Every finding on record at Neighbors - Central Neighborhood (The)

Based on interview, the facility failed to ensure the Infection Preventionist (IP) is trained in special education and training in infection prevention and control. This has the potential to affect all 25 residents. This is evidenced by: Surveyor did not find Director of Nursing (DON) B's training completed for Infection Control (IC). On 06/19/25 at 10:52 AM, Surveyor interviewed DON B and asked for Infection Control certification. DON B was confused by certification form to print and asked Surveyor to show DON B on DON B's computer which certification module Surveyor needed printed. Surveyor observed on DON B's computer that Post Assessment for training for infection control from the Center Disease Control (CDC) was not completed. DON B reported to Surveyor DON B was unaware there was a post assessment to complete before practicing as Infection Preventionist (IP). Surveyor indicated to DON B the post assessment needs to be completed to be appropriately trained in IC. DON B reported to Surveyor DON B would complete the post assessment test as soon as able. Surveyor asked DON B if anyone else who is certified is overseeing and taking care of infection control duties for Central unit. DON B reported to Surveyor Assistant Director of Nursing (ADON) C is managing IC duties with DON B, but ADON C is currently in training now for IC. DON B reported there is no one else working with IC on Central unit.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had potential to affect all 25 residents (R). -The facility did not have an accurate and complete infection surveillance process in place for months of January 2025-May 2025, including Influenza A outbreak in February 2025. Findings include: Facility policy titled, Infection Surveillance, dated reviewed in 2012, states in part, .Data Collection and Recording: 4. For targeted surveillance follow these guidelines: a. Daily: Record detailed information about the resident and infection on an individual infection report form. b. Monthly: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month. Monthly: Summarize monthly data for each nursing unit by site and by pathogen . Surveyor reviewed infection surveillance line lists dated January 2025-present. Surveyor found missing data every month of infection surveillance reviewed. Infection surveillance had missing data of well dates, when residents and staff went on isolation or stayed home from work when sick, what type of isolation for residents when sick, when the onset of symptoms started for infections, missing types of labs completed, and how staff determined if resident needed to be on antibiotics or not. Facility had missing data of location of resident's infections, or which residents' staff last worked with staff who became sick, including summary and analysis of the number of residents affected during the outbreak. Infection surveillance logs were reviewed with an Influenza A outbreak noted in February 2025. Surveyor could not distinguish when outbreak started and ended. Surveyor could not find documentation the facility documented follow-up activity in response to important surveillance findings (e.g., outbreaks). Surveyor could not find observations of staff including the identification of ineffective practices (e.g., not practicing hand hygiene and/or using PPE when indicated as well as practices which do not follow the facility's IPCP policies and procedures), if any; and the identification of unusual or unexpected outcomes, trends, and patterns pertaining to tracking infection surveillance. On 06/19/25 at 7:26 AM, Surveyor interviewed Director of Nursing (DON) B and asked for DON B to explain the line list and infection logs. DON B reported when the previous DON was in the position, the DON took infection logs and outbreaks and then combined into one spreadsheet. Surveyor asked DON B if there were any outbreaks in 2025. DON B reported there were a couple outbreaks and will be combined on the spreadsheet with each month in 2025. Surveyor reviewed a possible outbreak of Influenza A found in February 2025. Surveyor asked DON B if there were any other items pertaining to the outbreaks, or documentation of outbreaks anywhere else other than the spreadsheet handed to Surveyor as Surveyor could not find much data pertaining to the Influenza A outbreak in decreasing the spread of infection and what steps were taken during the outbreak. DON B reported to Surveyor all the information DON B has will be in the infection surveillance monthly logs. Surveyor did not find any summary or other information pertaining to the infection surveillance logs. On 06/19/25 at 7:45 AM, Surveyor interviewed DON B and asked if facility had tracking surveillance for staff and during outbreaks. DON B reported DON B keeps track of staff, but it is the line list for staff like the resident line lists, and DON B would bring Surveyor information requested. DON B reported to Surveyor DON B does not keep a summary of any other information pertaining to infections or outbreaks. Surveyor asked DON B for all logs back until last Survey in March of 2024. DON B reported after the previous DON left, DON B did not keep those records of staff infections and surveillance. DON B reported to Surveyor DON B would figure it out and try to see what DON B can bring to Surveyor. On 06/19/25 at 12:06 PM, Surveyor interviewed DON B and Assistant Director of Nursing (ADON) C and asked about infection surveillance with missing data of well dates, when residents and staff went on isolation or stayed home, when signs and symptoms started, types of labs completed, and how staff determined if resident needed to be on antibiotics. ADON C reported to Surveyor ADON C uses the McGeer's criteria but doesn't document if criteria are met or not. ADON C reported going forward ADON C will print off criteria, checkmark the symptoms on the infection line lists for thoroughness, educate provider if needed about antibiotics use or not, and then document if criteria meet antibiotic use. Surveyor asked ADON C about R5 in March of 2025 diagnosed with a UTI and prescribed antibiotics. Surveyor asked ADON C why R5 was not placed on the infection line list in March 2025 to show accurate data accumulation for infection surveillance so that residents are not being missed on infection surveillance throughout the facility. DON B answered for ADON C and reported to Surveyor that R5 must have been missed for placing on the infection line list and DON B is unsure how that happened. DON B reported to Surveyor infection line lists need to be revamped to show accurate onset symptoms started, when isolation was started, what tests were performed, results of tests, well dates, when isolation ended, and when antibiotics ended. DON B reported to Surveyor going forward DON B and ADON C will start summarizing the steps the facility did during an outbreak and how the outbreak turned out to decrease the chance of infections spreading. DON B and ADON C reported to Surveyor DON B and ADON C understand the importance and will update line lists and perform correct surveillance as supposed to.

Based on interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received pneumococcal immunizations, for 4 of 5 sampled residents, (R). (R20, R10, R18 and R13) This is evidenced by: The CDC Pneumococcal Vaccine Timing for Adults reads, in part: Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 . Facility policy titled, Pneumococcal Vaccine, dated reviewed 06/16/23, states in part, .Facility will provide an infection control environment that supports a decrease in the likelihood of pneumococcal illness with our residents. Procedure: 2. Identify residents in need of first, or final dose of PPV if five or more years have elapsed since previous dose. Use decision tree for pneumococcal vaccines . Surveyor reviewed immunization records for R20, R10, R18 and R13: R20 was admitted to the facility on [DATE]. R20's immunization record stated pneumococcal vaccinations were recommended last completed on 10/06/15. Facility did not have documentation the facility offered or educated R20 on the pneumococcal vaccinations recommended. The facility did not have a declination form in R20's record of the pneumococcal being declined. R10 was admitted to the facility on [DATE]. R10's immunization record stated pneumococcal vaccinations were recommended last completed on 10/26/20. Facility did not have documentation the facility offered or educated R10 of the pneumococcal vaccinations recommended. The facility did not have a declination form in R10's record of the pneumococcal being declined. R18 was admitted to the facility on [DATE]. R18's immunization record stated pneumococcal vaccinations were recommended last completed on 02/10/17. Facility did not have documentation the facility offered or educated R18 of the pneumococcal vaccinations recommended. The facility did not have a declination form in R18's record of the pneumococcal being declined. R13 was admitted to the facility on [DATE]. R13's immunization record stated pneumococcal vaccinations were recommended, and last completed unknown. Facility did not have documentation the facility offered or educated R13 of the pneumococcal vaccinations recommended. The facility did not have a declination form in R13's record of the pneumococcal being declined. On 06/19/25 at 10:43 AM, Surveyor interviewed Director of Nursing (DON) B and asked about the missing pneumococcal vaccinations for R20, R10, R18, and R13. DON B reported to Surveyor DON B noticed R20, R10, R18, and R13 have not been offered Pneumococcal vaccination and facility knows R20, R10, R18, and R13 are due for pneumococcal vaccination and will be ordering it from pharmacy and giving it. DON B reported to Surveyor this process has not been being completed and DON B would be educating Assistant Director of Nursing (ADON) C on correct process when residents are admitted to facility.

Based on the interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) which must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect 1 of 1 residents (R) reviewed. (R5) The facility did not ensure the standard of practice for infection surveillance and treatment, and McGeer's criteria were being utilized in the facility's antibiotic stewardship program for R5. This is evidenced by: Facility policy titled, Antibiotic Stewardship, dated reviewed in 2012, states in part, .Procedure: #5. Tracking a. IP will be responsible for infection surveillance and MDRO tracking. b. IP will collect and review data such as: i. Type of antibiotic ordered, route of administration, antibiotic costs iii. Whether appropriate tests such as cultures were obtained before ordering antibiotic . Surveyor reviewed R5's Electronic Health Record (EHR) which showed R5 had a Urinary Tract Infection (UTI) recognized by the facility on 03/18/25. Orders were obtained and R5 started on Cefadroxil 1 gm oral for 5 days. R5's symptoms worsened and R5 was admitted to the hospital on [DATE], where R5 was placed on Zoysn intravenous during R5's stay in hospital. Surveyor reviewed infection surveillance line lists dated January 2025-May 2025. Surveyor found R5 missing on March's infection line list. On 06/19/25 at 12:06 PM, Surveyor interviewed DON B and Assistant Director of Nursing (ADON) C and asked about infection surveillance with missing data of R5's UTI, and how staff determined if resident needed to be on antibiotics. ADON C reported to Surveyor ADON C uses McGeer's criteria but doesn't document if criteria is met or not. ADON C reported that going forward ADON C will print off criteria, checkmark the symptoms on the infection line lists for thoroughness, educate provider if needed about antibiotics use or not, and document if criteria meet antibiotic use. Surveyor asked ADON C about R5 in March of 2025 diagnosed with an UTI and prescribed antibiotics. DON B was present and answered for ADON C and reported to Surveyor R5 must have been missed for placing on the infection line list and DON B is unsure how it happened. DON B reported to Surveyor the infection line lists need to be revamped.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 2 residents (R174) reviewed for at risk of Pressure Injury (PI) development received the necessary treatment and services to prevent new pressure injuries from developing. - R174 is moderate risk for the development of PIs and developed a stage 2 PI after admission into facility. This is evidenced by: Example 1 According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high-risk status. Facility policy titled, Wound Management, dated reviewed on 01/21/25 states in part, .Procedure: V. New wounds, including new admissions, are referred to the Assistant Clinical Mentor via the New Wound Identification and Follow-Up Checklist . R174 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia, malignant neoplasm of unspecified part of left bronchus or lung, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease and diabetic nephropathy, iron deficiency anemia secondary to blood loss (chronic), morbid (severe) obesity due to excess calories, chronic obstructive pulmonary disease, unspecified, hyperlipidemia, unspecified, atrioventricular block, first degree, unspecified right bundle-branch block, and dysthymic disorder. Surveyor reviewed Minimum Data Set (MDS) assessment for PI risk. MDS not completed yet and it is due 06/19/25. Surveyor reviewed physician note dated on 06/14/25, R174 had shearing on coccyx found, apply protective cream and cover with foam dressing. Change every 3 days and as needed. Daily documentation in matrix until healed, then x7 days and then discontinue. Surveyor reviewed R174's assessments in Electronic Health Record (EHR): -On 06/12/25, Skin assessment completed. No sores or open areas on skin. -On 06/12/25, Braden skin assessment scored 13 moderate risk for skin breakdown. Surveyor reviewed Hospice notes, which stated in part: .-On 06/12/25, Next skilled nurse visit follow (SNV) up on patient's ability to pivot transfer and order equipment-bed side commode, air mattress for facility hospital bed (bariatric). -On 06/16/25, Facility staff did request a delivery of bed extender and/or a bariatric bed. Bariatric bed order placed through State Serv . Surveyor reviewed R174's Physician orders, which stated in part, .-Wound: coccyx shear daily documentation until healed x7 days then discontinue. Daily documentation should include amount drainage, type of drainage, dressing intact, odor after cleansing, pain, progress of wound, wound edges, healed. Special Instructions: Notify MD of symptoms of infection - change of appearance. Once A Day. Start 06/14/2025. -Wound: coccyx shear-treatment: Cleanse/irrigate wound with NS, apply skin sealant to peri-wound skin (avoid any open areas), apply protective cream cover with foam dressing, change every 3 days: and PRN for dislodgment or leakage. Once a day. Start 06/16/2025 -Wound: coccyx shear- treatment: Cleanse/irrigate wound with NS, apply skin sealant to peri-wound skin (avoid any open areas), apply protective cream cover with foam dressing, change every 3 days: and PRN for dislodgment or leakage. As Needed. Start 06/16/2025. -Skin Risk Assessment w/Braden Scale weekly X 3 PM's. Once a Day on Mon. Start 06/23/2025. -Encourage resident to be out of bed for up to 1 hour at a time. Reposition every 2 hours when in bed. Reposition every 1 hour when in chair. Equagel cushion to all chairs, check placement every shift. Alternate mattress to bed. Check functions every shift. Start on 06/18/25. Surveyor reviewed R174's treatment orders, which stated in part, .On 06/14/25 cleanse coccyx shear with normal saline, apply protective cream, and cover with foam dressing. Change every 3 days and as needed for leakage. Daily documentation in matrix until healed; then x7 days and then discontinue. -On 06/18/25 Discontinue current treatment. Coccyx stage 2 Pressure Injury (PI), cleanse with normal saline, Apply skin sealant to peri-wound skin, apply foam dressing, and change every 5 days and as needed for leakage. Daily documentation in Matrix until healed; then x7 days and then discontinue. Weekly measurement and documentation on Wednesday in the mornings until healed . Surveyor reviewed R174's progress notes of Nurse Practitioner (NP) update from facility, which stated in part, .-On 06/18/2025 at 1:23 PM, NP updated on the progression of residents coccyx wound. wound has progressed into a stage 2 PI overnight. resident is currently on hospice and has recently been declining. On admission resident was noted to be up and mobile and now resident is mostly in bed. NP wrote new treatment order to apply a foam dressing and change every 5 days. hospice ordered an alternate air matt previously, staff place alt air matt on bed today from facility until hospice mattress arrives. repo resident Q 2 hours in bed and Q1hr when up in chair. enc resident to only be up for a max of 1 hour at a time. add equagel to all chairs if resident is choosing to get up . Observations: On 06/18/25 at 9:33 AM, Surveyor observed Certified Nurse Assistant (CNA) G and CNA F perform peri cares and catheter cares on R174. CNA G rolled R174 to the right and washed R174's legs and bottom. Surveyor observed redness to R174's coccyx and bilateral buttocks. Surveyor observed two small red irritated open wounds on R174's coccyx area. CNA G stated to CNA F, We better get the nurse in here to look at [R174's] bottom. CNA F exited R174's room and grabbed LPN E. LPN E reported to Surveyor shearing was noted on R174's coccyx area back this last Sunday on 06/15/25. Surveyor asked LPN E why other interventions were not implemented or dressing as ordered not currently on R174's coccyx. LPN E reported to Surveyor LPN E was unsure what the game plan was for R174's wound on coccyx but LPN E would find out soon with Assistant Director of Nursing (ADON) C. LPN E measured R174's wound and stated, There are two openings now. One is 1cmx1.1 cm and the second wound is 0.5cmx0.8cm. LPN E noted the area was still blanchable. LPN E applied skin prep and applied Meplix dressing to R174's coccyx area. LPN E exited R174's room and CNA G and CNA F attempted to reposition R174 off of coccyx by repositioning to the right side and providing a pillow behind R174. On 06/18/25 at 10:00 AM, Surveyor interviewed LPN E on why R174 did not have a Meplix on when CNA G and CNA F were providing cares. LPN E was unsure why R174's Meplix was not on and was going to confirm with ADON C. On 06/18/25 at 10:31 AM, Surveyor interviewed ADON C and Director of Nursing (DON) B and asked why R174 did not have Meplix on as ordered on 06/14/25. ADON C reported the nurse on 06/17/25 took Meplix off to let R174's wound air dry. ADON C and DON B reported Registered Nurse (RN) D from 06/17/25 should not have taken dressing off to air dry without contacting provider for further orders or treatment changes. DON B reported to Surveyor DON B will be calling RN D to figure out exactly what had occurred and provide education on correct measures. On 06/18/25 at 11:01 AM, Surveyor requested all documentation pertaining to skin assessments, Braden assessments, and treatment orders for R174. ADON C reported to Surveyor R174's Braden score was at a 20 and not at risk for skin breakdown on the last Braden score dated 06/15/25. On 06/18/25 at 11:16 AM, Surveyor interviewed DON B and asked if R174's Braden was accurate on 06/15/25 as scoring 20 but R174's admission Braden was scored at 13 with R174 being at moderate risk for skin breakdown. DON B reported RN D who assessed R174's Braden score on 06/15/25 documented wrong score and measures but DON B had a call out to RN D who assessed R174's Braden on 06/15/25 to educate RN D on correct assessment and scoring of R174's Braden scale. DON B reported to Surveyor R174 is at high risk for skin breakdown and has been throughout R174's stay in the facility. On 06/18/25 at 11:10 AM, Surveyor interviewed ADON C and ADON C reported to Surveyor the first shearing noticed on R174's coccyx was on 06/14/25. Surveyor asked ADON C if there was any interventions put into place for R174 after nurse had assessed shearing to R174's coccyx on 06/14/25. ADON C reported to Surveyor if any interventions were put into place, the interventions would not be on R174's baseline care plan but the base line care plan refers staff to review the MAS. Surveyor asked ADON C what the MAS is. ADON C indicated it is the Master Communication Sheet (MAS). This is where the CNA has a master copy of a detailed day to day care plan and tasks R174 would need for provision of cares through the day. Surveyor requested to review the MAS for R174. ADON C and Surveyor reviewed MAS for R174. ADON C reported there were no updates or new interventions put into place for R174's shearing of the coccyx from 06/14/25. ADON C reported there should have been some repositioning interventions or something put into place back on 06/14/25. DON B reported as soon as the nurse on 06/14/25 assessed the shearing, nurse should have placed R174 on wound identification and follow up check list so R174's treatment interventions were updated as needed and accurate for R174's needs. On 06/18/25 at 11:28 AM, ADON C reported to Surveyor ADON C reviewed progress notes back on 06/14/25 and noted nurse did educate R174 to try to lift completely up when shifting in bed to prevent shearing of the skin. ADON C reported to Surveyor since 06/14/25, R174 has declined in mobility even further and no longer can make slight reposition moves for himself. ADON C reported to Surveyor there should have been more interventions put into place once shearing had occurred. On 06/18/25 at 1:25 PM, Surveyor reviewed documentation made from DON B concerning a conversation DON B had with RN D who left R174's wound dressing open to air on 06/17/25 as well as other interventions which were not followed. DON B reported to Surveyor RN D indicated to DON B, R174's wound appeared to be shearing and did not feel the dressing was needed for R174, so RN D left open to air. DON B reported to Surveyor DON B provided education to RN D about following wound treatment orders and calling provider if any changes need to be made or for further guidance. Also, DON B reported to Surveyor RN D indicated to DON B an air mattress and bariatric bed was delivered by a third-party company to facility for R174, but RN D turned away the bariatric bed due to the bed being all metal and crank style. RN D reported to DON B, RN D did not know if facility accepted these items. DON B asked RN D why R174's air mattress was not applied to R174 right away when receiving air mattress. RN D replied with, There was no good time to apply. DON B reported to Surveyor, DON B educated RN D of importance of applying interventions right away or finding equivalent interventions such as frequent repositioning, etc. until more in depth could be applied.

Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for the diagnosis of Congestive Heart Failure (CHF) with the use of a diuretic for 1 of 12 residents (R) R5 reviewed for care plans. This is evidenced by: R5 was admitted to the facility on [DATE] with a diagnosis of chronic diastolic congestive heart failure, hypertensive heart, chronic kidney disease with heart failure, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type 2 diabetes mellitus, and narcolepsy. R5's Minimum Data Set (MDS) assessment, completed on 02/26/24, confirmed R5 scored 15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. Record review identified a CHF/respiratory assessment completed weekly from 11/15/23 to 03/20/24. Review of R5's medical record identified orders for the following diagnosis of CHF: -Torsemide give 30 milligrams (mg) by mouth once a day in the am for diagnosis of CHF. -Weekly CHF assessment once a day on Wednesday for diagnosis of CHF. -Weekly weights once a day on Wednesday for weights for diuretics, CHF/renal disease. -Add 24-hour total intake and output on NOCs once a day. -Intake and output every shift to ensure adequate fluid intake and encourage water every shift. Review of R5's care plan identified no problems or interventions related to R5's diagnosis of CHF and use of diuretics. On 03/27/24 at 9:15 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C and asked if R5's care plan included a CHF plan to address R5's diuretic use and interventions. ADON C indicated ADON C reviewed R5's care plan and found no care plan for R5 to address R5's diagnosis of CHF or diuretic use. ADON C indicated that going forward MDS coordinator/Registered Nurse (RN) D will add a CHF care plan and interventions for R5's diuretic usage. ADON C provided Surveyor with a copy of R5's current care plan. On 03/27/24 at 10:15 AM, RN D gave Surveyor R5's updated care plan. Surveyor reviewed R5's updated care plan dated 03/27/24 CHF care plan with interventions in place.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection, such as COVID-19, which had the potential to affect all 19 residents of the facility. The facility did not ensure staff wore appropriate Personal Protective Equipment (PPE)/eye protection in resident care areas when the community transmission for COVID-19 was high. This is evidenced by: According to Centers for Disease Control and Prevention (CDC) guidance for Responding to COVID-19 in Long-Term Care Facilities (LTCFs), health care personnel (HCP) working in facilities located in counties with substantial or high transmission: .eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. According to the Center for Disease Control (CDC) COVID Data Tracker, the Community Transmission rate for the facility's county, for the month of May, the level was High. On 05/23/22 at 8:05 a.m., Surveyor conducted entrance conference with the Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Surveyor was informed of two current residents positive for COVID-19. Surveyor conducted the initial tour of the facility and identified all staff in resident area not wearing eye protection. At 8:40 a.m., Surveyor interviewed Registered Nurse (RN) C asking what PPE is to be worn in resident areas. RN C indicated staff are to wear a mask and if going into a COVID-19 positive room all PPE of gown, gloves, mask, and eye protection is to be worn. At 12:15 p.m., Surveyor interviewed the Nursing Home Administrator (NHA) A asking about the community transmission level and what PPE is to be worn. NHA A indicated the county positivity rate is low and masks are to be worn. When staff go into COVID-19 positive rooms all PPE of gown, gloves, mask, and eye protection are to be worn. NHA A indicated the county Department of Health sends the report from the Department of Health Services website of the county positivity rate and this is what the facility has been using. Surveyor reviewed with NHA A the community transmission level documentation. NHA A indicated the transmission rate for the county they reside in has been high. NHA A stated she will have staff wear eye protection right away.

Based on interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury for 1 of 2 residents (R) 316 reviewed for pressure injury. R316 developed an abrasion noted on right buttocks on 9/23/21 that became stage 2 pressure injury (PI) to the right buttocks on 9/30/21. The facility did not regularly assess the wound condition per their policy and professional standards. The facility did not get alternate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The facility policy, entitled Wound Management dated 11/02/2015 states: . II. Assistant Clinical Mentors or licensed designee are responsible for weekly wound documentation. III. If there is an increase in wound size or change drainage color that is purulent or foul smelling, physician is to be notified . R316 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] identified that R316 had no unhealed pressure injuries at time of admission. R316's Observation Detail List Report dated 7/21/21 identified that R316 had a Braden score of 16. This means R316 was identified as at risk for pressure injuries at the time of his admission to the facility. The master assignment sheet Certified Nursing Assistant (CNA) Care Plan attached to R316's medical record on 9/16/21 had nothing checked under the skin section for pressure relieving measures. Review of R316's medical record identified the following nursing progress note: 9/30/21 Resident voiced complaints of increased pain to right buttock. Writer assessed resident's buttock and noted that area that was originally noted as an abrasion has progressed to a stage 2 pressure injury. Area measured 2.0 cm [centimeters] in length by 1.1 cm in width, area tender to touch, bed of wound pink and appears free of infection. Area cleansed with normal saline, applied skin prep to surrounding skin. Applied opti-foam. Resident encouraged to lay in bed and reposition from side to side to help decrease pressure to buttocks. Resident already has an alternating air mattress on bed. Will initiate ROHO cushion to recliner, resident often spends most of his time in his recliner. Dietary updated and resident was added to MD [Medical Doctor] list for liquacel to be added for wound healing per dietary. Hey therapy [request for therapy] also sent. Resident spent the rest of this shift in his bed repositioning with some assistance from side to side. PRN [as needed] [MEDICATION(S)] was given per resident's request for buttock and back pain. ACM [Assistant Clinical Mentor] updated on pressure injury. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) from 10/01/21- 11/05/21 document the resident refused dressing changes or the PI was left open to air on the following dates 10/12/21, 10/15/21, 10/18/21, 10/21/21, 10/24/21, 11/02/21 and 11/05/21. Review of the nursing progress notes show the doctor was not notified that R316 was refusing the dressing change. No request for change in wound care order was identified. Review of the documentation identified the following nursing progress notes: 10/02/2021 sacral dressing placed about 2000. Resident now refuses dressing. removed per his demand allowed staff to apply protective cream only. no dressing. 10/30/2021 refused to have foam dressing placed on buttock wound. protective cream applied. wound is dry and some scabs present. continuing to encourage to lay in bed or off load but refuses. sits in recliner. The treatment policy and TAR instruct to measure the wound weekly and document on the TAR and put into electronic medical records. During review of the medical record a measurement of the PI was completed on 9/30/21. No other measurements were identified in the medical record since 9/30/21. On 11/10/21 at 1:00 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C. ADON C stated R316 was at risk for PI since admission, but was refusing to lay in the bed, and spent most of the time in the recliner. R316 also slept in the recliner. ADON C stated there were no interventions put in place to prevent skin breakdown prior to the development of a pressure injury on 9/30/21. ADON C did not think R316 had any pressure relieving devices in the recliner at this time. Surveyor noted there was no pressure relieving devices in R316's recliner during observations. ADON C said they had orders for a dressing to the wound, but R316 began to refuse to allow the dressing and requested to leave the dressing open to air. Surveyor asked if the physician was notified about R316 refusing the dressing changes. ADON C stated they didn't think they needed to notify the doctor because the wound was getting better. ADON C stated that the PI was to be assessed and measured by the nurses on the floor weekly. ADON C noted the weekly wound measurements and documentation were not done by the nurses. ADON C was not sure why staff were not documenting the wound measurements.

Based on interview and record review, the facility did not complete comprehensive weekly wound assessments for 1 of 2 residents (R)7 to ensure that residents receive treatment and care in accordance with professional standards of practice. R7 did not receive weekly measuring and assessment of a skin injury or have a root cause for the skin injury. This is evidenced by: Review of the facility's policy titled: Wound management with the revised date of 07/31/14, read in part: .PURPOSE: To track, prevent, heal pressure ulcers/wounds according to standards of practice . PROCEDURE: .II. Assistant Clinical Mentors or licensed designee are responsible for weekly wound documentation. III. If there is an increase in wound size or change drainage color that is purulent or foul smelling, physician is to be notified. IV. If there is no improvement in the wound in 2 weeks, physician should be notified for a possible change in dressing. Review of R7's medical record documented current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) dated [DATE] an annual assessment documented in section M as R7 being not at risk for pressure injuries. In section G documented R7 requires extensive assist of 1 staff for bed mobility and toileting and requires staff supervision with set-up for transfers. On 11/09/21 at 11:14 a.m., Surveyor interviewed R7 asking if have any bed sores or open areas on their skin. R7 indicated having had an area on buttocks and the area gets better and then comes back. Review of nursing progress notes document in part, on 09/20/21 at 2:44 p.m., [Physician name] updated on dry skin to lower extremities, fungal rash to right breast fold, and new open area to inner buttock area. Treatment orders for all areas initiated . Review of the nursing progress notes did not document comprehensive assessments or measurements of the open area on R7's buttocks. Surveyor requested nursing progress notes documenting comprehensive assessments with measurements and descriptions of the wound on the buttocks. Surveyor was not provided with documentation. Review of Treatment Administration Record (TAR) documented orders on 09/20/21 Wound: right inner buttock -- daily documentation until healed x7 days then DC. This documentation did not provide a weekly measurement or a wound assessment. On 09/24/21, the TAR documented orders for Wound: left buttock stage 2 PI (pressure injury)--daily documentation until healed x7 days then DC. This documentation did not provided a weekly size measurement and a weekly wound assessment. On 09/29/21, the TAR documented measurement of 0.5 x 0.3 cm right buttock pressure injury. No further documentation of measurements were completed for the right or left buttock wound. Review of the wound documentation in the electronic medical record documented on the right buttock pressure ulcer: 9/29/21: length 0.5 width 0.3 cm, stage II, granulation tissue - wound healing status: Stable and on 11/10/21 length 1.5 , width 0.7 cm, stage II granulation tissue - wound healing status: stable. Consistent weekly wound assessments were not completed from 9/29 - 11/10/21. Surveyor was not able to identify weekly wound assessments for the open area on the left buttock. On 11/11/21 at 10:15 a.m., Surveyor interviewed Registered Nurse (RN) D asking about wound documentation for R7. RN D indicated staff will document when it is open and not when healed over. R7's wound had healed a couple of weeks ago and just opened over this last weekend. RN D did measure the area and did not document in the computer the area was 1.5 x .4 cm on 11/07/21 on the right buttock. Surveyor asked if the physician was updated with the change. RN C indicated R7 still had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan was to monitor for 7 days for healing. On 11/11/21 at 11:46 a.m., Surveyor interviewed with ADON C and Director of Nursing (DON) B asking about both buttock wounds and if weekly comprehensive assessments with measurements were completed. ADON C indicated the left buttock wound was never there. Licensed Practical Nurse (LPN) F noted a right buttock wound and the next day physician was notified. Someone put on doctor's list as a left buttock wound. RN E completed order for a left buttock wound. ADON C indicated when she looked wound was not on the left buttock. ADON C indicated the wound was felt to be more of a shearing and not a pressure injury. RN E wrote the orders as a stage 2 without looking at the wound. Surveyor asked how often the orders are reviewed and how often are wounds documented. ADON C indicated she does not review the TAR and will look at the progress notes for last 24 hours or if on Monday will review the last 72 hours. ADON C indicated she did not look at the orders until yesterday and doesn't know why a nurse didn't bring to her attention. ADON C indicated she doesn't make a note of assessments when looking at the wound but will talk to nurses and ask if it's getting better. ADON C indicated with a skin tear or shear she will not document on wound bed. R7's wound was not from pressure it was caused by shearing. Surveyor asked if ADON C investigated to find out the cause of the shearing. Surveyor was only provided the initial incident report. The event report dated 09/19/21 was completed by LPN F of an open area right inner buttock measuring 2 cm x 2 cm with no documentation of an RN review. The event report did not identify a root cause of the wound. Surveyor asked if an RN assessed the wound when first discovered as an LPN had started the initial event report. ADON B indicated there was not an RN assessment at the first initial findings. Surveyor asked if the physician had observed the wound. ADON C indicated the physician does not look at the wounds and if a physician needs to look at the wound would send them to the ER. Surveyor asked when ADON C last looked at R7's wound. ADON C could not remember when she looked at R7's wound as it was last week and it was small. ADON C indicated the wound shape was like a tear drop and determined it was shearing and not pressure. Surveyor reviewed with ADON C, DON B and RN D to verify that the wound was healed and now reopened. The physician was not notified nor was this documented in the medical record.

Based on observation and interview, the facility did not serve food in accordance with professional standards of practice for food safety for all 11 residents located on the Arrowhead unit. Cross contamination occurred during food service. This is evidenced by: On 11/04/19 at 12:07 p.m., Homemaker F served residents on the Arrowhead hall. While preparing to make a grilled cheese, Homemaker F removed bread from container with gloved hands after touching the outside of the refrigerator, scoops, ladles, and the side of counter. Homemaker F held the bread in one hand while buttering one side, then placed the bread face down by hand into a frying pan. Next, Homemaker F held the top piece of bread. Then Homemaker F removed a slice of cheese from a plastic bag. Next, without removing gloves or performing hand hygiene, Homemaker F placed a slice of cheese on the bread that was in the frying pan, and using her hands, placed the other piece of bread on top of the cheese. This was repeated twice. Homemaker F also prepared half of a grilled cheese in the same manner. After preparing the grilled cheese, Homemaker F removed gloves and performed hand hygiene. On 11/05/19, Surveyor observed Homemaker F prepare a breakfast plate. Wearing gloves, Homemaker F broke two eggs into a pan, then disposed of the shells. Then without changing gloves or performing hand hygiene, Homemaker F prepared a slice of toast by removing the bread from the package by hand and placing a slice in the toaster. When the toast was done, Homemaker F removed it by hand and placed it on a plate. After adding cooked bacon with gloved hands, Homemaker F removed the cooked eggs from a pan and served the resident. Surveyor interviewed Homemaker F. Homemaker F stated she has not had food service training in a long time, and she wished the facility would have it more often. Surveyor interviewed Culinary Manager (CM) G and Nursing Home Administrator (NHA) [NAME] Surveyor informed CM G and NHA A of the above observations. CM G agreed foods should not be touched after touching items in the environment. NHA A stated the food service training included safe food handling and was mandatory for all employees, which was held 04/08/19.

Based on record review and interviews, the facility did not ensure accurate behavior monitoring and did not ensure non-pharmacologic approaches were in place for 1 of 6 residents reviewed for [MEDICAL CONDITION] medications, Resident (R) R20. An antipsychotic medication was increased due to inaccurate behavior monitoring for R20. R20's care plan did not include resident centered non-pharmacologic interventions. Non-pharmacologic interventions were not attempted prior to an increase in an antipsychotic medication. This is evidenced by: R20's [DIAGNOSES REDACTED]. On 11/04/19 at 1:20 p.m., Surveyor interviewed R20. R20 was sitting in a broda chair. R20 stated she did not have any complaints, and she was not the type to complain. On 11/06/19 at 7:30 a.m., Surveyor reviewed R20's clinical record. The record showed on 03/06/19, R20 was started on [MEDICATION NAME] (an antipsychotic) for episodes of aggression, taking food from others and throwing objects at others. The physician's note, dated 03/06/19 read: Will try [MEDICATION NAME] 12.5 mg (milligrams) at noon and we can titrate this as needed. Will follow. The facility began recording episodes of aggression and other behaviors on a form entitled Antipsychotic Medication Monitor form which is filled out daily by the staff. Another form entitled Monthly Behavior Summary/Sheet calculates the number of monthly behaviors for physician review. On 04/10/19, R20's [MEDICATION NAME] was increased from 12.5 mg daily, to 12.5 mg a.m. and 25 mg at noon. The monthly behavior summary, dated 05/08/19, recorded 26 incidents of aggression. The daily antipsychotic medication monitor form showed 22 incidents from 04/10/19 to 05/10/19. On 06/05/19, another monthly behavior summary sheet was submitted to the physician for review. The monthly monitoring form showed R20 experienced 17 episodes of verbal aggression. Two episodes of throwing food were also noted. A notation stated, in part, Increase in aggression, esp (sic) after lunch, pulling hair, kicking, verbal. Based on this information, R20's [MEDICATION NAME] was increased from 12.5 mg in a.m. and 25 mg at noon, to 25 mg in a.m. and 25 mg at noon. R20's daily antipsychotic medication monitoring form showed R20 did experience this number of incidents. On 08/28/19, R20's [MEDICATION NAME] was increased from 25 mg twice a day, to 25 mg in the a.m., and 50 mg at noon. This was based on the monthly behavior sheet information, dated 08/05/19, which stated R20 experienced 15 episodes of verbal aggression. However, R20's daily antipsychotic medication monitoring form showed R20 experienced three episodes of aggression from 08/01/19 to 09/01/19. At 1:25 p.m., Surveyor interviewed Director of Nursing (DON) B. DON B stated on 10/04/19, she had emailed the nurses to encourage documentation compliance with the daily antipsychotic medication monitoring form. DON B stated the monthly behavior incidents are calculated by the members of the behavioral committee. DON B acknowledged the calculations submitted to the physcian were probably inaccurate, but R20's overall behaviors have improved. Care Plan Intervention Review: Surveyor reviewed R20's plan of care. The plan of care stated, in part, R20 is on an antipsychotic medication, [DIAGNOSES REDACTED]. Surveyor reviewed a section of the daily antipsychotic medication monitor form. The section was titled Behavior Management Intervention. The interventions were listed with a cooresponding letters, and included interventions such as: Taken to the bathroom, positive reinforcement, redirection, live the moment validation, food/fluids offered, music/activity offered and medication offered. These interventions were standard on the form, and the care plan did not include individualized interventions. No additional non-pharmacologic interventions were included in R20's plan of care with increased behaviors leading to increase in [MEDICATION NAME] doses on 04/10/19, 06/05/19 or 08/28/19. Surveyor interviewed DON B. DON B acknowledged the interventions on the current care plan are standardized and not individualized, and new interventions were not attempted when the medication was increased.

Based on observation, record review and interview, the facility did not review and revise a resident's plan of care to reflect specific assistance required. This occurred for 1 of 17 care plans reviewed, Resident (R) R20. The facility did not include repositioning or toileting assistance frequency on R20's plan of care. This is evidenced by: On 11/07/19 at 7:20 a.m., Surveyor observed R20. R20 was sitting in a broda chair. R20 was in the dining area and had already finished the breakfast meal. At 8:18 a.m., Registered Nurse (RN) C assisted R20 from the dining area into an adjacent lounge area to watch television. At 9:05 a.m., Homemaker (H) F brought R20 a cup of hot chocolate and a cookie. At 9:54 a.m., RN C assisted R20 to her room to be examined by a physician. At 9:59 a.m., R20 was returned to the lounge area. R20 remained in the lounge area. At 11:30 a.m., Surveyor interviewed Certified Nursing Assistants (CNAs) D and E. CNA [NAME] and CNA D stated they did not take R20 to the bathroom or assist R20 with position change. Surveyor reviewed R20's CNA assignment sheet. The assignment sheet indicated R20 required assistance with transferring and toileting. Repositioning was not listed. Surveyor interviewed Director of Nursing (DON) B. DON B stated residents who are immobile require repositioning every two hours, as well as toileting assistance every two hours. DON B stated this should have been included on the CNA assignment sheet.

Based upon record review and interview, the facility did not do complete and accurate documentation in the medical record for 1 of 12 (R5) sampled residents. R5 had a skin tear that was receiving treatments. The daily wound assessments were not completed. This is evidenced by: The facility policy titled, Wound Management, last revised 4/11/18, includes in part, .The residents .will receive appropriate assessment, and interventions to prevent and treat wounds .Procedure: V. New wounds are referred to the Assistant Clinical Mentor via the New wound identification and follow-up check list. The wound Identification and Follow-up checklist in part, 5. Initiate daily wound documentation in Matrix . R5 has was admitted to the facility 04/04/13 and has [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) documents R5 has a Brief Interview for Mental Status score of 12 meaning R5 is able to recall and answer most questions accurately. Surveyor noted in the record that R5 was getting treatments to a skin tear on her right lower leg. The physician orders [REDACTED].>11/12/18 Wound: Right shin skin tear-Daily documentation until healed; then x 7 days . 11/13/18 Wound: right skin tear-cleanse with normal saline, Apply [MEDICATION NAME] with pad. Change every 3 days and prn. 12/7/18 Hold Ted Stocking to R (right) lower extremity until ST (skin tear) heals. Tubgrip to RLE (right lower extremity) on am, off HS (hour of sleep) for [MEDICAL CONDITION]. 12/13/18 [MEDICATION NAME] 500 mg BID (twice a day) x one week 12/13/18 Wound tx (treatment) Right LE x 2. Cleanse irrigate wound with NS (normal saline), apply skin sealant to peri-wound skin .apply foam adhesive, can change prn for dislodgment or leakage. 12/13/18 R (right) LE (lower extremity) x 2 Daily documentation in matrix until healed . The nurses notes in part: 11/11/18 Resident noted to sustain a 7 cm x 4 cm skin tar to right shin during self transfer . 11/12/18 MD alerted to new skin tear .Treatment orders approved . 11/26/18 Dressing changed to right shin skin tear. Area continues with scant bloody drainage . 12/03/18 Treatment order for skin tear to right lower leg . There is no daily wound assessment to explain why there is a new order or the condition of the wound. 12/05/18 Skin tears on right lower shin and side of leg healing well . 12/09/18 Wounds to right shin and outer leg healing well, scant drainage . 12/13/18 Resident seen by MD on rounds this am. due to redness and [MEDICAL CONDITION] to right lower extremity .orders received for [MEDICATION NAME] .treatment orders changed . The physician note on 12/13/18 indicates R5's lower leg is red. The MD is concerned it is [MEDICAL CONDITION] (an infection of the skin tissue) and orders Cephadroxil (antibiotic) 500 mg for 7 days. The Medical Administration Record (MAR) was reviewed that documents the nurses have signed daily that they have completed the daily wound assessment. Surveyor reviewed the medical record for the daily wound assessments prior to the start of the antibiotics on 12/13/18. Review of the record has a wound assessment completed 11/18/18, then not again until 12/07/18 that includes in part, If declined or no change in 2 - 4 weeks was the physician notified? This is marked N/A (not applicable). There are no daily wound assessments completed the days prior to the physician order [REDACTED]. As of 12/20/18 no further daily wound assessments have been completed since 12/17/18. The daily wound assessment includes details such as amount of drainage, odor of drainage, type of drainage, wound edges, progress of the wound, and if there is no change or improvement to notify the MD. On 12/20/18, Surveyor interviewed the Director of Nursing (DON) at 1:15 p.m. about the right leg skin tear and not being able to find documentation on the status of this prior to the start of the antibiotic. The DON acknowledged the order was in the computer for daily wound assessments of the area but she can not locate any in the days prior to the antibiotic except for 12/07/18. The DON acknowledged the wound assessments have not been completed, although ordered and being signed out as done. The DON said she spoke with staff that worked most of these days and the staff stated they did not complete the daily wound assessment documentation.

Based on record review and interview, the facility did not do accurate bladder assessments to determine the needs to maintain bladder function of 1 of 1 (R3) residents sampled for a decrease in bladder continence. R3 had a decline in her bladder continence; the past four assessments completed since 03/11/18 were not accurate. This is evidenced by: R3 has [DIAGNOSES REDACTED]. R3's most recent quarterly Minimum Data Set ((MDS) dated [DATE] documents R3 is frequently incontinent of bladder. The bladder assessment completed on the same date documents R3 is occasionally incontinent of bladder (less than 7 episodes of incontinence in 7 days.) The assessment indicates R3 is not a candidate for bladder retraining; it does not give any rationale for this decision. The assessment indicates to continue the plan of care. Surveyor reviewed the quarterly MDS, dated [DATE], that documents R3 is frequently incontinent of bladder. The 09/10/18 bladder assessment documents R3 is continent of bladder and needs no program. The area to indicate care plan action is marked, continue plan of care. The 06/10/18 quarterly MDS documents R3 is occasionally incontinent. The Bladder assessment dated [DATE] documents R3 is frequently incontinent of bladder (7 or more episodes of urinary incontinence). The MDS dated [DATE] documents R3 has a catheter so the continence is not rated. The 03/11/18 bladder assessment states R3 has no catheter and occasional incontinence. The area to evaluate the need for a bladder training program is marked as none of the above. Indicate care plan action is marked, continue plan of care. Surveyor reviewed the record for a bladder incontinence care plan, none was located. On 12/20/18 at 1:15 p.m., Surveyor interviewed the Director of Nursing (DON) and Registered Nurse (RN) B. The DON reviewed the bladder assessments and MDS sections and could not understand why the assessments were not accurate. The DON indicated it made no sense to do the assessment with inaccurate information and no rationale for a bladder program. On 12/20/18 at 3:00 p.m., Surveyor interviewed RN C who completes the MDS section for bladder incontinence. RN C stated she looks at the tracking from the CNAs to answer the MDS question; she does not coordinate with the nurse that does the assessment. RN C indicated the nurses doing the assessment are not getting accurate information to complete the assessment but probably just asking the CNAs on the floor. RN C stated the assessment needs to be done accurately so an appropriate program can be set up for the residents. RN C indicated she has met with the DON and they will work on a system to coordinate the assessment with the MDS information.

Based on record review and interview, the facility did not ensure that fall interventions to prevent future falls were put into place for 1 of 3 (R24) sampled residents. R24 had two falls in the facility; the interventions to prevent falls were not implemented. This is evidenced by: R24 was admitted on [DATE]. The quarterly Minimum Data Set (MDS) documents a brief interview for mood status score of 7, meaning R24 has cognitive impairment making it difficult for him to remember things. R24 is determined to be at risk for falls. The medical record documents two falls since R24's admission. On 12/18/18 at 9:41 AM, Surveyor interviewed R24, who stated he fell here. He does not recall the details. The roster matrix has falls marked for R24. The falls investigations were reviewed and include in part: 10/7/18 - R24 fell on [DATE], description fell from bed, tripped on over bed table . Describe measures: Overbed table changed. Overbed table to not be placed over the bed at night. On 12/20/18 at 7:00 a.m., Surveyor observed R24 in bed, with the bed table up next to the bed, partially over the bed causing a potential tripping hazard. 10/14/18 - R24 fell at 7:30 a.m., in the hallway .Staff will attempt to walk resident whenever he is seen in the hall Care plan reviewed: Yes, reeducated on need to call for assistance. (R24 has a BIMS of 7). Will ask resident to walk when he is noted in hall in W/C. R24's care plan for falls does not include the interventions from the falls investigations which were added to prevent future falls . On 12/19/18 at 2:44 PM, Surveyor interviewed Certified Nursing Assistant (CNA) A, asking what the fall interventions are for R24. CNA indicated if he wants to walk we use a gait belt. Surveyor asked if there are any other things at night. CNA A indicated to make sure the bed is in the lowest position. CNA A said if the recliner is in a high position they are to lower it. Surveyor did not locate the recliner information as an intervention in the falls reports or care plan. Surveyor asked if it is in the care plan. Surveyor reviewed the care assignment card for R24 with CNA A. CNA A reviewed the falls interventions of keep bed in lowest position, Do not leave on toilet alone. CNA A stated there is nothing else on the care plan. Surveyor asked how the staff know the falls interventions. CNA A stated, That is a good question, maybe in a communication book? CNA A then said that staff talk to each other day to day and know what to do. Surveyor then shared the new interventions from the past two falls. CNA A indicated she was not aware of them. Surveyor interviewed the Director of Nursing (DON) on 12/20/18 at 1:20 p.m. to review the falls interventions. The DON stated she has talked to staff, looked through paper and the computer and admits the interventions are not on the care plan or CNA assignment sheet. The DON indicated she called the nurse who completed the falls investigation, and the interventions were not followed through with.

Based on observation, record review and staff interview, the facility did not provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs, to meet the needs of 1 of 10 sampled residents (R7). R7 was observed self-administering a nebulizer treatment. The facility did not have an assessment completed which deemed R7 safe to self-administer medications. This is evidenced by: The facility policy Medication Administration dated 04/06/17 states in part, Policy: Medications are to be administered using current standards of practice, checking the right resident, right medication, right dose, right route, and right time. Purpose: It is the goal of the facility to administer medications correctly and timely, and to optimize their effectiveness, the resident's satisfaction, and the nurse's legal and professional obligations. Procedure: 1. A physician order is obtained for every medication administered by a nurse or medication technician, or self administered by the resident. 4. Medication administration b. All medications are given after nursing assessment as to appropriateness, resident's current condition, allergies [REDACTED]. R7 has a [DIAGNOSES REDACTED]. On 11/02/16, the physician ordered Ipratropium/sol Albuter nebulize 1 vial three times daily. The most recent Self-Administration of Medication assessment dated [DATE] documented the following: Self-Determination - Does resident want to self-administer medications? No. Cognitive Status - What is the resident's daily decision making ability? Moderately impaired-Decisions poor, cues/supervision required. Fine Motor Skills - Can resident properly dispense eye drops, inhalers, nebulizers, nasal sprays, etc? No. Evaluation - Based on the answers, is it appropriate for resident to self-administer any medications? No. On 10/03/17 at 8:05 a.m., Surveyor observed R7 in her room seated at the bedside holding a hand held nebulizer to her mouth. R7 was self-administering a nebulizer treatment. R7 was unsupervised. Surveyor questioned Licensed Practical Nurse (LPN) A if R7 was able to self-administer the nebulizer treatment and if the physician had given orders for R7 to self-administer medications. LPN A stated she didn't know and would check the medical record. On 10/03/17 at 9:15 a.m., Surveyor informed the Assistant Director of Nursing (ADON) of the surveyor's observation of R7 self-administering a nebulizer treatment. Surveyor requested a copy of the physician order and a self-administration of medications assessment for R7. The ADON reviewed the medical record and could find no physician order and no self-administration of medication assessment documenting the resident was safe to self-administer medications. The ADON stated the facility would now assess the resident.

Based on interview and record review, the facility did not ensure that residents received proper foot care according to the current standards of practice for diabetic foot care for 1 (Resident #5) of 2 residents that were reviewed for treatment and specialty care needs. This is evidence by: Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/05/16, Surveyor reviewed Resident #5's record and could not locate a care plan addressing diabetic foot care. On 10/05/16 at 2:50 p.m., Surveyor requested the standard of practice used by the facility for diabetic foot care. On 10/06/16 at 8:50 a.m., the Director of Nursing (DON) stated that the Standard of Practice the facility follows for diabetic foot care is American Medical Directors Association (AMDA). Surveyor and the DON discussed the guidelines and the need for daily inspection of diabetic feet by a trained employee. It was also discussed that Resident #5 was considered high risk by the guidelines due to his current diagnoses. Care planning, daily inspections and documentation were discussed. It was determined this was not being done on a daily basis.

Based on observation, record review and interview, the facility did not ensure that procedures were followed to ensure accuracy of administration of medication to residents who reside in the facility for 1 supplemental resident (Resident #11) reviewed for medication administration in the dining room who did not receive appropriate supervision. As evidenced by: On 10/05/16, Surveyor reviewed the medical record for Resident #11 and noted the following: - Current physician orders, received 10/05/16, stated Resident #11 has a current order to self-administer insulin and check his own blood sugars and facility nursing staff are to document monthly on safety and ability to do on his own. Orders also stated Resident #11 has an order to self-administer nebulizer treatments and nursing staff are to document monthly for safe, correct use. Surveyor was unable to identify a current physician order for [REDACTED]. - Facility self-administration assessment, completed on 06/10/16, states Resident #11 is able to self-administer some medications. - Current physician orders for Resident #11 included Furosemide 20 mg tablet to be given daily by mouth. On 10/05/16 at 8:50 a.m., Surveyor was sitting at the nursing station desk interviewing Registered Nurse (RN) H. Surveyor noted Dietary Homemaker (DH) J approach the nursing desk with a small clear cup containing a pill and handed it to RN H stating, I found this pill left on room [ROOM NUMBER]'s plate. RN H stated, It looks like a Lasix pill. Surveyor asked the name of the resident in room [ROOM NUMBER] and RN H said it was Resident #11. RN H then went to the medication cart located in the hallway and retrieved Resident #11's medication blister packets and compared the pill in the cup to the pills in the Lasix blister pack. RN H then entered Resident #11's room and stated, Found a pill at your table .looks like your Lasix pill .can I give you a new one? RN H then threw the pill in the cup away. Resident #11 stated, I thought I had taken it .don't remember leaving a pill in the cup. RN H then left the room and returned with a new Lasix pill and administered it to Resident #11. On 10/05/16 at approximately 9:15 a.m., Surveyor interviewed RN H, who stated there was no order for Resident #11 to self-administer the Lasix pill. On 10/06/16 at 10:30 a.m., Surveyor interviewed the Director of Nursing in regard to the above observation and discussed concerns of Resident #11 not being appropriately supervised during medication administration and having no physician's order to self-administer the Lasix.

Based on observation and interview, the facility did not ensure to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of their own individuality for 1 (Resident #9) of 9 sampled residents. This is evidenced by: On 10/06/16 at 6:20 a.m., Surveyor was outside, walking down the sidewalk to enter the building. Looking to the left, Surveyor could see a resident's room light was on and the shade was all the way up and the door to the hallway fully open. Surveyor could see into the resident's room and there was an employee dressed in all navy blue scrubs standing in the doorway to the resident's bathroom; the bathroom light was also on. As the employee pushed the bathroom door all the way open and walked inside the bathroom, Surveyor could see the resident sitting on the toilet from the sidewalk outside the building. Surveyor entered the building and went to the room in question. The door was fully open, the shade on the window was all the way open and an employee dressed in dark blue scrubs was assisting the resident to a recliner. Surveyor asked Certified Nursing Assistant (CNA) I who was assisting Resident #9 with morning cares and she stated it was Physical Therapy (PT). Surveyor then approached the nurse, Registered Nurse (RN) H, and explained what the surveyor had seen. On 10/06/16 at 6:50 a.m., Surveyor discussed with Assistant Clinical Mentor (ACM) C the above observation. ACM C stated the windows are shaded and that prevents someone from seeing in during daylight. In the dark with lights on in the room, you can see into the rooms from the outside of the building. On 10/06/16 at 8:50 a.m., Surveyor discussed the observation with the Director of Nursing (DON). The DON stated that she would speak with PT.

Based on observation, interview and record review, the facility did not provide reasonable accommodation of individual needs and preferences for 1 of 9 sampled residents. The facility did not provide Resident #4 with a trapeze to aide in bed mobility as ordered by the physicain. This is evidenced by: Resident #4's has [DIAGNOSES REDACTED]. On 10/13/15, Surveyor observed hygiene assistance provided to Resident #4 by CNA (Certified Nursing Assistant) M. Resident #4 did not have an overhead trapeze on her bed. CNA M assisted the resident into a sitting position on the edge of the bed. The resident was able to walk to the bathroom with one assistance and a 2 wheeled walker. After Resident #4 was dressed, CNA M assisted the resident via her wheelchair per her choice, to the main dining area for breakfast. On 10/13/15, Surveyor reviewed Resident #4's clinical record. A physicians' order dated 10/2/15, read: Overhead trapeze on bed for positioning. Another physicians' order dated 10/13/15, read: Discontinue Trapeze. On 10/13/15, Surveyor interviewed Resident #4. Resident #4 stated, The therapist was wondering about the trapeze. I never did get it. I think it would help if I had one. Surveyor interviewed Assistant Director of Nursing (ADON) A. ADON A was not sure if Resident #4 ever had a trapeze. Surveyor interviewed PT (Physical Therapist) I. PT I told Surveyor that she thought that a trapeze would benefit Resident #4, but the facility did not obtain the device for the resident. PT I provided a list of recommendations, written on 10/2/15, which included a recommendation for a trapeze. Surveyor interviewed CNA G. CNA G stated that she had assisted the resident many times since admission and there was never a trapeze on the bed. Surveyor interviewed the Director of Nursing who indicated that the trapeze should have been ordered for the resident as recommended by PT I and ordered by the physician.