges: well defined, not attached to base . Exudate type: foul purulent, color yellow, odor moderate, consistency watery, amount small/minimal - wound tissues are very moist or wet; drainage covers less than 25% of the dressing moist . Healing progress: worsened stage 2 PI .measurement: 1.0 x 0.8 -Area 3: Coccyx . initial stage 2 . Tissue type: slough . wound tissue: yellow . Necrotic tissue: loosely adherent yellow slough, 75 - 100% wound covered . Wound shape: round/oval . Wound edges: well defined, not attached to base . Exudate type: foul purulent, color yellow, odor moderate, consistency watery, amount small/minimal - wound tissues are very moist or wet; drainage covers less than 25% of the dressing moist . Healing progress: worsened stage 2 PI .measurement: 0.5 x 0.5 . Will ask that Geriatric Nurse Practitioner (GNP) to look at this again on her next rounds . Sent an email to GNP and she said OK with repositioning and trying to keep her off this area and she will see her if needed -8/6/18 PI: Has partial thickness loss of skin layers that presents as an abrasion or blister/pressure stage 2 initially .Coccyx .initial stage 2 now advanced . Tissue type: slough necrotic/eschar . Wound tissue: yellow/black . Necrotic tissue: loosely adherent yellow slough, adherent, soft, black eschar . 75 - 100% wound covered . Wound shape: round/oval like two circles joined together . Wound edges: well defined, not attached to base . Surrounding wound tissue: dark red or purple and/or non-blanchable . Exudate type: foul purulent, color brown, odor foul, consistency thick, amount moderate - wound tissues are wet; drainage involves more than 25% - 75% of the dressing saturated . Healing progress: worsened stage 2 PI . measurement: 3 x 3. *It is important to note that facility provided no evidence that R81's MD was notified of the worsening PI. It is also important to note that the dressing/treatment order is the same as the first day it was reported to MD on 7/12/18 despite the PI continuing to worsen. -8/13/18 PI: Has full thickness of skin lost, exposing the subcutaneous tissues, presents as a deep crater (pressure stage 3) . Coccyx . initial stage 2 worsened now to a stage 3 with yellow slough noted .Tissue type: slough . Wound tissue: yellow . Granulation tissue: pink around wound edges . Necrotic tissue: yellow adhered slough . 75 - 100% wound covered . Wound shape: round/oval . Wound edges: well defined, not attached to base . Surrounding wound tissue: dark red or purple and/or non-blanchable . Exudate type: foul purulent, color yellow, tan, odor foul, consistency watery, amount moderate - wound tissues are wet; drainage involves more than 25% - 75% of the dressing moist . Healing progress: worsened stage 2 PI now stage 3 due to slough and not being able to see wound bed . measurement: 3.5 x 2.2 . dark area around open wound measure 9 x 6 . Hospice doesn't do much for healing care just comfort care. She may not heal this wound with all against her but we can still try . R81's NN, 8/14/18, includes, in part: Physician/NP contact: Nurse with Hospice here to see resident today . Order to insert catheter . for comfort and promote wound healing . *It is important to note that facility provided no evidence of MD notification of wound status or to discuss other treatment options. R81's Wound Follow-Up Assessments include, in part (continued): -8/19/18 PI: Has full thickness of skin lost, exposing the subcutaneous tissues, presents as a deep crater (pressure stage 3) . Coccyx . Tissue type: slough . Wound tissue: yellow pink . Granulation tissue: pink, and/or dull, dusky red and/or fills less than or equal to 25 % of wound . Necrotic tissue: loosely adherent yellow slough . 75 - 100% wound covered, about 20 % pink tissue . Wound shape: round/oval . Wound edges: well defined, not attached to base . Surrounding wound tissue: pink, normal . Exudate type: [MEDICATION NAME] . color yellow, odor none, consistency watery, amount moderate - wound tissues are wet; drainage involves more than 25% - 75% of the dressing moist . Healing progress: improving . measurement: 3.0 x 3.0 . * Please note that this measurement showed improvement in length, but worsened in width by 0.8. Facility provided no evidence of MD notification of worsening PI and treatment remains the same as initially reported to MD on 7/12/18. -8/27/18 PI: Has full thickness of skin lost, exposing the subcutaneous tissues, presents as a deep crater (pressure stage 3) . Coccyx . Tissue Type: granulation slough . Wound tissue: yellow pink . Granulation tissue: pink, and/or dull, dusky red and/or fills less than or equal to 25 % of wound . Necrotic tissue: loosely adherent yellow slough . greater than 50 and less than 75% wound covered . Wound shape: round/oval . Surrounding wound tissue: bright red and blanches to touch . Exudate type: [MEDICATION NAME] . color yellow, odor none, consistency thin, amount moderate - wound tissues are wet; drainage involves more than 25% - 75% of the dressing moist . Healing progress: improving . measurement: 3.4 x 2.0 . *It is important to note that the length has worsened from the previous measurements by 0.4. The facility provided no evidence of consultation with R81's MD on worsening PI. The treatment remains the same as initially reported to MD on 7/12/18. R81's Hospice Notes (HN) include, in part: - 7/26/18 .Hospice RN (Registered Nurse): Hospice Admission today . *This note does not address R81's PI. -7/31/18 . Hospice RN: Wound added pre-existing . discussed with Wound Nurse (RN H) *It is important to note that two wound follow-up assessments (7/23/18 and 7/30/18) indicate wound is worsening and no evidence was provided by facility or Hospice of R81's MD being notified. -8/14/18 . Hospice RN: Dressing to Coccyx (not legible) patient refused to let writer look at wound . Facility staff requesting catheter for comfort and wound healing . *It is important to note the goal of wound healing mentioned in this note. Also important to note, R81's Wound Follow-Up Assessment, dated 8/13/18, describes Pressure Injury: has full thickness of skin lost, exposing the subcutaneous tissues, presents as a deep crater (pressure stage 3) and not as a stage 2 indicating the PI was worsening. No evidence of MD notification provided by facility or Hospice of worsening PI. -8/21/18 . Hospice RN: . got hand off report from RN H . dressing dry and intact to right buttock and report healing slowly . *It is important to note R81's Wound Follow-Up Assessment, 8/19/18, wound measurement worsened in width by 0.8. -8/28/18 Hospice RN: . talked with staff about wound to coccyx . * It is important to note no further details were provided. On 8/27/18 at 3:55 PM, Surveyors observed R81 lying in bed and her low air loss mattress pump was powered off. The setting was set between 7 and 8. Surveyor felt the air mattress with her hand and it was flat. On 8/27/18 at 4:10 - 4:15 PM, during an interview, CNA E (Certified Nursing Assistant) indicated that R81's bed should be on and was not sure why it was off. CNA E indicated that she had not assisted R81 this afternoon, but her partner, CNA F, did. CNA F indicated that she assisted R81to bed just before report and R81 was really sweet at that time. CNA F indicated report was at 2:30 PM. CNA F also indicated that she didn't know air mattress was off. Surveyors observed CNA E slide the button over to power on the low air loss mattress. Surveyor felt mattress with her hand and could feel the mattress inflating/air moving about. On 8/28/18 at 8:17 AM, during an interview, CNA F indicated that the low air loss pump on R81's bed was changed out since it was found off the previous day and she was unsure why. Surveyor observed R81's low air loss mattress pump to be a different model with a blue light that indicated power on. On 8/28/18 at 2:20 PM, Surveyors observed R81 sitting in her wheelchair, in her room. R81 was sitting on a bath towel, warming blanket, or mattress pad folded in half and in half again in four layers and under the layers was a pressure reducing cushion. *It is important to note the layers between R81 and her pressure reducing cushion. On 8/29/18 at 9:10 AM, DON B (Director of Nursing) indicated that R81's low air loss pump should be powered on and she would have liked to know if the equipment failed or wasn't working or if R81 refused to allow staff to turn her low air loss pump to on. DON B indicated that she was unsure why R81's low air loss pump had been replaced and RN H is the one who assesses residents and decides what mattress they should have, if mattress should have a pump, and at what setting it should be set at. On 8/30/18 at 7:40 AM, Surveyor observed R81's wound during dressing change. Wound was oval in shape, covered 75-80% in slough, periwound edges dark pink in color. R81's low air loss mattress pump was powered on and setting was at 7. Surveyor observed R81 to have 5 layers between her and her low air loss mattress that consisted of a bottom sheet, a positioning sheet folded in half, and two disposable stacked chucks. According to the NPUAP (National Pressure Ulcer Advisory Panel), dated 6/13/12, includes, in part: Recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. On 8/30/18 at 8:31 AM, during a phone interview, PS G (Product Specialist) indicated that if the wound was assessed to need the pump and care planned as such, the staff would want to engage the pump/should have the pump powered on. PS G stated, The mattress will do what it says it will do, but if staff are not turning resident, putting multiple layers between resident and surface, or not following care plan, it can be a problem. On 8/30/18 at 3:39 PM, during an interview, DON B indicated that staff did not ask for a change in treatment or update MD about R81's changing wound, because her goal was not to heal wound, but to be comfortable. RN H indicated that a sore bottom isn't comfortable but Hospice refuses to pay for different treatments to get rid of slough, such as [MEDICATION NAME] or Santyl. Surveyor asked if Hospice won't pay for it, what does the facility do to make sure R81 gets what she needs. DON B stated, We do. We didn't, because her (R81) goal is to be comfortable not heal. DON B indicated that R81's care plan should reflect this goal. *It is important to note R81's current care planned skin goal is have my skin heal and be avoid infection. Example 2 is not at the level of actual harm: Example 2: The Quick Reference Guide entitled Pressure Ulcer Prevention, published by the NPUAP in 2009, indicated to prevent PU's (Pressure Ulcers) in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. According to the NPUAP, dated 6/13/12, which includes, in part: Recommends use of positioning devices and incontinence pads that are compatible with the support surface and to limit the amount of linen and pads placed on the bed. They also direct clinicians not to leave moving and handling equipment under the individual after use. R79 was admitted , on 8/2/18, with [DIAGNOSES REDACTED]. R79's Admission MDS, with an ARD of 8/9/18, BIMS scored an 11, indicating R79's cognition to be moderately impaired. Section G110 - A. Bed mobility: Indicates R79 requires extensive physical assistance by two or more staff for bed mobility. B. Transfer: Indicates R79 is totally dependent on physical assistance by two or more staff for transfers. Section M0150 indicates R79 is at risk for PI. Section M0210 indicates R79 does not have an unhealed PI. R79's Baseline Care Plan, initiated 8/2/18, includes, in part: I can't complete my cares on my own because I had a stroke and have left sided weakness .I reposition in bed with help of 1 person bearing my weight. I use a trapeze . goal: Improve my ability to participate in activities of daily living (ADLs) . goal date 11/30/18. I have potential for skin injury because . I need my nurses to reduce pressure and friction between myself and my bed or chair, elevate my heels when I'm lying in bed . provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface .Goal: Keep my skin healthy and intact . Goal date: 11/30/18 . R79's Braden - Admission Skin Assessment, dated 8/2/18, scored 15, indicating R79 was at mid-risk for skin breakdown. R79's NN, dated 8/17/18, includes, in part: Resident noted this shift to have superficial area on his buttocks . R79's Wound Initial Assessment, dated 8/19/18, includes, in part: PI: Has partial thickness loss of skin layers that presents as an abrasion or blister pressure stage 2 .onset/discovery date: 8/17/18 . Initial stage: Stage 2 . Tissue type: granulation . Wound tissue: pink . Granulation tissue: partial thickness wound . Wound shape: square/rectangle . Exudate type: serous . Exudate color: clear, no odor, Consistency: thin . measurement: 0.5 x 0.5 x less than 0.1 . Interventions: . heel lifts or heel suspension device . R79's Comprehensive Care Plan, dated 8/30/18, includes, in part: I can't complete my cares on my own because I had a stroke and have left sided weakness .I reposition in bed with help of 1 person bearing my weight. I use a trapeze .goal: improve my ability to participate in ADLs . Goal date 11/30/18 . I have potential for skin injury because . I show this by stage 2 PI to buttock,, I need my nurses to reduce pressure and friction between myself and my bed or chair, elevate my heels when I'm lying in bed . provide me with my heel lift cushion in my bed/recliner/chair when my heels may potentially come in contact with any surface . Goal: keep my skin healthy and intact . Goal date: 11/30/18 . On 8/27/18 at 11:23 AM, Surveyor observed a positioning trapeze above R79's bed. The trapeze was up, over the bar, out of R79's reach. When asked if R79 could reach the trapeze, R79 attempted and could touch it with the tip of one finger. R79 demonstrated that he was unable to release the trapeze for his use. Surveyor also observed R79's heels to be directly on the mattress. There was a heel lift device in room, on the floor in R79's room. R79 was unable to verbalize what the device was used for when asked. R79's wife indicated that the device was used at times to elevate R79's heels. On 8/28/18 at 2:25 PM, during an interview, R79 indicated that he uses the trapeze to move himself and shift in bed, but sometimes the staff forget to put it down for him. On 8/28/18 at 4:47 PM, during an interview, RN I indicated that she just assisted R79 into his wheelchair and she was finished assisting R79. Surveyor observed R79 in a Broda chair, a split full body sling was underneath him, and a heels-up cushion was in corner of his room on floor. R79 indicated that he was not sure if he should have that device under his heels while in his Broda chair. R79's heels were supported with a pillow at this time. On 8/29/18 at 7:35 AM, Surveyor observed R79 lying in bed and his trapeze was positioned up over the bar, out of his reach. On 8/29/18 at 9:46 - 10:00 AM, Surveyor observed R79 in room in Broda chair with a split full body sling and soaker pad, with an hour glass incontinence pad, layered between resident and resident's pressure reducing cushion. Surveyor observed staff transfer R79 to his bed and RN J perform wound care. Surveyor observed all staff leave room and R79's heels remained flat on the mattress and his trapeze triangle was up over the bar, out of R79's reach. *It is important to note the layers between R79 and his pressure reducing cushion and his heels not being offloaded while in bed. On 8/30/18 at 2:03 PM, during an interview, CNA K indicated that R79 uses his trapeze over his bed for repositioning and staff usually put it over the bar when they sit him up or lay him down or transfer him so they don't bump his head on the trapeze. CNA K also indicated that the blue heel lift cushion should be used under R79's feet while he is in bed and in his chair. CNA K indicated that R79 has not refused blue heel lift cushion when she has assisted him.

Based on observations, interview and record review, the facility did not ensure that they provided the necessary care and services to provide effective pain management for 2 of 2 residents (Resident # 9 and #7) observed who complained of pain during personal cares and/or treatment observations and did not assess pain as being a causative factor for 1 resident (Resident #6) who was non-compliant with cares and treatment. As evidenced by: The facility's S.O.C. (Standard of Care) Systems Assessment: Pain, referred to in the resident's care plan, states: -Assess pain on admission, quarterly and prn (as needed). -Use mild, moderate, severe or very severe or face scale to assess. -Document location, duration and frequency. -Assess effectiveness of medication. -Observe for side effects of medication. -Handle gently when moving or repositioning. -Report complaints of pain or non-verbal indicators to the nurse. -Maintain body alignment. -Allow to verbalize feelings of anger, powerless and anxiety. -Keep call light in reach. -Notify MD prn (as needed) or changes in comfort status. -Provide nonpharmacologic interventions prior to [MEDICATION NAME] whenever possible. 1. Resident #9's [DIAGNOSES REDACTED]. Pain medication orders include: -07/29/13 [MEDICATION NAME] 300 mg three times daily for spinal stenosis -04/15/14 [MEDICATION NAME] Patch 12 mcg/hr for pain. Apply topically and change patch every 3 days. -07/29/13 Tylenol 650 mg every 6 hours as needed for mild pain. -03/18/14 [MEDICATION NAME] 5 mg every 6 hours as need for pain Resident #9's care plan contains a problem, dated 07/29/13, "Potential for Comfort Alteration: in pain Related To: spinal stenosis, hx (history) of tx (treatment) pressure ulcers Manifested By: Communication of pain description, Guarding, limping or protective behavior." The Approach is: 07/29/13 Nurse/Nurse Aide: S.O.C. Systems Assessment Pain. Resident #9's pain assessment, completed on 02/18/14, identified a significant change in comfort. The site of the pain was, "Bottom Open Area" and the duration of pain was constant and burning. Resident #9 was able to communicate her pain verbally. The pain limited her daily activities. Resident #9 expressed pain both verbally and by grimacing. Pain relief was obtained by medications, other techniques and repositioning. On 06/09/14, nurses' notes documented that Resident #9 had scheduled [MEDICATION NAME] for pain and required prn pain medications three times in the past two weeks. Resident #9 was monitored for both verbal and nonverbal indicators of pain. On 06/09/14, Resident #9's physician progress notes [REDACTED]. The note stated that Resident #9 had a pressure ulcer in her natal cleft, chronic back pain, sciatica, severe central spinal stenosis and [MEDICAL CONDITION] of her knees. On 07/08/14 at 6:42 a.m., Surveyor observed Wound Care Consultant, Registered Nurse (RN) K and Nurse Tech (NT) R perform the treatment to Resident #9's pressure ulcer. As Resident #9 was being positioned on her right side she was moaning and saying, "Oh, Oh." As NT R removed the packing from Resident #9's pressure ulcer, Resident #9 was observed moaning. NT R asked Resident #9 if she was having pain. Resident #9 replied, "Yes." NT R stated that when they were done with her treatment she would have to give Resident #9 a pain pill. As NT R was packing the pressure ulcer with the moist gauze strips, Resident #9 was saying, "Oh that hurts. It hurts me bad." As Resident #9 was repositioned she was observed to moan and say, "Oh." At 6:49 a.m., RN K and NT R exited the room. On 07/08/14 at 7:05 a.m., Certified Nursing Assistant (CNA) Q entered the room to perform Resident #9's morning cares. Resident #9 was resting quietly in her bed. During the care observation, Surveyor observed Resident #9 expressed the following: -While washing her own face and hands, "My hands hurt. No one knows how bad." -As her gown was removed, "Oh, be careful. Ow." -As CNA Q washed below her breasts, "Oh, it hurts. Oh-Oh." CNA Q told Resident #9 she would be as careful as she could. -As CNA Q raised Resident #9's arms, "Ouch. Everything hurts." -As CNA Q was drying Resident #9, Resident #9 stated, "Oh, that hurts. Why do I have to do this anyway?" CNA Q informed Resident #9 it was so she could get up for breakfast. -As CNA Q washed Resident #9's legs, separated her legs and washed under her abdominal fold Resident #9 was saying, "Oh, Oh." CNA Q informed Resident #9 that she knew Resident #9 hurt. -As CNA Q positioned Resident #9 onto her left side Resident #9 stated, "That hurts terrible. But it's OK I guess." -As CNA Q positioned Resident #9 onto her right side and held Resident #9 on her right side with her hand on her left buttocks Resident #9 stated, "Oh, dear. Oh no. Oh what have I done to deserve this." -As CNA Q lifted Resident #9's lower extremities and applied her stockings Resident #9 was whimpering and saying, "Ow, Ow. Why are you doing that? Oh dear, Oh dear. Why are your hurting me like that? Oh, Oh you are hurting me. Oh dear, I don't like that." CNA Q stated that Resident #9 was "so fragile." -As CNA Q was putting Resident #9's shirt on, Resident #9 was whimpering and said, "What have you done? It hurts." -CNA Q moved Resident #9 to the left side of the bed using the lift sheet and placed part of the Hoyer lift sheet under her. Resident #9 was saying, "Oh, Oh. Oh dear. Oh that hurts. Oh dear. Oh, Oh, Oh it hurts so bad." CNA Q stated that she was "thinking she was going to have to get assistance" as Resident #9 was "so fragile" that morning. -CNA Q left the room to get assistance. CNA Q returned to the room with Licensed Practical Nurse (LPN) S. As they were positioning Resident #9 side to side in bed to place the Hoyer lift sheet, she was saying, "Oh, Oh. Ow. Oh dear. Ow, Ow, OW. Why are you doing this to me? It hurts." LPN S informed Surveyor that "Sometimes you had to go slow with Resident #9 otherwise she gets upset." -As LPN S put on Resident #9's gripper socks, she was saying, "Oh, Oh, don't do that. It hurts me. It hurts me so." LPN S asked Resident #9 if she was having pain. Resident #9 stated she was. LPN asked Resident #9 if she wanted a pain pill right now. Resident #9 said, "No not right now." -As Resident #9 was transferred from her bed to the Broda chair with the Hoyer lift she was saying, "Ow, Oh, Oh, Oh." -As CNA Q tucked in the Hoyer lift straps and lifted Resident #9's arms and legs she was saying, "Oh, dear. Ow. Ow. What have I done to deserve this." LPN S stated Resident #9 does not receive pain medication prior to morning cares. LPN S verified that Resident #9 was expressing pain during the time she was assisting with cares. CNA Q stated, "She complains of pain all the time when we care for her, that is the reason we can't rush her. She is so fragile. It don't matter when we work with her she complains of pain. The nurses are very well informed of this. Resident #9 does not complain of pain when she is laying still in bed or seated in her Broda chair. Then she is good." CNA Q asked Resident #9 how she felt. Resident #9 replied, "Pretty good." When asked if she was having any pain Resident #9 stated, "A little bit but I'm not paying attention to it." After placing Resident #9 in the dining room, CNA Q spoke with NT R. On 07/08/14 at 1:00 p.m., Surveyor interviewed CNA Q who stated she had informed NT R of Resident #9's pain during cares that morning. CNA Q stated she tells the nurses each time Resident #9 complains or expresses indications of pain. On 07/08/14 at 1:10 p.m., Surveyor interviewed NT R related to Resident #9's pain. NT R stated she had not given Resident #9 any prn pain medications on this date. NT R stated Resident #9 does really well with 1:1 interactions and her complaints of pain are on and off. NT R stated Resident #9 is not administered pain medications prior to her treatment or cares. NT R stated that Resident #9 never requests any prn pain medications. NT R verified that Resident #9 expressed pain during the treatment. NT R stated that when she saw Resident #9 later, she was seated in her Broda chair and she did not say anything about having pain. On 07/08/14 at 3:20 p.m., Surveyor observed Resident #9 seated in her Broda chair in her room. Surveyor asked Resident #9 if she was having any pain. Resident #9 stated, "It hurts in my butt." When asked if anything relieves her pain she stated that, "If she sits sideways it's not so bad." On 07/09/14 at 1:35 p.m., Surveyor discussed the care and treatment observations from 07/08/14 with Assistant Director of Nurses (ADON) D who stated the treatment and cares should have been stopped when Resident #9 was expressing/exhibiting signs of pain. Resident #9 should have received a prn pain medication. ADON D stated that Resident #9 receives a scheduled [MEDICATION NAME] that is changed every three days. ADON D stated that she expected staff to monitor pain and use non-pharmological interventions prior to administering a prn pain medication. On 07/10/14 at 6:10 a.m., Surveyor interviewed LPN S who stated Resident #9 does give the impression that she is uncomfortable during the night. When Resident #9 is asked if she has pain she often does not answer but sometimes she will say, "No." LPN S stated she does not administer pain medications to Resident #9 because she does not request them. On 07/10/14 at 10:10 a.m., Surveyor interviewed RN U who stated Resident #9 does have some pain, more so when being repositioned and moving. Resident #9 does not complain of pain when she is still and doesn't need a lot of pain medication. On 07/14/14 at 10:17 a.m., Surveyor interviewed CNA V who stated Resident #9 does complain of pain. Resident #9 complains of a lot of pain in her right foot. CNA V stated once cares are started Resident #9 complains of pain. CNA V stated when Resident #9 is not receiving cares or being repositioned she does not complain of pain. CNA V stated she had just repositioned Resident #9 in her Broda chair by using the lift sheet under her to shift her body weight and she voiced pain during repositioning. 2. On 07/07/14, Surveyor reviewed Resident #7's medical record. The resident has [DIAGNOSES REDACTED]. Resident #7 has orders to receive scheduled Tylenol 325 milligrams (mg), two tablets, every day at 8:00 a.m. for mild pain. The resident also has an as needed (prn) order for Tylenol 500 mg, one tablet every four hours, for mild pain. These orders were obtained on 03/31/14, and 01/03/14, respectively. Resident #7's Minimum Data Set (MDS) assessments, dated 04/15/14 and 07/07/14, indicate the resident is dependent on staff for Activities of Daily Living (ADLs) including, bathing, dressing, toileting, and mobility. The resident's Brief Interview for Mental Status (BIMS) scores, dated 04/15/14 and 07/07/14, were both 07 out of 15 possible points. This score indicates Resident #7 has severe cognitive deficits. On 07/08/14 at 1:20 p.m., Surveyor observed RN G perform a dressing change to Resident #7's toe ulcer. The resident's daughter was also present during the entirety of the observation. RN G removed the resident's right slipper and right sock. When RN G touched the resident's fifth toe, Resident #7 began flinching her body and said, "Ow, ow!" The resident's hands, at the time, were located in her own lap. During the continued observation, RN G applied saline to a piece of gauze, and cleaned the skin between Resident #7's fourth and fifth toes. At this time, Resident #7 started flinching her body and said, "Ow, ow, ow!" RN G then applied a clean, dry piece of gauze between the resident's fourth and fifth toes. The resident continued to say, "Ow, ow!" Surveyor observed both of the resident's hands were holding onto each of the chair's armrests. During the continued observation, RN G then washed her hands, cut a small piece of [MEDICATION NAME], and attempted to place it between the resident's right fourth and fifth toes. Resident #7, again, started flinching and said, "Ow, ow" to which RN G replied, "I'm sorry (Resident #7's first name)." The resident continued flinching her body and said, "Ow, ow!" RN G then wrapped a piece of gauze around the entirety of the resident's fourth toe, to which Resident #7 responded, "It hurts...ow!" RN G stated, "I'm almost done," cut a small piece of tape, and taped the two ends of the gauze together. At this time, Resident #7 continued to say, "Ow, ow!" RN G then slowly put on the resident's right sock. At this time, Resident #7's body began flinching and said, "Ow, ow!" Surveyor observed both of the resident's hands holding onto each of the chair's armrests. The observation was completed at 1:40 p.m. Surveyor did not observe RN G attempt to stop the dressing change when Resident #7 continued to yell out in pain and flinch, nor did the nurse offer the resident any pain medication, prior to or during the dressing change. On 07/09/14 at 6:41 a.m., Surveyor interviewed RN B. RN B stated Resident #7's dressing change is generally completed about 10:30 a.m. to 11:00 a.m. each day. RN B further stated she has never pre-medicated Resident #7 prior to the dressing changes, or has offered the resident any as needed Tylenol during a treatment. On 7/09/14 at 10:30 a.m., Surveyor interviewed RN G. Surveyor asked if any of the residents in the facility are pre-medicated with pain medication prior to a dressing change. RN G stated some residents in the facility are pre-medicated, but not all residents. Surveyor then asked what RN G would do if a resident is experiencing pain during a dressing change. RN G replied the nurses will stop the dressing change and go back at a later time to finish the treatment, if the resident's pain is "extreme." RN G defined "extreme" pain as having a resident "jerking and crying out a lot." Surveyor asked RN G to describe Resident #7's pain. RN G replied the resident's level of pain is "okay" until the resident's toes are touched. Surveyor asked if RN G ever pre-medicates Resident #7 with as needed pain medication (i.e. Tylenol) prior to a dressing change. RN G stated sometimes she will pre-medicate the resident, but she hadn't given Resident #7 any pain medication prior to the dressing change on 07/08/14. During the continued interview, RN G stated the resident's dressing change is ordered for the "a.m." time, but there is no scheduled time in which the charge nurse changes the toe dressings. RN G stated the dressing change is sometimes completed about 10:30 a.m. to 11:30 a.m., but is usually done "whenever we (nurses) have a free moment." According to medical professionals, the effects of Tylenol generally last anywhere from three to six hours, depending on the individual taking the medication. If Resident #7 is receiving scheduled Tylenol at 8:00 a.m., there is the possibility the effects of the medication may be wearing off at the time of the resident's ulcer treatments. During the continued interview with RN G, Surveyor asked if Resident #7 was referred for a wound care consult, as ordered by the podiatrist on 06/23/14. RN G replied the facility made a wound clinic consult appointment for the resident, on 07/08/14. RN G stated she did not make a referral for the wound clinic prior to 07/08/14, since she thought the order meant the resident needed to be referred to the facility's wound care nurse. On 07/09/14 at 12:55 p.m., Surveyor interviewed Resident #7 regarding pain. Resident #7 stated she does not have any pain in her right foot unless "somebody touches it." Resident #7 was able to remember the pain she experienced when the nurses touched the resident's foot this morning. Surveyor reviewed Resident #7's nurses' notes and Medication Administration Record [REDACTED]. No other as needed Tylenol for pain was given to the resident from 06/26/14 to 07/09/14. On 07/09/14 at approximately 2:00 p.m., Surveyor interviewed the Director of Nursing (DON) as well as the ADON D. Surveyors , and were also present during the interview. Surveyor discussed Resident #7's dressing change observation from 07/08/14. The DON stated she was not aware Resident #7 was having pain during dressing changes, and further stated she would want RN G to pre-medicate the resident prior to the dressing change, if the resident was experiencing pain. During the continued interview, Surveyor asked when the facility conducts pain assessments for each resident. ADON D explained the resident's pain assessments are completed at the time of the MDS assessment, or when the resident has any changes in pain medications. The DON and ADON D stated Resident #7 was not re-assessed for pain upon the discovery of the toe ulcer. 3. Resident #6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #6 has received no scheduled pain medication since admission. Resident #6 developed a blister on the back of the left heel on 01/21/14, which had progressed to a Stage 3 pressure ulcer. Review of Resident #6's medical record identified that she had recurrent [MEDICAL CONDITION] and the pressure ulcer has required debridement. Resident #6's nurses and skin care notes identify she is non-compliant with personal cares and treatment to the Stage 3 pressure ulcer on her left heel, sundowns in the afternoon and evening, and is very hard of hearing. No assessments were found in Resident #6's medical record related to pain being assessed as a causative factor for her non-compliance with care and treatment. The Minimum Data Sets completed since admission do not identify she has pain. Resident #6's care plan contains a problem, dated 12/04/13, "Potential for Comfort Alteration: has discomfort Related To: DJD ([MEDICAL CONDITION] joint disease) Manifested By: Communication of pain description." The Approach is: 12/04/13 Nurse/Nurse Aide: S.O.C. Systems Assessment Pain. On 04/14/14, the physician progress notes [REDACTED].#6 was aware her heel is causing her some discomfort. It was not unusual for Resident #6 to refuse her treatment. "She is hard of hearing and I do think this plays a factor with some of her behaviors because she misinterprets what is being said to her." On 04/24/14, the skin care notes identified Resident #6 stayed in bed all am shift due to her heel bothering her. Resident #6 refused any prn [MEDICATION NAME] or treatments. On 06/06/14, the skin care notes identified Resident #6 complained of pain during the treatment, but this subsided afterwards. Resident #6 did not want any prn [MEDICATION NAME]. The skin care notes on 06/06/14, 06/07/14 and 06/08/14 identified the debrided area of the ulcer was tender. Resident #6 expressed some discomfort while cleansing the wound, which subsided immediately afterwards. On 06/08/14, the skin care notes identified that Resident #6 winced when cleaning the wound. This subsided immediately afterwards. On 07/08/14 at 10:15 a.m., Surveyor interviewed CNA Q about Resident #6's non-compliance with cares. CNA Q stated Resident #6 does not like to be moved and often resists cares and transfers. CNA Q stated Resident #6 wants to be left alone and when she is left alone Resident #6 does well. CNA Q stated Resident #6 can become quite combative with cares and will yell at staff. CNA Q stated Resident #6 was very hard of hearing making it difficult to communicate with Resident #6 even when she was wearing her hearing aids. On 07/08/14 at 3:10 p.m., Surveyor interviewed RN L who stated Resident #6 did not usually have pain. RN L stated she did not know if Resident #6 had been assessed for pain being a causative factor for refusing/resisting her care and treatments and non-compliance with the interventions attempted. RN L stated Resident #6 was not on any scheduled pain medications. RN L stated Resident #6 was much more agreeable to her treatments since starting on Zyprexia (05/12/14). RN L stated Resident #9 often refused to take her oral medications. She did not know if staff had discussed using a topical pain patch or a if a trial of scheduled pain medication had been utilized to see if Resident #9's non-compliance improved. On 07/09/14 at 1:43 p.m., Surveyor interviewed ADON D about Resident #6's non-compliance and documentation of pain in the skin care notes during treatments. ADON D stated she was not aware that Resident #6 had pain in her left heel. Resident #6 had not been on scheduled pain medications. ADON D stated she did not recall pain being assessed as a causative factor for the non-compliance with the dressing changes, cares and interventions. ADON D stated Resident #6 often refused her medications and did not recall a discussion related to the possibility of a topical pain patch being utilized. Surveyor requested to review any additional information related to pain assessments and any prn (as needed) [MEDICATION NAME] use from 03/01/14 to 07/09/14. On 07/10/14 at 7:15 a.m., a sheet of paper with "No prn use since March - staff reports does not c/o (complain of) pain with dressing change'' was provided. No additional information related to pain assessments was provided.

Based on observation, interviews, and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being to 1 of 2 residents who had a significant condition change. Resident #3 was sent to the emergency roiagnom on the afternoon of 05/02/12 due to increased weakness and was returned to the facility that same evening. Resident #3 experienced a fall without injury following his return and then throughout the night, day, and afternoon shifts on 05/03/12 experienced a further condition change with signs/symptoms including [MEDICAL CONDITION] twice requiring additional insulin, back pain without complete relief following the administration of pain medication, persistent fever, [MEDICAL CONDITION](elevated pulse), increased respirations with cough and diminished breath sounds (portable chest x-ray identified left atelectasis), weakness, difficult urination, "tremors" and complaints of not feeling well, inability for foley catheter to be placed following multiple attempts, and abdominal distention and tenderness. One complete set of vital signs including blood pressure and oxygen saturation were documented by facility staff from midnight on 05/03/12 to 10:00 p.m. that evening. Facility staff did not adequately evaluate, monitor and take appropriate action when Resident #3 demonstrated signs and symptoms suggestive of an infection. Facility staff did not follow the standard of care and did not appropriately measure vital signs to include temperature, heart rate, blood pressure and respiratory rate. Even though facility staff were unable to insert the Foley catheter past Resident #3's prostate and notified Physician C of this fact, facility staff accepted another order from Physician C to place a Foley catheter in Resident #3 which resulted in the inability to obtain a urinalysis. Facility staff did not immediately consult with the MD when staff identified that Resident #3 had a significant change in condition whereas his abdomen was hard and tender and his temperature remained elevated. Subsequently, an ambulance was summoned at approximately 9:42 p.m. on 05/03/12 and the resident was identified by ambulance personnel to have poor oxygen saturation in the 70's and decreased blood pressures in the 60's (systolic). The resident was transported to the emergency room and then to a larger hospital where he was closely monitored in the intensive care unit with a total 5 day hospitalization . Confirmed [DIAGNOSES REDACTED]. This is evidenced by the following: On various dates from 07/24/12 - 07/30/12, Surveyor reviewed Resident #3's medical record as well as the ambulance record, the hospital records and the facility policy and procedure related to reporting changes in vital signs to a practitioner. Resident #3 has lived at the facility for several years. Current [DIAGNOSES REDACTED]. The hospital report, dated 05/03/12, identified the resident had MEDICATION ORDERS FOR [REDACTED]. The Minimum Data Set (MDS) assessment, completed 04/12/12, identified that Resident #3 had moderate cognitive impairment. Resident #3's nurses' notes included the following vital signs and oxygen saturations on the afternoon of 05/02/12: temperatures (in degrees Fahrenheit) of 98.9 and 99.8, pulse rates of 100 and 109; respirations of 18 and 24; blood pressures of 107/54 and 110/72; and, an oxygen saturation of 92%. Resident #3's nurses' notes on 05/02/12 identified the resident was transported to the local emergency room sometime in the afternoon following 3 falls within a 30 minute period and returned sometime that evening. The emergency room report included the following vital signs all within normal limits: temperature 98.4 degrees Fahrenheit; pulse 98, respirations 16; blood pressure 129/75; and, an oxygen saturation of 98% on room air. It was also identified the resident's blood sugar was elevated at 428 but noted this might have been normal due to reports of the resident's medication refusal and a [DIAGNOSES REDACTED]. Following Resident #3's return to the facility on the evening of 05/02/12, the nurses' notes identified he fell again at 10:00 p.m. with the following vital signs and oxygen saturations recorded: an elevated temperature of 101.9 degrees Fahrenheit, pulse 90; respirations 18; blood pressure 149/89; an oxygen saturation of 90%; and, reports of significantly elevated blood sugars of 567 and 497, requiring an insulin order. It was stated the (on call) physician was aware of the elevated temperature but there was no documentation in the record that it was treated. Facility staff noted that Resident #3's temperature was 101.9 degrees F and noted that the on-call MD was aware of the elevated temperature however there was no indication as to what the physician's response was to the increased temperature and there was no indication that facility staff administered Tylenol and rechecked vital signs until 5/3/12 at 11:30 a.m. at which time Resident #3 was noted to have a "fever" and his temperature was recorded at 100.6. On 05/03/12, Resident #3's nurses' notes by a Licensed Practical Nurse (LPN) identified the resident's blood sugar was 375 at 12:45 a.m., that 6 units of regular insulin was administered per physician order, and that a recheck blood sugar at 6:00 a.m. was 268. There was no documentation that the elevated temperature was rechecked nor that any other vital signs were taken. On 05/03/12, the following was documented in Resident #3's nurses' notes by Registered Nurse (RN) C. -At 8:01 a.m., [MEDICATION NAME] ([MEDICATION NAME]) 50 milligrams (mg) was administered for back pain which was "slightly better" at 9:00 a.m. -At 11:30 a.m. the resident had a "fever" and complained of back pain with Tylenol 650 mg administered at that time. Vital signs at approximately 11:00 a.m. (see following interview) included a temperature of 100.6 degrees Fahrenheit, pulse 115 (increased), respirations 24 (increased), and blood pressure 121/66 and oxygen saturation of 92% (both within normal limits). -At 12:30 p.m. the resident was resting and his temperature had decreased from 100.6 to 100.1 degrees Fahrenheit. -At 2:48 p.m., RN B documented the following. She had called the clinic that morning (time not stated) and talked to a clinic nurse to update the attending physician (Physician D) of "the resident's change in condition." The resident was not himself, sliding down in his reclining chair, leaning to the right side, had weakness, and had trouble urinating with a bladder scan indicating greater than 999 cubic centimeters (cc). As the morning progressed, the resident was able to urinate "a decent amount," but it did not state how much the resident voided nor if the residual left in the bladder was checked by bladder scan. The resident accepted both his diabetic medication ([MEDICATION NAME]) and the [MEDICATION NAME] (administered at 8:01 a.m.) which was "somewhat helpful." The resident had a loose sounding cough with diminished breath sounds in the right lower lobe. New orders were given by Physician D that included a urinalysis and culture, a portable chest x-ray, and to update a physician if the resident's temperature was greater than 101.3. The chest x-ray was done but the resident was unable to void since receiving the orders. -At 2:54 p.m., the resident's temperature had decreased to 99 degrees Fahrenheit and Physician C was aware of the resident's emergency room visit and events from 05/02/12. Surveyor interviewed RN C on 07/25/12 at 10:35 a.m. she stated she would have taken the above full set of vital signs at approximately 11:00 a.m. just prior to administering the Tylenol. RN C stated she only rechecked the resident's temperature because the other vital signs were previously within normal limits. RN C stated the pulse was slightly elevated at 115 but added that it was not out of the ordinary for his pulse to be that rapid. RN C stated she would have included a full set of vital signs in her rechecks if he had been in any further distress. RN C did not check a blood pressure or oxygen saturation after approximately 11:00 a.m., but did pass on to the evening shift all of the days events. On 05/03/12, the following was documented in Resident #3's nurses' notes by RN E. -4:41 p.m. Chest x-ray results included atelectasis of the left lung base which was called to Physician C who said when the urine was obtained (straight catheterize if needed), get it to the clinic and notify the on call physician. The resident was unable to urinate. "He is a bit resistive at this time to the cath (catheterization). He now has a high blood sugar (529 per a subsequent note) and call was placed to MD (physician) for update. He is tremors and is not feel well." According to a March 30, 2012 Medscape article, "Atelectasis is defined as diminished volume affecting all or part of a lung...Following obstruction of a bronchus, the circulating blood absorbs the gas in the peripheral alveoli, leading to retraction of the lung and an airless state within a few hours. In the early stages, blood perfuses the airless lung; this results in ventilation-perfusion mismatch and arterial hypoxemia. A filling of the alveolar spaces with secretions and cells may occur, thereby preventing complete collapse of the atelectatic lung. The uninvolved surrounding lung tissue distends, displacing the surrounding structures. The heart and mediastinum shift toward the atelectatic area, the diaphragm is elevated, and the chest wall flattens. If the obstruction is removed, any complicating postobstructive infection subsides and the lung returns to its normal state. If the obstruction is persistent and infection continues to be present, fibrosis develops and the lung becomes bronchiectatic...Most symptoms and signs are determined by the rapidity with which the [MEDICATION NAME] occlusion occurs, the size of the lung area affected, and the presence or absence of complicating infection. Rapid [MEDICATION NAME] occlusion with a large area of lung collapse causes pain on the affected side, sudden onset of dyspnea, and cyanosis. [MEDICAL CONDITIONS] fever, and shock may also occur. Slowly developing atelectasis may be asymptomatic or may cause only minor symptoms...The following may be areas of medicolegal concern regarding diagnosis...Failure to recognize that the lung collapse is a medical emergency because patients may develop respiratory distress and hypoxemia..." RN E's nurses' notes continue on 05/03/12. -4:50 p.m. The clinic nurse called with orders. A physician ordered 10 units of regular insulin "now" and the night time on call physician was identified. -8:34 p.m. A call was placed to the on call physician to inform of the inability to obtain a urinalysis. A bladder scan identified 735 cc in the bladder. His temp (temperature) is now 101.4 (degrees Fahrenheit). We have tried a cath (catheterization) and so far have been unable to pass it past his prostate." The on call physician ordered to place a foley catheter if possible, send a urinalysis to the laboratory, start an antibiotic (Cipro) for 5 days, and follow up with Physician C on Monday. There were no further nurses' note entries on 05/03/12 written by RN D. Staff did not take a complete set of vitals so they could be reported to the on-call MD. Surveyor interviewed RN E on 07/25/12 at 3:05 p.m. RN E identified she worked as the charge nurse on 05/03/12 and that LPN G (according to the nurses' notes) would have been the floor nurse. RN E stated she learned of the resident's chest x-ray results in shift report and called the physician who then gave several orders. RN E stated she attempted to catheterize Resident #3 that evening as well as 2 or 3 other nurses but all were unable. RN E stated it would have been the floor nurse's responsibility to any "hands on assessments" which would have included checking the resident's vital signs. RN E confirmed she did not check Resident #3's vital signs on 05/03/12. On 05/03/12, the following entries were made by LPN F. -9:49 p.m. Temperature during shift 101.4 with "hard and tender" abdomen upon palpation. Unable to place foley catheter that was ordered and bladder scan greater than 735 cc. "Resident does respond to verbal stimuli but slowly." Staff did not take a complete set of vital signs, conduct a thorough assessment, nor immediately call the physician when the resident was noted with a hard and tender abdomen in the presence of atelectasis as well as multiple attempts to place a catheter which could result in trauma to the urethra. -9:52 p.m. (late entry). Accucheck 529 with 10 units Regular insulin administered at 5:30 p.m. Staff did not adequately monitor the resident's blood pressure and oxygenation saturation to assure he had adequate oxygen perfusion. According to the AMDA Guideline Common Infections in LTC, Table 5 Initial Nursing Assessment /Evaluation of a Suspected Infection, it is recommended to; Obtain and evaluate vital signs. High or low temperature ... If the patient is known to have diabetes ...elevated blood glucose levels in a previously controlled patient may indicate the presence of infection ... On 05/03/12, the following entries were made by LPN G. -10:34 p.m. Unable to place foley catheter that was ordered with resident's abdomen "distended, hard and tender." Resident responded to verbal stimuli but "appeared to have a glazed appearance noted to his eyes." Resident's legal representative was contacted who agreed to an emergency room evaluation. The resident left by "non emergent ambulance" at 10:00 p.m. -10:37 p.m. (late entry). Temperature 101.4 degrees Fahrenheit during shift. As needed Tylenol given at 8:00 p.m. with "little effect noted." The temperature remained the same with a recheck of 101.4 degrees Fahrenheit. Staff did not adequately monitor the resident's blood pressure and oxygenation saturation to assure he had adequate oxygen perfusion. Surveyor interviewed LPN G on 07/25/12 at 3:18 p.m. LPN G identified she starts her shift at 2:30 p.m. and would have checked Resident #3's vital signs at approximately 3:00 p.m. but possibly did not document them. LPN G stated she felt "horrible" for Resident #3 on 05/03/12 because he was so sick. LPN G stated the resident's color was "white" and she asked RN E to see the resident. LPN G stated the resident's abdomen was distended and tender and he was slow to respond. LPN G stated she and at least 2 other nurses attempted to catheterize the resident but all were unable. LPN G stated she did not recall checking any vital signs other than those taken at 3:00 p.m. and the subsequent temperature checks adding that she would have documented them. LPN G stated she follows the American Medical Director Association (AMDA) guidelines for change of condition. The Clinical Practice Guideline for the Evaluation of Fever and Infection in Older Adult Residents of Long Term Care Facilities: 2008 Update by the Infectious Disease Society of America notes the following recommendations; II. WHAT ARE THE CRITERIA FOR FEVER AND SYMPTOMS AND SIGNS THAT SUGGEST INFECTION IN A RESIDENT OF AN LTCF? Recommendation 2. Infection should be suspected in LTCF residents with: A. Decline in functional status, defined as new or increasing confusion, incontinence, falling, deteriorating mobility, reduced food intake, or failure to cooperate with staff (B-II). B. Fever, defined as: (1) A single oral temperature 1100_x0003_F (137.8_x0003_C); or (2) repeated oral temperatures 199_x0003_F (137.2_x0003_C) or rectal temperatures 199.5_x0003_F (137.5_x0003_C); or (3) an increase in temperature of 12_x0003_F (11.1_x0003_C) over the baseline temperature (B-III). III. WHO SHOULD PERFORM THE INITIAL EVALUATION OF THE RESIDENT WITH SUSPECTED INFECTION? Recommendations 3. The initial clinical evaluation of infection should be a 3-tiered approach involving a CNA, the on-site nurse, and an advanced-practice nurse, physician assistant, or physician (B-III). 4. CNAs should measure vital signs (temperature, heart rate, blood pressure, and respiratory rate). Residents who are suspected of having an infection or who have fever, as defined previously, should be reported immediately to the on-site nurse (B-II). IV. WHAT CLINICAL EVALUATION SHOULD BE PERFORMED FOR AN LTCF RESIDENT WITH SUSPECTED INFECTION? Recommendation 5. Initial clinical evaluation should involve assessment of respiratory rate, hydration status, mental status, oropharynx, conjunctiva, skin (including sacral, perineum, and perirectal areas), chest, heart, abdomen, and indwelling devices (if present) (B-III). V. HOW CAN LTCF STAFF EFFECTIVELY COMMUNICATE ABOUT POSSIBLE INFECTION WITH CLINICIANS WHO WILL BE MAKING TREATMENT DECISIONS? Recommendations 6. Information should be relayed to the responsible advance-practice nurse, physician assistant, or physician for decisions regarding further evaluation (B-III). 7. The full extent of the clinical evaluation should be documented as part of the medical record. If specific diagnostic measures are consciously withheld, the reasons should be recorded (B-III). Evidence Summary ... When calling the clinician, certain minimum information should be available to report at the time of the call. In addition to vital signs and acute or subacute changes in functional status, depending on the presenting symptom, a directed review of systems will help with an over-the-phone determination of what needs to be done next. Presence of a urinary catheter or any other indwelling device (e.g., vascular devices) should always be reported, along with whether entry sites are [DIAGNOSES REDACTED]tous or tender. Similarly, staff should report breathlessness and cough (or a change in these if chronically present), most recent bowel movement and its character, and any urinary symptoms. Assessment should also include the following: an assessment of respiratory status, including use of accessory muscles, retractions, and quality of breath sounds; presence of bowel sounds; and any wounds or areas of tenderness or redness. Any abnormal vital signs should be repeated. An example of what should be reported for a variety of conditions can be found in the American Medical Directors Association patient evaluation guideline (57). An independent consensus panel has suggested that pneumonia be considered a possible [DIAGNOSES REDACTED]. Surveyor reviewed the facility's policy and procedure related to change of condition, page 1 of 10, "Framework for Reporting Changes In Vital Signs or Laboratory Values to a Practitioner," no date and no source identified. The policy/procedure included the following to be reported immediately to the physician unless the values were consistently at that level and the practitioner was aware: Systolic blood pressure less than 90 millimeters of mercury. Surveyor reviewed the facility's policy and procedure related to change of condition, pages 2 through 10, "Suggested Guidelines for Physician Notification of Clinical Problems in Facility Residents," referenced from AMDA Guidelines, undated. The policy/procedure included the following to be reported immediately to the physician: Low blood pressure with a systolic less than 90 or diastolic less than 50 millimeters of mercury or more than 20 points below usual, OR accompanied by chest pain, altered level of consciousness, fever, falling, dizziness, diaphoresis. Surveyor interviewed the Director of Nursing (DON) on 07/25/12 at 3:45 p.m. who confirmed the policy and procedure for condition change was current and available to nurses who were responsible to follow the policy and procedures for change in condition. On 05/03/12, Resident #3 was transported via ambulance to the local hospital's emergency department. The ambulance report identified this was a non emergent transfer on 05/03/12 and when they arrived at the facility the resident was flaccid and withdrawn with a bladder scan showing 780 cc of urine and a blood glucose of 464. The resident was identified by ambulance personnel to have poor oxygen saturation in the 70's and decreased blood pressures in the 60's (systolic). An intravenous line was unable to be established and rhonchi were auscultated in the lung bases. On 05/03/12, the local emergency department dictation identified the resident was seen immediately upon arrival with decreased level of responsiveness, inability to pass urine and low blood pressure. "The course/duration of symptoms is worsening. The character of symptoms is pain and bladder fullness. The degree of symptoms is severe." The resident's legal representative was present and confirmed a do not resuscitate status but readily agreed to intravenous lines and aggressive cares. Resident #3 stated, "do whatever you have to, to help me." The resident's initial vital signs in the emergency department at 10:24 p.m. were as follows: pulse high at 122; respirations high at 24; blood pressure low at 54/45; and, oxygen saturation low at 79% (on room air). The resident was diagnosed with [REDACTED]. On 05/03/12, Resident #3 was transported via ambulance from the local hospital to a larger hospital's intensive care unit. The ambulance report identified this was an emergent transfer and when they arrived at the hospital to make the transfer the resident was in trendelenberg position (due to the low blood pressure), had an intravenous line with antibiotic running, had a blood sugar in the 500s with insulin provided to administer enroute, was distended with approximately [PHONE NUMBER] cc of fluid in the bladder (thus to limit the administration of fluids), was on a nonrebreather mask with oxygen at 15 liters (saturations upper 80s to lower 90s), had abnormal lung sounds and was in sinus [MEDICAL CONDITION] On 05/03/12, the admission history and physical from the larger hospital identified Resident #3 was admitted with abnormal vital signs (pulse 119, respirations 37 and blood pressure 71/50). The hospital discharge summary, dated 05/08/12, confirmed [DIAGNOSES REDACTED]. Surveyor interviewed attending Physician D on 07/30/12 at 9:50 a.m. Physician D stated he talked with facility nurses at noontime on 05/03/12 regarding Resident #3. He stated he did not give orders to check the resident's vital signs at any specific intervals and was unaware of the facility's routine for checking vital signs. Physician D stated that with Resident #3's change of condition on 05/03/12, he would have expected facility staff to check a complete set of vital signs more frequently than once per shift.