Every finding on record at Onalaska Care Center

Based on interview and record review, the facility did notify the resident representative of a change in condition for 1 of 3 residents (R) reviewed (R1). R1 had multiple syncopal episodes resulting in one fall, and R1's family/representative was not notified for each occurrence. This is evidenced by: Facility policy titled, Change in Condition, with a revised date of 08/12/24, states in part: Purpose: To assure appropriate medical intervention in the event of significant change in resident's physical or mental condition. Procedure: .3. The Charge Nurse will assess the resident and will immediately consult with the provider and notify the family/HCPOA when a deviation occurs, including: i. An accident, which results in an injury and has potential for requiring physician intervention. 2. The provider and family/HCPOA will be notified immediately if the resident has a significant change in status relating to a previous accident that had originally resulted in no change. (i.e. increased pain, bruising, deformity, swelling, etc.) ii. A significant change in physical, mental or psychological status. (i.e. a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications.) R1 was admitted to the facility on [DATE] with pertinent diagnoses of atrial fibrillation, congestive heart failure, hypotension, and syncope and collapse. R1's admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 14/15 indicating cognition intact, able to be understood, and understands others. Surveyor reviewed R1's admission documentation and noted R1's son was the designated healthcare power of attorney (HCPOA) which is not activated. R1's HCPOA was designated as R1's emergency contact. R1's daughter-in-law was also noted as a family contact. Surveyor reviewed R1's social worker notes and noted on 01/14/25 they state R1 is cognitively intact, own decision maker, and states preference to notify family/representative of incidents. On 05/12/25, Surveyor reviewed R1's nursing notes and noted the following: -03/22/25 at 2:43 PM, R1 had an unwitnessed fall. R1 was assessed and noted no injuries, no pain, and no musculoskeletal deformities. Provider notified. R1 declined family notification. -03/23/25 at 11:45 AM, R1 had syncopal episode during transfer resulting in a skin tear on left inner forearm. Wound was cleansed, steri-strips and gauze applied. R1 was assessed and noted no injuries, no pain, and no musculoskeletal deformities. -03/24/25 at 12:32 PM, R1 had syncopal episode after repositioning. R1 complained of moderate pain in left leg with lifting leg and knee flexion. No musculoskeletal deformity noted. No documentation of provider or family/HCPOA notification at this time. -03/25/25 at 12:34 PM, R1 was assessed and noted to have left foot externally rotated, left lower extremity range of motion loss, Activity of Daily Living (ADL) interference, and/or risk of injury present. Provider and family notified. R1 was sent to hospital for evaluation. On 05/12/25, Surveyor reviewed R1's hospital summary and noted R1 was admitted to the hospital on 03/25/25. Hip/pelvis x-ray confirmed acute left femoral neck fracture. Chest x-ray noted non-acute, healing, nondisplaced fractures of anterior or lateral left 4th, 5th, 6th, 7th, 8th, 9th ribs. Due to increased risk, R1 was not a surgical candidate. R1 and family agreed to palliative care. R1 was discharged from hospital on 03/27/25 on hospice and returned to facility. On 05/12/25 at 1:41 PM, Surveyor interviewed R1's Family Member (FM) G, who stated not being notified of a fall or a syncopal episodes that occurred between 03/22/25-03/24/25. FM G stated family was notified mid-afternoon on 03/25/25 of R1 having a possible leg/hip fracture and would be transferred to the hospital for evaluation. On 05/12/25 at 4:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding notifications. LPN C stated if a fall or a significant change is assessed in a resident, charge nurse is notified, who will be responsible for notifying the provider and/or family. On 05/12/25 at 4:38 PM, Surveyor interviewed Registered Nurse (RN) E regarding notifications. RN E stated being charge nurse role and would have the responsibility of notifying the provider and family with changes or concerns. RN E stated if a resident is their own decision maker, they are asked if they would like their family notified. RN E stated they notify family based on resident preference. On 05/12/25 at 4:47 PM, Surveyor interviewed Director of Nursing (DON) B regarding notifications. DON B stated if a resident has an activated HCPOA, notification is always made immediately after incidents or change in condition. If a resident is their own decision maker, then they are asked their preference on notification to family. Surveyor asked DON B about R1's preference for notifying family. DON B stated being aware that R1 wanted family notified, but that R1 was asked after each incident if family should be notified. Surveyor asked DON B if this would be documented asking R1 on notification. DON B stated yes, it should. DON B stated that R1 was likely asked if family should be notified but was unable to provide the documentation of this.

Based on interview and record review, the facility did not ensure residents received care and treatment in accordance with professional standards of practice for 1 of 3 residents (R) reviewed (R1). Staff did not complete comprehensive and focused respiratory, skin and pain assessments after R1 had a fall and complained of rib pain. This is evidenced by: Facility policy titled, Resident Fall, with a revised date of 01/06/25, states in part: .After immediate/emergent needs have been addressed, head-to-toe assessment of resident to be performed by the RN/Charge LPN including assessment for head trauma, any obvious injury, pain, possible fracture, ability to move all extremities, any deformity/shortening/rotation of legs. According to the American Journal of Nursing, When a fall occurs, a comprehensive assessment must be completed to include visual observation of skin to assess for bruising, pallor, and trauma; note any pain and points of tenderness. Be aware of the following warning signs: numbness or tingling in the extremities, back pain, rib pain, or an externally rotated or shortened leg .Focused assessments should be completed frequently when any abnormalities are assessed to monitor for changes and efficacy of treatment. Current professional standards for pain assessment include pain intensity, location, quality, functional impairment, onset, and duration to evaluate for efficacy of interventions and changes that may indicate a need for further evaluation or worsening of condition. R1 was admitted to the facility on [DATE] with pertinent diagnoses of atrial fibrillation, congestive heart failure, hypotension, and syncope and collapse. R1's admission Minimum Data Set (MDS) assessment, dated 01/22/25, noted a Brief Interview for Mental Status (BIMS) score of 14/15 indicating cognition intact, able to be understood, and understands others. R1 was noted to have chronic pain occasionally present in left and right hip rated 3/10. Surveyor reviewed R1's electronic medical record and noted: On 02/12/25 at 12:05 AM, R1 was found on floor. No injuries assessed. R1 denied pain. Vital signs, musculoskeletal system, and neurological assessments completed with no abnormalities noted. No documentation of a head to toe skin assessment noted. On 02/12/25 at 11:00 PM, fall occurred due to weakness/dizziness during transfer. No injuries assessed. R1 denied pain. Vital signs, musculoskeletal system, and neurological assessments completed with no abnormalities noted. No documentation of head to toe skin assessment noted. On 02/13/25 at 1:56 PM, R1 complained of dizziness/vertigo, syncope, weakness, shortness of breath with exertion and at rest, respirations noticeably quick and short, lung sounds clear upper bilaterally and diminished lower bilaterally, and had 3+ pitting edema of R1's bilateral lower extremities. Of note: Provider and family notified. R1 declined transfer to hospital for evaluation. No skin assessment documented. No further comprehensive respiratory assessment noted. On 02/16/25 at 2:00 PM, R1 found on floor and stated sliding out of wheelchair. No injuries assessed at this time. R1 denied pain. Vital signs, musculoskeletal system, and neurological assessments completed with no abnormalities noted. No documentation of skin assessment noted. No documentation of comprehensive respiratory assessment noted. On 02/17/25, R1 complained of left rib pain rated 6/10. Of note: Comprehensive respiratory assessment not completed. Comprehensive pain assessment to include quality, functional impairment, onset, and duration was not completed. On 02/18/25, R1 complained of painful coughing and left rib pain following recent fall. R1's respirations elevated, shallow. Congested cough, non-productive. Lungs clear throughout. Left side chest tender to touch/palpation. No skin assessment noted. Comprehensive pain assessment to include quality, functional impairment, onset, and duration was not noted. On 02/20/25, R1 complained of left hip pain going up left side rated 8/10. Of note: Comprehensive respiratory assessment not completed. Comprehensive pain assessment to include quality, functional impairment, onset, and duration was not completed. On 03/22/25 at 2:43 PM, R1 found on floor with wheelchair on top of R1's body. R1stated losing balance when trying to move wheelchair. R1 denied pain. Vital signs, musculoskeletal system, and neurological assessments completed with no abnormalities noted. No documentation of skin assessment noted. No documentation of comprehensive respiratory assessment noted. On 03/22/25 at 8:15 PM, R1 complained of left hip pain rated 8/10. Of note: Comprehensive pain assessment to include quality, functional impairment, onset, and duration was not completed. On 03/25/25 at 12:03 AM, R1 complained of pain that was aching, almost constantly Night shift documented in musculoskeletal note, mild to moderate pain in left leg, but did not complete a comprehensive pain assessment to include functional impairment, onset or duration. On 03/25/25 at 12:34 PM, R1 complained of pain to left hip while lying at rest in bed. Assessment noted left foot was externally rotated. Skin assessment noted no abnormalities. At 4:11 p.m., R1 was transferred to the hospital for evaluation. All falls documented included fall investigation to determine root cause, identify risk, and contributing factors. Safety interventions were appropriately implemented. Provider was appropriately notified and assessed. Surveyor reviewed R1's hospital discharge summary and noted: On 03/25/25, CT of chest noted non-acute, healing, nondisplaced fractures of lateral left 4th, 5th, 6th, 7th, 8th, 9th ribs. Chest x-ray noted left pleural effusion, suspected pulmonary edema, potentially with infectious/inflammatory or aspiration pneumonitis. Hip/pelvis x-ray noted acute fracture of the left subcapital femoral neck. On 05/12/25 at 4:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN) C regarding post-fall assessments. LPN C stated residents are to be assessed head-to-toe, which includes skin, respiratory status, pain, and cognition. LPN C stated if any abnormalities are assessed, the charge nurse is notified, and follow-up focused assessments would be completed. On 05/12/25 at 4:27 PM, Surveyor interviewed Registered Nurse (RN) D regarding post-fall assessments. RN D stated residents should be assessed head-to-toe. RN D stated that if a resident complains of rib pain, then a focused respiratory assessment should be completed to include lung sounds, respirations, shortness of breath, muscle use, and skin color. RN D stated pain assessment should include location, severity, and duration. Surveyor asked if this was documented in a resident's chart. RN D stated if it was assessed, then it should be documented in a nursing note. On 05/12/25 at 4:47 PM, Surveyor interviewed Director of Nursing (DON) B regarding post-fall assessments. DON B stated staff are expected to assess residents head-to-toe and document findings. DON B stated nursing is expected to monitor pain using location and severity and complete follow-up assessments for efficacy. Surveyor asked DON B how pain is monitored for changes. DON B stated interventions are assessed for efficacy to determine if pain is worsening. Surveyor asked DON B if this practice would be effective in monitoring for changes in pain, as R1 was noted to have hip pain on admission. DON B acknowledged staff did not assess for changes or worsening in R1's hip pain. Surveyor asked DON B if a focused lung assessment should have been completed with R1 after noting rib pain. DON B stated yes.

Based on observation, interview and record review, the facility did not maintain a safe and sanitary environment in which food is prepared and distributed. This has the potential to affect all 53 residents who reside in the facility. Facility staff did not conduct appropriate hand hygiene and were observed touching ready to eat foods with contaminated gloved hands. This is evidenced by: Facility's policy Handwashing and Sanitizing with the recent effective date of 10/28/24 read in part, Handwashing/Sanitizing indications: .after removing gloves .Handwashing: Wet hands thoroughly with warm running water. Soap hands thoroughly, working up a lather. Wash all parts of hands for 20 seconds. Rinse hands thoroughly. Leave the water running. Dry hands with paper towels. Turn off faucet with dry paper towel . On 01/27/25 at 11:42 AM, Surveyor observed Dietary Aide (DA) E wash hands, apply gloves, touch the bread bag to take a piece of bread out and put in toaster, touching the toaster knobs. DA E continued with the same gloved hands and touched ladles to serve the resident meal plates for room trays. With the same gloved hands, DA E touched the toast and placed on a resident's meal plate that went into the transport cart. On 01/27/25 at 11:48 AM, Surveyor observed DA F wash hands and turn off faucet with clean hands, tapped fingers on the inside of the sink, dried hands, and applied gloves. DA F continued with placing meal plates into the transport cart. On 01/28/25 at 11:40 AM, Surveyor observed DA F wash hands and turn faucet off with clean hands, not using a paper towel, and dried hands. Then DA F applied gloves, proceeded to prepare resident meal trays of drinks and set resident meal plates in the transport cart. On 01/28/25 at 11:43 AM, DA E washed hands, turned water off with elbow and dried hands. Then DA E applied gloves and started serving the resident meals. With gloved hands, DA E touched ladles and touched the bag with dinner rolls. With the contaminated gloved hands, DA E touched the ready to eat dinner roll and placed it on a resident's plate that was placed in the transport cart that was to be delivered to a resident eating in their room. On 01/28/25 at 11:45 AM, DA F returned from delivering the meal tray transport cart and washed hands, turned off faucet with clean hands, not using a paper towel, and dried hands. DA F touched pen to write on meals slips. DA F washed hands, turned off faucet with clean hands, dried hands and applied gloves. DA F proceeded to place plastic lids on drinks in meal transport cart. On 01/29/25 at 9:15 AM, Surveyor interviewed Nutrition Services Director (NSD) G about proper hand washing. NSD G indicated hands should be washed, dried, and faucet turned off with a clean paper towel. Surveyor reviewed the above observations with NSD G concerning hand hygiene and touching ready to eat foods. NSD G indicated staff had training in a computer based healthcare training about proper hand hygiene and dietary trainings.

Based on observation, interview and record review, the facility did not establish a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents and staff. The facility did not ensure an adequate surveillance system was in place for tracking onset of illness date and resolution of illness symptoms resulting in an outbreak to be lifted prematurely or identify communicable diseases on the line list for R29 and R19. Staff did not practice proper hand hygiene during observation of cares for 4 of 9 residents (R) (R25, R28, R13, and R153). Enhanced barrier precautions were not in place for R14 or followed for R19 Staff did not sanitize a mechanical lift during observation of transfers of 2 residents (R25 and R28) who are roommates. This is evidenced by: Facility policy titled Infection Prevention and Control Program Policy with revised day of 1/23/25, states in part: Purpose: to prevent infections in residents, employees, and other persons in contact with our residents. Surveillance: residents and healthcare personnel will be monitored for acquisition of infections. Example 1 - Surveillance Per CDC Guidelines for Prevention and control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings (2011 states: during outbreaks, Place patients with norovirus gastroenteritis on contact precautions for a minimum of 48 hours after the resolution of symptoms to prevent further exposure of susceptible patients. Exclude ill personnel from work for a minimum of 48 hours after the resolution of symptoms. On 01/29/25 at 10:41 AM, Surveyor reviewed the facility's infection control line list for staff and residents and noted on 01/02/24 the facility recognized an outbreak of Norovirus on the 200 and 300 wings of the facility. The facility lifted the outbreak on 02/01/24. The facility line lists provided by facility continued to have residents and staff with symptoms of norovirus after 02/01/24 lifting of Norovirus outbreak. -R203 had an onset of nausea, vomiting and diarrhea on 01/27/24 and resolved on 02/03/24. -R204 had an onset of nausea and multiple loose stools on 02/04/24 with no resolution date of symptoms resolution noted. -Certified Nursing Assistant (CNA) J had onset of nausea, vomiting and diarrhea on 01/30/24 with no resolution date of symptoms resolution noted. -CNA K had an onset of vomiting on 02/02/24 with no resolution date of symptoms resolution date. On 01/29/25 at 11:24 AM, Surveyor interviewed Director of Nursing (DON) B and Infection Preventionist (IP) H regarding the facility's surveillance of the Norovirus outbreak and how to determine when to lift an outbreak in the facility. DON B and IP H confirmed the illness should have been monitored for last date and time of last symptom to be able to determine when to lift the outbreak and should have considered both residents and staff onsets and resolutions of symptoms before lifting outbreak. Example 2 R29 was admitted to the facility on [DATE] with pertinent diagnoses of congestive heart failure, stage 2 pressure injury, and chronic kidney disease stage 3. R29's admission Minimum Data Set (MDS) dated [DATE] noted pressure ulcer/pressure injury present requiring wound care and application of ointment/medications to area other than feet. R29's physician orders: Vancomycin HCl 125mg cap 1 cap PO four times a day x14 days FOR Clostridioides difficile Infection FIRST DATE: 12/6/24 through 12/19/24 Vancomycin HCl 125mg cap 1 cap PO twice a day x7 days FOR Clostridioides difficile Infection FIRST DATE: 12/20/24 through 12/26/24 Vancomycin HCl 125mg cap 1 cap PO daily x7 days FOR Clostridioides difficile Infection FIRST DATE: 12/27/24 through 1/2/25 Vancomycin HCl 125mg cap 1 cap PO every other day FOR Clostridioides difficile Infection FIRST DATE: 1/3/25 through 1/10/25 Vancomycin HCl 125mg capsule 1 cap PO every three days FOR Clostridioides difficile Infection FIRST DATE: 1/11/25 through 1/25/25 Surveyor reviewed R29's electronic medical record noted: 12/05/24 - stool sample resulted positive for Clostridioides difficile toxin; results acknowledged by provider On 01/29/25, Surveyor reviewed facility's infection surveillance logs. On 11/16/24, R29 was added to the surveillance log with symptoms of diarrhea, lab confirmation positive for Clostridioides difficile (C. diff), treatment with Vancomycin (antibiotic), initiation of transmission-based precautions (TBP) of contact precautions on 11/16/24 and discontinued on 11/26/24, and symptoms resolved on 11/28/24. R29 was not documented at any time on the facility's surveillance log in December 2024 or January 2025 for the c. diff infection. On 01/29/25 at 2:09 PM, Surveyor interviewed IP H regarding the facility's infection surveillance logs. Surveyor asked IP H why R29's TBP precautions were discontinued on 11/26/24. IP H stated that R29 had been on antibiotic treatment and symptoms were intermittent, so TBP was no longer necessary. Surveyor asked IP H is she was aware that another stool sample collected on 12/05/24 resulted positive for c. diff and the provider began another antibiotic treatment course. IP H stated yes, she was aware of the antibiotic treatment but thought it was just a taper dose from the prior infection. IP H stated not being aware of a second positive c. diff result and that this should have been documented on the surveillance log. IP H stated recognition of the potential harm this could have for R29 and the other residents in the facility by not monitoring and tracking the infection for efficacy and potential outbreaks. Example 3 R19 was admitted to the facility on [DATE] with pertinent diagnoses of herpes zoster (also known as shingles). R19's admission Minimum Data Set (MDS) completed on 12/30/24 noted skin conditions present requiring application of ointments/medications to area other than feet. R19's physician orders: Valacyclovir 1 gram tab take 1 tab PO daily for 4 doses for herpes zoster START DATE: 12/20/24 Surveyor reviewed R19's hospital discharge notes and noted the following: 12/19/24: ISOLATION FOR INFECTION AFTER DISCHARGE: He has Herpes Zoster (Shingles) which requires contact precautions. On 01/29/25, Surveyor reviewed the facility's infection surveillance logs. R19 was not documented at any time on the facility's infection surveillance log for herpes zoster infection during the month of December 2024. On 01/29/25 at 2:09 PM, Surveyor interviewed IP H regarding infection surveillance. IP H stated being aware of R19's herpes zoster infection on admission. Surveyor asked IP H why R19 was not added to the infection surveillance log. IP H stated she must have missed it. IP H stated recognition that this infection had the potential to cause harm to other residents and that it should have been properly documented and tracked on the surveillance log to monitor for treatment efficacy and potential outbreak concerns. Example 4 - Hand hygiene Policy and procedure titled: Handwashing and Sanitizing with effective date of 10/28/24, states in part: Handwashing/Sanitizing: Indications: Always wash/sanitize hands before doing cares on residents, after cares, between residents, .after removing gloves and before leaving a room. On 01/28/25 at 7:48 AM, Surveyor observed CNA D conduct morning cares on R28. CNA D washed hands donned a clean pair of gloves and washed R28's face. CNA D then proceeded to: -Open closet to get basin with supplies, remove gloves, take out a key from pocket to unlock a cabinet to retrieve a tube of cream for R28's peri area. -Without conducting hand hygiene, don a clean pair of gloves, remove supplies from basin, pick up garbage bin and move it closer to bedside. -Open a clean incontinent product and unfasten and remove the contaminated incontinent product that had urine and feces. Then use a wet washcloth and cleanser, complete incontinence care and remove gloves. -Without conducting hand hygiene, don a clean pair of gloves, place peri cream on R28's coccyx, position clean incontinent product, fasten in place and remove gloves. -Without conducting hand hygiene, roll R28 back and forth to place a dress and a transfer sling under R28. On 01/28/25 at 8:23 AM, Surveyor observed CNA D after completing cares on R28, without conducting hand hygiene, don a clean pair of gloves and conduct morning cares on roommate R25 which included incontinence care. CNA D proceeded to do the following: -Wet washcloths and washed face. -Picked up and placed garbage bin near bed. -Removed gloves and without conducting hand hygiene donned new pair of gloves and raised bed height for cares. -Removed R25's incontinent product and stated that R25's pad is wet. With same contaminated gloves, picked up and opened clean incontinent product. -Rolled resident to right side, to complete incontinent care and apply barrier cream to R25's buttocks. -Without removing contaminated gloves and conducting hand hygiene, rolled R25 towards left side to position and fasten clean incontinent product and transfer sling for transfer. -Without conducting hand hygiene, removed dirty gloves and placed new pair of gloves, began to wash R25's upper body, arms and hands with bath wipes, disposed used wipes in garbage, dried with towel, touched the supplies in R25's basin looking for baby powder, applied baby powder under R25's breast, dressed R25 in clean pants and placed in linen bag, On 01/28/25 at 8:52 AM, Surveyor interviewed CNA D regarding facility expectation of when to conduct hand hygiene. CNA D stated the expectation would be to conduct hand hygiene by using sanitizer or washing hands before and after conducting cares and in-between gloves changes. Surveyor asked CNA D the facility expectation of conducting hand hygiene between resident cares. CNA D stated the expectation would be to conduct hand hygiene after competing cares on R28, before starting cares on R25. CNA D confirmed Surveyor's observation of no hand hygiene conducted during R25's cares, after removing gloves and between cares of R25 and R28. On 01/28/25 at 12:43 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding observation and expectation of no hand hygiene conducted after removing gloves during resident care and between residents during morning cares. NHA A stated expectation would be to conduct hand hygiene after removing gloves. On 01/28/25 at 1:00 PM, Surveyor interviewed DON B regarding observation of no hand hygiene after removing gloves during resident care, including between cares of R25 and R28. DON B stated expectation would be to conduct hand hygiene after removing gloves. Example 5 R13 was admitted to the facility on [DATE] with a diagnosis of Parkinson's (a movement disorder that affects the nervous system and worsens over time) and age-related osteoporosis (a disease that weakens your bones and makes them more likely to break). R13 had a restorative program that included pulley with weights to upper extremities three times per week. R153 was admitted to the facility on [DATE] with diagnoses of muscle spasm, and osteoarthritis (occurs when the smooth, slippery cartilage that coats the endings of bones begins to deteriorate at a joint). On 01/29/25 at 10:44 AM, Surveyor entered R13's room. CNA I already had gloves on her hands and was assisting R13 with restorative cares to upper body with the use of weights on R13's wrist and pulley. After the 5 minutes of pulley exercises, CNA I removed her gloves and did not perform hand hygiene. Surveyor observed CNA I finish restorative cares with R13. CNA I then put on gloves without performing hand hygiene and began to clean the equipment used by R13. Then R13's roommate, R153, asked CNA I if she (R153) could get her nails clipped. CNA I replied to R153, Yes. CNA I then removed her gloves and did not perform any hand hygiene, left this resident's room, walked to the nurses' station and opened a drawer in the nurses' station taking out a pair of fingernail clippers. CNA I then walked back into the resident's room and no hand hygiene was performed. CNA I then clipped R153's fingernails. When CNA I had finished with R153, CNA I exited the room without performing any hand hygiene and returned the nail clippers to the nurses' station. Surveyor then watched CNA I go on to the next resident for restorative care. On 01/29/25 at 10:50 AM, Surveyor interviewed CNA I regarding observation made. Surveyor asked CNA I, When would you be expected to perform hand hygiene? CNA I replied, Before going into the room and when leaving the room and definitely before I clipped the roommate's fingernails. On 01/29/25 at 10:55 AM, Surveyor interviewed DON B about what the expectation would be regarding this observation as it relates to hand hygiene. DON B replied, Hand hygiene should be performed before entering a resident's room, prior to putting on gloves and after removing gloves. 49353 Example 6 - Enhanced Barrier Precautions Facility policy titled, Policy and Procedure: Enhanced Barrier Precautions, with a reviewed date of 01/23/25 stated in part: PURPOSE: To provide an effective system for the prevention, identification, and control of MDROs. 1. Enhanced Barrier Precautions a.The use of a gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. b. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator viii. Wound care: any chronic skin opening requiring a dressing R14 was admitted to the facility on [DATE] with pertinent diagnoses of stage 3 pressure ulcer of sacral region, lymphoid leukemia, and polyneuropathy. R14's most recent MDS noted a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognition is intact. R14 is noted to have occasional incontinence of bowel and bladder, has 1 stage 3 pressure ulcer/pressure injury present on admission and receives wound care. R14's care plan initiated on 11/15/24 noted: Problem: Tissue integrity impairment -REVISED: 11/25/24: EBP precautions for pressure injury R14's orders: 1/21/25: Stage 3 coccyx- gently cleanse with soap & water, pat dry apply skin prep to peri-wound for protection, cover with duoderm . During survey period of 01/27/25 - 01/30/25, Surveyor observed no signage outside of R14's room to indicate use of enhanced barrier precautions (EBP). No EBP personal protective equipment (PPE), such as gowns, were observed inside or readily available for use in R14's room. On 01/29/25 at 12:57 PM, Surveyor interviewed DON B regarding EBP. Surveyor asked DON B how staff and visitors are made aware of a resident being on EBP. DON B stated that an EBP sign would be posted outside of the resident's door and nursing staff would be updated through the resident's care plan. Surveyor asked DON B when EBP would be initiated. DON B stated some examples would include having a catheter, non-healing wound, or other medical indwelling device. Surveyor asked DON B if R14 should have EBP in place. DON B stated that she thought R14's wounds were healed and EBP was not needed. DON B then reviewed R14's current orders and noted that wound care and dressing changes were still being completed. DON B stated that R14's EBP should still be in place and recognized the increased risk for infection that still exists. DON B stated that she would immediately reimplement EBP for R14 and inform nursing staff. Example 7 R19 was admitted to the facility on [DATE] with pertinent diagnoses of herpes zoster (also known as shingles), obstructive and reflux uropathy (blocked urinary flow), and retention of urine. R19's admission Minimum Data Set (MDS) completed on 12/30/24 noted a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment, presence of indwelling catheter, and skin conditions present requiring application of ointments/medications to area other than feet. R19's physician orders: 12/19/24: change indwelling foley catheter (16fr coude with 10 cc balloon) REASON FOR INDWELLING: acute urinary retention/obstruction daily as needed On 01/28/25 at 8:48 AM, Surveyor observed EBP sign outside of R19's door and disposable gowns located inside R19's room on the back of the resident's door. Surveyor observed CNA C complete hand hygiene and don gloves prior to starting cares with R19. CNA C did not don a gown. Surveyor observed CNA C assist R19 to the toilet and completed personal cares that included washing of face, body and peri area. CNA C then completed catheter care by disconnecting the urinary catheter tube and resting it on the toilet seat while emptying the urinary bag contents into a graduate container placed directly on the bathroom floor without first placing a barrier down between the graduate container and floor. CNA C disinfected the catheter connector with an alcohol wipe before connecting to the new tubing connector. CNA C then removed gloves, completed hand hygiene, and assisted R19 with putting his pants on. CNA C did not have gloves or gown on. On 01/28/25 at 9:17 AM, DON B knocked and entered R19's room. DON B reminded CNA C to complete hand hygiene in-between cares and handed her a gown to put on. DON B reminded CNA C that R19 was on EBP, and staff needed to wear a gown and gloves when providing direct cares. CNA C stated confusion of needing to wear the gown as her understanding was it was only necessary for MRSA (Methicillin-resistant Staphylococcus aureus) infections. DON B stated that was incorrect and R19 was on EBP for having an indwelling foley catheter and that when CNA C was finished with assisting R19 they would complete some additional training on EBP. On 01/29/25 at 12:57 PM, Surveyor interviewed DON B regarding observation of cares for R19. DON B stated that she was disappointed entering R19's room and seeing CNA C not wearing the proper personal protective equipment (PPE) required for EBP. DON B stated that she completes frequent audits and impromptu teaching with staff regarding infection control and EBP. DON B stated that follow-up education had already been completed with CNA C and additional education would be completed with the rest of the nursing staff as this is a vital step in preventing infection. Example 8 - Sanitization of lift Facility policy titled Equipment Cleaning last reviewed on 11/15/24, states Purpose: Maintain infection prevention techniques to help prevent the spread of illness. Under section titled Procedure 1. Shared equipment needs to be disinfected after each resident use with hydrogen peroxide wipes. On 01/28/25 at 8:11 AM, Surveyor observed CNA D transfer R28 from bed to chair after completing cares using a mechanical lift No sanitizing of lift prior to and after transfer was observed. On 01/28/25 at 8:46 AM, Surveyor observed CNA D transfer R25 from bed to chair after completing cares using a mechanical lift. No sanitizing of lift prior to and after transfer was observed. On 01/28/25 at 8:52 AM, Surveyor interviewed CNA D regarding expectation of when to sanitize mechanical lift. CNA D stated the expectation of cleansing lifts is after use and between residents. CNA D confirmed not sanitizing lift before or between roommates R25 and R28. On 01/28/25 at 1:00 PM, Surveyor interviewed DON B regarding observations of no sanitizing of mechanical lifts before and between R25 and R28's transfers. DON B stated the expectations would be to sanitize mechanical lifts between resident transfers. 46694

Based on policy review and interview, the facility failed to ensure facility's admission packet did not request or require residents to waive potential facility liability for losses of personal property. This failure had the potential to affect all 53 residents residing in the facility. This is evidenced by: Facility document titled, Personal Property Notice, stated in part: Residents of any [corporation name] facility may have in their possession whatever personal property they choose within reason and in keeping with space limitation, infection control concerns and safety issues for all residents and staff. HOWEVER, please be aware that [corporation name] is not responsible for the loss, damage or maintenance of any personal possessions or property. To avoid any potential problems regarding your personal property, we recommend that you not bring items of significant monetary or sentimental value, which may, through no fault of [corporation name] become lost or damaged. Staff cannot accept responsibility or possession of your personal property and at no time should you ask that they do. I acknowledge that I have read and understand this document and will be provided with a copy for my records. A signature line for resident, responsible party, and care center staff at bottom. On 01/29/25 at 1:14 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding facility policy for loss of resident's personal belongings. Surveyor asked NHA A if there was a policy to outline the facility's responsibility for the loss or damage of high-value items. NHA A stated that residents are given the Personal Property Notice on admission and asked to sign acknowledging that the facility holds no responsibility if items are lost or damaged, but beyond that there is only a policy specific to dentures. NHA A stated they allow and encourage residents to bring personal items with them while residing in the facility, but as a rule the facility does not take responsibility for loss or damage of personal property unless proven to be the facility's fault. NHA A stated recognition that this kind of coverall policy asking residents to waive facility responsibility could have the potential to be problematic and would bring this concern to Quality Assurance Performance Improvement (QAPI) team for review.

Based on observation and interview the facility failed to distribute food under sanitary conditions; improper glove use, food handling without proper hand hygiene. This has the potential to affect all 48 residents who reside in the facility. This is evidenced by: The facility policy and procedure entitled, Hand Washing, updated 06/21/21 states in part, Hands shall be washed immediately before engaging in food preparation . After handling soiled equipment or utensils, During food preparation, as often as necessary to remove soil and contamination when changing tasks. When switching between working with raw food and working with ready to eat food, before donning gloves for working with food. On 12/04/23 at 11 AM, Surveyor observed noon meal service in the main dining room. Cook C washed her hands and dried her hands then left the water running when a visitor asked her to adjust the volume of music. Cook C went to a wall switch and adjusted the volume. Cook C then returned, got a paper towel, shut off the water and then placed gloves on her contaminated hands. Cook C began plating food; at one point she removed her gloves and placed them on a cart with a tray. CNA C then went out of the room for a bit then re-entered and placed the same contaminated gloves on CNA C's hands, that were on the cart. Cook C was observed to uses tongs to get a bun out of a package and placed it on a plate. Then Cook C put meat on the bun, then handled the roll with meat inside with her gloved hands to cut it with a knife. Cook C was observed to adjust the placement of food on the plate repeatedly with her gloved hands. Cook C was observed to plate buns using her gloved hands. Cook C was observed to wipe off areas on the plate where sauce had been with her gloved hands. Cook C put meat on the bun, then touched the top of the bun with gloved hands. Cook C then removed her gloves and went to the kitchen. Cook C then re-entered with a pan of food from the kitchen. Cook C washed her hands and placed a pair of gloves on that had been resting on the counter. Cook C added the contents of the pan to a well in the steam table, Cook C then resumed touching multiple items including the counter, scoop handles, ready to eat food, with the gloves that had been lying on the counter by the sink. On 12/04/23 at 11:34 AM, Surveyor observed Nutrition Services (NS) D pick up a slip of paper from the floor and handle it with both hands thereby contaminating her hands. NS D then returned to passing out plates of food to residents, without washing her hands or doing any hand antisepsis. On 12/05/23 at 10 AM, Surveyor interviewed Nutrition Services Director (NSD) E. Surveyor asked about glove use in the kitchen, NSD E stated that gloves are single task gloves and staff should do one task, remove gloves, stop and wash their hands, then put on new gloves. Staff should wash their hands when they change gloves between tasks. Surveyor asked about Cook C taking off her gloves and then placing the same gloves back on. NDS E stated staff should never re-use gloves, they should have been thrown away and hands should have been washed and new gloves placed on. When asked about NS D picking the item off of the floor, NDS E stated all staff should wash their hands after picking up a dirty item off of the floor.

Based on observation, interview and record review, the facility did not ensure 1 of 1 (R5) resident reviewed for respiratory care received the necessary care of respiratory equipment consistent with the comprehensive person-centered care plan. R5 had no respiratory care plan or parameters for changing the oxygen tubing or humidified water reservoir. This is evidenced by: The facility policy, entitled Oxygen Procedures, dated 12/06/23, states: .Concentrator Maintenance: .Once a week replace oxygen tubing and humidified water - document change in TAR . R5 was admitted to the facility on [DATE], and has diagnoses that include in part cough, shortness of breath, anxiety disorder, panic disorder, and obstructive sleep apnea (OSA). R5's Minimum Data Set (MDS) assessment, dated 09/18/23, indicated respiratory treatments of oxygen therapy. Review of Internal Medicine Provider note for R5 dated 04/06/23: lethargy, OSA severe, insomnia. CPAP poor tolerance. Will try adding oxygen via NC (Nasal Canula) at night for nocturnal hypoxia signs and symptoms of OSA with goal of improving sleep quality. Review of Internal Medicine Provider follow up note for R5 dated 06/01/23: R5 seems to tolerate the NC well and reports some improvement in sleep quality. Recommend continued use of continuous oxygen when sleeping. R5's Provider Orders: On 04/06/23, oxygen 2 Liters via NC (Nasal Cannula) at night while asleep. Diagnosis: nocturnal hypoxia secondary to OSA. On 05/15/23, oxygen 2 liters via CPAP (Continuous Positive Airway Pressure) or NC at bedtime. On 12/05/23, Surveyor reviewed R5's care plan and did not see oxygen use included in the care plan even though the oxygen was ordered on 04/06/23 by the provider. R5's Care Plan, dated 04/17/20 and updated 07/14/22, states: Problem: altered respiratory status related to history of pneumonia and OSA manifested by cough, now very occasionally. Approach: 04/17/20: Nurses assess respiratory status as needed. 07/14/22: Nurses encourage cough and deep breathing. On 12/05/23, Surveyor reviewed R5's Treatment Administration Record (TAR) and did not see anything concerning staff changing the oxygen NC tubing and the humidified water reservoir. R5's TAR did include Apply oxygen 2 liters via CPAP or nasal cannula at bedtime. TAR documentation included the liter amount of 2 liters and the oxygen saturation readings. The TAR did not document if R5 wore the CPAP or NC. On 12/04/23 at 12:56 PM, Surveyor observed R5's oxygen concentrator with humidified water reservoir and NC tubing both with no date on them to indicate when they were last changed. CPAP was sitting on night stand next to R5's bed. On 12/05/23 at 7:46 AM, Surveyor interviewed R5 about the use of CPAP and oxygen. R5 said he feels better using the oxygen at night and has not used the CPAP for a long time because it was uncomfortable to use with the mask. R5's NC tubing and humidified water reservoir on the oxygen concentrator continue to not have any date on them. On 12/06/23 at 7:33 AM, Surveyor interviewed R5 about what he wore last night for sleeping. R5 pointed to the oxygen concentrator. Surveyor asked R5 about when he had a sleep study and R5 said Halloween night. R5 said they want me to use the CPAP, but that he would rather use the oxygen with NC at night because the mask was difficult to wear. Surveyor asked R5 if the staff change out the oxygen NC tubing and humidified water reservoir. R5 said yes once a week they change it. Surveyor observed the NC and humidified water reservoir do not have a date on them. On 12/06/23 at 7:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked if R5's NC tubing and humidified water reservoir was changed. LPN G said yes, weekly the charge nurse documents this and dates the NC tubing and humidified water. On 12/06/23 at 8:20 AM, Surveyor interviewed the charge nurse Registered Nurse (RN) H concerning changing oxygen NC tubing and humidified water reservoir. RN H said the night shift charge nurse will go around once a week to change out the oxygen NC and humidified water reservoir, date the NC tubing and humidified water reservoir, and document in the TAR that this was completed. On 12/06/23 at 8:50 AM, Surveyor interviewed Director of Nursing (DON) B concerning when does the oxygen NC tubing and humidified water reservoir needed to be changed. DON B said that the NC tubing was changed on night shift weekly and documented in the TAR and that it should be dated on the tubing. DON B was not sure about when the humidified water should be changed and would have to look at the policy. Surveyor shared with DON B the observations noted above. DON B said that R5 liked the oxygen better. Surveyor asked DON B about not seeing anything about oxygen on R5's care plan or TAR regarding changing the NC tubing and humidified water reservoir. Surveyor asked DON B for R5's oxygen care plan, provider orders, documentation of changed oxygen NC and humidified water, and the facility's policy for oxygen use. On 12/06/23 at 11:04 AM, DON B provided R5's information and said there was nothing in R5's TAR to have the oxygen NC or humidified water reservoir changed. DON B said today DON B entered in R5's TAR the need to change the oxygen tubing (on concentrator and tank) and replace humidified water reservoir 1 time a week on Saturdays. DON B also said that there was nothing in R5's care plan that included oxygen use. DON B added oxygen to R5's care plan.

Based on observation, interview and record review, the facility did not maintain an infection control program to prevent the spread of infections for 1 of 1 (R28) resident on contact precautions and 1 of 1 (R5) reviewed with a urostomy. This is evidenced by: The facility policy, entitled Isolation Guidelines Transmission-Based precautions, dated 11/06/23, states: In addition to standard precautions, use contact precautions to prevent nosocomial spread of organisms that can be transmitted by direct contact (hand or skin-to-skin contact that occurs when performing resident care) or by indirect contact (touching) of environmental surfaces or contaminated resident care equipment and Contact precautions may be considered for residents who have: 1. Infection with antibiotic resistant microorganisms (ARMS) such as Methicillin-Resistant Staphylococcus Aureus (MRSA) or Vancomycin-Resistant Enterococcus (VRE). Policy & Procedure further states, Gloves: 1. Clean, nonsterile gloves will be worn when providing direct care to residents with ARMS; 2. Gloves should be worn when handling items potentially contaminated by ARMS, this may include items such as bedside tables, over-bed tables, bed rails, bathroom fixtures, television, and bed controls, suction and oxygen tubing and Gowns: 1. A clean, nonsterile gown with long sleeves will be worn when direct care is provided or when substantial contact with secretions/excretions is anticipated; 2. The gown should be put on prior to entering the room or approaching the resident and Resident care equipment: If equipment is to be shared, it must be cleaned and disinfected before use by another resident. R28 was admitted to the facility on [DATE], and has diagnoses that include Alzheimer's disease, dementia advanced, and Vancomycin Resistant Enterococci (VRE) in urine. R28's Minimum Data Set (MDS) assessment, dated 11/15/23, indicated a Brief Interview for Mental Status (BIMS) score of 99 (severe cognitive impairment). MDS indicates that R28 is occasionally incontinent of urine and does not have an indwelling Foley catheter or urinary device. On 10/02/23, a Urinalysis (UA) with culture & sensitivity (C&S) was collected due to an increase in R28's behaviors, complaint of burning with urination and blood-tinged urine with incontinence care. Result from C&S, verified 10/06/23 shows, >100,000 cfu/ml Vancomycin Resistant Enterococcus faecium, Multi-Drug Resistant Organism (MDRO). R28 had a room change on 10/10/23. Room change notification was signed by R28's husband and Power of Attorney (POA). Reason for room change states, has diagnosis of VRE-needs private room. Physician's order, dated 10/26/23 states, VRE in urine: contact precautions through at least 01/02/24 FYI. R28's care plan, dated 11/17/23, states, Contact precautions due to VRE in urine. Surveyor observed a contact precautions sign is on the wall next to R28's door. There is a personal protective equipment (PPE) bin directly underneath the sign containing gowns and disposable equipment. Hand sanitizer, gloves, and cleaning wipes are on top of the PPE bin. There is a garbage receptacle next to the PPE bin. On 12/06/23 at 7:05 AM, Surveyor observed Certified Nursing Assistant (CNA) I entering R28's room without putting on PPE. CNA I then left the room and came back with a sit to stand lift. CNA I took the sit to stand lift into R28's room and closed the door. CNA I did not put on PPE. A few moments later CNA I brought the sit to stand lift out of R28's room and parked the lift in the hallway opposite of R28's room against the wall approximately 6 feet from Surveyor. CNA I went into a staff lounge and did not clean the lift. R28 was observed in bed by Surveyor prior to CNA I entering the room. Surveyor observed R28 up in a wheelchair after CNA I brought the sit to stand lift out. On 12/06/23 at 7:19 AM, Surveyor interviewed CNA I regarding R28 being in contact TBP for VRE and PPE use. CNA I stated that she is aware that R28 has VRE in urine, but stated that R28 was crawling out of bed so she decided to go in and get R28 up. CNA I stated the only time PPE is required is when peri care is being performed. On 12/06/23 at 8:15 a.m., Surveyor continued to observe the sit to stand lift that was used for R28 was still parked in the hallway opposite of R28's room where CNA I left the lift. CNA I did not return to clean the lift. Surveyor informed the charge nurse, Registered Nurse (RN) H, that the lift had been used on R28 and had not been cleaned. RN H stated that RN H would make sure that the sit to stand was cleaned. On 12/06/23 at 8:30 AM, Surveyor interviewed Director of Nursing (DON) B regarding the expectations for staff when caring for a resident with VRE who is on contact precautions. DON B stated that R28 is on contact precautions for VRE until R28 can be retested on [DATE]. DON B stated that staff should be wearing gowns and gloving prior to contact with R28 and R28's environment. 47284 Example 2 The facility policy, entitled Routine Handwashing and Sanitizing, dated 3/31/21, states: Purpose: to prevent the spread of infections. Handwashing/Sanitizing indications: Always wash/sanitize hands before doing cares on residents, after cares .after removing gloves . R5 was admitted to the facility on [DATE] and has diagnoses that include in part malignant neoplasm of bladder and prostate and artificial openings of urinary tract status. R5's Minimum Data Set (MDS) assessment, dated 09/18/23, indicated urostomy appliance. R5's care plan states: Altered urine pattern related to urostomy. Approach: monitor output from urostomy, assist with urostomy cares and seal changes, assess for UTI (Urinary Tract Infection) signs/symptoms as needed, empty every shift (urostomy bag) R5's Provider Orders: Use the [NAME] bag and adapter with urostomy changes with Adapt paste with pouch. Change urostomy appliance use [NAME] brand (brown) with 1 1/8-inch convex wafer. Use adhesive remover when taking off old appliance, cleanse skin surrounding stoma with warm water and wash cloth, use no-sting skin prep (not alcohol) to area where appliance will sit, let dry, then apply appliance. Once a week on Thursday and as needed. On 12/05/23 at 9:10 AM, Surveyor observed Registered Nurse (RN) F change the urostomy appliance for R5. RN F gathered the necessary items, use of hand sanitizer before starting and applied gloves. RN F removed the old urostomy appliance, threw it in the garbage, removed her gloves, and placed new gloves on. RN F did not use hand hygiene between glove change. RN F cleaned the area around the stoma with warm water washcloth and let dry. RN F changed gloves, no hand hygiene between glove change. RN F applied skin prep and allowed to dry, changed gloves, no hand hygiene between glove change. RN F placed adapt paste around the wafer and placed the appliance over the urostomy. RN F removed gloves and cleaned hands. After each glove change, hand hygiene should have been completed to prevent the spread of infections. On 12/06/23 at 8:20 AM, Surveyor interviewed RN H asking what the expectation was for staff to complete hand hygiene while doing urostomy care/change. RN H said staff are to use hand hygiene before and after the procedure and after every change of gloves. On 12/06/23 at 8:40 AM, Surveyor interviewed DON B concerning what the expectation was for staff regarding hand hygiene while doing urostomy care/change. DON B said staff are to use hand hygiene before and after the procedure and after each change of gloves.

Based on observation, interview, and record review, the facility did not ensure that residents with limited Range of Motion (ROM) received appropriate treatment and services to increase ROM or prevent further decrease in ROM. The facility did not provide ROM exercises 5 days per week for 2 or 2 residents reviewed (R18). R18 has a Restorative Program for Active Range of Motion (AROM) exercises once daily, walking two times a day every day, and pulleys three times a week. The facility was not providing AROM exercises once daily, walking twice daily, and pulleys three times a week. R28 is care planned to have passive and active range of motion weekly and did not receive these services consistently. This is evidenced by: The facility's Restorative Nursing Program policy, last revised on 6/2021, includes, in part: Policy: All resident admitted to this facility will be evaluated for Restorative Nursing Care on admission, quarterly, and as condition warrants. Restorative nursing care will be provided based on evaluation of the resident's functional status and needs. Procedure: 3. Restorative CNA (Certified Nursing Assistant) Program: Resident who require continuation of rehabilitative measures not requiring a formalized therapy program, or residents who have been assessed at risk for potential functional loss that need a specific preventative program, will be placed on a Restorative CNA program developed by OT (Occupational Therapy)/PT (Physical Therapy) or Nursing. C. Restorative Nursing Program: 1. Unit CNA's will provide Restorative care to residents as indicated in their plan of care. 2. Unit staff will utilize the Restorative Schedule report to ensure restorative cares are completed and document care. Night nurse will print out the Restorative Schedule weekly. Each day unit nurses will review the schedule to make sure resident is being offered the interventions in their restorative plan. Example 1 R18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 has a Brief Interview of Mental Status (BIMS) score of 14, which indicates R18 is cognitively intact. R18 has a Restorative Program which indicates, Active Range of Motion: 15 reps (repetitions) once a day every day. Walking: Assistive Devices: two times a day every day. Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday. Pulleys: Three times a week. Sunday, Wednesday, and Friday. Documentation for AROM (Active Range of Motion) minutes completed indicates that in the last month R18 did not receive AROM on the following dates: 9/05/22, 9/06/22, 9/07/22, 9/08/22, 9/09/22, 9/10/22, 9/11/22, 9/13/22, 9/17/22, 9/18/22, 9/19/22, 9/21/22, 9/22/22, 9/23/22, 9/24/22, 9/25/22, 9/26/22, 9/27/22, 9/29/22, 10/01/22, and 10/02/22. Documentation for Walking minutes completed indicates that in the last month R18 did not receive Walking twice daily on the following dates: 9/06/22, 9/07/22 (completed once), 9/08/22, 9/09/22, 9/10/22, 9/11/22, 9/12/22, 9/14/22, 9/15/22 (completed once), 9/16/22 (completed once), 9/17/22, 9/18/22, 9/19/22, 9/20/22 (completed once), 9/21/22, 9/22/22, 9/23/22, 9/24/22 (completed once), 9/25/22, 9/26/22 (completed once), 9/27/22 (completed once), 9/28/22, 9/29/22, 9/30/22,10/01/22, 10/02/22, and 10/03/22. Documentation for Pulley minute completed indicates that in the last month R18 did not receive Pullies on any days in the last month. On 9/4/22 at 8:03 AM, Surveyor interviewed R18. R18 verbalized concern that she was not getting restorative therapy from the trained CNAs (Certified Nursing Assistants) who do this. R18 stated that she would like to be able to walk more. R18 states that she used to walk 3 to 5 miles a day and would like to try to be more active. R18 indicates it is sporadic as to when and if staff come in to offer her to walk. R18 is not sure why this is. R18 was in room sitting in wheelchair at time of interview. On 10/5/22 at 7:36 AM, Surveyor interviewed LPN D (Licensed Practical Nursing). Surveyor asked LPN D about the facility restorative program. LPN D indicated that if the Restorative CNA is not here the CNA's and Nurses care as the resident if they would like to walk or use the new step. The only time really that we might have to complete this is after lunch if after residents have been laid down or toileted and there is still time. On 10/5/22 at 7:51 AM, Surveyor interviewed CNA E. Surveyor asked CNA E who completes restorative therapy for residents. CNA E stated, We have people we schedule to do restorative with the residents. Two CNAs are designated to it, but other CNA's do it sometimes, that is if we have time. Surveyor asked CNA E how she knows needs restorative or who has already had it completed. CNA E stated, We can look in computer but the CNA's assigned to do restorative usually finish everyone. On 10/5/22 at 8:07 AM, Surveyor interviewed RN F. Surveyor asked RN F (Registered Nurse) who was scheduled to be completing Restorative therapy today. RN F stated, There is no restorative aide today. On 10/5/22 at 9:27 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A the facility process for completing Restorative Therapy with residents. NHA A stated, This is an area we need to work on. We have recognized that a couple of times. We did have two CNAs designated to complete restorative for the last half of their shift, but all CNAs are responsible for ensuring it is completed. The two we had doing it went back to school so we recently added another CNA but that just started in the last two weeks. Surveyor asked NHA A how they receive restorative orders from therapy. NHA A stated, Therapy updates the care plan with the restorative plan. Surveyor asked NHA A what the current plan is for their Restorative Program. CNA A stated, CNA G who is also the scheduler is going to be doing primarily Restorative Monday thru Friday. We did recognize this is something we needed to look at and the Restorative Programs need to be more realistic. Example 2 R28 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28 has passive ROM (Range of Motion) restorative assignments for his lower left extremity and left upper extremity up to 15 repetitions, up to 3 times per week. Additionally, R28 has active ROM restorative assignments for his right lower extremity up to 15 repetitions up to 3 times per week. Additionally, R28's CNA (Certified Nursing Assistant) care plan, or Guidelines for Daily Care, states R28 is to have passive ROM 3 times per week (Sunday, Wednesday, Saturday) and active ROM 3 times per week (Monday, Tuesday, Thursday). On 10/4/22 at 8:01 AM, R28 stated to Surveyor that he was in therapy previously but now is only to have restorative but does not regularly receive restorative and needs assistance to do so due to his [CONDITION(S)] after his stroke. Facility documentation shows R28 received active ROM on the following dates since August 11: 8/11/22 8/16/22 8/18/22 8/24/22 8/31/22 9/12/22 9/20/22 10/3/22 Additionally, facility documentation shows R28 received passive ROM on the following dates since August 11: 8/11/22 8/16/22 8/18/22 8/24/22 8/31/22 9/12/22 9/14/22 9/15/22 9/20/22 9/28/22 On 10/4/22 at 2:29 PM, Surveyor interviewed CNA C, who acts as the facility restorative aid. CNA C stated that restorative depends on the staffing at the time as to when and if restorative programs get completed.

Based on interview and record review, the facility failed to ensure that residents who use [CONDITION(S)] drugs receive gradual dose reductions, unless clinically contraindicated, to discontinue these drugs for 1 of 5 residents investigated for unnecessary medications (R26). R26 was receiving a [CONDITION(S)] medication and the facility did not ensure R26 received a gradual dose reduction, unless clinically contraindicated. The facility was unable to provide documentation of the clinical rationale for not attempting a GDR nor documentation of persistent behaviors to support not completing trial dose reductions. This is evidenced by: On 10/5/22, Surveyor requested the facility policy for [CONDITION(S)] medications/gradual dose reduction. The facility provided an untitled document that indicates, the following: Procedure to ensure gradual dose reduction (GDR's) are completed for all psychoactive medications by health system preference . Required GDR assessment frequency: .Scheduled psychotropics (excluding sedatives/hypnotics): 1st year - minimum of twice in 2 separate quarters with at least a month between attempts. After 1st year - minimum of once per year. Required GDR documentation options if clinically contraindicated: Clinical rationale AND continued use is in accordance with current standards of practice (not an option for most hypnotics) OR Clinical rationale AND target symptoms returned or worsened after most recent GDR attempt within the facility. R26 was admitted to the facility on [DATE], with diagnoses that include, in part: Unspecified dementia without behavioral disturbance; mild cognitive impairment; and depression . R26's physician orders note, in part: [MEDICATION(S)] 37.5mg tablet Dose Ordered: (0.5/18.75mg) by mouth twice a day AM HS (at bedtime) first date: 2/13/21 FOR: Depression and Pain R26's Monthly Medication Reviews provided by the facility, indicates, in part, the last dose reduction was completed 3/13/21 .[MEDICATION(S)] decreased to 18.75mg . On 11/11/21, a pharmacy recommendation form titled, Psychoactive Mediation Review, was completed and indicates, in part, the following: .2/12/21 [MEDICATION(S)] 37.5MG Tablet; Dose Ordered: (0.5/18.75mg) by mouth twice a day AM HS; first date: 2/13/21; FOR: Depression and Pain. Previous Psychoactive Medication Review - Nurse Summary: Summary of efficacy: Requesting for physician to complete a GDR review of Resident's [MEDICATION(S)] medication. Staff have no concerns of any depressed moods or behaviors. She has been coming out to the dining room for meals and activities. For most of her days, she does like to stay in her room reading. She also has a roommate [sic] which both are getting along. Will continue to monitor Resident's mood and provide support. As far as for pain, she has been stable. Looking back a month, Resident has received PRN (as needed) Acetaminophen once for a headache which when followed up, she was resting. Prescriber Assessment and Plan (please include in your dictation): (Of note, two check box options are provided on the form) The first option is marked: No GDR - All psychoactive medications were assessed. Gradual Dose Reduction clinically contraindicated at this time because: A handwritten note indicates below this information, indicates see note 11/11/2021. The form is signed by the Nurse Practitioner. Surveyor requested the 11/11/21 note referenced in the GDR. The facility provided a visit note completed by the NP (Nurse Practitioner). The note indicates, in part: Behaviors: nursing notes for the past 2 weeks show no behavioral or mood issues . Of note, Surveyor could find no evidence of a reference to or a documented clinical rationale against a GDR for [MEDICATION(S)]. On 10/5/22, Surveyor requested R26's last three months of behavior charting. The following documentation was provided to the Surveyor: 8/9/22 .Behavior Care Plan Analysis - Care plan has been reviewed and is current, Care Plan goals remain current and appropriate. Interventions effective. 8/23/22 .Behavior: Resident is cooperative and interacts well and smiles easily 9/6/22 .Behavior: No behavior issues. 10/4/22 .Behavior: No behavior issues On the morning of 10/5/22 a document was provided to the surveyor that contained GDR documentation for R26, that indicates, in part: 2/12/21 .[MEDICATION(S)]. Med change occurred on 2/5/21 Started 37.5mg daily for Pain and Depression. Med change occurred on: 2/12/21 Decrease 18.25mg [sic] BID (twice a day). 5/12/21 .GDR Assessment: 5/7/21 First year: 1st GDR [MEDICATION(S)]. No change in medication. See provider note on: 5/7/21. 11/13/21 .GDR Assessment: 11/11/21 First year: 2nd GDR [MEDICATION(S)]. No change in medication. See provider note on: 11/11/21. Of note, there no evidence of a clinical rationale for not attempting a trial dose reduction for 5/12/21 and 11/13/21 in this documentation. 11/13/21 .GDR assessment due: 11/10/22 For: Annual GDR [MEDICATION(S)]. On 10/5/22 at 12:15 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B when reviewing R26's behavior documentation if it warranted not attempting a trial dose reduction of her [MEDICATION(S)]. DON B reviewed R26's behavior documentation on her computer and indicated, no, there is nothing harmful, no violence, no depressive statements. Surveyor reviewed the information from the Psychoactive Medication Review Form, dated 11/11/21, with DON B. During review of the document, DON B indicated, these are all good things. I would say a trial reduction could be done. Surveyor asked DON B to review the provider note from 11/11/21 referenced in the same review form. Surveyor asked DON B if she was able to find any information regarding the GDR or clinical rationale for not attempting a GDR at that time. DON B indicated she was not able to find this information either. The facility did not provide evidence of a clinical rationale for why trial dose reductions for R26's [MEDICATION(S)] have not been attempted.

Based on observation, interview, and record review the facility did not ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 (R33) of 1 residents reviewed for pressure injuries out of a total sample of 19. This is evidenced by: The facility policy entitled, Pressure Injury and Wound Treatment, effective January 5, 2014 and reviewed March 7, 2019 which states in part, use the following guidelines for specific stages .Stage 2 pressure injury/partial thickness wound .protect the wound from undue stress .assess pressure reduction devices .ROHO (a cushion with individual cells that move independently to bend and adapt to curvature of the body) or matrix cushions for actual pressure injuries or high risk .wound care certified nurse or designee to review or assess stage 3, 4 and unstageable pressure ulcers weekly. Staging of Pressure Ulcers: The facility follows the National Pressure Injury Advisory Panel (NPIAP) guidelines for Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Pressure injuries are staged using the system below: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed .until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . The facility policy entitled, Wound Assessment written August 12, 2004, and reviewed March 7, 2019, states in part .a comprehensive wound assessment will be done when the wound is initially identified and weekly thereafter .to include site/location of wound, type of wound, measure and document size including length, width and depth in centimeters. The facility procedure entitled, Prevention of Pressure Injuries reviewed on July 29, 2021, states in part, Pressure Injury prevention strategies will be included in the care plans of residents found to be at risk for the development of pressure ulcers. Upon completion of a Risk Assessment the nurse will develop a plan of care using the following guidance: At Risk (score of 15-18), If bedbound reposition every 2 hours, if chair bound, reposition every hour, use a pressure reduction device on bed or chair. Moderate Risk (score of 13-14) . if bedbound, reposition every 2 hours, if chair bound, reposition every hour, use a pressure reduction device on bed or chair, teach resident and family about prevention of skin breakdown. R33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21, R33 was unable to perform a mental status review. R33's power of attorney (POA) was activated on 10/1/2018. R33's quarterly minimum data set (MDS) assessment dated [DATE] under section M - Skin Conditions, reveals the resident to be at risk for pressure injury development; has one unhealed Stage 1, and one unstageable pressure injury, and one venous and/or arterial ulcer. Section G - Functional Status, indicates R33 required extensive assistance (one person physically assisting) in bed mobility which includes how the resident moves to and from the lying position, turns side to side and positions self while in bed or alternate sleep furniture and totally dependent for any transfers. R33's Braden score was documented as 14-moderate risk on 1/11/21. R33's care plan with review date of 4/20/21 identified: Self-care deficit and the need of assist of one with bed mobility on 10/4/13 and assistance of one with transferring by use of lift and sling on 6/21/21. Alteration in nutrition/hydration related to wounds, poor dentition, and history of weight loss on 1/26/21. Impairment of tissue integrity with interventions dated 10/04/2013 that include: pressure relieving device for chair and bed, skin assessment per policy, evaluate risk scores date 9/27/2018. Weekly skin assessment dated [DATE] inspect skin with cares & report changes. Encourage repositioning. Of note, the care plan does not direct staff to use a pressure relieving device in either chair. Facility notes from the Nutrition Team Review which is an interdisciplinary team (IDT) meeting for residents at nutritional risk and pressure injury/wound healing risks, reveals on 2/15/21 resident has a new area on coccyx and 4/19/21 open area on coccyx. Team notes state on 4/29/21 solid intake has been 0% and fluids 50-100% over the past week. 6/8/21 notes state, weight is down to 185 pounds from 193 pounds on 1/26/21. On 8/17/21, Surveyor observed R33 in the recliner at 7:50 AM, 10:12 AM, 1:21 PM, and 4:07 PM. On 8/18/21, Surveyor observed R33 in the recliner at 8:10 AM, 9:50 AM, 11:00 AM and 2:00 PM. The alternating pressure pad was in another chair in the room, not under the resident. The lift sling was under the resident but no other pressure relieving device. There was no documentation or assessment declaring the sling was of greater benefit to the resident if left beneath vs. removing. Facility wound care documentation: 2/10/21: Wound #2 Coccyx Stage 2, 1.9 cm (centimeter) l x 1.1 cm, pink, slight discoloration, and treatment is a bordered foam dressing every 3 days. 2/17/21 Wound # 2 Coccyx Stage 2, 1.2 cm l x 1.0 cm pink, clean, area noted to be slightly smaller .noted active bleeding .awaiting proper cushion arrival to apply to Broda chair .no change in wound treatment. 2/26/21 Wound #2 Coccyx Stage 3, partial thickness loss, 1.2 cm l x 1.2 cm w, 75% slough with 25% red granular .no change in treatment .no ROHO yet Of note, R33 does not have a cushion for the recliner and R33's pressure injury deteriorated from a Stage 2 to a Stage 3. R33 spends the majority of time in the recliner and does not lay in bed. 3/3/21 Wound #2 Coccyx, Stage 3, 1.5 cm l x 1.5 cm .no change in treatment .no ROHO. Of note, R33 continues without a ROHO in the recliner. Treatment remains unchanged despite deterioration in the pressure injury (PI). 3/12/21 Wound #2 Coccyx, Stage 3, full thickness lost, exposing Sub Q tissues, presents as a deep crater, Stage #3 .no measurements. 100% red and ruddy. Treatment now daily .cleanse with hypochlorus acid then apply collagen to wound bed and cover with a bordered foam dressing to be changed daily until healed. Of note, this is 9 days since the last PI assessment and the facility did not complete measurements. 3/31/21 Wound # 2 Coccyx, Closed, fragile stage 3 to coccyx; 0 x 0; border foam dressing continues Of note, there was 19 days between PI assessments. 4/9/21 Wound # 2 No assessment 4/14/21 Wound # 2 Coccyx full thickness loss, no measurement 4/24/21 Wound # 2 Coccyx, small white, 100 % slough spot, clean intact. No measurement, treatment is a bordered foam dressing Of note, the facility documented the PI as 100% slough a deterioration there in no update to the MD and no measurements of the PI. 5/4/21 Wound #2 Coccyx, open area, 100% slough white, becoming smaller, no measurement, no change in treatment. 5/13/21 Coccyx, open area, no odor or drainage, Border foam intact to area. No measurements. 5/20/21 Coccyx, Wound 100 % White slough, becoming smaller, no change to treatment. 5/26/21 #2 1.3 cm l X 1.0 CM, pink, clean abrasion or blister, stage 2 coccyx same treatment Of note, this PI was documented as 100% slough making the area unstageable a PI cannot be categorized to a lower stage thus the PI must remain an unstageable PI. 6/2/21 Coccyx, no measurements, wound pink with dry skin, bordered foam dressing. 6/15/21 no charting on coccyx wound 6/23/21 no documentation regarding coccyx wound 7/3/21 no charting regarding coccyx wound 7/7/21 Coccyx, desensitized skin, pink wound tissue, and treatment is a bordered foam dressing. 7/17/21 no documentation or assessment of coccyx area 7/24/21 no charting on coccyx wound 7/31/21 no documentation of coccyx wound 8/4/21 no charting on coccyx wound 8/10/21 no description of # 2 wound of the coccyx; charting now identifies an area labeled as area # 3, coccyx with length of 1.1 cm x 1.1 cm, partial thickness loss of skin layers that presents as an abrasion or blister, stage 2, wound tissue red and ruddy 100%, bordered foam dressing applied. 8/19/21 No documentation of area # 2,; Area # 3, coccyx, 1.3 cm l x 1.4 cm w, worsened stage 2 pressure ulcer, now a stage 3, wound tissue is 80% red granular and 20% white slough, moderate amount serosangineous exudate; worsened and noted to be slightly larger with a small 0.2 cm x 0.2 cm superficial area to the left side of current wound, possible pressure/moisture related will treat as a separate wound at this time, #4. Area # 4 Coccyx, size 0.2 cm l x 0.2 cm w; has partial thickness loss of skin layers that present as an abrasion or blister; pressure stage 2; blood tinged drainage, wound red and ruddy 100%. Area cleansed with soap and water, applied hypochlorus acid to wound bed then collagen and covered with a bordered foam. Will notify provider of new open area and treat with current coccyx wound dressing treatment. Of note it is difficult to ascertain if PI #2 healed and a new area #3 developed or if this is the same referenced area. On 8/18/21 at 2:31 PM Surveyor asked CNA C, Does R33 go to bed during your shift? CNA C replied, No, not usually. Surveyor asked CNA C, Is resident in the recliner most of the day? CNA C, answered, Yes, she doesn't like the bed, we transfer her to the bedside commode and change her, but usually she goes back to the recliner. On 8/18/21 at 2:45 PM, Surveyor requested to observe wound treatment on 8/19/21. On 8/19/21 9:40, Surveyor asked DON B, did you know R33 had the lift sling under her all day yesterday and today; do you think that impacts her wound healing? DON B answered, No, Surveyor asked DON B, Does R33 go to bed to change position? DON B replied, No, R33 is resistive to this, doesn't like it. If the nurses have to do a treatment, R33 goes to bed for that. Surveyor reminded DON B that I had requested to observe coccyx wound care for R33. DON B replied, You don't have to look at it, that wound is closed. Surveyor made the request to be notified when wound care was going to be done. On 8/19/21 at 10:15 AM, Surveyor observed CNA E transfer R33 via hydraulic lift to the bedside commode. Surveyor asked CNA E, Is R33 in the recliner all day? CNA E, Yes, we transfer her to the bedside commode and to the bed if the nurses want to look at the wound. Otherwise, she is in the recliner. On 8/19/21 at 10:35 AM, Surveyor observed RN F completing coccyx wound care for R33. RN F states, Oh, gosh, it has gotten worse since last week. Surveyor asked RN F, is R33 pre-medicated for pain or anxiety prior to wound care. RN F stated, I don't know. Surveyor asked, RN F what kind of pressure relieving cushions does R33 use? RN F stated, A ROHO for the recliner and an APP (alternating pressure pad) for the Broda. Surveyor asked, Where is the ROHO? RN F replied, I'm not sure, it may have gotten soiled as I don't see it either. On 8/1921 at 10:48 AM, Surveyor asked LPN D, Did you hear anything about R33's ROHO in report, is it soiled and in laundry? LPN D responded, No. Surveyor asked LPN D, have you seen R33's ROHO cushion in the past week? LPN D, answered, No. On 8/19/21 at 11:40 AM, Surveyor asked DON B, tell me what pressure relieving devices are used for R33? DON B answered, the alternating pressure pad is used in the Broda chair and the ROHO in the recliner. Surveyor asked DON B, Is R33 in the Broda chair much anymore? DON B replied, No. Surveyor asked DON B, what cushion do you use in the recliner, DON B answered, The ROHO and the APP in the Broda. Surveyor stated, staff couldn't find the ROHO cushion in R33's room. DON B stated, Oh, maybe she doesn't have the ROHO anymore. I will have to check with our wound care nurse. The cushions aren't in her care plan so I'm sorry for that. It's hard to get her in the bed because she doesn't like it. Surveyor asked DON B, have you discussed the risk of not providing position changes with the POA-HC? DON B replied, I think so, I will have to look. On 8/19/21 at 12:16 PM Surveyor received a document from DON B, outlining the risks and benefits for position changes for R33, written on 8/19/21. This had not been reviewed with the POA. On 8/19/21 at 2:00 PM, Surveyor asked DON B for the invoice or delivery date of the ROHO or APP cushions and was not provided with either. The facility failed to implement interventions to prevent PI develop or deterioration of PI's. Once identified, the wounds were not properly measured or assessed weekly to ensure the treatment provided was consistent with current standards of practice.

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 50 residents who reside in the facility. Cook M touched her face covering three times while preparing lunch for residents, without hand washing. Cook J indicated the dented can (observed in circulation) is ok to use because it does not have a visible hole in it. Surveyor observed opened flour and sugar bags with no open dates. Cook J, DA K, and DA L were unsure of open date or how long it is good for. Surveyor observed opened, undated, and unlabeled beverage and food containers in resident unit refrigerator. CNA I was unaware of who it belonged to and if they should throw it out or leave it. Surveyor observed two spatulas in circulation to be nicked with missing pieces. Cook J indicated this could have happened while using the mixer and could have contaminated the food being prepared. Surveyor observed a stored mixer to be spattered with food particles. Evidenced by: Handwashing: On 8/18/21 at 10:10 AM Surveyor observed Cook M touch her face mask three times while temping pureed fries, pureed corn dog, chicken noodle soup, cream of potato soup, Swedish meatballs, and mashed potatoes. During an interview, Cook M indicated she should have washed her hands after touching her mask and before continuing to work with the food. On 8/19/21 08:58 AM during an interview Asst. DM H indicated Cook M should have washed her hands after touching her facial mask and before continuing to prep food. Food dating: Facility policy, entitled Food from Outside Sources, reviewed 1/2017, includes, in part: . Any food or beverage brought into the facility for resident consumption to be stored in refrigerator units will be checked by staff member during daily audits by nutrition services and housekeeping staff. Any outdated, unlabeled, undated, suspicious, or obviously contaminated food or beverage will be discarded immediately . all food items that are already prepared by the family or visitor brought in must be labeled with content, date (the item was brought into the facility) and resident's name . On 8/16/21 at 7:52 PM Surveyor observed a refrigerator in a room outside of the nurse station to have an opened Starbuck's frappe with no name or date on it. Also observed was an unlabeled and undated container with a patty and vegetables. CNA I (Certified Nursing Assistant) indicated these items should be marked with a date and labeled with a name of who it belongs too. On 8/17/21 at 9:25 AM during an interview, DM G (Dietary Manager) and Asst. DM H indicated food stored in refrigerator is to be dated and have a resident name on it. On 8/18/21 at 10:47 AM Surveyor observed a second refrigerator in a room outside of the second nurse station. Surveyor observed a container labeled with a resident name, but no date. The container contained a piece of pie and visible condensation in it. Surveyor also observed a Tupperware with unidentifiable food in it with no name or date on it. On 8/19/21 at 8:58 AM during an interview, Asst. DM H indicated it is everyone's responsibility to mark and date the food in the refrigerators on the units. Facility policy, entitled Food Storage, dated 2010, includes, in part: Plastic containers with tight fitting covers must be used for storing . flour, sugar . All containers must be legible and accurately labeled. On 8/16/21 at 6:43 PM Surveyor observed a bag of flour 1/4th full with no open date. Surveyor also observed a bag of sugar 1/4th full with no open date. Cook J, DA K (Dietary Aide), and DA L indicated they were unsure when these were opened and it is the first shifts responsibility to date them upon opening them. On 8/17/21 at 9:25 AM during an interview, DM G indicated the opened flour and sugar should have an open date on them. Compromised spatulas: Facility policy, entitled HACCP and Food Safety, dated 2010, includes, in part: Physical hazards may include: foreign objects such as metal, glass, plastic, or wood. Cross contamination occurs when harmful substances are transferred from one source to the food. On 8/16/21 at 6:43 PM Surveyor and Cook J observed two spatulas that had pieces of the food surface missing. Cook J indicated the pieces could have been broken off while using the mixer and went into the food being prepared. Cook J put the spatulas back in the drawer. Cook J indicated she did not have the authority to throw these out or remove them from circulation. On 8/17/21 at 9:25 AM during an interview, DM G indicated the spatulas should be removed from the drawer to avoid contamination and he would take care of this. Dented can: On 8/16/21 at 6:43 PM Surveyor observed a dented can of Ready to Eat Potato Salad. Surveyor asked Cook J if they have a process for dented cans. Cook J indicated the staff use dented cans unless they have a hole in them. On 8/17/21 at 9:25 AM during an interview, DM G indicated the dented can should not be used and should be removed from the shelf. DM G indicated he will be educating his staff on this. Mixer: On 8/16/21 at 6:43 PM Surveyor and Cook J observed a stored mixer to have food particles spattered on the undercarriage. Cook J indicated this should have been cleaned after use and before storing.

Based on interview and record review the facility did not ensure that they followed their Policy and Procedure to screen staff for abuse upon hire. For 5 of 8 staff background checks reviewed. CNA R (Certified Nursing Assistant) did not have a background check completed upon hire. CNA N did not have an out of state background check completed upon hire. CNA Q did not have a background check re-completed at four years. SW O (Social Worker) and RN P (Registered Nurse) did not have all pages of BID (Background Information Disclosure) present. This is evidenced by: The Facility's Policy and Procedure entitled Freedom from Abuse, Neglect, and Exploitation dated November 28, 2016, documents in part: .II. Employee Screening .C. For the employee screening procedure, please reference the Corporation Policy Caregiver Background Checks. The Facility's Policy and Procedure entitled Caregiver Background Checks dated 3/1/21, documents in part: I. Covered Individuals: A. New hires over the age of 18 .B. Existing employees every four years .II. The Caregiver Background Check (CBC) Consist of: A. The Background Information Disclosure Form (BID) .*A Check of the WI (Wisconsin) or other state's licensing or credential checks, and the WI or other state misconduct registry .*A Name-based background Check (WI DOJ (Department of Justice) Criminal History Search, an IBIS (Integrated background information system) letter from the DHFS (Department of Health and Family Services) and a CIB (Crime Information Bureau) check from any other state lived in the last 3 years.) .D. A copy of military discharge papers (DD-214) from any person discharged from the military within the last 3 years . Example 1 CNA R was hired 5/27/21. The facility did not complete a background check for her upon hire. Example 2 CNA N was hired 7/27/21. CNA N dated her BID form 7/22/21 and documented that she lived out-of-state in Colorado from 1971 to 2020. The facility did not complete an out-of-state background check upon hire. Example 3 CNA Q was hired 5/10/17. CNA Q did not have an every four year background check completed in May of 2021 as he should have. Example 4 SW O was hired 7/21/97. SW O's most recent DOJ and IBIS are dated 1/4/19. SW O's BID form is missing the signature and date page. Example 5 RN P was hired 4/20/15. RN P's most recent DOJ and IBIS are dated 1/4/19. RN P's BID form is missing the signature and date page. On 8/19/21 at 11:00 AM, Surveyor interviewed BAA S (Business Administrative Assistant). Surveyor asked BAA S if background checks should be completed for all new hires, BAA S said yes. Surveyor asked BAA S if someone has indicated on their BID that they've lived outside of WI if an out-of-state background check should be done, BAA S stated I learned today that you need to run an out-of-state background check. Surveyor asked BAA S if all pages should be kept when completing a background check, BAA S replied yes all pages should be put together in their personnel file. Surveyor asked BAA S how often background checks should be re-run, BAA S said every four years. Surveyor asked BAA S if CNA Q's background check from 5/10/17 should've been re-run in May of 2021, BAA S stated yes, it should have been. On 8/19/21 at 11:29 AM, NHA A (Nursing Home Administrator). Surveyor asked NHA A if background checks should be completed for all new hires, NHA A said yes. Surveyor asked NHA A if someone has indicated on their BID that they've lived outside of WI if an out-of-state background check should be done, NHA A stated yes Surveyor asked NHA A if all pages should be kept when completing a background check, NHA A replied yes. Surveyor asked NHA A how often background checks should be re-run, NHA A said every four years. Surveyor asked NHA A if CNA Q's background check from 5/10/17 should've been re-run in May of 2021, NHA A stated yes, it should have been.

Based on observations, record review, and family and staff interviews, the facility did not ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for 1 of 5 sampled residents reviewed (R1). R1 was to have a restorative program started on 4/01/21. This did not occur. Evidenced by: R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/26/21 indicates R1 has a BIMS (Brief Interview of Mental Status) of 10, indicating R1 has moderate cognitive impairment. R1 requires extensive assistance with bed mobility and transfers, limited assistance with dressing, set-up assistance with eating, and limited assistance with walking in room. R1 is occasionally incontinent of urine and always continent of bowel. R1's Care Plan Focus Areas do not address the therapy recommendation of restorative therapy starting on 4/01/21. On 6/02/21 Surveyor reviewed Restorative documentation. Orders were put into place by OT D (Occupational Therapy) on 4/01/21 at 1:03 PM stating, RUE (Right Upper Extremity): at elbow, forearm, wrist and hand only. Do not do shoulder. Replace palm guard and sling to R (right) arm when done. R Wrist, R Hand, Fingers, R Elbow, 10 reps every day. Prevent decline in ROM (Range of Motion). Note: There is no other documentation that restorative therapy was completed any time after 4/01/21 with R1. On 6/02/21 Surveyor reviewed CNA (Certified Nursing Assistant) and Nursing documentation on Restorative therapy performed. Surveyor was unable to locate any documentation and the facility was unable to provide any documentation that restorative therapy was done for R1 after it was ordered by OT (Occupational Therapy) on 4/01/21. On 6/02/21 at 11:37 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B about the facilities restorative program. DON B stated that at this time the facility is working on training staff with therapy. Once training is complete staff will be responsible for completing any restorative program ordered by therapy. Surveyor asked DON B if he was aware R1 had orders for restorative therapy and whether he knew if it was completed or not. DON B stated he was not aware there were orders for R1 to have restorative and that he did not think it was being done as the facility is still in the process of training staff. On 6/02/21 at 4:18 PM, Surveyor interviewed NP C (Nurse Practitioner). Surveyor asked NP C if she felt that a restorative program would have been helpful for R1. NP C stated, It would have been a reasonable expectation that the facility would complete restorative if recommended by therapy.

Based on observation, interview and record review, the facility failed to prevent the spread of infections and transmission of COVID-19 as evidenced by failure to adhere to infection control practices related to: proper disinfection of shared medical equipment and faceshield; isolation precautions; proper glove usage and storage of clean linens. These practices had the potential to affect all residents residing in the facility. Findings include: 1. A. On 6/24/20 at 11:20 am, Registered Nurse 1 (RN1) was observed checking the oxygen saturation level (O2 sat is amount of oxygen in a blood cell) and temperature of R1 in room [ROOM NUMBER]. Using an alcohol pad, RN1 wiped the pulse oximeter (device that clips on your finger, toe, or earlobe to measure blood oxygen saturation) for eight seconds. RN1 opened another alcohol pad and wiped the thermometer for nine seconds. At 11:22 am, RN1 entered R2's room to check R2's O2 sat level and temperature. After the procedure, RN1 wiped the pulse oximeter with one alcohol pad for eight seconds and took another alcohol pad and wiped the thermometer for seven seconds. At 11:25 am, RN1 went to R3's room to check R3's O2 sat level and temperature. RN1 wiped the pulse oximeter with alcohol pad for seven seconds and took another alcohol pad and wiped the thermometer for nine seconds. When asked if she always used alcohol pads to wipe the pulse oximeter and thermometer, RN1 stated, Yes. When asked if she uses the Hydrogen Peroxide disinfecting wipes on any equipment, RN1 stated I usually do that when I'm all done. Then at 11:26 am, RN1 proceeded to wipe the pulse oximeter for five seconds and seven seconds on the thermometer using the hydrogen peroxide wipe and dispose off the wipe. Review of facility's policy titled Equipment Cleaning dated 4/23/20 revealed, Purpose: Maintain infection prevention techniques to help prevent the spread of illness. Under Procedure, 1. Vital Machines, cuffs, thermometer - outside avoiding sensor part, stethoscopes, face shields, goggles, weight scales, commodes, toilets will be cleaned after each resident use with Hydrogen Peroxide wipes .2. Contact time for Hydrogen wipes is 1 minute, wipe surface and make sure surfaces are wet and remain wet for 1 minute .3. Special cleaning consideration on electronic equipment, oxygen sensors, infrared thermometer sensors .Sensor type equipment should have 20 second scrub with alcohol wipes then air dry for 5 to 10 seconds .5. Surfaces made wet with the cleaning solution, then remain wet for the contact time of 1 minute for hydrogen peroxide for normal cleaning .7. Make sure contact time completed and equipment dry before next use. B. Review of facility's list titled Residents admitted in the Care Center in the last 2 weeks (6/10/20 to 6/24/20) revealed, (R4) - room [ROOM NUMBER] - Adm (admission) 6/17. COVID testing 6/16, 6/10 at Gundersen - Both were negative. R4 was placed on droplet and contact precautions. On 6/24/20 at 12:00 pm, Nursing Assistant1 (NA1) was observed entering R4's room. At 12:02 pm, NA1 exited the room and removed the personal protective equipment (PPE) in the following sequence: gloves, gown and mask. NA1 kept her faceshield on. NA1 sanitized her hands and put on a new facemask. NA1 failed to disinfect her faceshield after exiting an observation room. On 6/24/20 at 12:04 pm, when Acting Administrator was asked about her expectation from staff on donning and doffing of PPE, the Acting Administrator stated, Staff should put on double gloves. Before coming out, they remove the outer gloves inside the room. Staff then remove their isolation gown and dispose it in the garbage bin marked outside of the room. Staff use peroxide wipe to sanitize their face shield then dispose of the inner gloves. On 6/24/20 at 12:07 pm, when asked what she missed, NA1 stated she should have disinfected her face shield after coming out of an observation room and added, I should have done that after leaving the room. During interview with the Assistant Director of Nursing (ADON) on 6/29/20 at 1:22 pm, when asked about her expectation from staff on disinfection of equipment, the ADON stated, So they (staff) are supposed to clean the equipment and per policy, clean it and wait for the contact time before they use it on different person. The ADON further stated, Wet the surfaces for a minute. They can set the equipment down and wait. Review of facility's procedure titled Doffing PPE dated 6/17/20 revealed under Faceshield/Goggles, Leave room, apply gloves, remove faceshield/goggles and wipe with disinfectant wipe, wiping inside first, then outside and let shield/goggles air dry. In a CDC article titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic dated June 19, 2020 revealed under Environmental Infection Control, All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings .Refer to List N on the EPA website for EPA-registered disinfectants that have qualified under EPA's emerging [MEDICAL CONDITION] pathogens program for use against [DIAGNOSES REDACTED]-CoV-2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html In a CDC article titled Strategies for Optimizing the Supply of Eye Protection dated June 28,2020 under Implement extended use of eye protection revealed, If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g. when leaving the isolation area) prior to putting it back on. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html#conventional-capacity In a CDC article titled Personal Protective Equipment: Questions and Answers dated March 14, 2020 revealed under Gloves, Is double gloving necessary when caring for suspected or confirmed COVID-19 patients in healthcare settings? CDC Guidance does not recommend double gloves when providing care to suspected or confirmed 2019 COVID patients. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use-faq.html 2. A. On 6/24/20 at 11:30am, droplet and contact precaution signage was observed posted and an isolation set-up was placed outside of R5's room. Two garbage bins with lids were observed outside of R5's room: one garbage bin with lid was used for soiled reusable isolation gowns and the second garbage bin with lid was used for dirty linens. An open small garbage outside of R5's room was used for soiled gloves and used disinfecting wipes. Review of R5's nurses notes dated 6/24/20 at 10:25 pm revealed, COMMENTS: Was reported resident displayed symptoms of runny nose, myalgia, occasional lethargy, and elevation of temperature that did not reach or exceed 100.0. In response to aforementioned symptoms, resident was placed on droplet precaution and COVID tested . COVID test result was negative and no reported symptom observation noted on 6/24/20 as of 2221 (10:21pm). Will continue droplet precaution until resident exceeds 48 hours without symptom. RESPIRATORY INFECTION: placed on isolation, (IC DON) B. Review of R4's medical chart revealed an admission date of [DATE]. On 6/24/20 at 11:47 am, droplet and contact precaution signage was observed posted and an isolation set-up was placed outside of R4's room. Two garbage bins with lids and one small open garbage bin were placed outside of R4's room. One garbage bin with lid was used for soiled reusable gowns and the second garbage bin with lid was used for dirty linens. The open small garbage was used for soiled gloves and used disinfecting wipes. At 11:58 am, when asked, RN2 stated, I guess since the COVID. Not sure why it is outside. Usually it's inside the room. During interview with the Assistant Director of Nursing (ADON) on 6/29/20 at 1:22 pm, when asked about the placement of garbage bins for isolation rooms, the ADON stated, Usually most of them (supplies) are disposed in the room. The residents are agitated and we left it (garbage bins) outside of the room. The ADON further stated that it was a safety concern because one resident had mobility issues and the other resident got agitated. Review of Isolation room sign provided by the facility revealed under Contact Precautions, Providers and staff must also .Discard gloves before room exit. Discard gown before room exit. Review of facility's policy titled Isolation Guides dated 6/16/20 revealed under Procedure for Contact Precautions, Gloves .4. Gloves will be removed and discarded before leaving the resident's room, hands will immediately washed with soap and water, or waterless hand sanitizer will be used .Gowns .4. The gown will be removed and appropriately discarded before leaving the resident's environment. In a CDC article titled Preparing for COVID-19 in Nursing Homes dated June 25, 2020 under Core Practices revealed, Provide Supplies necessary to Adhere to Recommended Infection Prevention and Control Practices .Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room or before providing care for another resident in the same room. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fprevent-spread-in-long-term-care-facilities.html In an article titled Annex E Isolation rooms or areas dated 2014 revealed under E.1. Preparation of the isolation room or area, Place appropriate waste bags in a bin. If possible, use a touch free bin. Ensure that used (i.e. dirty) bins remain inside the isolation rooms. https://www.ncbi.nlm.nih.gov/books/NBK 1/?report=printable 3. A. On 6/24/20 at 11:43 am, while in the 300 unit, a clean linen cart with folded linen and towels was observed inside the shower room, exposed. The clean linen cart was next to the hamper for dirty linen with the lid left open. This was confirmed by NA2. B. On 6/24/20 at 12:22 pm, in the 300 unit, the door to the clean linen closet was observed open. Gowns, pads and other supplies are folded on the shelves but exposed. NA3 confirmed the observation. C. On 6/24/20 at 1:57 pm, while in the 100 unit, a clean linen cart was observed inside the shower room. Folded towels and clean linen were on the second and third shelves, exposed. D. On 6/24/20 at 2:00 pm, four linen carts with folded blankets, gowns and pads were observed in the main linen room. The front cover for the four linen carts were pulled back exposing the clean linen. The door to the main linen room was left open. During interview with the ADON on 6/29/20 at 1:22 pm, when asked how staff should store and handle clean linen, the ADON stated that clean linen should be covered before they get delivered to residents' rooms. Review of facility's policy titled Linen Handling dated 4/24/20 revealed, Purpose: Maintain infection prevention techniques to help prevent the spread of illness. Under Procedure, it revealed, 6. Linen needed on units is to be placed on wing linen carts and then covering placed over when in transport or not in use .8. Linen may be placed in clean linen closets on unit and doors on wing linen closets closed when not in use. In a CDC article titled Appendix D - Linen and Laundry Management dated March 27, 2020 under Best practices for management of clean linen revealed, Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html 4. On 6/24/20 at 12:09 pm, housekeeping staff (E1) was exiting R6's room wearing gloves and holding a trash bag. E1 disposed the bag inside the cleaning cart. Still wearing the same gloves, E1 took the key from her pocket and unlocked the cart. E1 took a bottle of disinfectant spray and went back to R6's room. E1 exited the room and took the mop and the dustpan. E1 failed to remove her gloves and perform hand hygiene after exiting R6's room and before using the key to the cleaning cart. When E1 was asked when should she remove or change her gloves, E1 stated, I use one pair until I'm done in the room. During interview with the Assistant Director of Nursing (ADON) on 6/29/20 at 1:22 pm, when asked when if she expected staff to remove their gloves upon exiting the room, the ADON stated, Correct. Review of facility's undated policy titled Routine Handwashing and Sanitizing revealed, Purpose: To prevent the spread of infections. Handwashing/Sanitizing indications .before leaving a room. In a CDC article titled Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings dated 6/29/04 revealed under Gloves, Gloves protect you against contact with infectious materials. However, once contaminated, gloves can become a means for spreading infectious materials to yourself, other patients or environmental surfaces .Limit opportunities for touch contamination- protect yourself, others and environmental surfaces .Think about environmental surfaces too and avoid unnecessarily touching them with contaminated gloves. Surfaces such as light switches, door and cabinet knobs can become contaminated if touched by soiled gloves .Change gloves as needed. If gloves become torn or additional patient care tasks must be performed, then change the gloves before starting the next task .Perform hand hygiene immediately after removing PPE. https://www.cdc.gov/hai/pdfs/ppe/PPEslides6-29-04.pdf In a CDC article titled Core Concepts for Hand Hygiene: Clean Hands for Healthcare Personnel revealed, Bacteria can survive for days on patient care equipment and other surfaces like bed rails, IV pumps, etc. It is important to use hand hygiene after touching these surfaces and at exit, even if you only touched environmental surfaces. Under When Should You Clean Your Hands, 5. After touching surfaces around a patient. https://www.cdc.gov/infectioncontrol/pdf/strive/HH101-pdf https://www.cdc.gov/infectioncontrol/pdf/strive/HH101-

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents in 3 of 8 residents (R20, R5, and R50). The facility did not follow care plan interventions for R20 and R5. The facility also did not follow manufacturer guidelines when using the Arjo Sara 3000 stand lift to toilet R20. R50 was known to wander into other resident rooms and the facility failed to ensure the safety of all residents in the facility. Surveyor observed on two occasions that R20's tray table and water next to the curtain that divides the shared room, and not next to the resident within her reach while in bed. This was a fall intervention following a fall with a head injury that required staples. Surveyor observed CNA M (Certified Nursing Assistant) unlock the brakes on the stand lift while providing perineal care to R20 in the tub room. While R20 was standing up in the lift, the lift started rolling away from CNA M. CNA M was able to grab the lift and stop it from rolling. Surveyor observed CNA M transfer R20 with a stand lift and did not check to confirm the appropriate size sling for R20. CNA M was not aware of the process to confirm the correct sling size. Surveyor observed that staff did not leave R5's call light in within her reach or line of sight. Surveyor observed CNA L (Certified Nursing Assistant) leave R5 alone in the bathroom. R5's care plan states she is not to be left alone in the bathroom. Evidenced by: The manufacturer Instructions for Use for the Sara 3000 lift, dated 4/2016, states, in part, on page 12: While the resident is raised, make any necessary adjustments to clothing, incontinence pads, etc., before lowering again. Use the hand control to carefully lower the resident. Apply the foot operated rear castor brakes to keep the Sara 3000 in position. Example 1 R20 was admitted to the facility, on 2/8/19, with [DIAGNOSES REDACTED]. R20's Admission MDS (Minimum Data Set), dated 2/15/19, indicates the following: Brief Interview for Mental Status (BIMS) indicating she has severe cognitive impairment. Requires extensive physical assist of 1 person for bed mobility, transfers, and toileting. R20's care plan, revised date 4/22/19, states, in part: Self Care Deficit with ADL's (Activities of Daily Living) Nurse Aide - TRANSFERRING: 1 assist, stand pivot transfers from bed to WC (wheelchair) and WC to bed. TOILETING: Continent/Incontinent wears brief 1 assist, Use hall bathroom and wall mounted bar, Offer bathroom upon rising, after breakfast, after lunch, before dinner, after dinner, and at bedtime. R20's care plan, dated 2/8/19, states, in part: Potential for falls, Related To: Falls history, Vision status, Medications, Mobility, Dementia, resident self transfers. Manifested By: See Behavior Care Plan for Targeted Behavior. Approach: .5/14/19 Nurse Aide- Equipment - padded tray table and keep close to resident with water available. R20's CNA Care Card, dated 6/5/19, in part: Safety Devices and Equipment: .padded tray table and keep close to resident with water available. On 6/5/19 at 9:20 AM, while waiting to observe cares for R20, Surveyor noted that R20's padded tray table next to R20's curtain and not within R20's reach. On 6/5/19 at 9:25 AM, Surveyor observed CNA M provide care to R20. In preparation to transfer R20 with the Arjo Sara 3000 lift (stand lift), CNA M put a blue sling with green trim on resident and stated it looks way too big; CNA M removed this sling. CNA M then put blue sling with yellow trim on R20. On 6/5/19 at 9:54 AM, Surveyor observed CNA M toileting R20 in the tub room. CNA M raised the stand lift, unlocked the brakes, and began to provide perineal care. The floor in the tub room is not even and the stand lift began rolling. CNA M was able to stop the stand lift. On 6/5/19 at 10:00 AM, Surveyor asked CNA M if R20 has any CP (care plan) interventions regarding tray table. CNA M replied, I haven't worked down here so I'm not sure, you will need to ask one of the permanents that work down here. CNA M stated this is her first time working on this wing and she worked on the 200 and 400 wing when orienting. Surveyor asked CNA M if she needed to know how to care for a resident, where would she look. CNA stated she would refer to the Care Card in room or go ask another CNA. Surveyor asked CNA M to look at R20's Care Card. CNA M read R20's Care Card and read, Padded tray table keep close to res (resident) with water. Surveyor asked where the tray table with water was located. CNA stated by wall. Surveyor asked next to curtain? CNA stated, Yes, not in reach. There is also a sign on R20's bulletin board, above her bed, that reads, Please help me get a drink of water. I cannot reach it myself. Surveyor asked CNA M where should R20's tray table with water be located. CNA M stated it should be next to R20's bed within her reach. Surveyor asked CNA M how do you know what sling to use when transferring. CNA M stated, it's based on their weight, I believe, and it's in their care plan too. Surveyor asked CNA M did you check R20's CP. CNA stated, I should have checked her CP, but I didn't. CNA stated green was too big so I switched to yellow. CNA stated she does not know R20's weight. Surveyor asked CNA M should you have locked the brakes on the lift when providing pericare, so the lift didn't start rolling. CNA M stated, Yes. On 6/5/19 at 12:54 PM, Surveyor observed R20's overbed table next to the curtain again, and not next to her while she was in bed. This was Surveyor's second observation of this fall intervention not in place. Surveyor asked CNA L to come to resident's room. CNA L stated she does not put the overbed table up to the bed (on the mat). CNA L stated, For drink wise she can't reach her water where it is now, there she's not able to reach any water. CNA L pushed the overbed table next to R20's bed. CNA L stated, This will be my correction, I will put this here. Surveyor asked CNA L should R20's overbed table and water be in reach next to her bed. CNA L stated it's going to have to be like that (next to R200 within reach); it should have been where it is right now. CNA L stated, She helps herself to her liquids. She drinks a lot of ice water! On 6/6/19 at 1:47 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B what intervention was put in place following R20's fall on 5/11/19. DON B read, Padded tray table and keep close to resident with water available. Surveyor asked DON B should the tray table be next to R20's bed with water. DON B stated the whole idea of padding her tray table was so it could be next to R20 on the mat. Surveyor asked should the tray table be next to her. DON B stated, Yes. Surveyor asked DON B how R20 transfers/toilets. DON B stated R20 is a 1A (one person assist) stand pivot from bed to WC, same with toileting. She can walk short distances, up to 15 ft (feet), usually. DON B stated, If staff don't feel safe transferring, they can always go up (upgrade from pivot to stand lift) but not down. Surveyor asked DON B what R20's weight is. DON B stated, 117 pounds. Surveyor discussed sling size with DON B, DON B determined the sling CNA M used was an appropriate size; however, the concern is that she guessed and didn't confirm before she transferred R20 multiple times. Surveyor asked DON B should staff review care plans before caring for residents. DON B stated, Yes. Surveyor asked DON B should staff lock wheels on a lift when providing pericare. DON B stated, I guess that would be my preference. Example 2 R5 was admitted to the facility, on 8/6/18, with [DIAGNOSES REDACTED]. R5's quarterly MDS, dated [DATE], indicates the following: BIMS indicating she is cognitively intact. R5 requires extensive physical assist of 1 person for bed mobility, transfers, and toileting. R5's care plan, revised date 4/22/19, states, in part: Self Care Deficit with ADL's Nurse Aide - TRANSFERRING: 1 assist, Stand Lift. TOILETING: Continent/Incontinent 1 assist, DO NOT LEAVE ALONE IN BR (BATHROOM), Assist to bathroom upon rising, before and after meals, at bedtime, when awake at night. R5's care plan, revised dated 6/2/19, states, in part: Potential for Falls related to: Falls history, [MEDICAL CONDITION], Manifested By: fall (or near fall) in past 180 days, unsteady gait, pain, cognitive impairment, is able to use call light appropriately at times but does not fully comprehend safety issues and will forget or decline to use call light to ask for assistance-needs anticipation of needs or bed call light to alert staff of needs. EQUIPMENT: Bed call light, gripper socks or shoes at all times. R5's CNA Care Card, dated 6/6/19, states, in part: Safety Devices and Equipment: .Bed call light, gripper socks or shoes at all times. On 6/3/19 at 8:31 PM, Surveyor entered R5's room with permission. As Surveyor was speaking with R5, R5 stated to Surveyor that she can't find her call light and was looking for it to call nurse for pain medication. Surveyor observed R5's call light to be hanging over (behind) the head of her bed, out of R5's reach and line of sight. Surveyor observed a sign above R5's bed that reads, USE CALL LIGHT DON'T FALL!!! Surveyor handed the call light to R5 at 8:33 PM. NT K (Nurse Tech) answered the light at 8:36 PM and was bringing R5 her evening medications, including pain medication. On 6/3/19 at 8:40 PM, Surveyor spoke with NT K. Surveyor asked NT K if residents' call light should be within reach. NT K stated yes, they should be in reach and should be clipped or wrapped so they are readily available to residents. Surveyor showed NT K where R5's call light was, over the head of her bed. Surveyor asked NT K is the call light in reach when it's hanging over the head of her bed, out of reach and out of sight. NT K stated no, that is not in reach. Surveyor asked NT K if R5's call light should have been in reach. NT K stated, Yes. (It is important to note that resident was admitted to the facility with a history of falls and has a history of fall while at the facility. R5 has had the following falls at the facility: 1/25/19, 1/31/19, 3/1/19, 5/3/19, 5/23/19, and 6/2/19.) On 6/5/19 at 8:29 AM, Surveyor observed R5 request to be toileted. CNA L toileted R5 in the tub room. CNA L used the stand lift to transfer R5 to the toilet, wiped her with a disposable wipe. At 8:45 AM and 20 seconds, CNA L left the bathroom to get barrier cream for R5. CNA L returned at 8:46 and 10 seconds. CNA L was gone 50 seconds and left the resident alone in the bathroom. R5 is not to be left alone in the bathroom per her care plan. On 6/6/19 at 1:00 PM, Surveyor spoke with CNA [MI] Surveyor asked CNA L if she recalls why she left the bathroom when toileting R5. CNA L stated she needed to get barrier cream. Surveyor asked CNA L if it is acceptable to leave R5 in the bathroom alone. CNA L stated she thinks it's ok, then stated she's unsure. Surveyor got R5's Care Card from her room and showed to it CNA [MI] Surveyor asked CNA L, per the resident's CP, is it ok to leave her in the BR unattended. CNA L stated, No. Surveyor asked CNA L if she knows why R5 is not supposed to be left alone in the bathroom. CNA L stated because she could get up and fall. On 6/6/19 at 1:43 PM, Surveyor spoke with DON B. Surveyor asked DON B if call lights should be in reach for residents. DON B stated, Yes. Surveyor described to DON B where Surveyor observed R5's call light, hanging over the head of her bed, out of reach and out of her line of sight. Surveyor asked DON B if R5's call light should have been within R5's reach. DON B stated, Yes. Surveyor asked DON B is it ok for R5 to be left in the bathroom alone. DON B pulled up R5's care plan on the computer and stated, No. Surveyor asked DON B should CNA L have stayed with the resident in the bathroom. DON B stated, Yes, somebody else could have got the cream. Example 3 R50 was admitted to the facility, on 8/10/18, and his most recent MDS, dated [DATE], shows a BIMS score of 5, which indicates R50 has severe cognitive impairment. The MDS also documents that R50 wanders and his wandering significantly intrudes on the privacy of activities of others. R50's care plan states, Problem: Potential for injury and potential for sadness/behavior. Approach: Nurse Aide--15 minute checks. R50's care plan does not address wandering into other resident rooms or how the facility will ensure the safety of R50 or the residents whose rooms he enters. R15 was admitted to the facility, on 8/29/18, and her most recent BIMS, documented on 3/4/19, scores a 15, which indicates R15 is cognitively intact. The facility documented the following behaviors for R50: 1/4/19: Going into people's rooms, taking things off the walls, example a stocking from 300 hallway. He also has taken a box of gloves from somewhere and is in his room taking them out of the box. 1/14/19: Resident repeatedly tried to exit fire escape doors, dining room doors, and front doors; he was re-directed but would continue wandering about the facility after being returned to room and 400 wing area. Wandering into other resident's room. 1/20/19: Entered several occupied and unoccupied rooms. 1/21/19: Attempting to enter other rooms. 1/24/19: Entered several resident rooms occupied and unoccupied. 1/27/19: Attempted to enter a peer resident's room x2 (twice). 2/2/19: Resident would wander into another resident's room, be re-directed, and then enter another resident's room again. 2/12/19: Resident has been wandering in the hallways picking things off the walls and other residents' rooms. 2/15/19: Wandering into several resident rooms. 2/17/19: Going into other resident's room. 2/19/19: Resident also was wandering into other residents rooms all day. At least 5 times I took him out of people's rooms. 5/18/19--wandered 1 2/20/19: Wandering building, entering other resident's room. 2/24.19: Wandering into other people's rooms and taking stuff from their counter tops and refusing to give it back. 3/1/19: Resident was wandering in and out of other residents' rooms all shift. 3/26/19: Attempt to enter peer resident rooms. 4/16/19: He was going in other resident rooms and taking things off the med cart. 5/23/19: Wandering halls, going into other resident's rooms. 5/26/19: Wandering the halls, entering other resident rooms. On 6/4/19 at 10:50 AM, Surveyor observed R50 in his wheelchair at the doorway (feet at threshold) of R15's room. FM G (Family Member) saw him (R50) in the hallway and wheeled him back to the 400 unit where he resides. Surveyor asked HK J (Housekeeper), who was in R15's room cleaning, if R50 was supposed to be down the 300 unit. HK J stated she did not know. No other staff was visible in hall or nearby. A stop sign was visible outside R15's door, folded up and attached to one side of the door frame. On 6/5/19 at 9:59 AM, Surveyor interviewed FM G, wife of R31. In regards to R50's wandering, FM G stated, I'm not afraid of R50 but it bothers me and I don't know how my husband is going to react as they (R31 and R50) both have dementia. On 6/4/19 at 4:35 PM, Surveyor interviewed CNA H (Certified Nursing Assistant). CNA H stated R50 is on either 15 minute checks or 30 minute checks. On 6/5/19 at 7:47 AM, Surveyor interviewed CNA I. CNA I stated R50 wanders everywhere, other people's rooms, and outside. Some residents don't like it and they can be heard saying get out of here. On 6/5/19 at 8:48 AM, Surveyor interviewed CNA D. CNA D stated R15 had the stop sign because R50 had wandered into her room. CNA D stated she was not sure when the stop sign is supposed to go up on R15's room. CNA D stated she heard that R50 goes into other residents' rooms other than R15's, but wasn't aware of who those residents were. On 6/5/19 at 9:26 AM, Surveyor interviewed R15. Regarding R50, R15 stated, That guy keeps coming in my room. I caught him a couple times. He's been in several other rooms. I'm annoyed and it affects my privacy and it's not fair to me. I'm always looking over my shoulder and it bothers me and I can't defend myself. I'm always on guard and it's not right. This is my home. The first time I saw him, he was spooky. I do worry about him and if something is lost I'm not sure if it is me or if he took it. He doesn't scare me, but it takes my privacy away and I feel uncomfortable. He's been in my room probably 3 times. When I see him cruising around I wonder what he's thinking. On 6/5/19 at 8:10 AM, Surveyor interviewed CNA F. CNA F stated R50 wanders down the hall and has gone into other people's rooms. CNA F stated she wasn't exactly sure why the stop sign is up outside R15's room, but R15 usually puts it up and staff don't do anything with it. CNA F also stated R50 is on 15 min checks and, with staffing shortages at times, We do the best we can, maybe that's a 30 minute check. On 6/5/19 at 1:25 PM, Surveyor interviewed SW C (Social Worker). SW C stated, My understanding is that he (R50) went in there (R15's room) a few times before staff had passed the information on. SW C went on to say that she talked to two residents in the room kitty corner to R15, but did not speak with anybody else and did not speak to R15 about R50 specifically. SW C stated if she had known R15 felt an invasion of privacy, she (SW C) would have spoken with other residents, spoken with staff and then updated the care plan to reflect R15's needs. SW C stated she did not update R15's care plan to reflect the stop sign, its usage or the reasons why it was being used. On 6/5/19 at 1:59 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated if she heard about a resident and their violation of privacy, she would speak with the resident and set up an IDT (Interdisciplinary Team) meeting and would also speak with other residents. DON B stated she did not do that with R15, nor did the facility speak with other residents to ensure their safety and right to privacy. The facility was aware R50 was wandering into other resident rooms, did not follow up with resident concerns and did not did put measures into place to ensure the safety of R50 and other residents.

Based on observation, interview and record review, the facility failed to ensure each resident is treated with respect and dignity and cared for each in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality for 1 of 18 residents (R15). R15 felt her privacy was being violated due to another resident (R50) wandering uninvited into her room and the facility did not care plan or address R15's needs. Findings include: R15 was admitted to the facility, on 8/29/18, and her most recent BIMS (Brief Interview for Mental Status), documented on 3/4/19, scores a 15, which indicates R15 is cognitively intact. R50 was admitted to the facility, on 8/10/18 and his most recent MDS (Minimum Data Set), dated 5/14/19, shows a BIMS score of 5, which indicates R50 has severe cognitive impairment. The MDS also documents that R50 wanders and his wandering significantly intrudes on the privacy of activities of others. On 6/4/19 at 10:50 AM, Surveyor observed R50 in wheelchair at the doorway (feet at threshold) of R15's room. A family member of another resident, from a nearby room, saw R50 in the hallway and wheeled him back to his hall. A stop sign was observed folded on the outside frame of R15's door. On 6/5/19 at 8:48 AM, Surveyor interviewed CNA D (Certified Nursing Assistant). CNA D stated R15 had the stop sign because R50 had wandered into her room. CNA D stated she was not sure when the stop sign is supposed to go up on R15's room. CNA D stated she heard that R50 goes into other residents' rooms other than R15's, but wasn't aware of who those residents were. On 6/05/19 at 9:26 AM, Surveyor interviewed R15. Regarding R50, R15 stated, That guy keeps coming in my room. I caught him a couple times. He's been in several other rooms. I'm annoyed and it affects my privacy and it's not fair to me. I'm always looking over my shoulder and it bothers me and I can't defend myself. I'm always on guard and it's not right. This is my home. The first time I saw him, he was spooky. I do worry about him and if something is lost. I'm not sure if it is me or if he took it. He doesn't scare me, but it takes my privacy away and I feel uncomfortable. He's been in my room probably 3 times. When I see him cruising around I wonder what he's thinking. On 6/05/19 at 1:16 PM, Surveyor interviewed CNA [NAME] who was working the hall where R50 resided. CNA [NAME] stated she was not aware R50 wandered into any other resident rooms. On 6/5/19 at 8:10 AM, Surveyor interviewed CNA F. CNA F stated R50 wanders down the hall and has gone into other people's rooms, but hasn't gotten anyone upset. CNA F stated she wasn't exactly sure why the stop sign is up outside R15's room, but R15 usually puts it up and staff doesn't do anything with it. On 6/5/19 at 1:25 PM, Surveyor interviewed SW C (Social Worker). SW C stated, My understanding is that he (R50) went in there (R15's room) a few times before staff had passed the information on. SW C went on to say she talked to two residents in the room kitty corner to R15, but nobody else and did not speak to R15 about R50 specifically. SW C stated if she had known R15 felt an invasion of privacy, she (SW C) would have spoken with other residents, spoken with staff and then updated the care plan to reflect R15's needs. SW C stated she did not update R15's care plan to reflect the stop sign, its usage or the reasons why it was being used. On 6/5/19 at 1:59 PM, Surveyor interviewed DON B (Director of Nursing). DON B stated if she heard about a resident and their violation of privacy, she would speak with the resident and set up an IDT (Interdisciplinary Team) meeting. DON B stated she would also speak with other residents. DON B stated she did not do that with R15. R15's care plan does not address the stop sign outside her door, when and how it is to be used or her value of privacy. R50's care plan does not mention R50's wandering into other resident rooms.

Based on observation, interview and medical record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PIs) from developing, worsening or to heal PIs, for 2 of 5 residents (R70 and R76) with PIs, out of a total sample of 19. R70 developed 3 unstageable PIs and one stage 2 PI while at the facility. The first unstageable deep tissue injury (DTI) was not identified as that, or assessed by the facility's Wound Care Certified Nurse, or re-measured until 12 days after it was discovered. The facility did not provide effective alternate/additional measures to prevent other PIs from developing or to promote healing of current areas of PIs in a timely manner. All nursing staff were not re-educated after the PIs were discovered. R76 was admitted without a PI and was identified as at risk of developing one. The facility failed to put aggressive measures in place to prevent R76 from developing a PI. R76 developed a PI. This is evidenced by: Example 1 The facility roster matrix, provided to Surveyors on 2/26/18, identified R70 had facility acquired PIs/ulcers and R70 had worsened PIs. On 2/28/18, Surveyors were provided with a list of residents who had PIs. The list identified R70 had PIs that were present on admission and had developed at the facility. Stage listed was Unstageable. R70 has [DIAGNOSES REDACTED]. R70 also had type 2 diabetes, diabetic [MEDICAL CONDITION] and peripheral artery/vascular disease. R70's 1/8/18 Admission Braden Scale (an assessment to determine PI risk) was 15, which indicates at risk for PI development. R70's 1/15/18 MDS (Minimum Data Set) Assessment identified R70 required extensive assistance of two staff for bed mobility and transfers, and had impaired mobility of one lower extremity. (R70 had impaired mobility in his L leg due to the femoral fracture and he was wearing a leg abductor, which was secured around both of his legs). This MDS identified R70 was at risk for PI development. It identified R70 had one unstageable DTI that was present on admission. (Though R70's Admission Skin Assessment showed no sign of an unstageable DTI. It identified R70 was provided with a pressure reduction device for his bed and chair. No turning and repositioning intervention was identified on this MDS or his 1/21/18 MDS.) R70 was admitted to the facility on [DATE] at 4:05 PM. An Admission Skin Assessment, completed the evening of 1/8/18 by RN C (Registered Nurse), identified R70 had no PIs. The note identifies the L hip incision site, bruising of the L hip incision site and bruising on arms from IV (Intravenous) therapy and blood draws at the hospital. This note reads, in part: Has had no foot problems or care in past 7 days . And Heels-Off loaded with pillows. Receives turning/repositioning program. Has pressure reducing device for bed. Has pressure reducing device for chair . On 2/28/18 at 3:40 PM, Surveyor interviewed RN C and asked RN C if he had looked closely at R70's heels on the evening of 1/8/18. RN C said he did and there was nothing there, no discoloration or anything. Surveyor asked RN C if he directed staff to float R70's heels. RN C said he did. RN C was asked if they started pressure relieving boots right away, that evening. RN C said he didn't think so. On 2/28/18 at approximately 4:00 PM, Surveyor asked CNA E (Certified Nursing Assistant), who worked with R70 on 1/9/18, if she recalled using a pillow to float R70's heels. CNA E said all new residents get 2 pillows, one for their head and one for their feet, but the pillows are squishy, not fluffy. Surveyor asked if one pillow was enough to float R70's heels. CNA E said no. Surveyor asked CNA E if she got more pillows so R70's heels would be floated off the mattress. CNA E said no, she was not sure where to find more pillows. Surveyor asked CNA E if she had told the nurse R70 needed more than one pillow to float his heels. CNA E said no. Surveyor reviewed R70's nursing notes from 1/8/18-1/12/16 and did not locate documentation of R70 refusing to float his heels on pillows or refusing to wear the foam boots offered, until the note of 1/12/18, after the L heel PI was found. Left Heel: A Nursing Progress Note of 1/12/18 at 11:13 AM reads, in part: L heel discoloration . WOUND TISSUE: blue and purple, mooshy. Percentage of each type 100%. PR[NAME]EDURE DONE: Area Assessed. (Initials and ADON (Assistant Director of Nursing) notify, float heels . length (cm) (centimeter) 0.37 width (cm) 0.27. (These measurements were incorrect, per interview with DON B (Director of Nursing) and RN D on 3/1/18 beginning at 1:50 PM. DON B told Surveyor, the decimal point was put in the wrong place and the measurement should have read length 3.7 cm and width 2.7 cm.) Nursing notes regarding R70's L heel: 1/13/18-identified R70's L heel as blue and purple and mooshy . Area left open to air. 1/14/18-Identified R70's L heel as brown/purple-soft to touch . heels elevated when in bed. 1/15/18-brown/purple/yellow . Area left open to air. An entry at 9:50 PM on 1/15/18 read, in part: GENERAL SKIN CONDITION: Reports no problems. SKIN PROBLEMS: See wound charting. FOOT PROBLEM/CARE: Has no foot problems or care in past 7 days . (Despite having the L heel DTI). SKIN TREATMENT: Heels off loaded with pillows. 1/16/18- . dry and has a small crack in heel, heel is brownish/purple in color . 1/17/18- . soft light purple dry with small crack . 1/18/18- . pink . 1/19/18- . dry, scaly, with dark brown areas that are hard . 1/20/18- .dark brown center that's hard, with dry white yellow skin . 1/21/18- .dark brown center that's hard, with dry white yellow skin with small amount of fluid . 1/22/18- .intact, soft purple area. Has tiny dry slit that is scabbed over next to soft purple area . 1/23/18- .heel continues to have some discoloration. Distal heel has a large, intact, fluid-filled blister . HEALING PROGRESS: worsened (non-pressure ulcer) blister appears larger .tenderness present . Area left open to air. R70's L heel area was not identified as a DTI, PI until 1/24/18. No additional measurements of R70's L heel wound were documented since the 1/12/18, questionable measurement of 0.37 cm x 0.27 cm, until the area was assessed by RN D, who is the facility's wound care nurse, on 1/24/18. On 3/1/18, during the interview with DON B and RN C, Surveyor asked why R70's L heel area was not assessed as an unstageable DTI and re-measured until 1/24/18. RN D said the nurses are not to categorize the wounds. That is for RN D to do. Surveyor asked why the delay occurred. RN D said that was probably the day they took the next pictures. RN D's 1/24/18 note read, in part: Area #1 L heel has unstageable DTI consisting of large fluid filled blister at the point. SIZE: length: 4.0 cm, width: 5.3 cm. ODORS: none. DRAINAGE: none. WOUND TISSUE purple area covered with blister . HEALING PROGRESS: still evolving DTI. Comments: would recommend skin prepping area to try and keep skin intact . 1/27/18- .L heel .deflated blister, light purple underneath, small pin point open area where fluid is draining . PR[NAME]EDURE DONE: Area assessed. Cleansed ABD (abdominal) pad and cling applied. 1/31/18- . L heel DTI had fluid filled blister that rubbed off and has red wound base with some purplish discoloration under wound and a smaller blood blister area toward outer aspect of heel next to large blister area . AREA: #1 L DTI. SIZE: length: 6.3 cm, width: 5.8 cm, depth: 0 cm. ODORS: none. DRAINAGE: bloody. AMOUNT: small. WOUND TISSUE: red with dark purple discoloration under much of area . Comments: still would not stage this wound yet as base of wound purplish color and still evolving. Resident has heels off cushion for bed. Declines to wear foam boots and recommended not wearing left shoe unless in therapy or transfers. Request for multi-podus boot (pressure reduction boot) to be ordered . MD (Medical Doctor) NOTIFIED: 1/31/18 requested different treatment for [REDACTED]. 2/2/18- .L heel TYPE: blister/discoloration . DRAINAGE: blood-tinged . WOUND TISSUE: brown/purple . length 3.5 width 2.5 . 2/6/18-AREA #1 L heel DTI blister became unstable so treating with Xeroform (dressing that prevents air from reaching wound) and believe quicker debridement needed, so will make referral wound clinic request to GNP (Geriatric Nurse Practitioner). Has new clear fluid filled blister above original DTI that is 1 cm by 2 cm. Has 1 to 2 + [MEDICAL CONDITION] in L leg yet. SIZE: L heel. DTI length: 7 cm, width: 5 cm, depth: 0 cm. DRAINAGE: clear and some blood-tinged. AMOUNT: small. WOUND TISSUE: yellow slough . 2/14/18-Area #1 L heel DTI unstageable. SIZE: length: 6.5 cm, width 6.5 cm, depth: 0 cm. DRAINAGE: blood-tinged scant. WOUND TISSUE: eschar with bright red edges around 80% of wound. SURROUNDING TISSUE: normal. WOUND EDGES: maceration. HEALING PROGRESS: debrided edges by wound clinic. DESCRIPTION: appears more clean on edges . 2/16/18-L heel. TYPE: desensitized skin /open blister. DRAINAGE: yellow . WOUND TISSUE: black eschar 75%, yellow and pink tissue 25%. HEALING PROGRESS: worsened (non-pressure ulcer). DESCRIPTION: becoming larger . length (cm): 6.5 width (CM): 4.5. 2/21/18-AREA #1 L heel DTI-unstageable. SIZE: length 6.5 cm, weight: 6.5 cm, depth: 0 cm, . WOUND TISSUE: bottom part of heel has hardened black eschar, top part of wound up the heel cord is discolored skin with superficial peeling of skin 4cm by 2 cm (of the 6.5 by 6.5 total of heel. (also just lateral about 1 cm from of heel eschar is small 0.9cm by 0.3cm dark scab) . WOUND EDGES: appear dry and doesn't have the bright red edges of last week so stabilized eschar area now . Comments: area treated with [MEDICATION NAME] and covered with dry dressing, wears [MEDICATION NAME] for 3 + [MEDICAL CONDITION] in left foot and wears offloading heel boots provided by wound clinic. RIGHT HEEL: On 2/6/18, R 70 was identified to have a second DTI. AREA #2 right (R) heel. DTI SIZE: length 2.2 cm, width: 2.5 cm, depth 0 cm, . WOUND TISSUE: deep purple to black hardened. MD NOTIFIED: 2/6/2018. Comments: treat with skin prep and off load. Resident had declined to wear foam boots and was wanting to wear his tennis athletic shoes, but explained that we could use those with his heels and use gripper socks until area healed and [MEDICAL CONDITION] down. Foam boot will be tried again, but he said, Oh I don't want those, and got angry when tried to explain why it was important stating, I don't care. Resident has a Heels-Off cushion in bed, but has been seen bending his R leg up and resting heel directly on cushion instead of floating them, and is difficult to redirect and forgets instruction . 2/7/18- . R heel . dark area with peeling tissue around it . 2/14/18-AREA #2 R heel unstageable. DTI SIZE: length: 3 cm, width: 3 cm, depth: 0 cm, . WOUND TISSUE: eschar . 2/14/18-Resident had been declining to use our foam boots and wanted to wear normal shoes. Now has stopped therapy for time being and is OK with using the heels off boots provided by wound clinic at this time as they are little more pliable than foam boots. Will use those in bed and in chair if resident allows, and if wants boots off can use heels off cushion, but resident has a tendency to bend R leg up and place heel directly on cushion which is not effective. Resident has little feelings in toes and feet, but was bothered by lotioning of feet, but not dressing changes . 2/21/18-R heel unstageable. DTI, SIZE: length: 3 cm, width., 4 cm, depth: 0 cm. ODORS: none. DRAINAGE: none. WOUND TISSUE: eschar 100% . DESCRIPTION: Area appears to have measure (sic) wider, as this is a deep tissue in evolution yet . R LATERAL MALLEOLUS: On 2/13/18, R70 went to the wound clinic for evaluation of his L and R heel DTI's. While at the wound clinic, an unstageable area of eschar was identified on R70's R lateral malleolus. On 2/13/18, the wound clinic provided R70 with the TruVue heel suspension boots. Different boots had not been offered or provided prior to 2/13/18. 2/14/18-AREA #3 R lateral malleolus unstageable. SIZE: length: 0.6 cm, width: 0.5 cm, depth: 0 cm. WOUND TISSUE: eschar . DESCRIPTION: had missed this area earlier on assessment. Comments: [MEDICATION NAME] and open to air at this time . 2/21/18-AREA #3 R lateral malleolus unstageable. SIZE: length: 0.6 cm, width: 0.5 cm, depth: 0 cm, . WOUND TISSUE: eschar 100%. During an interview with DON B and RN D, on 3/1/18 beginning at 1:50 PM, Surveyor asked about the R lateral malleolus unstageable PI being charted as it was found at the wound clinic. Surveyor asked if it should have been found here and not at the wound clinic. RN D said she first noted it too after that appointment. DON B said he had a lot of tiny areas. C[NAME]CYX AND ABOVE SACRUM: On 2/17/18, Nursing Progress Notes identify R70 was found to have open areas on his coccyx and above the rectum. These are described as: TYPE: Stagged (sic) ulcer/Open Areas (No stage identified). DRAINAGE: blood-tinged from the coccyx. AMOUNT: scant. WOUND TISSUE: Above the rectum-deep pink excoriation-like (top layer of skin gone) . WOUND EDGES: Coccyx-white soft tissue. HEALING PROGRESS: N/A (new area). DESCRIPTION: tenderness present. PR[NAME]EDURE DONE: Area Assessed. Cleansed Vaseline/[MEDICATION NAME] applied to both areas. Boarder (sic) foam applied to coccyx. AREA: Coccyx length (cm): 2 width (cm): 1 depth: Superficial AREA: Above the rectum length (cm) 3.5 width (cm) 3 depth Superficial. 2/20/18-Coccyx and above Rectum TYPE: Staged Ulcer (no stage identified) . DRAINAGE: blood-tinged. AMOUNT: scant. WOUND TISSUE: clean, moist, intact, above the coccyx is deep pink but the coccyx is a mixture of deep pink/white tissue . 2/21/18-AREA #4 coccyx stage. 2 SIZE: length 2 cm, width: 0.8 cm, depth: 0 cm. DRAINAGE: scant. WOUND TISSUE: pink. HEALING PROGRESS: improving. DESCRIPTION: area appears smaller than when found was superficial area very close to rectum that is closed. Comments: .Resident's legs are flexing and with his preferred back lying position it causes him to push heel off cushion up and pushes his heels into bed. Will have staff attempt side lying, but with [MEDICAL CONDITION] and his history of back lying may not like to lay this way. Will discuss leg flexing with therapy . On admission (1/8/18), R70 was provided with a gel/foam pressure reducing cushion for his wheelchair. R70 was later using a Broda chair (tilt and recline positioning wheelchair) and the gel/foam cushion was in use with the Broda chair. On 2/17/18, R70 was found with the stage 2 PI/open areas to his coccyx and above his rectum. PI Treatment Observation: On 2/27/18, beginning at 9:08 AM, Surveyor observed RN D and RN F perform the treatments to R70's heels and to the R lateral malleolus PIs. RN D removed R70's heel boots and then the dressings for both feet. Surveyor looked at R70's L heel and noted an approximate 6-7 cm x 6-7 cm area of dark brownish black eschar. The eschar extends up the back of R70's L heel to near the Achilles area. There is also an approximate 1 cm area of eschar on R70's lateral L heel. Surveyor then looked at R70's R heel and observed an approximate 4 cm x 5 cm area of dark brownish black eschar over the back of R70's R heel. Surveyor noted an approximate 1 cm of light redness around the upper portion of the eschar on R70's R heel. Surveyor asked if the redness if new. RN D said, no it has been like that. RN D said the areas don't look much different than they did last week. Surveyor observed R70's R lateral malleolus PI and noted an approximate 1 cm circular area of brown eschar. R70 was wearing green TruVue heel suspension boots, the boots provided by the wound clinic on 2/13/18. A Heels-Off cushion was also in use. During an interview with DON B and RN D, on 3/1/18 at 2:39 PM, Surveyor asked when the ROHO cushion (wheelchair cushion) was started for R70. Surveyor was told on 2/21/18. Surveyor asked why the ROHO was not implemented sooner given R70's PI risk factors and the stage 2 areas found on 2/17/18. DON B said, that is when our Wound Team would have met (2/21/18), we look at what interventions are in place. He had the gel cushion and it was determined he needed to be upgraded. DON B said the other thing that had happened, he was no longer in therapy and he was deteriorating. They felt he would benefit from a Broda chair for positioning and pressure reduction. It was a couple days after that they found the area on his coccyx. Initially, the gel cushion was used in Broda and then they added the ROHO to the Broda chair. Review of R70's care plan includes an approach dated 1/12/18: REPOSITIONING: 1 assist, Float heels. Surveyor was told R70 did not like to lay on his sides in bed. This was not on his care plan. It was documented R70 would flex his legs and push his heels into the bed/mattress. This was not on R70's care plan. R70 was not provided with a different type of mattress until 2/21/18, after the 4 PI's had occurred. On 2/28/18, Surveyor reviewed R70's CAA (Care Area Assessment) dated 1/20/18. This read, in part: Resident was admitted with skin issues from hospitalization with [MEDICAL CONDITION]. DTI on L heel (affected side from [MEDICAL CONDITION]) started at hospital. During an interview with RN D and DON B, on 3/1/18 beginning at 1:50 PM, Surveyor questioned this statement, based on interview with RN C and documentation review of no skin areas present at the time of admission. RN D stated Dr. (name), at last year's Focus conference, said DTI's can start 72 hours before there is anything visible on the skin. Surveyor pointed out, per documentation and interview with RN C, R70 had no sign of a DTI on his L heel on his Admission Skin Assessment, completed the evening of 1/8/18. The actual time that RN C did R70's skin assessment was not documented. RN C's note was entered in to the computer starting at 9:44 PM. On 1/12/18, the actual time the L heel PI was found was not documented. The note was entered in to the computer at 11:13 AM. R70's L heel DTI was discovered on the morning of 1/12/18, this would be over 72 hours, closer to 84-86 hours. Despite that information, RN D and DON B felt the L heel DTI began before he was admitted . On 3/1/18, Surveyor requested a copy of R70's Initial Care Plan that would have been put in place at time of admission and any updates made within 48 hours of R70's admission. DON B said they do not keep the Initial/48 hour care plans. DON B provided Surveyor with a copy of a To Do List for R70. Entries on this To Do List, started on 1/9/18, included Admission Assessment for AM shift 1/9/18. This is not initialed by a nurse. On 1/10/18, an entry identified Give 48 Hour Care Plan, was initialed by a nurse on 1/10/18. On 3/1/18, Surveyor reviewed R70's behavior documentation from 1/17/18 to AM shift of 3/1/18. (No behavior documentation was provided for 1/8/18 to 1/16/18.) There are entries of behaviors of wanting to toilet frequently, calling out, moaning and having increased confusion. Surveyor looked for behaviors related to refusal of care, specifically regarding refusal of floating heels or wearing the pressure reliving boots. Surveyor noted the following entries: 1/20/18-Resident was argumentative with staff when staff was unable to fit his left shoe on before supper. 2/19/18-Restless on and off all shift .,threw one of his foam boots on the floor. No other entries were made regarding R70's refusal to float his heels or wear the heel protection boots. On 3/1/18, during the interview beginning at 1:50 PM, with DON B and RN D, Surveyor referenced the 1/12/18 nursing note that read, in part: WILL FLOAT HEELS. Surveyor questioned this note as it reads like they were not floating his heel/s before this. RN D said that is when they started using the Heels-Off cushion. Surveyor pointed out notes from 1/8/18 to 1/12/18 do not identify R70 was refusing to wear the heel float boots, to float his heels or that R70 was educated on the risks of not wearing the heel lift boots or floating his heels. Surveyor discussed on 1/16/18 discontinued entry from R70's care plan identified to leave shoes off except when in therapy. Surveyor asked if he was still wearing his shoes until 1/16/18. DON B said, yes, whenever he was up, he was wearing his shoes until 1/16/18. RN D said he was walking with therapy. Surveyor asked, even after the L heel PI was found on 1/12/18, R70 was wearing his shoe on that foot. RN D said it was his preference. Surveyor asked if R70 was educated on the risk of wearing his shoe on his L foot, with having the DTI on his heel. RN D said she had spoken to him about wearing gripper socks instead of his shoe, but she may not have documented it. Surveyor reviewed PT (Physical Therapy) notes from 1/9/18-1/22/18, and noted R70 had PT from 30-70 minutes out of his day. EDUCATION: On 3/1/18, Surveyor asked RN D if nursing staff were re-educated on PI prevention and measures to promote healing of PIs, after the DTI was discovered on R70's L heel on 1/12/18, or after the DTI on R70's R heel was found. RN D provided minutes from a nurses' meeting on 2/8/18 and said some re-education was done at that meeting. The minutes included the following: 6. Quality measure show us high on . Also pressure ulcers. So be aware of our interventions for these. Care plan items for . and those at risk for skin in front of wing books and your narc books. Surveyor asked for a list of the nurses and their titles that attended that meeting and received that information. This was not provided. Surveyor asked if CNAs were re-educated. RN D said since (MONTH) we haven't, except for the annual training. Surveyor reviewed the annual training sheets for CNAs and found that 2 CNAs did the annual PI education since 1/12/18. RN D said R70's care plan is updated. Surveyor asked how CNAs are made aware of changes in a resident care plan. DON B said care plans get flagged and we highlight the change on CNA Care Plan. We put a post it note flag on it and have them initial or sign that they read and understand it. Surveyor was provided with a daily sheet used by the CNAs and Nurses that includes information about the residents. At the bottom of this sheet it reads: Skin Risk Residents: .(R70)-buttock/feet ) During the 3/1/18 interview with DON B and RN D, Surveyor asked what would you expect in terms of repositioning for a resident with R70's risk factors from onset/date of admission. DON B said he came in with a [MEDICAL CONDITION]. There was nothing in his record that he had [MEDICAL CONDITIONS], we learned that later, so we did not set him up with any specialized repositioning. On day one he was moving around, up and down a lot. Everybody comes in at risk, his condition deteriorated. Surveyor asked DON B and RN D if R70's L heel PI was avoidable. DON B said it was not avoidable. Surveyor asked what that was based on. DON B said because we feel he came here with that. The L heel process began in the hospital. Surveyor asked what about the R heel PI. DON B stated they feel that was not avoidable either, because they had put the Heels-Off cushion in place and encouraged him to not wear his shoes. He was still going to therapy. RN D said he had behaviors. DON B said he ended up with [DIAGNOSES REDACTED]. RN D said that falls under the heels and behaviors. DON B said it falls under his [MEDICAL CONDITION] and it was not avoidable. They could not do ABIs (Arterial Brachial Indexes), because he had no pedal pulse present. (That was not known/determined until his 2/13/18 appointment at the wound clinic.) Surveyor asked about his PI on his coccyx area. DON B said that was unavoidable too. We had him on pressure relieving surfaces, providing him extra nutrition. He was being repositioned. RN D said he had a pretty strong preference to lay on his back with being a fresh hip. That has changed. Surveyor asked if it was on his care plan, his preference to lay on his back. Both RN D and DON B said they didn't know. Surveyor shared she was unable to locate that information on R70's current care plan, or in discontinued care plan approaches. Surveyor had observed R70 up in his Broda chair during the survey with the lift sling under him. Surveyor asked if the total lift sling should be left under him while up in his Broda chair, as that can decrease the effectiveness of the Broda cushion. DON B said that depends on his pain level. Surveyor asked how they assure that staff are repositioning residents who are at risk for PIs or have PIs. DON B said nurses monitor it. Surveyor asked if it is documented for R70, as Surveyor did not locate documentation of that, other than two entries. Surveyor was told it is not specifically documented for R70. Surveyor asked how it is determined how often a resident should be repositioned, who is at risk for or has PI/s. DON B said we look at the individual, look at pain, kind of support surface they are on. Surveyor asked if they have a standard for how often a resident should be repositioned. DON B said for most people it is every 2-3 hours. Surveyor asked what about after R70's L heel DTI was found. DON B said probably the same. Surveyor asked if R70's physician or his Nurse Practitioner have seen and assessed R70's PIs, other than when done at the wound clinic on 2/13/18. DON B said his doctor has looked at the incident reports and RN D said they have looked at the pictures. Example 2 R76 was admitted on [DATE] with [DIAGNOSES REDACTED]. R76's CAA worksheet, associated with MDS/ARD (Assessment Reference Date) of 3/15/17, indicated R76 was at risk for developing PI due to the need for assistance in bed mobility, frequent urinary incontinence, frequent bowel incontinence, and her [DIAGNOSES REDACTED]. cradle and Broda chair, and will utilize barrier cream as needed. R76's MDS, with an ARD of 9/11/17, indicated R76's cognition to be moderately impaired. R76's MDS also indicated she was totally dependent on one staff to perform bed mobility, transferring, and toileting and that R76's upper extremities had impairment on both sides. R76's Braden, dated 9/25/17, scored at 14, indicating R76 was at moderate risk for PI development. The facility used a Comfortex Res Q mattress as their standard mattress and this mattress is rated for prevention and treatment of [REDACTED]. R76's Comprehensive Care Plan states, in part: Problem: Skin integrity impairment . Interventions/Approaches: 11/9/15 (date initiated) Nurses- pressure relieving devices for chair, pressure relieving devices for bed 11/9/16 (date initiated) Nurses- instruct aides to inspect skin with daily cares, and report changes to nurse 11/17/16 (date initiated) Nurses- skin assessment per policy, take initial photo, assess pain for skin condition 1/30/17 (date initiated) Nurse Aide- Encourage and assist to reposition, sits in pedal Broda wheelchair 2/2/17 (date initiated) Nurse Aide- Assist with hygiene and general skin care, keep skin clean and dry, barrier as needed 9/4/17 (date initiated) Nurse Aide- Encourage foam boots refuses , keep heels off bed with blue wedge 9/4/17 (date initiated) Nurse Aide- [MEDICATION NAME] (healing lotion) to lower extremities as needed. [MEDICATION NAME] (antifungal) spray to feet . before legs are wrapped . Nurses Note, dated 11/3/17 at 9:42 PM, states, in part: Date of Incident: 11/3/17 Time of Incident: 7:00 PM .Narrative of what happened: Found with cares to have on her right heel a very red/pink 4cm x 4cm area non-open, no drainage . Possible cause: Had gripper socks and wraps on this day and was up today sitting in her wheelchair with legs elevated, right foot on metal pedal Changes were made to R76's Comprehensive Care Plan/Problem: Tissue Integrity Impairment including: 11/14/17 (date initiated) Discontinue Nurse Aide- Encourage and assist to reposition, sits in pedal Broda wheelchair 11/14/17 (date initiated) Discontinue Nurse Aide- Encourage foam boots (refuses), keep heels off bed with blue wedge 11/24/17 (date initiated) Discontinue Nurse Aide- [MEDICATION NAME] to lower extremities as needed. [MEDICATION NAME] spray to feet . before legs are wrapped . (It is important to note the facility did not provide evidence of the care plan being altered between the date the PI was discovered (11/03/17) and 11/14/17, which is 11 days after discovery.) R76's Physician order [REDACTED].>3/13/16 (date initiated) wear loose fitting clothing 11/27/17 (date initiated) state: Apply [MEDICATION NAME]= left leg [MEDICATION NAME]= right leg, be careful has fragile skin with skin tears (Important to note that facility provided no evidence of Physician order [REDACTED].) On 3/1/18 at 1:45 PM, during an interview, CNA J indicated that R76 was in a pedal Broda chair and then later, when she declined, she was in a regular Broda chair. On 3/1/18 at 2:00 PM, during an interview, CNA K indicated that staff had to move R76, because she was unable to move herself. CNA K also indicated that R76's leg rests had metal foot pedals that went up and down with padded shin rest. CNA K stated that nurses double wrapped R76's feet and legs and explained that R76 wore TED hose, ACE wraps that wrapped around the base of her foot and went up the leg, and then gripper socks over top of ACE wraps and TED hose. CNA K indicated that she did not have to do anything special with R76's feet and legs while she was in bed, but she did have to turn her every two hours. CNA K showed Surveyor a pedal Broda chair with metal foot pedals that were removable. CNA K also showed Surveyor a regular Broda chair with cushions foot rests that were not easily removable. CNA K indicated that she saw R76 in a pedal Broda chair lots of times with her feet on medal pedals. On 3/1/18 at 2:15 PM during an interview, CNA L indicated that she used to assist R76 in the afternoon, sometimes, and that staff positioned her on her left side toward the window, with a pillow between her legs in bed. On 3/1/18 at 2:29 PM, during an interview, RN M indicated that she saw R76's feet on and off of the medal pedals of her pedal Broda chair and that R76 was often restless and would slide her feet back and forth, rubbing around. (It is important to note that the facility did not provide any evidence of education given to staff with topic of offloading, while in wheelchair after becoming aware of this PI.)

Based on record review and interview, the facility did not have documented registry verification that 1 of 5 Certified Nursing Assistants (CNA's) reviewed, met competency evaluation requirements. The facility was unable to provide documentation that CNA I was on the Wisconsin Nurse Aide Registry. This is evidenced by: On 2/27/18 at 2:00 PM, Surveyor completed the Verification of Nurse Aide Employment Eligibility Status form and noted CNA I did not have documentation that she was on the Wisconsin Nurse Aide Registry. On 2/28/18 at 7:57 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the documentation that CNA I is on the Wisconsin Nurse Aide Registry. NHA A indicated CNA I failed her test to become a CNA. NHA A indicated that CNA I was suspended as of yesterday. NHA A indicated CNA I was going to re-test on 3/5/18. Surveyor reviewed CNA I's personnel file and noted the hire date of 12/7/17. CNA I started the CNA course on 9/6/17 and completed the course on 11/22/17. To be noted, once a student completes the CNA course they have 120 days to pass the test and be included on the Wisconsin Nurse Aide Registry or they cannot work in the role of a CNA. CNA I completed 120 days on 1/3/18. Surveyor reviewed the CNA schedule and noted CNA I worked independently in the role of a CNA, Jan and Feb (YEAR), on 1/28, 2/2, 2/3, 2/5, 2/12, 2/16, 2/19, 2/25, and 2/26. It is important to know that CNA I was signing her charting using the CNA credentials when she was not certified. On 3/1/18 at 9:38 AM, Surveyor interviewed NHA A regarding CNA I working in the role of a CNA when she was not listed on the registry. NHA A indicated the previous HR G (Human Resource Director's) last day was 12/3/17 and the new HR H started on 1/2/18. NHA A indicated that HR G did all the new hire paperwork for CNA I. NHA A indicated that she was not sure if HR G thought it would be a training opportunity for HR H to verify that CNA I was on the registry. NHA A indicated the facility corporate HR trained HR H. NHA A indicated there was a note left in the HR Managers office, indicating that CNA I needed the registry verified. HR H was hired and for some reason it was not done. The facility corporate HR trained HR H on how to look up a license, and for whatever reason, CNA I was not verified. NHA A indicated that CNA I fell through the cracks. Surveyor asked NHA A if CNA I should have been verified that she was on the Wisconsin Nurse Aide Registry prior to working with residents. NHA A indicated yes. Surveyor asked NHA A if CNA I should have been allowed to work as a CNA after she had failed the CNA exam. NHA A indicated no, the facility would have suspended her if we had known.

Based on observation, interview and record review, the facility did not ensure that each resident who entered the facility without pressure injuries did not develop a pressure injury; and each resident with a pressure injury was provided with the necessary treatment and services to promote healing, prevent infections and prevent new injuries from developing for 4 of 8 sampled residents (R5, R6, R2, R12) reviewed for pressure injuries. 1. R5 developed a pressure injury related to a medical device on the left leg. R5 did not have additional skin assessments with the medical device, increased [MEDICAL CONDITION] in the legs and new pressure injuries were noted. The facility did not promptly assess the proper fitting of the medical device and make arrangements to have the medical device adjusted or re-adjusted after indications of poor fit. The facility did not stage the pressure injuries, and apply new interventions when new pressure injuries occurred. 2. R6 developed pressure injuries and the facility did not stage the pressure injuries, measure timely, apply new interventions when new pressure injuries occurred, consistent description of locations of the wounds and did not document if an area had healed. 3. R2 has a pressure injury on the coccyx. R2 was not repositioned according to current standards of practice. 4. R12 is at risk for pressure injuries and foam boots were not applied to both feet while in bed per the current plan of care. This is evidenced by: The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. 1. Inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury on the surrounding tissue 1.1 Conduct more frequent (greater than twice daily) skin assessments at the skin-device interface in individuals vulnerable to fluid shifts and/or exhibiting signs of localized or generalized [MEDICAL CONDITION] The health professional should apply any type of medical device cognizant of the potential for tissue expansion and worsening [MEDICAL CONDITION]. Depending on the type/purpose of the device, loosening, replacement or removal (i.e., compression stockings) may be advised. 2. Classify medical device related pressure ulcers using the International NPUAP/EPUAP Pressure Ulcer Classification System, with the exception of mucosal pressure ulcers. Pressure ulcers related to medical device use are not a new category of pressure ulcer, and should be classified according to level of tissue loss using the International NPUAP?EPUAP Pressure Ulcer Classification System outlined in the Classification of Pressure ulcers section of this guideline 1. R5 was admitted to the facility on [DATE], and has current [DIAGNOSES REDACTED]. Review of R5's Minimum Data Set (MDS) with the target date of 01/12/16, documents R5 as having moderate impaired cognition, needing extensive assist of two staff for bed mobility, total dependence of two staff for transfers, total dependence of one staff for ambulation and at risk for skin breakdown with no current breakdown. The MDS with the target date of 10/05/16, documents R5 as being cognitively intact, extensive assist of two staff for bed mobility and transfers, total dependence of one staff for ambulation and at risk for skin breakdown with six unstageable pressure ulcers with the dimension of an unhealed stage III or IV pressure ulcer or eschar being 3 cm x 4 cm. Review of R5's care plans documents: 03/29/16 PROBLEM: Potential for Tissue integrity impairment, and tissue integrity impairment .12/11/16 RELATED TO: Incontinence, Recent decline in ADLs, obesity fissure coccyx, [MEDICAL CONDITION] with weight gain, droop (sic) foot, 12/16, 10/19/16 MANIFESTED BY: incontinence and skin folds, discoloration left distal joint finger, bruising of extremities, H/O fluid blister bottom of left foot; scabs left foot and top of 3-5 toes; left outer heel scab, outer left foot/bottom inner great toe open area . APPROACH .01/05/16 Nurses --- Pressure relieving device(s) for chair, Pressure relieving devices(s) for bed low air loss air mattress. 01/05/16 Nurses --- Encourage and assist with repositioning according to resident wishes. 01/05/16 Nurses --- Instruct on the importance of good skin care and frequent repositioning. 12/11/16 Nurses --- Follow medical plan for treatment, for left heel and hallux and plantar 5th metatarsal head, [MEDICATION NAME] daily left leg incisions and left heel/foot, drsg. lower leg/ace wrap. 12/11/16 Nurses --- Elevate heels off bed, Rouke boot on left leg at all times, keep left leg elevated above level of heart as much as possible. 01/05/16 Nurse Aide --- elevate resident's heels off of bed, . Review of nurses' notes documents R5 complained of left foot pain on 08/02, 08/03, 08/04 times (x) 2, 08/06 x 3, 08/07 x 3, 08/09 x 3, 08/10 x 3, 08/12 x 2, 08/13, 08/14 and on 08/15 R5 complained to the physical therapist and noted resident was ambulating with PT and was c/o pain in left great toe when removed shoe brace and sock discolored area noted .ACTIONS: moleskin applied to brace will apply skin prep daily and monitor foot twice daily and continue with foam boots in bed. The nurses' notes did not document assessments of the skin under the brace when R5 complained of left foot pain and the facility did not document skin assessments under brace twice daily when the brace was initiated. The facility did not document if education was provided to R5 if non-compliant with removing of the AFO and wearing the foam boots. On 08/15/16, the initial assessment of outer bottom of left foot measured length 2 cm and(x) width 1.75 cm. This area was not identified with a pressure injury stage. 08/21/16 = R5 returned from hospital stay and no skin assessment with measurements were completed. 08/22/16 = 2 cm x 2 cm 08/29/16 = missing 09/05/16 = missing 09/12/16 = 1.5 cm x 1.5 cm 09/19/16 = 2 cm x 2 cm 09/26/16 = 2 cm x 2 cm 10/3/16 2 cm x 1.5 cm x 0 10/10/16 3 cm x 3 cm 10/17/16 = 2 cm x 1.5 cm x 0 10/24/16 = missing 10/31/16 = missing 11/07/16 = 2.5 cm x 3.0 cm 11/15/16 = 2 cm x 2 cm 11/19/16 = 1.25 cm x 1.25 cm 11/21/16 = missing 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements were completed. Review of nurse's wound charting on 09/05/16 the initial assessment of left foot top of 4 toes are scabbed with procedure done of shoe and brace removed and foam boot applied when not transferring. This area was not identified with measurements and was not staged until 09/19/16. Assessment measurements: 09/19/16 = 4th toe .25 cm x .25 cm 09/26/16 = left foot - top 3 middle toes #1. 0.25 cm x 0.25 cm #2. 0.75 cm x 0.75 cm #3. 0.125 cm x 0.125 cm 10/03/16 = 4th toe .5 cm x .5 cm 3rd toe pinpoint 10/10/16 = 4th and 5th toes 0.5 cm x 0.5 cm 10/17/16 = pinpoint scabs 10/24/16 = 2nd toe 0.1 cm x 0.1 cm 3rd toe 0.2 cm x 0.2 cm 4th toe 0.4 cm x 0.4 cm 5th toe 0.1 cm x 0.1 cm 10/31/16 = 5th toe 2.25 cm x 2.25 cm 11/15/16 = 4th toe 0.4 cm x 0.4 cm 5th toe 2 cm x 2 cm 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements were completed. On 09/05/16, initial assessment of the area of the left foot bottom of great inner toe blister/bruise 1.5 cm x 1.5 cm. This area was not identified with a pressure injury stage. No new interventions documented. 09/12/16 = 1 cm x 1 cm 09/15/16 = 1.25 cm x 1 cm 09/26/16 = 1.25 cm x 1 cm 10/03/16 = .5 cm x 0 10/10/16 = 1.5 cm x 1 cm 10/17/16 = .75 cm x .75 cm 10/24/16 = 0.3 cm x 0.3 cm 10/31/16 = 0.3 cm x 0.3 cm 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements were completed. On 09/07/16, initial assessment of the left outer heel with a purple bruise/blister 1.5 cm x 1.5 cm. This area was not identified with a pressure injury stage. No new interventions were initiated. 09/12/16 = 1.5 cm x 1.5 cm 09/19/16 = 1 cm x 1.5 cm 09/26/16 = 4 cm x 3.5 cm 10/03/16 = 3 cm x 4 cm x 0 cm 10/10/16 = 6 cm x 6 cm 10/17/16 = 2 cm x 3 cm 10/24/16 = 5 cm x 5 cm 10/31/16 = 2.5 cm x 2.5 cm 11/10/16 = slight odor, bloody/tan drainage - [MEDICATION NAME] ordered for [MEDICAL CONDITION]. 11/15/16 = 3.5 cm x 3 cm 11/19/16 = 3 cm x 3 cm 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements were completed. On 10/26/16, initial assessment of left shin previous bruise now scab. No measurements documented. 11/03/16 scab removed by wound clinic, no measurements documented. This area was not identified with a pressure injury stage. 11/7/16 = 0.5 cm x 0.5 cm 11/15/16 = 0.5 cm x 0.5 cm 11/19/16 = 0.25 cm x 0.25 cm 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements completed. On 11/07/16, initial assessment of left lower leg near ankle 1 cm x 1 cm. This area was not identified with a pressure injury stage. 11/15/16 [MEDICAL CONDITION] 11/21/16 = 0.5 cm x 0.5 cm 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements completed. On 11/21/16, right great toe scabs 1st 0.5 cm x 0.2 cm, 2nd 0.1 cm x 0.1 cm. 11/25/16 R5 admitted to hospital for an angiogram. 12/09/16 return from hospital stay and no skin assessment with measurements completed. Review of physical therapy documentation for ambulation/gait instruction: 08/22/16 17 minutes, 08/23/16 23 minutes, 08/24/16 25 minutes, 08/25/16 26 minutes, 08/26/16 20 minutes, 08/29/16 20 minutes, 08/30/16 11 minutes, 08/31/16 22 minutes. 09/01/16 15 minutes, 09/02/16 13 minutes, 09/06/16 25 minutes, 09/07/16 29 minutes, 09/08/16 25 minutes, 09/09/16 33 minutes, 09/12/16 30 minutes, 09/14/16 20 minutes, 09/19/16 15 minutes, 09/20/16 20 minutes, 09/21/16 12 minutes, 09/23/16 15 minutes, 09/23/16 25 minutes, 09/26/16 21 minutes, 09/27/16 10 minutes, 09/28/16 20 minutes, 09/29/16 10 minutes, 09/30/16 12 minutes. 10/03/16 15 minutes, 10/04/16 23 minutes, 10/05/16 25 minutes, 10/10/16 24 minutes, 10/12/16 20 minutes, 10/14/16 20 minutes. Surveyor reviewed physician documentation: On 02/19/16, the orthotist note read in part: She will need a stable heel counter and probably a shoe in a half size larger than she normally wears . A custom Fabricated In-House Left Solid Ankle AFO with heel post will be provided . The AFO was delivered to R5 on 03/18/16. On 04/01/16, the Nurse Practitioner note read in part: R5 was seen in followup today for concerns about [MEDICAL CONDITION] .Her [MEDICAL CONDITION] is minimal. I will have them monitor her weights 3 times a week rather than just weekly for at least a couple weeks to determine whether or not she does indeed need a diuretic. I do not see any reason to start one today, as this [MEDICAL CONDITION] is her baseline . On 05/13/16, the Nurse Practitioner note read in part: .She had pain in the left great toe area. She feels that the AFO is rubbing. It has been present for a few days . On 06/01/16, the Nurse Practitioner note read in part: R5 was seen today for concerns about her fluid status. She feels that she is retaining quite a bit of fluid and is requesting some [MEDICATION NAME]. She feels like a 'a fluid-soaked elephant.' .She feels like her feet are mostly the problem as far as [MEDICAL CONDITION]. Her shoes are not fitting as well nor is AFO on the left . On 06/07/16, the Nurse Practitioner telephone encounter note read in part: Update from NH staff 6/6 2125: has 3+ [MEDICAL CONDITION] in both lower extremities .Update from NH staff 6/7/845: weight 259 today. 260 on 6/6, 257 on 6/5, 258 on 6/4. Lungs clear, 1+ [MEDICAL CONDITION] left, +2 right. On 07/15/16, the Nurse Practitioner note read in part: .Extremities: 2+ lower extremity [MEDICAL CONDITION] below the knees bilaterally . On 07/20/16, the Nurse Practitioner note read in part: .Extremities - peripheral pulses normal, +2 [MEDICAL CONDITION] up to the knees bilaterally . On 08/05/16, the Nurse Practitioner note read in part: .She was able to walk 92 feet without symptoms today. Her [MEDICAL CONDITION] does feel like it is improving on the right; in particular the left is still fairly swollen and she is having some rubbing in the foot portion of her AFO . On 08/10/16, the Nurse Practitioner note read in part: .Her left leg brace is continuing to fit tightly in the foot and she is requesting a consult to have the brace possibly adjusted in the orthotics department Lower Extremities: +2 lower extremity [MEDICAL CONDITION] circumferentially below the knee and dependently up to the hips, left slight worse than the right . On 08/26/16 the orthotist note read in part: R5 was seen for adjustments to her left custom AFO which was delivered 3/1816 (sic) .R5 is using a wheelchair and wearing appropriate shoes. She has not been seen since the fitting of the AFO .I note that her ankle has swollen so much she cannot put her heel back into the AFO correctly. I did heat and widen the ankle area as the AFO is obviously not fitting her well. The foot plate was modified to allow more relief at the fifth met, and aliplast padding was added to wall of the footplate again to offload the blister on the lateral side. Her shoes are now large enough to fits over the AFO, but I did remove the liner from the left shoe and this provides more room inside the shoe for her foot and AFO . On 09/07/16, the Nurse Practitioner note read in part: .She reports that she now has a blister on her heel for which she is concerned about Nursing staff tell me that the blister on her left heel was noted in the past 48 hours. They have been using aggressive pressure offloading techniques both in bed and in her chair. They remove her AFO whenever she is not actively bearing weight, and she does not wear a shoe on that foot unless she is actively bearing weight .Extremities: +2 pedal ankle [MEDICAL CONDITION] bilaterally, 1+ up to about the knees bilaterally. There is a purple blister on the back of the left heel that is about 2 cm in length and 1 cm in width ad is a little bit tender on palpation. There are also a few flat purple blisters on the superior surface of the toes. There are 3 of these present The blister on the bottom of the foot is likely pressure related, though I am not convinced it is from her brace. I examined her foot in the brace. I do not see any areas that would specifically push on that part of her heel, though perhaps there is some shifting of tissues when she has her shoe on and actually upright in the foot. The question was raised as to whether or not she should continue to ambulate if the brace is contributing to the pressure. At this point if she stops ambulating I believe she will quickly lose strength and mobility which ultimately will not meet her goals of home going and may put her at other risk for issues with her mobility. We will us [MEDICATION NAME] paint to the blistered areas on her foot on a daily basis to help protect the skin. If the blister becomes unstable at any point will refer her immediately to the wound clinic . On 09/21/16, the Nurse Practitioner note read in part: .Extremities: +1 lower extremity [MEDICAL CONDITION] noted. The blisters on the left toes and heel are intact and appear purplish in color. They are tender on palpation . On 09/28/16, the Nurse Practitioner note read in part: .She had some difficulty with [MEDICAL CONDITION] which caused her foot to be larger and not fit as it should in the AFO. This led to some pressure areas on her foot, one on the heel and one at the 5th MTP joint, and then as her feet swell her toes also had some pressure against the front of the shoe .She complains that they continue to hurt at time .Her foot wounds, given that the heel blister has now opened and there is little bit of drainage, I am concerned about whether or not there needs to be a little bit of debridement. Will send her into the Wound Clinic for further evaluation and treatment of [REDACTED]. I explained that theses wounds are going to take more than just 2 days to heal and that even minimal decreases in her activity level will set her back and make her unable to achieve the goals of leaving the nursing home that she has. We will continue with using the AFO only when she is up and walking and immediately taking it off and putting on a pressure relief boots, which is what we have been doing for at least 2-3 weeks now . On 10/17/16, the Wound Center New Patient note read in part: .The patient is s/[MEDICAL CONDITION] 12/26/15, and has been in the SNF since this event. She has developed left foot drop and wears a fixed ankle AFO for this. They relate spending most of their day in a wheelchair with the brace and shoe one (sic) .She does use an offloading boot as well. They are concerned with the amount of WB (weight bearing) during therapy and the pain she has with her wounds .4. Regarding the left foot, I did recommend the following: .Should d/c PT/OT for distance ambulation. May continue to work with PT/OT for in-bed exercises as well as transfers. May be permitted WB with her AFO applied to the LLE for all transfers (on and off the commode, wheelchair, etc.) . On 11/07/16, the Nurse Practitioner note read in part: .She notes that her legs have been hurting more lately, particularly the left leg. She states when they took off the eschar on the left foot, that the leg has hurt a little bit more since. She has not been using anything for pain. It hurts the most when she is standing on it, although it does hurt sometimes when she is sitting .Extremities: trace to +1 pedal ankle [MEDICAL CONDITION] bilaterally . On 11/14/16, the Wound Center Follow-up note read in part: .3. Consult to Vascular given ABI/TCI results. Concerns for worsening wounds to LLE which may culminate in BKA if deep infection develops. 4. Regarding the left foot ulcerations. I did recommend the following: Must remain 100% NWB (non weight bearing) to the LLE, including transfers now. Recommend strict use of cradle/Hoyer lift. Should not stand with stand-lift .May continue to work with PT/OT for in-bed exercises On 11/17/16, the Wound Center Follow-up note read in part: .The cause of her ulcers is likely pressure and poor arterial flow. I have reviewed her non invasive studies with her and her husband. And she has moderate arterial perfusion deficient. I recommend urgent angiogram based on this study with limb salvage goal . On 12/15/16 at 7:02 a.m., Surveyor interviewed Registered Nurse (RN) G about wound assessments. RN G indicated the nurses take pictures of the wounds and the wound team looks at the pictures and don't look at the resident's wound. The nurses have a to-do list on the computer when the measurements are to be done and this is done by whichever nurse is on that day. At 7:50 a.m., Surveyor interviewed the Director of Nursing (DON). The DON indicated the wound team looks at the pictures and if there are questions the wound care nurses will look at the wounds. Surveyor reviewed with the DON of the incomplete documentation and inconsistent descriptions of the location of the wounds for R5 and R6. 2. Review of R6's medical record documents current [DIAGNOSES REDACTED]. Review of R6's MDS with the target date of 10/10/16 documented R6 as having moderate impaired cognition, extensive assist of two staff for bed mobility and transfers, total dependence of one staff for ambulation and at risk for skin breakdown with having no areas of breakdown. Review of the wound charting - nurses' notes document: 10/05/16 the nurses' notes documented Date of incident: 10/04/16 . a Certified Nursing Assistant (CNA) assisting resident with AM cares noted open area left inner ankle . POSSIBLE CAUSE: rubbing on chair or in bed .ACTIONS: will monitor daily until resolved and remind staff to offload heels. This is the first documentation of the wound and does not contain measurements. Review of the wound charting - nurses' notes did not contain documentation of this wound. 10/11/16 .Follow-up assessment right medial heel, TYPE: open area .DRAINAGE: clear, AMOUNT: small, WOUND TISSUE: granulation . This is the first documentation of pressure injury and does not contain measurements of the wound. No further assessments noted of this area. 10/12/16 left inner heel assessment did not include measurements. 10/19/16 left inner heel assessment did not include measurements. 10/26/16 left inner heel assessment did not include measurements. 11/01/16 left inner heel 0.6 cm x 0.4 cm x 0. 11/08/16 left inner heel assessment did not include measurements. 11/15/16 left inner heel 0.6 cm x 0.3 cm x 0. 11/22/16 left inner heel assessment did not include measurements. 11/29/16 left inner heel 1 cm x .5 cm. 12/06/16 left inner heel assessment did not include measurements. 12/12/16 left inner heel 0.5 cm x 0.1 cm. On 10/17/16, initial assessment for coccyx .TYPE: ecchymosis .WOUND TISSUE: purple/red .AREA: length (cm): 2.2 width (cm) 2. No documentation of new interventions initiated. 10/22/16 .coccyx ecchymosis .WOUND TISSUE: purple . no measurements noted. 10/30/16 ASSESSMENT TYPE: Initial assessment 10/30/16 TYPE: ecchymosis .WOUND TISSUE: dark purple .AREA: length (cm): 0.2 width (cm): 0.2. 11/06/16 no further assessment of the coccyx area or documentation the area is healed. 11/16/16 ASSESSMENT TYPE: Follow-up assessment buttocks around rectum open areas .WOUND TISSUE: beefy red . No measurements taken of area. 11/21/16 ASSESSMENT TYPE: Follow-up assessment buttocks around rectum .WOUND TISSUE: pink . No measurements taken of area and no further assessments of this area or documentation the area is healed. 3. R2's [DIAGNOSES REDACTED]. On 12/14/16, Surveyor observed R2 while up in a broda chair. The broda chair contained a low-lift roho cushion. Times observed were: 8:55 a.m.-9:55 a.m: R2 was up in a broda chair in her room. Staff did not reposition R2. 9:55 a.m. to 10:55 a.m.: R2 was up in a broda chair in her room. Staff did not reposition R2. At 11:55 a.m., Surveyor observed R2 sitting in the broda chair, receiving assistance with the noon meal. At 12:30 p.m., R2 was observed lying on her left side in bed. Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E stated, We take them (the residents) to the bathroom before and after meals, that is how we reposition them. Otherwise, we don't (reposition the residents). Surveyor reviewed R2's plan of care. The plan of care stated: Reposition every two hours while in bed, offer to assist off load onto side at least BID (twice a day). Surveyor interviewed Assistant Director of Nurses (ADON) F, who was responsible for wound cares, and is Wound Care Certified. When asked what procedure should be taken with a resident sitting up in a chair with a pressure injury, ADON F stated, The resident should be repositioned every hour. ADON F acknowledged this was not on the care plan. 4. On 12/14/16 at 2:30 p.m., Surveyor reviewed the medical record for R12 and noted R12 to be at risk for skin breakdown. Current CNA care plan, received 12/14/16, states R12 is to have foam boots applied to both feet while in bed. On 12/14/16 at 3:40 p.m., Surveyor observed R12 lying in bed with no foam boots on. Surveyor interviewed CNA B in regard to the noted observation. CNA B, along with Surveyor , observed R12 lying in bed with no foam boots on and heels directly on the mattress. CNA B stated R12 should be wearing foam boots and would ensure the boots be placed on immediately. On 12/15/16, Surveyor discussed the above noted observation with the DON.

Based on observations, record reviews and interviews, the facility did not ensure appropriate interventions were put into place to prevent future falls and did not follow current fall interventions for 4 of 13 residents (R4, R3, R7 and R1) reviewed for falls. 1. R4 had multiple falls and the facility did not ensure effective interventions were implemented, and did not identify a root cause and analysis for all the falls. 2. R3 had a fall and was not assessed prior to moving. 3. R7 had a fall and no root cause and analysis was completed and no new interventions were implemented. 4. R1's fall interventions were not in place during observations. As evidenced by: 1. On 12/12/16, Surveyor reviewed R4's medical record and noted the following: - Minimum Data Set (MDS), dated [DATE], states R4 was at risk for falls and had a fall in the facility. - MDS, dated [DATE], states R4 is at risk for falls. - Certified Nursing Assistant (CNA) care plan, received 12/12/16, states R4 requires assistance of two staff for all transfers and ambulation needs. Care plan states R4 is to have bed transfer rails up, floor mat on floor beside bed when resident is in the bed, bed alarm, tab alarm in broda chair (recline when left alone), tab alarm in wheelchair, keep call light close to resident during the day and at night, wide bed, 15 minute checks, 1:1 when restless and assist into broda. After lunch/nap if wide awake offer to transfer her out of bed into broda following toileting and then in hallway or at day room to try to keep in line of vision of staff. - Comprehensive nursing care plan, received 12/12/16, states R4 is at risk for falls and has had multiple falls within the facility. Care plan states R4 is at risk for falls due to fall history, fall with a left hip fracture, impaired sense of balance, unsteady gait and is manifested by behaviors. On 12/13/16, Surveyor reviewed facility fall reports for R4 and noted the following: - Between 12/26/15 and 05/06/16, R4 experienced five falls. Investigations completed, interventions implemented and care plans updated. - 06/12/16: Unwitnessed fall at 4:35 p.m.: R4 had slid out of bed onto the floor mat in her room while attempting to use the bathroom. Intervention noted was instructing R4 to use the call light and wait for help. Surveyor reviewed MDS, dated [DATE], and noted R4 was severely cognitively impaired with a BIMS of 6. - 09/11/16: Unwitnessed fall at 6:30 p.m.: Staff found R4 on the floor after coming back from supper. Intervention was for the facility's Safety Team to evaluate. Surveyor reviewed Safety Team note, dated 09/14/16, and noted it to state a facility memo is to be sent out to all volunteers and dietary staff when bringing R4 back to her room after activities and meals they are to alert nursing staff. Fall report stated the tab alarm was not placed on the resident and was not sounding. - 09/16/16: Unwitnessed fall at 1:55 a.m.: Staff found R4 on the floor mat. Root Cause: restless and anxious. Immediate intervention was for staff to bring R4 to the nurses station at night. There was no root cause analysis and no added interventions to the care plan. - 09/16/16: Unwitnessed fall at 2:15 p.m.: Staff found R4 on the floor on her back in her room near the bathroom door. Fall report indicates the resident complained of pain to left medial lower thigh. The reports states injury to left medial lower thigh, no first aid needed. Staff assisted resident off the floor. The nurse practitioner ordered ice to left thigh and knee and to send in for an evaluation. The x-ray result deformity of left femoral neck subcapital region consistant with a subcapital femural neck fracture, confirmation with routine left hip x-ray is recommended. Resident transferred to ER at 5:00 p.m. Intervention was for aromatherapy and IPOD to be implemented but not in use at this time. Surveyor was unable to identify a root cause and analysis for the fall. There was no indication if the care plan was followed. The investigation did not address if staff notified nursing of R4 being in her room and no indication if the alarm was on and sounding or not. - 09/21/16: Resident returned from hospital following post surgical left femur fracture. - R4 experienced two falls after her fracture. The Director of Nursing (DON) stated aromatherapy was added to the fall on 06/12/16 but was not indicated on the fall report. The DON stated for the fall on 09/11/16 at 6:30 p.m., she had sent a memo out to all nursing staff reminding them to please remember to have tab alarm attached to resident when in broda chair and recliner. The DON provided Surveyor a copy of the memo. The DON stated when staff read the memo it automatically sends her a date and time memo indicated education had been provided. Surveyor reviewed the returned messages and reviewed staffing schedules for the same time period and noted from 09/11/16 - 09/16/16 that 19 staff members had worked without reading the above noted education memo. Surveyor reviewed the facility Safety Team notes from 12/01/15 - 12/13/16 and noted the following entries: - 12/07/16: Purpose of Note: Annual: Current safety device: tab alarm in w/c, bed alarm, 2 bed transfer rail, fall mat, autobrakes to wheelchair, wide bed and broda recliner. [DIAGNOSES REDACTED]. Has a history of falls and has visual deficits. Area of concern: impaired decision-making skills, poor judgement, impulsiveness, unaware of safety issues, disregard for own safety, generalized anxiety, generalized weakness, unsteady gait, pain, impaired balance when standing, impaired balance when walking. Has short term member impairment. Easily distracted, periods of restlessness, mental function varies, due to dementia and memory deficits ongoing, the devices will continue to maintain maximum safety and comfort. On 12/14/16, Surveyor reviewed all therapy notes for R4 and noted from 12/12/15 - 12/14/16, R4 had been evaluated and treated by the therapy department during month of September 2016 due to a fracture sustained by a fall within the facility. On 12/14/16, Surveyor interviewed the DON in regard to R4 having multiple falls during this time period and no therapy had been recommended. The DON stated no therapy had been implemented other than for when R4 had a fall with a fracture during the month of September 2016. On 12/14/16, Surveyor reviewed nursing notes from 12/12/15 - 12/14/16 and noted multiple nursing entries where R4 was on 1:1 due to increase in behaviors. The DON stated the staff did multiple 1:1's with R4 during the above noted time frame. On 12/14/16 at 3:10 p.m., Surveyor observed R4 in her room in her broda chair. Surveyor noted no facility staff members in line of sight of R4. Surveyor interviewed Registered Nurse (RN) C in regard to the noted observation. RN C reviewed R4's care plan and stated R4 should not be left alone in her broda chair in her room per the current plan of care and should be in line of sight due to having a history of multiple falls. On 12/14/16, Surveyor discussed the above noted observation with the DON and Nursing Home Administrator (NHA). 2. On 12/12/16 at 2:50 p.m., Surveyor reviewed R3's medical record and noted the following: - MDS, dated [DATE], states R3 is high risk for falls and had a fall with a major injury. R3 requires extensive assistance for transfers and ambulation and has a decline in upper range of motion (ROM). - MDS, dated [DATE], states R3 is high risk for falls and had a fall with no injury. R3 requires extensive assistance for transfers and ambulation and had a decline in upper range of motion (ROM). - Comprehensive nursing care plan, received 12/12/16, states R3 is at risk for falls due to medication and mobility. - CNA care plan, received 12/12/16, states R3 requires assistance from two staff members for all ambulation needs. On 12/13/16, Surveyor reviewed facility fall reports for R3 and noted the following; - 08/10/16: Fall. Report states R3 had a fall and a CNA lifted the resident off the floor before nursing staff could assess her. The report states R3 did not suffer any injury. On 12/13/16, Surveyor interviewed the DON in regard to the above noted fall report. The DON stated the facility's policy is to have an RN complete a thorough assessment of any resident who falls prior to being lifted off the floor. 3. On 12/13/16 at 10:35 a.m., Surveyor reviewed R7's medical record and noted the following; - MDS, dated [DATE], states R7 is at risk for falls. - CNA care plan, received 12/12/16, states requires assistance from staff for all transfers and ambulation. - Comprehensive nursing care plan, received 12/12/16, states R7 is at risk for falls and requires assistance from staff for ambulation. On 12/13/16, Surveyor reviewed the facility fall report for R7 and noted R7 had an unwitnessed fall on 11/05/16 and was found on the floor in her room on a floor mat. The fall report stated R7 had fall measures in place prior to the fall which included 15 minute checks and a floor mat. The fall report stated the immediate intervention was for the facility Safety Team to review the residents fall and to develop an appropriate intervention. On 12/13/16, Surveyor reviewed the Safety Team note, dated 11/09/16, and noted the team report to state, She is off 15 minute checks due to deterioration of condition. Surveyor was unable to identify any further interventions to prevent future falls from occurring. On 12/14/16, Surveyor discussed the above fall report with the DON. 4. On 12/14/16, Surveyor reviewed R1's clinical record and identified [DIAGNOSES REDACTED]. The care plan stated that R1 was to have a fall mat next to the bed at all times when in bed. At 7:55 a.m., Surveyor observed R1 in bed sleeping. One side of the bed was against the wall. There was no fall mat on the floor next to the other side of the bed. A fall mat was vertically placed against the neighboring bed, which was unoccupied. Surveyor interviewed Licensed Practical Nurse (LPN) D. LPN D accompanied Surveyor to R1's room. LPN D acknowledged that the fall mat should have been on the floor next to R1's bed. The management team was notified of the observation on 12/15/16.

Based on medical record review, staff and family interview, observation and review of facility investigation, the facility did not ensure each resident receives adequate supervision to prevent accidents for 2 of 7 residents reviewed for falls. Resident #5 had a history (on 07/07/12) of falling during a transfer when staff did not stand in front of her wheelchair in the bathroom and her care plan was updated, stating, "staff to be in front of resident during transfer to/from bathroom to wheelchair do not stand behind wheelchair." On 08/02/13, Resident #5 was transferred by a Nurse Technician (NT) who did not follow the care plan, stood behind the wheelchair and let go of Resident #5 to move the wheelchair. Resident #5's knee buckled and she fell and sustained a neck (C-2) fracture and a laceration to the back of her head requiring staples. Resident #11 had 14 falls at the facility from 05/18 - 08/26/13. The facility did not always document a thorough investigation, did not always determine a root cause for her falls, did not set up clear parameters for when to start and/or stop one-to-one observations and did not add new interventions after 3 falls beginning 7/25/13. This is evidenced by: The facility's policy titled "Falls Prevention" dated 12/31/09, states in part, "2. A care plan will be developed and implemented to prevent accidents." 1. Resident #5's medical record states she has resided at the facility for several years. Resident #5's MDS (Minimum Data Set) dated 06/27/13 states she needed assist of one person for transfers, ambulation, dressing, and personal hygiene, could feed herself with set-up and was continent of bowel and bladder. She had a history of [REDACTED]. Surveyor interviewed Resident #5's daughter, Family Member (FM) G on 09/09/13 beginning at 3:55 p.m. FM G stated Resident #5 had falls in the past where staff wheeled her into the bathroom and the wheelchair was between the staff member and Resident #5. According to the Director of Nursing (DON), the most recent fall of this nature took place on 07/07/12. After this fall occurred, Resident #5's care plan was updated to state, "staff to be in front of resident during transfer to/from bathroom to wheelchair do not stand behind wheelchair. " A facility self-report contained a letter written on 08/06/13 by the DON to the Nursing Home Administrator (NHA) and stated on 08/02/13 at 4:30 p.m. NT D "had gone to (Resident #5)'s room to administer her 4PM medications. According to (NT D) she woke (Resident #5) up, sat her up on the edge of the bed and gave her the medication. (NT D) told (Resident #5) it was time to get up before supper. (Resident #5) asked to go to the bathroom. (NT D) knew the CNA's were busy with other residents so she told (Resident #5) she would help her. She got a gait belt and transferred her into her wheelchair. She turned the chair and pushed (Resident #5) into the bathroom. (NT D) then assisted (Resident #5) in standing up, had (Resident #5) grab the transfer bar on the wall and as (NT D) moved the wheelchair out of the way, she let go of (Resident #5). (Resident #5)'s left knee buckled and she fell backwards into the door. She sustained a laceration to the head. First aide (sic - aid) was applied and 911 was called. She was transported to Mayo Clinic Health System emergency room and was admitted to the hospital. A CT (computerized tomography) scan done of her head and it was determined she had a C2 (second cervical) vertebral (neck) fracture. "I (the DON) was notified of the incident after it occurred on 8/2/13. (Registered Nurse - RN F) RN Charge Nurse called me at home to tell me about it. During the conversation I asked if the care plan had been followed and was told it had been. During the course of the investigation of this incident it was discovered the care plan had not been followed. This was discovered on August 4, 2013. At this time both you and I were notified and a first report was sent into the State of Wisconsin. "It was determined during the transfer (NT D) was behind the wheelchair and unable to maintain control of the resident as she moved the wheelchair out of the way. (Resident #5)'s care plan instructed her to be in front of the resident during transfers in the bathroom. "(NT D) was immediately placed on suspension. During my interview with (NT D) on 8/5/13 she gave me an accounting of this episode and was very honest about how she had transferred (Resident #5). (NT D) told me she had transferred (Resident #5) this way many times. When asked if she was aware of the care plan instructions (NT D) said she was not. (NT D) was very remorseful about this incident. "Today we met with (Resident #5)'s daughters (names). We discussed the incident and how it had occurred. We discussed (Resident #5)'s desire to return here as she feels this is her home. We also discussed whether or not they wanted (NT D) to care for (Resident #5) in the future. They told us it was their desire (NT D) care for their mother as they felt this accident was not intentional. They felt it would be 'healing' for both (Resident #5) and (NT D)." As stated above, Surveyor interviewed FM G on 09/09/13 at 3:55 p.m. FM G stated after the fall of 08/02/13, Resident #5 was in "terrible pain" and her pain was initially difficult to control in the hospital. FM G was asked if the laceration on the back of Resident #5's head was sutured and FM G stated, "No, it was stapled." She stated although her sisters thought it would be alright if NT D continued to work with their mother, FM G stated she felt "now was not the right time" and her mother desired other caregivers' care for Resident #5. FM G stated, "This fall was really tragic regarding her mobility and now she clenches her hands so tight all the time. It's sad; I'm very sad for my mother. It has taken a tremendous physical toll on her, she has lost weight and has been on pain killers, has an upset stomach and had vomiting." FM G stated the physicians told the family her mother's tendons in her neck were strong enough so she did not need to wear a Halo; just a neck collar initially. She was very uncomfortable in the hard collar and was changed to a softer one. FM G stated she was really concerned when the DON told her NT D had stated other staff were also transferring Resident #5 incorrectly and said, "I can't fire her if others are doing it the same way." She stated she was informed the staff had to go through a class to learn how to do it correctly. Surveyor interviewed Family Member I on 09/10/13 at 4:20 p.m. FM I told Surveyor the family was very concerned, as this was not the first time Resident #5 had fallen like this and other staff had been transferring Resident #5 the same incorrect way. FM I stated, "We know how accidents can happen, but we also know how quickly a slip can happen. We go to care conferences with Mom and her only concern is how long she has to wait to get her light answered. The bathroom issue - it is my integrity as a person - why do I have to wet or soil myself? Otherwise Mom had very good comments about her care. It's unfortunate it was in the bathroom where the accident happened. We're told there is a lot of staff turn-over here. One new girl was going to try to walk Mom and she hasn't walked in 4 years." FM I stated her mother's pain after the incident was "incredible." Surveyor interviewed NT D, accompanied by the DON on 09/10/13 at 3:05 p.m. NT D basically verified the above narrative. She stated she had pushed Resident #5 in her wheelchair up to the grab bar in the bathroom and had her stand up and while she was moving the wheelchair, Resident #5 "fell before I could get to her." Resident #5 hit her head on the other doorframe in her bathroom, which is shared by the resident in the adjoining room. NT D stated Resident #5 may also have hit her head on the floor when she landed. She stated Resident #5's head was bleeding. Surveyor asked if Resident #5 was crying out at the time and NT D stated, "No, I don't think she realized what was going on - it was like she was shocked and a little scared." Surveyor asked if Resident #5 had said her neck hurts and NT D stated, "No, just her head." NT D stated she pulled the emergency light cord in the bathroom and no one responded for 30 seconds so, "I shouted out the door and saw a family member across the hall and I asked him to go get a CNA (Certified Nursing Assistant)." NT D stated one CNA was sent to get the charge nurse and the other got the vital signs machine, towels and a lift sheet. The charge nurse assisted NT D and the CNAs to pull Resident #5 out of the bathroom and they used the mechanical lift to get Resident #5 to her bed. NT D stated she held Resident #5's head in alignment during the transfer, holding ice and a washcloth on the laceration on the back of Resident #5's head. During this interview, Surveyor asked NT D if she finished her shift and if she worked the following day. NT D stated she did work the rest of her shift and the next day as well. NT D's Timecard Report, signed by the DON on 08/05/13, reflects NT D worked until 10:17 p.m. on 08/02/13 and from 2:29 to 9:47 p.m. on 08/03/13. Surveyor interviewed RN F on 09/10/13 at 4:45 p.m. RN F stated on 08/02/13, she was informed NT D was yelling for help in (Resident #5)'s room. RN F went to the room and saw Resident #5 on the floor next to the toilet, with NT D behind her, holding her head which was bleeding. She stated, "I asked what happened" and then told the CNAs to get ice and towels. (NT D) told me (Resident #5)'s legs gave out and she bumped her head on the wall and the door. I saw a moderate amount of blood on the floor. (Resident #5) was not crying - I don't know how to explain it. She was anxious and scared, with a worried look on her face. I asked her where does it hurt and she said, 'My head' and she also said one of her hands hurt. (Resident #5) has chronic pain in her shoulders and hands. I asked her if she hurt anywhere else, checking her hips. She said her butt kind of hurts, but the floor is hard. We got the ice, I told (NT D) to hold her shoulders, head and neck and we slid her out of the bathroom area - it's a tight spot. We moved her to more floor space; I maneuvered the lift sheet while (NT D) held her head and neck. All this happened within a minute. We got her outside the doorway. I noticed a moderate amount of blood. I went and called the ambulance, told them to come emergently because of the amount of bleeding and returned and wasn't sure if she could have rib fractures or a subdural (head injury). I wasn't thinking neck but I was thinking spine. I had (NT D) stabilize her shoulders, neck and head while we got her onto the bed with the Marissa lift. We felt good about how we handled it and the teamwork was excellent." Surveyor asked about investigating the way Resident #5 was transferred. RN F stated she looked on the top of the CNA care plan and saw Resident #5 was to be transferred with the assist of one and a gait belt. She stated she saw a gait belt on the resident, so she figured the care plan had been followed. She stated she did not see further down staff are to stand in front of her during transfers. RN F stated she was glad the facility has a safety committee which investigated the transfer and discovered it was done incorrectly. 2. Resident #11 was admitted to the facility on [DATE] with numerous [DIAGNOSES REDACTED]. Resident #11's MDS with an ARD (Assessment Reference Date) of 07/11/13 identifies impaired cognition. The functional screen identifies dependence on staff for all cares. Review of Resident #11's Safety Assessment form, dated 04/10/14 at 8:46 a.m. indicated Resident #11 had exhibited unsafe behaviors before admission to the facility and indicated the following: "-Unsafe behavior in wheelchair: Falls at home prior to admit. -Unsafe behavior in bed: Falls at home prior to admit. -care plan Interventions Reviewed: Yes -Other interventions/devices: Wheelchair -Type of Safety Device recommended: Tab alarm, bed alarm, bed transfer rail -Expected Benefits: Prevent injury to self and/or others Reduce potential for falls, increase mobility. -Expected Risks: Falls -Safety Device Free Periods: During one-to-one with staff -Is device least restrictive: yes -IDT (Inter-Disciplinary Team) Assessment: ID team has reviewed resident need for devices and find them to be appropriate for fall reduction and to promote good positioning. -Form electronically signed by: The DON, SWs (Social Workers) S and T and RN H. Safety Assessment did not indicate a scoring system. On 09/12/13 Surveyor received the following copies of Incident Reports which indicated Resident #11 had the following falls: -05/18/13 at 6:30 p.m. staff found resident sitting on her buttocks next to wheelchair and bedside table across the room; alarm was sounding. No apparent injury -05/25/13 at 10:30 a.m. resident was noted to be on the floor mat next to her bed. No apparent injury. -05/30/13 at 5:15 a.m. Resident found on floor next to bed on floor mat. No apparent injury. 05/31/13 at 2:20 a.m. resident's room, resident slid out of bed on to knees. No apparent injury -06/03/13 at 3:05 a.m. resident's room, resident's bed alarm sounded found resident on floor. No apparent injury. -06/23/13 at 12:45 a.m. Resident found on floor mat bedside bed lying on left side. No apparent injury. -07/03/13 at 1:50 p.m. CNA heard resident yelling out and CNA found resident sitting on her floor mat next to her bed. No apparent injury. -07/10/13 at 7:15 p.m. Resident found on floor in front of the sink area with the wastebasket by her and multiple wastebasket liners on the floor and resident lying face down on the floor. Resident was log rolled on to back and noted to have laceration on her forehead above her left eyebrow. Resident yelling out. Bright red blood running down the side of resident face onto the floor. Resident transferred to the emergency room for sutures. -07/25/13 at 7:30 a.m. resident's room, CNA reports she heard the alarm going off; she went to answer it and found resident on the floor beside her bed, on the floor mat. No apparent injury. -07/27/13 at 10:00 p.m. resident's room; resident was found sitting on floor without injury; mat had slid from bed. No apparent injury. -07/28/13 at 10:45 p.m. Nurse observed resident sitting on floor with back up against the low bed. Bed alarm was sounding. No apparent injury. -08/18/13 at 12:20 p.m. alarm sounded and resident was noted to be on her buttocks on the floor mat on the floor. No apparent injury. -08/22/13 at 10:15 p.m. resident had rolled out of bed on to her knees next to her bed on her floor mat. The bed alarm was not sounding as had slid down on the bed and resident was not lying on the alarm area. Red scrape-like area on her right lower leg. -08/26/13 at 7:00 p.m. heard the alarm going off and the resident was sliding out of bed onto floor mat. No apparent injury. On 09/12/13 at 8:50 a.m. Surveyor met with the DON and asked for an outline of the interventions put in to place after each time Resident #11 had fallen since 05/18/13. The DON replied, "You will find the notes in the computer." On 09/12/13 at 10:05 a.m., Surveyor received a document with outlines of interventions implemented after each fall and reported, "These are my notes from the safety committee which meets one time weekly and reviews each incident report at the meeting." The following document read as follows: -04/10/13 - Admission Resident #11 - Bed alarm, tab alarm, bed transfer rail. -05/15/13 Added auto brakes -05/18/13 frequent episodes of agitation using one-one on p.m. s -05/25/13 floor mat next to bed -05/30/13 increased supervision on nights -05/31/13 toileted -06/03/13 added pedal broda -06/23/13 up in wheelchair - back to one to one on nights -07/03/13 Bed alarm changed out. -07/10/11 Velcro belt alarm added as resident was disrobing -07/11/13 Bruise on left shoulder upon return from ER (emergency room ) -07/28-29/13 new meds changes on 07/26/13 - not effective-will have NP (Nurse Practitioner) address-added bolster mattress -08/18/13 alarm sounded - found on floor mat -08/22/13 alarm not sounding as it slipped out of position-gripper pad under alarm. On 09/12/13 at 9:00 a.m., Surveyor observed Resident #11 being assisted with breakfast by CNA N. Surveyor asked CNA N how often Resident #11 is observed by staff. CNA N responded, "She has been on 15-minute checks since the day she was admitted ." On 09/12/13 Surveyor received a copy from the DON of the most current CNA Assignment Sheets for each shift. In the column "Other" the document reads the same for each shift "Chart one to one visits AM shift, PM shift, NOC (Night) shift --From: 04/18/13." No indication noted on assignment sheets for start and stop time of one to one visits and no indication of 15-minute checks being implemented for Resident #11. On 09/12/13 at 10:15 a.m., Surveyor interviewed the DON regarding interventions put in to place after Resident #11's falls. The DON was asked, "When were the 1:1's with Resident #11 started and finished as an intervention?" The DON replied, "Staff did not always want to do the 1:1's so we probably just pulled a CNA off of their duties during their shift and had them do 1:1's they were not necessarily documented all of the time." The DON discussed how the family visited often and spent time with Resident #11 and she did not fall at those times. The DON was asked by Surveyor if there had been trending done with times of falls and location." The DON replied, "Yes but she was very unpredictable." During the interview Surveyor asked the DON about 15-minute checks by the CNAs with Resident #11 and how they are documented. The DON responded, "I will show you on the computer how to review them." On 09/12/13, during electronic review of Resident#11's 15-minute checks by CNA staff, Surveyor noted from 07/10/13 at 2:00 p.m. to 07/11/13 at 10:30 p.m. no 15-minute checks were documented as being completed during this time. Surveyor asked the DON about the lapse in time with the 15-minute checks during this time. The DON responded, "I am sure they did them but there was a newly hired CNA working the p.m. shift on 07/10/13 and she probably thought she didn't have to document them because the resident had left the facility to be treated at the emergency room ." On 09/12/13 at 12:20 p.m., Surveyor asked the DON if there were any other notes from the Safety Committee related to Resident #11's falls on 07/25, 07/26 and 08/26/13. The DON replied, "I will check again." On 09/12/13 at 2:50 p.m., Surveyor met with the DON and asked if there was any other information related to Resident #11's falls. The DON replied, "I cannot think of anything else. I have given you all of the information to the best of my knowledge that I have." No further information was provided to Surveyor .