Every finding on record at Park View Health Center

Based on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and spread of communicable disease and infection. This practice had the potential to affect more than 4 of the 88 residents residing in the facility. The facility did not track last symptoms of illness and return to work dates for 3 staff (Certified Nursing Assistant (CNA)-D, CNA-E, and Licensed Practical Nurse (LPN)-F) during a gastrointestinal illness (GI) outbreak. R10 was on enhanced barrier precautions (EBP). LPN-F did not wear a gown or goggles while administering a tube feeding for R10 and while flushing R10's enteral tube. In addition, LPN-F did not complete hand hygiene prior to exiting R10's room. R37 was on EBP. Registered Nurse (RN)-G did not wear gloves during cares for R37. Findings include: The Facility's Acute Illness Policy and Procedure-Staff, dated 2/2024, indicates: To prevent the spread of illness within the facility by restricting staff with acute illness from working. Procedure for staff experiencing gastrointestinal (GI) illness: Symptoms include (minimum of 2 episodes of vomiting or loose stools); Acute onset of vomiting; Acute, explosive loose diarrhea; Low grade fever, nausea, chills, body aches, fatigue, abdominal cramping in addition to vomiting and diarrhea .1. Staff should call in according to the Employee Sick Call policy if they are experiencing acute GI illness symptoms of fever, vomiting, diarrhea and should be removed from the schedule. 2. Staff with GI symptoms must call scheduling daily to update on symptoms. 3. Staff must be removed from the schedule until 48 hours after the last incident of vomiting and/or diarrhea. The facility's Infection Control; Enhanced Barrier Precautions policy, dated 1/2025, indicates: Enhanced Barrier Precautions (EBP) expand the use of personal protective equipment (PPE) to include the use of gowns and gloves (face protection should also be used if there is a potential for splashes or sprays) during all high-contact resident care activities that provide an opportunity to transfer multidrug-resistant organisms (MDROs) to staffs' hands and clothing .Enhanced barrier precautions will be used for residents with any of the following: open wounds requiring dressing, indwelling urinary catheters, . feeding tubes .4. Staff will don a gown and gloves (face protection should also be used if there is a potential for splashes and sprays) prior to performing any of the following: .Device care or use: .feeding tubes .wound care .5. Once the above have been completed, PPE should be removed and disposed of and hand hygiene should be performed. 1. On 4/15/25, Surveyor reviewed the facility's infection surveillance and staff line list for a GI outbreak that started on 12/18/24. The staff line list included names, last worked dates, dates and times of onset of symptoms, symptoms, lab results, dates and times of last symptoms, well dates, and return to work dates. During the outbreak from 12/18/24 to 2/26/25, the staff line list did not include last symptom dates for staff who called in sick during that time period. On 4/15/25 at 10:50 AM, Surveyor interviewed Infection Preventionist (IP)-C who indicated call-in sheets are used to identify staffs' last symptom and when they can return to work. Surveyor asked to review the call-in sheets for 3 employees who had return to work dates that were 2 days after their initial call-in day with symptoms. ~ CNA-D called in sick on 12/16/24 with symptoms of nausea, vomiting, and abdominal cramps. CNA-D returned to work on 12/18/24. There was no date listed for CNA-D's last symptom. ~ CNA-E called in sick on 12/21/24 with symptoms of nausea and vomiting. CNA-E returned to work on 12/23/24. There was no date listed for CNA-E's last symptom. ~ LPN-F called in sick on 12/26/24 with symptoms of nausea and vomiting. LPN-F returned to work on 12/28/24. There was no date listed for LPN-F's last symptom. IP-C indicated IP-C could not provide call-in documentation for last symptoms for CNA-D, CNA-E, and LPN-F. IP-C indicated the facility's procedure is for the employee to call back when their symptoms have resolved and return to work 48 hours after the resolution of symptoms. IP-C indicated the facility's policy was not followed for CNA-D, CNA-E, and LPN-F. IP-C was not sure when CNA-D, CNA-E, and LPN-F's symptoms resolved. 51044 2. On 4/16/25, Surveyor reviewed R10's guidelines for daily cares, dated 4/15/25, which indicated R10 was on EBP due to an enteral tube. On 4/15/25 at 9:10 AM, Surveyor observed LPN-F complete a tube feeding flush and administer R10's tube feeding. LPN-F completed hand hygiene, entered R10's room, and donned gloves. LPN-F did not don a gown or goggles prior to entering the room. LPN-F attached R10's tube to the gastric button, opened the clamp, and flushed the tube with water. LPN-F then attached R10's tube to an extension tube and started R10's tube feeding. LPN-F then removed gloves and exited R10's room. LPN-F did not complete hand hygiene prior to exiting the room. On 4/15/25 at 1:30 PM, Surveyor interviewed LPN-F and Director of Nursing (DON)-B regarding PPE and hand hygiene. LPN-F verified LPN-F did not wear a gown and goggles during R10's flush and tube feeding. LPN-F indicated LPN-F was aware of the need to wear a gown and goggles during the flush and tube feeding due to R10's EBP status. LPN-F also verified LPN-F did not complete hand hygiene before exiting R10's room. DON-B indicated R10 was on EBP due to an enteral tube and catheter and indicated staff should follow the facility's EBP policy. 3. On 4/16/25, Surveyor reviewed R37's guidelines for daily cares, dated 4/16/25, which indicated R37 was on EBP due to wounds. On 4/16/25 at 8:27 AM, Surveyor observed RN-G complete wound care for R37. RN-G washed hands, donned gloves and a gown, and completed wound care for R37's legs and left wrist. RN-G then removed RN-G's gown and gloves. Without cleansing hands and applying clean gloves, RN-G applied tubigrips to R37's legs, put on R37's socks, picked up a lift pad off the floor, and disposed of soiled bandages and the lift pad. R37 then sanitized hands and exited R37's room. On 4/16/25 at 8:41 AM, Surveyor interviewed RN-G regarding EBP and PPE. RN-G verified RN-G did not wear gloves while applying R37's tubigrips and socks and when RN-G disposed of R37's soiled bandages and lift pad. RN-G indicated RN-G should wear gloves at all times during cares for R37.

Based on observation, staff, resident and resident representative interview, and record review, the facility did not ensure appropriate supervision was in place to address wandering behavior and related concerns for 3 residents (R) (R32, R64, and R71) of 4 sampled residents. R32 wandered into residents' rooms and displayed intrusive behavior. R64, R71, and R71's Power of Attorney for Healthcare (POAHC) expressed concerns regarding R32's unwanted entry into their rooms. The facility did not provide adequate supervision or implement interventions to prevent R32 from entering residents' rooms. Findings include: The facility's Aggressive Behavior Prevention and Response policy, dated 11/26/18, indicates: .To identify causes, prevention techniques, and reaction methods for residents at risk of aggressive behavior. Performed by: All staff. Preventing Aggressive Behavior: Contributing factors: Dementia/cognitive impairment, delusions, hallucinations, situational causes and triggers, unwanted entry into bedroom; Procedure: .3. Call the Registered Nurse (RN) shift supervisor and they will respond to the area of concern. 4. Keep other residents safe .7. Once the resident is calm, the neighborhood nurse will assess the resident(s) involved for any injuries and initiate .immediate interventions to monitor physical and psychosocial status. The need for 1:1 monitoring of the resident will be assessed immediately following the incident .10. The Interdisciplinary Team (IDT) will complete a review of the incident to identify what led to the acute aggressive episode and put interventions in place to avoid reoccurrence. (Of note: When Director of Nursing (DON)-B provided the policy to Surveyor on 4/16/25, DON-B indicated the policy covered wandering behavior as well.) From 4/14/25 to 4/16/25, Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia with psychotic disturbance, Alzheimer's disease, generalized anxiety disorder, and delusional disorder. R32's Significant Change Minimum Data Set (MDS) assessment, dated 3/31/25, indicated R32 was severely cognitively impaired. The MDS assessment also indicated R32 wandered 1-3 days during the observation period which significantly intruded on the privacy or activities of others. A care plan, dated 3/28/25, indicated R32 had the potential to feel overwhelmed, anxious/restless, and paranoid due to cognitive impairment and anxiety and indicated R32 may yell, shout, scream, not talk, have a hard time expressing what R32 needs, and may pace/wander throughout the neighborhood. The care plan indicated R32 was not able to distinguish between areas R32 was welcome to enter and those that R32 was not. The care plan instructed staff to provide 15 minute checks if R32 became intrusive, redirect R32 from areas where R32 was not welcome, and offer snacks or drinks (chocolate ice cream or cranberry juice) which were generally effective if R32 became resistive. R32's medical record indicated the following: ~ On 10/22/24, the facility implemented 1:1 supervision for R32 due to falls and intrusive behavior (wandering). At that time, R32 ambulated with a cane in the facility. ~ A physician note, dated 11/13/24, indicated quetiapine (an antipsychotic medication) was recently increased due to increased behaviors. R32 was also on buspirone (an anxiolytic medication) for generalized anxiety disorder. R32 continued to require 1:1 monitoring due to fall risk, pacing, and wandering into peers' rooms. ~ On 3/4/25, R32 went to the hospital due to a change in condition. R32 returned from the hospital on 3/10/25 with diagnoses including pneumonia, urinary tract infection (UTI), urinary retention, and sepsis. R32 was no longer ambulatory at that time. ~ On 3/17/25, the facility initiated a short-term care plan (STCP) that indicated: Trial (discontinue) of 1:1. The care plan instructed staff to document intrusiveness, provide 1:1 supervision as needed for increased agitation/intrusive behavior, use distraction techniques such as snacks, repositioning, fluids, walks, check and change, fidgets, etc., and update the Social Worker (SW) or RNs with concerns A Social Services note, dated 3/18/25, indicated the IDT discussed discontinuing R32's 1:1 on 3/17/25. Since R32 returned from the hospital, R32 was no longer ambulatory but attempted to self-propel a wheelchair. Nursing staff would transition R32 to a peddler Broda chair for comfort and mobility. Concerns with R32's behavior had decreased since R32 was less mobile and R32 had not been intrusive with peers. R32's 1:1 supervision was discontinued on 3/17 PM shift and R32 transitioned to 15 minute checks for 48 hours. A progress note, dated 3/23/25 at 9:21 PM, indicated R32 was on 15 minute checks, was not able to be redirected, and was intrusive while self-propelling a wheelchair around the neighborhood. A behavior assessment, dated 3/23/25, indicated R32 wandered aimlessly, had hallucinations, and significantly intruded on the privacy or activity of others. Interventions included 1:1 activity, reorientation, reassurance, offer a snack, and toileting. R32's behavior had not changed since the last assessment. A progress note, dated 3/25/25 at 8:36 AM, indicated a STCP was initiated on the 3/23/25 PM shift for increased agitation with cares and biting staff. Staff were instructed to immediately report further biting/agitation to the nurse. Fifteen minute checks were continued. Charting from 3/24/25 indicated R32 rested comfortably in bed the majority of the AM and PM shifts. R32 continued to be irritated with cares but was calm afterward. From 4/14/25 to 4/16/25, Surveyor reviewed R71's medical record. R71 was admitted to the facility on [DATE] and had diagnoses including dementia, major depressive disorder, generalized anxiety disorder, and difficulty in walking. R71's MDS assessment, dated 1/29/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R71 had moderate cognitive impairment. R71 had an activated POAHC who visited daily. On 4/14/25 at 11:30 AM, Surveyor interviewed R71 and POAHC-L. R71 and POAHC-L expressed concerns about a resident (R32) who wandered into R71's room. R71 and POAHC-L indicated (R32) previously had a staff with (R32) at all times, however, staff were no longer with (R32) who entered R71's room uninvited. R71 informed Surveyor that R71 did not have a call light (per choice) recently when R71 was in R71's recliner. R71 indicated (R32) entered R71's room and touched R71's toe. R71 yelled for help and staff finally came. POAHC-L indicated sometimes (R32) enters R71's room when POAHC-L is visiting. POAHC-L stated POAHC-L tries to get (R32) out of the room. R71 indicated R71 witnessed (R32) be mean to staff and is not sure what (R32) will do when (R32) enters R71's room. R71 indicated it is scary to have to live like that. R71 and POAHC-L indicated staff are aware that (R32) wanders into rooms and have removed (R32) from R71's room. R71 and POAHC-L indicated staff had not talked to them about implementing interventions to deter (R32) from entering R71's room. From 4/14/25 to 4/16/25, Surveyor reviewed R64's medical record. R64 was admitted to the facility on [DATE] and had diagnoses including dementia and cerebrovascular disease. R64's MDS assessment, dated 1/22/25, had a BIMS score of 11 out of 15 which indicated R64 had moderate cognitive impairment. On 4/15/25 at 10:15 AM, Surveyor interviewed R64 who was sitting in a chair in R64's room. R64 indicated last week (R32) entered R64's room and waved both hands at R64. R64 indicated R64 thought (R32) wanted to fight R64 or live with R64. R64 activated the call light and staff responded. R64 indicated R64 does not like it when (R32) enters R64's room but indicated staff respond right away. R64 indicated R64 does not like it when people sneak up on R64 because R64 is a nervous person, is small, and cannot fight anyone if R64 needs to. On 4/15/25 at 10:17 AM, Surveyor observed R32 wandering in the hallway with no staff present. R32 slowly self-propelled a wheelchair down the hallway and entered a room on the left side of the hallway. Approximately one minute later, staff walked down the hallway, observed R32 in the room, and backed R32's wheelchair out of the room. Surveyor noted the resident whose room R32 entered was asleep on the bed. On 4/15/25 at 1:19 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-H who worked the PM shift on R32's unit. CNA-H confirmed R32 wanders on the unit regularly, continues to enter residents' rooms, and is difficult to redirect at times. CNA-H indicated a few residents express concerns when R32 is in their room. CNA-H indicated R32 has not been aggressive toward other residents, just toward staff during cares. When asked if R32 had entered R71's room, CNA-H indicated R32 tried to get in R71's bed and was difficult to redirect. (R71 was not in bed at the time.) CNA-H indicated CNA-H has shut residents' doors, however, R32 opens doors easily. On 4/15/25 at 1:58 PM, Surveyor interviewed RN-J who confirmed R32 enters residents' rooms regularly. RN-J had not received any resident concerns regarding R32 and indicated when RN-J was on the unit, R32 was easily redirectable. On 4/15/25 at 2:01 PM, Surveyor interviewed CNA-K who worked on R32's unit the last two days. CNA-K indicated R32 was often in residents' rooms, however, no residents expressed concerns in the last two days. Surveyor reviewed progress notes for R32 since R32's 1:1 supervision was discontinued on 3/17/25. The progress notes did not indicate whose rooms R32 entered or was removed from. Surveyor also reviewed R64 and R71's progress notes which did not indicate R32 was found in either of their rooms. On 4/16/25 at 10:14 AM, Surveyor interviewed Unit Manager (UM)-I who indicated R32 was removed from 1:1 supervision when R32 returned from the hospital. UM-I was not aware residents expressed concerns that R32 wandered into their rooms. UM-I indicated R32 resides on a dementia unit and needs to be allowed to wander, however, interventions should be implemented to address the residents' concerns. Surveyor and UM-I discussed safety for R32 if R32 enters someone's space uninvited. UM-I indicated if residents express concerns, staff should report the concerns to the nurse or shift supervisor. UM-I indicated UM-I and the Social Worker communicate so the team can address any concerns appropriately. UM-I was unsure if staff followed-up with residents when R32 was removed from their rooms. On 4/16/25 at 12:10 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated since R32 was not ambulatory when R32 returned from the hospital, the IDT trialed a removal of 1:1 supervision and monitored R32 and staff's reactions. DON-B indicated R32 was not aggressive toward peers and stated R32 was only aggressive during cares. DON-B was not aware that residents expressed concerns regarding R32 wandering into their rooms. When Surveyor informed DON-B that staff indicated residents had expressed concerns about R32 wandering into their rooms, DON-B indicated staff should communicate with the IDT so the concerns can be addressed.

Based on staff interview and record review, the facility did not ensure dishwasher temperatures were monitored and recorded to ensure proper sanitization of dishware on 5 of 5 neighborhoods in the facility. This had the potential to affect all residents residing in the facility. Dishwasher temperatures were not monitored or documented daily on all 5 neighborhoods in the facility. Findings include: The facility's Temp Dot For Household Dishwasher policy, dated 12/2023, indicates: Certified Nursing Assistants (CNAs) will perform temperature indicator verification of each household dishwasher daily to assure sanitization temperature of 160 degrees is reached by locating the temperature log on the cabinet above the dishwasher and documenting the max temperature on the Dishwasher Temperature Log with initials .Unit Assistants (UAs) will monitor for completion of the temperature log at a minimum of once weekly. If logs are incomplete, UAs will follow up with the assigned staff. UAs will store temperature indicator logs in a designated area on the neighborhood for a duration of one year. On 8/22/24, Surveyor reviewed the dishwasher temperature logs from March 2024 through August 2024 and noted the following missing temperatures: Lakeside 1 North: Missing 8/7, 8/16, and 8/18 Lakeside 1 South: Missing 8/7 and 8/20 Lakeside 2 North: Missing 4/28 and 4/30 Lakeside 2 South: Missing 6/10 Parkside 1 North: Missing 4/3, 4/20, 5/3, 6/1, 6/2, 6/21, 6/22, 6/23, 8/7, and 8/15 Parkside 1 South: Missing 4/10, 5/3, 5/26, 5/27, 6/1, 6/2, and 8/15 Parkside 2 North: Missing 7/27, 7/28, 8/3, 8/18, 8/19, and 8/20 Parkside 2 South: Missing 7/27 and 7/28 Prarieside 1 North: Missing 7/6, 8/3, 8/6, 8/11, 8/13, and 8/15 Prarieside 1 South: Missing 8/4 and 8/6 (noted to be out of service as of 8/17/24) On 8/22/24 at 10:45 AM, Surveyor interviewed CNA-D regarding dishwasher temperature logs. CNA-D stated whoever does the dishes is responsible for monitoring and documenting the temperature on the tracking sheet located above each dishwasher. On 8/22/24 at 11:55 AM, Surveyor interviewed UA-C regarding the neighborhood dishwasher temperature logs. UA-C stated UAs are responsible for checking regularly to make sure temperature logs are filled in by either CNAs or Dietary Aides. UA-C stated if logs are not filled in, UA-C reports the concern to the Unit Manager to follow-up. On 8/22/24 at 12:29 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding monitoring and documenting dishwasher temperatures. NHA-A verified staff should monitor and document dishwasher temperatures daily on the neighborhoods.

Based on observation, staff interview and record review, the facility did not ensure staff performed proper hand hygiene during the provision of cares for 1 Resident (R) (R1) of 3 residents. On 9/12/23, Certified Nursing Assistant (CNA)-C did not perform appropriate hand hygiene during an observation of perineal care for R1. Findings include: The facility's Hand Hygiene Policy, dated 2/24/17, indicates: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: .Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); .Before and after assisting a resident with personal care .Before and after touching inanimate objects .Before and after assisting a resident with toileting (hand washing with soap and water); .After handling soiled or used linens .After removing gloves .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections .Except for situations where hand washing is specifically required, antimicrobial agents such as ABHR (alcohol based hand rubs) are also appropriate for cleaning hands and can be used for direct resident care . In addition, gloves or the use of baby wipes are not a substitute for hand hygiene. On 9/12/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (group of disorders that affect movement, muscle tone, balance, and posture) and vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain). R1's Minimum Data Set (MDS) assessment, dated 8/17/23, indicated R1 was rarely/never understood and required extensive assistance of one staff for personal hygiene. On 9/12/23 at 6:18 AM, Surveyor observed CNA-C assisted R1 to the toilet and pulled down R1's pants and brief. CNA-C donned gloves, removed R1's soiled brief and, with the same gloved hands, washed and dried R1's legs with a washcloth and towel. CNA-C placed a clean brief, clean pants, socks, and shoes on R1. CNA-C shaved R1, combed R1's hair, removed a wet soaker pad from R1's bed, and placed a clean soaker pad on the bed. CNA-C then assisted R1 to a standing position, provided perineal care by washing and drying R1 with a washcloth and towel, and removed gloves. Without performing hand hygiene, CNA-C obtained barrier cream, placed a glove on CNA-C's right hand, applied barrier cream to R1's rear perineal area and removed the right glove. Without performing hand hygiene, CNA-C adjusted R1's clothing, walked R1 to the common area, and assisted R1 into a chair. CNA-C returned to R1's room, and removed a garbage bag and soiled linens from R1's bathroom. CNA-C exited R1's room, walked through the hallway, and removed a key from CNA-C's pocket. CNA-C put the key back in CNA-C's pocket when another staff unlocked the utility room door. CNA-C put a glove on CNA-C's right hand, and sorted R1's soiled linen from the garbage. CNA-C put the soiled linen in the washing machine, put the garbage in a container, and removed the right glove. Without performing hand hygiene, CNA-C removed a key from CNA-C's pocket, opened a cabinet, and poured laundry detergent into a cup. CNA-C put the key back in CNA-C's pocket, started the washing machine, and moved clean clothing from a second washer to a dryer. CNA-C placed a dryer sheet in the dryer, started the dryer and then washed hands. On 9/12/23 at 6:39 AM, Surveyor interviewed CNA-C who indicated the facility educated staff to perform hand hygiene always before going into a room and as soon as done with cares. CNA-C indicated ABHR was allowed, but stated, I didn't have any (ABHR) in my pocket. CNA-C indicated CNA-C sanitized hands with ABHR prior to entering R1's room and verified CNA-C should have performed hand hygiene after removing gloves and when moving from dirty to clean tasks. On 9/12/23 at 10:58 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility expected staff to complete hand hygiene before applying gloves, after removing gloves, after providing care, and when moving from dirty to clean tasks. Following a discussion of the above observations, DON-B stated, That's not our expectation.

Based on observation, staff interview, and record review, the facility did not ensure food was stored, and served under sanitary conditions. This practice had to potential to affect 94 of 98 residents. (Four residents were exclusively fed via tube). Staff did not identify and address the main kitchen warewashing machine (dishwasher) internal surface temperature monitoring device did not reach the required 160 degrees Fahrenheit (F) since July of 2022. Staff did not date foods and beverages that were time and temperature controlled for safety upon opening and did not discard outdated items in accordance with food safety practices. Findings include: On 2/13/23 at 8:52 AM, Dietary Manager (DM)-H stated the facility used the Food and Drug Administration (FDA) Food Code as its standard of practice. Dishwasher Internal Temperature FDA Food Code 2022 documented at 4-703.11 After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: .(B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71oC (160oF) as measured by an irreversible registering temperature indicator On 2/13/23, during an initial kitchen tour beginning at 8:52 AM, Surveyor reviewed the main kitchen dishwasher monitoring logs and noted the internal surface temperature was not reaching 160 degrees F. DM-H and Surveyor reviewed dishwasher documentation which revealed the dishwasher internal surface temperature stopped reaching the required minimum 160 degrees F in July 2022. DM-H explained DM-H referred to the FDA Food Code requirement at 4-501.112(A) which documented the maximum temperature of the sanitizing rinse is 194 degrees F when DM-H reviewed the dishwasher monitoring logs. Surveyor reviewed the FDA Food Code 4-703.11(B) with DM-H at that time. On 2/14/23 at 1:24 PM, Surveyor observed an internal surface temperature monitoring device run through dishwasher and reach the required minimum temperature of 160 degrees F. DM-H stated the facility determined the internal surface temperature monitoring device which registered temperatures below the required minimum was discovered by staff as defective and replaced by a new monitoring device. Time and Temperature Foods FDA Food Code 2022 documented at 3-501.17(B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety On 2/13/23, during an initial kitchen tour beginning at 8:52 AM, Surveyor observed and DM-H verified the main kitchen walk-in refrigerator contained a one gallon container of lemon juice, delivery dated 10/4/22, which was open and undated. Food Keeper (foodsafety.gov) indicated lemon juice is good for two months in the refrigerator once opened. DM-H and Surveyor toured the household kitchenettes and noted the following Resident (R) specific foods in refrigerators were open and undated: R350 - 12 ounce (oz) jar of marinated herring R9 - 64 oz apple juice Surveyor observed and DM-H verified a household kitchenette freezer contained a Ziploc bag with 8 pancakes and an obvious build-up of ice particles in the bag and on the pancakes. The bag was marked with a use-by date of 1/20/23. DM-H verified all food products must be date marked at the time of opening and items past use-by dates should be discarded timely.

Based on staff interview and record review, the facility did not ensure assessments, interventions, and increased monitoring were implemented after a statement of suicidal ideation was verbalized by 1 Resident (R) (R69) of 5 residents reviewed for behavioral and emotional well-being. Licensed Practical Nurse (LPN)-I wrote a progress note that indicated R69 voiced a statement of suicidal ideation. LPN-I did not update the facility's Interdisciplinary Team (IDT), therefore, assessments, interventions and increased monitoring were not implemented and R69's psychologist/psychiatrist was not informed. Findings include: From 2/13/23 through 2/15/23, Surveyor reviewed R69's medical record and noted R69 had diagnoses to include Alzheimer's disease and anxiety disorder. LPN-I documented during staff intervention of R69's elopement attempt on 12/15/22, R69 stated, I should just go die in a snow bank. R69's Patient Health Questionnaire (PHQ)-9 (depression severity assessment) scores remained in the minimal depression range between 9/28/22 and 1/25/23 and decreased from 4 to 1 (lower score is less severe on 30 point scale). Surveyor noted R69's medical record did not contain a suicide prevention care plan, an assessment on the date of the statement, or increased monitoring following the statement. R69 met with psych on 12/20/22. The visit note documented R69 had no suicidal ideation. During the course of survey, LPN-I, who documented the 12/15/22 progress note, was not available for an on-site interview and did not respond via telephone. On 2/14/23 at 11:41 AM, Surveyor interviewed Social Worker (SW)-F regarding R69's 12/15/22 statement of suicidal ideation. SW-F denied awareness of R69's statement. SW-F stated the facility's practice was for staff to report statements of suicidal ideation to the unit manager, Registered Nurse (RN)-G, and/or report the incident to SW-F, who were members of the IDT. SW-F stated when SW-F is notified of suicidal ideation, SW-F assesses the resident to determine the urgency of a psychology visit. The urgency level either results in a phone call for an urgent visit or placement of the resident on the list for the next scheduled psych visit. SW-F also stated the IDT would create a short-term care plan. SW-F verified R69 had a psych visit on 12/20/22. SW-F stated SW-F and RN-G usually rounded with psych and SW-F would have informed psych of R69's suicidal ideation if SW-F was aware. On 2/14/23 at 12:15 PM, Surveyor interviewed RN-G regarding R69's suicidal ideation statement. RN-G denied awareness prior to Surveyor's investigation. RN-G stated there was an expectation that suicidal ideation statements be reported up the chain of command. RN-G verified suicidal ideation statements always required follow-up.

Based on staff interview and record review, the facility did not ensure medical records contained documentation related to influenza immunizations for 3 Residents (R) (R10, R22 and R55) of 5 residents reviewed for immunizations. R10's medical record did not contain documentation indicating the facility offered or administered the influenza immunization for the 2022/2023 season. R22's medical record did not contain documentation indicating the facility offered or administered the influenza immunization for the 2022/2023 season. R55's medical record did not contain documentation indicating the facility offered or administered the influenza immunization for the 2022/2023 season.Findings include: The facility's Influenza Immunization Policy, dated 02/2018, contained the following information: The facility has developed policies and procedures that ensure that - (i) Before offering the influenza immunization, each resident or the resident representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident representative has the opportunity to refuse immunization; (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. (v) The resident or resident representative will be re-offered the influenza vaccine with increased levels of influenza-like illness within the building or in the community. The facility's Seasonal Influenza Vaccination Procedure - Residents, dated 09/2022 contained the following information: 2. RN Neighborhood Supervisors: .Inform Infection Preventionist of any refusals *Refusals must be approached three times and documented in ECS (electronic medical record) for each encounter . The facility's Informed Consent - Influenza Immunization document, dated 02/2018, contained the following information: Procedure: 1. Prior to the annual vaccination date, which is determined by the QAA (Quality Assessment and Assurance) Committee sometime each fall usually after October 1st): a. Give competent resident a consent form and a copy of the most current VIS (Vaccine Information Sheet) from CDC (Centers for Disease Control and Prevention.) b. Mail consent forms and VIS forms to the resident representative of incompetent/incapacitated residents. 2. Forward completed consent to the RNNS (Nurse Supervisor)/Infection Preventionist. On 2/15/23, Surveyor reviewed R10, R22, and R55's medical records for documentation related to their influenza vaccination status and documentation for the 2022/2023 influenza season. R10, R22, and R55's medical records contained the following: 1. R10 was admitted to the facility in September of 2012. The most recent influenza consent/declination document in R10's medical record was signed and dated 11/1/20. 2. R22 was admitted to the facility in April of 2021. The most recent influenza consent/declination document in R22's medical record was signed and dated 4/6/21. 3. R55 was admitted to the facility in June of 2017. The most recent influenza consent/declination document in R55's medical record was signed and dated 9/26/19. On 2/15/23, Surveyor interviewed Registered Nurse Manager/Quality Assurance & Infection Control (IP)-C. IP-C stated IP-C had a log that contained documentation of all resident immunizations. IP-C stated IP-C would provide Surveyor a copy of the consent/declination forms. On 2/16/23 via e-mail, IP-C provided Surveyor with additional information which included progress notes related to influenza immunization consents and declinations as follows: R10 late entry dated 2/16/23 at 8:26 AM; R22 late entry dated 2/16/23 at 8:22 AM; R55 late entry dated 2/16/23 at 8:24 AM. On 2/16/23 at 2:02 PM via e-mail, IP-C stated IP-C documented the attempts on 2/16/23. IP-C attached the copies of the original consents that were sent to R10's, R22's, and R55's powers of attorney (POAs) on 9/22/22 and 12/1/22. IP-C stated IP-C did not see the documents in the chart but had the original copies with original logs that IP-C prepared at the start of the influenza season.

Based on observation, interview and record review, the facility did not ensure resident environment was as free of hazards as possible for 2 residents (R) (R30 and R87) of 25 residents reviewed for accidents. On 1/15/22, R30 fell while operating an electric lift recliner and was sent to the emergency room (ER). The family asked that the electric lift recliner be unplugged. This did not occur. On 1/17/22, R30 sustained another fall while operating the same electric lift recliner and was sent to the ER. R30 was not reevaluated following the 1/15 fall to determine if R30 could safely operate the lift recliner. Interventions which addressed the root cause of the fall were not put in place following the 1/15 fall. R87 had a fall on 12/31/21 that resulted in a broken left hip. R87 had subsequent falls on 1/9/22 and 1/21/22. No new falls interventions were initiated to reduce the risk of falls. Findings include: Facility policy titled Fall Prevention Plan dated 9/21 read as follows: Annually, with a significant change of condition assessment and after each fall: A licensed nurse completes a Morse Fall Scale in ECS (electronic medical record software) and updates the plan of care to reduce identified fall risks. Fall Assessment for Prevention: The licensed nurse will complete an assessment of the resident after the fall and initiate a short-term plan of care with interventions at the time of the incident The RNSS (Registered Nurse Shift Supervisor) completes follow-up fall documentation under QA (Quality Assurance) Fall Charting. The RN (Registered Nurse) Neighborhood Supervisor will further review the circumstances to the fall and may request a consultation by therapy to review the medical record, the care plan, and with resident, staff and family/resident representative input, provide suggestions for revision in the plan of care. A consultation may result in evaluation by Therapy Services which will require physician agreement. The RNNS will then document a concluded fall note summary in ECS under meeting notes following each fall. Upon assessment of a resident who is shown to be at high risk for falls via the Morse Fall Scale and/or has had frequent falls and/or a fall with a major injury, a licensed nurse and/or the RN Neighborhood Supervisor will complete the following when appropriate: .Review all plans of care for fall risk factors and implement new interventions. Review Risks versus benefits with residents/family members/resident representative and document education provided Resident falls will be discussed at morning IDT (Interdisciplinary Team) stand-up meetings and read on 24-hour reports. Weekly resident falls are discussed, care plans reviewed and updated, and interventions assessed for effectiveness at care conferences on the respective neighborhoods by the neighborhood IDT and documented in the I-Team (IDT) folder. Falls will be reviewed and discussed at QA every other month to monitor for resident trends in falls along with QAPI (quality assurance and performance improvement) Fall Committee meetings to assess for improvements in facility fall interventions, and to discuss additional updates to improve fall prevention plans. 1. On 2/7/212, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE]. R30's diagnoses included dementia, [CONDITION(S)] (plaque build up in artery walls), [CONDITION(S)] syndrome (poorly-formed blood cells) and diabetes mellitus. On 2/07/22 at 11:03 AM, Surveyor observed R30 in R30's room. R30's forehead was swollen and bruised, and there was a scab approximately the size of a penny on the left side of R30's forehead. Bruising was present under each of R30's eyes and much of R30's face. Surveyor interviewed R30, who stated, Someone hit me. On 2/07/22 at 11:06 AM, Surveyor interviewed Unit Nurse Supervisor (NS)-H. NS-H indicated that R30 sustained the facial bruising/injury from falls which occurred on 1/15/22 and 1/17/22. NS-H confirmed both falls were due to R30 attempting to raise the electric lift recliner in R30's room with the recliner's remote control. NS-H stated, We have consents from families and do safety evaluations for electric lift recliners. NS-H indicated that R30 was evaluated on 1/15/22 and staff spoke with R30's family who indicated the family would like to keep the electric lift recliner. NS-H indicated R30 did not have prior issues (related to the lift recliner) and that it (fall) was a one time thing. NS-H indicated R30 was reevaluated on 1/17/22 and the remote control for the recliner was removed. NS-H confirmed R30 was sent to the ER both dates following the falls. NS-H indicated R30 has the hematoma (bruising, swelling of clotted blood inside body tissue) to the head and no fractures were discovered. NS-H indicated that R30 hit their head both falls. On 2/07/22 at 11:14 AM, Surveyor observed R30 in R30's room sitting in wheelchair. The electric lift recliner was noted to be in R30's room, the back of chair was elevated approximately 10 inches from floor, the chair was plugged into the wall and the remote was fastened to the recliner with a clip which was clipped to the top back of the recliner, just behind where a person's head would be located if sitting in the chair. The surveyor confirmed the remote control was operational. On 2/7/22, Surveyor reviewed R30's medical record. The facility conducted fall risk assessments for R30 on 12/1/21 which indicated R30 was at high risk for falls. On 1/16/22 a fall risk assessment was again completed which indicated R30 was at high risk for falls. On 12/1/21, a cognitive screen indicated R30's scored 8/15, moderate cognitive impairment. Document titled Guidelines for Daily Care indicated, Transfers: Extensive assist 1 staff, use standing aide. R30's long-term care plan with a review date of 2/8/22 indicated: 9/7/21 - I have the potential to fall down and hurt myself (last fall on 1/11/2021 with left hip fx(fracture)/surgical). I am at risk for injuring myself. I am unaware of safety risks. I need to use an assistive device. I like to transfer on my own. I sometimes get confused and attempt actions beyond my capabilities. In the past I have fallen. Fall prevention interventions included 'give me non-skid footwear so I don't slip' implemented 9/7/21; 'no-slide' (a mat-like device which prevents slipping) in chair/in recliner implemented 12/20/21. Review of fall charting included a fall occurred on 12/20/21 which indicated: Per Certified Nursing Assistant (CNA), resident slid from chair (recliner) as CNA was preparing to transfer resident. CNA stated that CNA used the lift chair to raise resident up to a proper position to be hooked to the stand aid (a device used to transfer people who cannot do so on own). CNA stated that resident started sliding out of chair and CNA lowered resident to the ground to resident's buttocks Resident was not wearing non-skid footwear. Interventions: 15 minute checks, no-slide placed in stationary chair, monitor via STCP (short-term care plan). Further chart review indicated R30 fell on [DATE], documentation included: Time of Incident: Saturday 20:00 (8 PM). Found laying on back in front of recliner. Recliner was elevated. Recliner remote on floor. Hematoma on left frontal lobe (area on forehead). Left leg externally rotated and appears shorter than right leg. Pain Related To Incident: Yes. Interventions: Orders to send to ER. Record review also indicated R30 fell on [DATE], documentation included: Time of Incident Monday 11:05 AM. Found on floor with injury. Appears as if resident used the recliner remote to lift recliner all the way up and the resident slid out of recliner. Cognitive State: poor safety awareness, doesn't recognize potential hazards in environment, orientated to person. Activity at time of fall: Attempting to transfer self. Observed: Limb shortening external rotation left leg c/o (complained of) pain to left leg, hematoma to forehead. Pain Related to Incident: Yes. Interventions: RNSS (RN Shift Supervisor) RNUM (RN Unit Manager) Updated immediately. Resident sent to ER for evaluation and treatment. Follow up fall charting indicated: 1/16/22 6:11 AM, complaint of pain - forehead and left leg. 1/16/22 10:52 AM, complaint of pain to legs and head. 1/16/22 11:16 AM, black eye - prior assessment eye was drooping. Now eye is almost completely closed. More bruising noted. 1/17/22 9:42 AM, continues with bruising to forehead and bruising surrounding both eyes and lower eyelids. Slight complaints of pain to face where bruising noted. Following 1/17/22 11 AM fall, follow up fall charting indicated: 1/17/22 19:00 (7 PM), continues with contusion to left forehead and bruising to bilateral eyes. Pain: Resident is offering complaint of pain with repositioning and transfers, unable to specify location or rating. 1/18/22 11:33 AM Continues with hematoma to forehead with small abrasions - Band-Aid removed, continues with bruising and slight swelling to bilateral eyes. Pain: Complaint of pain to head. 1/19/22 2:29 AM Resident continues with slight raised bruised hematoma to left forehead and to bruising around both eyes and left hip. 1/19/22 11:12 AM, Resident did offer complaints of pain to bruising noted around both eyes and to the hematoma on forehead. 1/19/22 18:20 (6:20 PM), Resident did offer complaints of pain to hematoma to forehead. On 2/08/22 at 10:27 AM. the Surveyor observed R30 to be in the electric lift recliner with the the recliner's foot rest up. The recliner was plugged in and the remote was clipped to the top of the recliner behind the top area where R30's head was. The Surveyor noted the remote to be functional. On 2/8/22 at 1:33 PM, Surveyor further interviewed NS-H. NS-H indicated the facility has a fall committee (a group of staff who meet to determine root cause analysis of falls), but the fall committee does not meet after each fall; NS-H stated, We have them (meetings) on hold for COVID-19. NS-H indicated that staff do discuss resident falls every other month during Quality Assurance (QA) meeting. NS-H indicated that interventions after a fall depends on the fall. NS-H confirmed the expectation is that the floor nurse or the RN shift supervisor working the shift the fall occurred on, put an immediate intervention in place within the shift the fall occurred. The manager will then do a follow up review of each fall and put a note in the electronic record within 2-3 days of the fall. NS-H also indicated to Surveyor that lift chair assessments are done quarterly at which time we (staff) get a new consent signed during the resident's care conference. On 2/08/22 at 3:50 PM, Surveyor interviewed NHA-A. NHA-A reviewed the fall charting for R30 and indicated the family wanted R30 to keep the lift recliner after the 1/15 fall. NHA-A confirmed that each of the falls were due to R30 utilizing the recliner remote. NHA-A indicated after the falls were reviewed on 1/17/22, the lift recliner remote was moved. The fall review read as follows: 1/17/22 11:38 AM (by NS-H): Follow up from 'found on floor with injury' on 1/15 (Saturday) and 1/17/22 (Monday) - Resident was in lift chair during both incidents. Resident accessed remote control and lifted self into highest position and attempted to self transfer and fell to the floor. Sustained a large hematoma to forehead with noted external rotation and pain to L hip from fall on 1/15. Was sent to the ER for evaluation. CT (computerized tomography) of head, labs and L hip/knee x-rays were completed which were all negative. Returned from ER. STCP initiated for fall and ER return, placed on 15 minute checks x 24 hours. On 1/17/22 around 11:00, resident was found on floor again after putting self in the highest position in recliner. Noted L leg shortening and rotation and complaints of pain. Continues with large hematoma on forehead and bilateral black eyes. NP (Nurse Practitioner) notified with orders to send to ER. Paramedics are here at this time. First contact notified. Plan of care updated - no longer to have access to lift recliner remote. On 2/9/22 at 9:30 AM, Surveyor interviewed R30's Power of Attorney for Healthcare (POA)-N, POA-N indicated after the fall of 1/15/22, the facility was asked to unplug the lift recliner when R30 was in it. POA-N stated, That second fall could have been avoided and actually they (staff) have the remote hooked on the back of the chair now and I would prefer they unplug it. All they have to do is bend over and unplug it. I believe there is a doctor order to unplug it. I was there yesterday and saw it (remote) was hooked to the back of the chair. I would rather be safe than sorry . (R30) fell on (R30's) face twice in a matter of two days. POA-N added that in the past, R30 fell at the facility and broke R30's hip. POA-N indicated with the recent January falls, having sat hours in the ER and that R30 had no transportation back from the ER to the facility so family had to utilize a slide device (a device to assist patients who do not transfer on their own from surface to surface) to get R30 into a family member's personal car. POA-N added, (R30) is very easily confused and when they send (R30) out, it takes days for (R30) to readjust. POA-N confirmed, We as a family did not want (R30) to use the lift chair remote. POA-N indicated after the fall on the 15th we told them (facility) to unplug it (chair/remote). POA-N indicated that POA-N's sister told a nurse and a CNA that (R30's) chair should not be plugged in also. POA-N indicated that POA-N also told the facility staff this (not to have chair/remote plugged in) on the phone following the 1/17/22 fall. POA-N indicated, We wanted the chair, we just don't want it plugged in. POA-N stated that R30 now thinks some big-shot man came in and punched R30 in the face (because of the bruising) and R30 doesn't know why. POA-N added that since falling prior, when R30 broke the hip, R30 is very frightened of falling. On 2/9/22 at 12:08 PM, Surveyor interviewed NHA-A and DON-B who confirmed following R30's 1/15 fall, the fall documentation entered by the Shift Supervisor indicated New Intervention Put in Place of a no-slide device in w/c (wheelchair) and non-slip footwear. NHA-A and DON-B confirmed these interventions had already been put in place from prior falls and were not new. DON-B confirmed the interventions put in place on 1/15/22 following R30's fall were also to update MD (doctor) and 15 minute checks. Documents titled Assessment, Decision To Use, And Informed Consent For Equipment were reviewed with DON-B and NHA-A. An assessment and consent form dated 1/17/22 indicated: Type of Equipment: Lift recliners for cognitively impaired individuals RESIDENT DOES NOT OPERATE LIFT CHAIR, ONLY STAFF. Consent completed for: Use of Lift Recliner. Attempt to identify the root cause of the medical symptom: Poor Muscle and Impaired Physical Strength. Can the cause of the medical symptoms be eliminated or reduced? No, Explain: Resident has generalized weakness d/t (due to) age, decreased muscle tone [CONDITION(S)]. What alternatives have been considered or used? What were the risks and benefits of the equipment alternatives? Equipment Alternative: Regular recliner chair, PT/OT (physical/occupational therapy). Risk: If resident were to operate remote, could cause self to fall out of chair. Benefit: Comfort, decrease LE (lower extremity) [CONDITION(S)]. Resident's Response: Resident's family provided lift chair, resident does not operate, only staff operate. Selected possible negative outcomes identified related to equipment use: X Decline in physical functioning. X Increase in the incidence of falls or head trauma due to falls and other accidents (strangulation and/or entrapment). The document was signed by a nurse, a Social Worker and POA-HC. The physician had not yet signed. DON-B confirmed there were no previous assessments or consent documents related to the lift chair completed following the 12/20/21 nor the 1/15/22 falls. NHA-A confirmed the most recent of these types of assessments was completed on 12/9/21 and confirmed R30's POAHC had not signed that document. NHA-A confirmed the document dated 12/9 included a possible negative outcome for using the lift recliner included Increase in the incidence of falls or head trauma due to falls and other accidents . On 2/9/22 at 1:53 PM, Surveyor interviewed RN Shift Manager (RN)-K. RN-K confirmed having worked the evening/PM shift of 1/15/22 when R30 fell . RN-K indicated, My intervention was to send R30 to the ER because it appeared R30's leg was internally rotated and shortened (a sign of hip fracture). RN-K indicated that R30 came back from theER on the night shift. RN-K confirmed night shift should have put something in place (an intervention) then on R30's return. RN-K confirmed not having removed or unplugged the lift recliner or its remote following R30's fall on 1/15/22. RN-K indicated the floor nurse would have contacted the POAHC on 1/15, but RN-K does not recall the results of the conversation - we were trying to get resident out the door quickly. RN-K confirmed having worked Sunday 1/16/22 on PM shift. RN-K indicated that on Sunday, RN-K had asked staff if R30 had any unsafe behaviors and staff said no, that R30 was resting in bed on that evening shift On 2/9/22 at 2:26 PM, NHA-A provided Surveyor with a statement signed by two staff, dated 2/9/22 which indicated the 12/9/21 recliner assessment/consent was not signed by POAHC due to POAHC not being at the care conference and that the consent had been mailed, but not yet returned. NHA-A provided Surveyor with an updated consent for 1/17/22 which was now signed by the doctor. NHA-A also provided Surveyor with an email dated 1/27/22 that was sent out to CNA, Nurses and Hospitality Aides from the Staff Development Coordinator with a Subject line that read: Lift Chair Reminders. The email read as follows: Hello - A couple reminders when residents have electric recliners (or lift chairs): 1. It will say in their guidelines for daily care if they are allowed to have access to the lift remote (examples below). Everyone should be making sure they are aware of this when using the recliners. 2. If a resident is continually unsafe with a lift chair an intervention we can put in place would be to remove their access to the lift chair. If we do this, a consent needs to be signed and the guidelines need to be updated, so make sure you are involving the RNNS (register nurse nursing supervisor). The email showed two examples of care plan selections, One example stating Equipment: Lift chair remote access denied. Place remote out of reach. Another example stating Equipment: Lift chair remote access allowed. NHA-A indicated not being sure why this email went out on 1/27/22, but added that NS-H did a review of R30's falls on 1/17. NHA-A confirmed NS-H's review of R30's fall occurred after the fall on the 17th. NHA-A provided the Surveyor with a short-term care plan (STCP) which was started for R30 following the 1/15 fall. The STCP indicated that R30 was sent toER on ,d+[DATE] and returned on 1/16 at 12:30 AM. NHA-A showed surveyor that an update was made to the STCP on 1/17/22 which stated No remote for recliner following R30's 1/17/22 return from the ER after the second fall. The STCP also indicated Fall with injury 1/17/22, ER Return, Hematoma to forehead, black eye, contusion L (left) hip and c/o pain to hip. NHA-A confirmed when R30 returned from theER on ,d+[DATE], a fall intervention should have been put in place. 2. R87 was admitted to the facility on [DATE]. R87 had Brief Interview of Mental Status (BIMS) (a brief test which gives an indication of one's cognitive functioning) score of 13/15 which indicates R87 was cognitively intact. R87's related diagnoses at the time of this survey include: Fracture unspecified part of neck of left femur (broken left hip); adjustment disorder with anxiety; major depressive disorder, single episode; repeated falls; unsteadiness on feet, mild cognitive impairment, and unspecified [CONDITION(S)]. Facility Falls Prevention Plan Policy dated 09/21 indicates: Annually, with a significant change of condition assessment and after each fall: a licensed nurse completes the Morse Fall Scale in ECS (Electronic Charting System) and updates the plan of care to reduce identified fall risk factors. On 2/9/22, Surveyor reviewed R87's Long Term Care Plan (LTCP) related to falls dated 11/9/21 which indicated: -I have the potential to fall down and hurt myself. I have the potential to lose my balance and stumble. I need to have someone help me. I like to feel independent. I like to walk as I choose. I like to do things on my own. I like to transfer on my own. Because I sometimes get confused. Because I take some medications that can make me dizzy, tired, confused, or weak. In the past I have fallen. I show this by not being able to move around like I used to, trying to move around without help, forgetting to use my assistive device, declining/resisting assistance. I need my nurses to keep an eye on my behavior, request therapy screen as needed, remind me to ask for help, monitor my toileting program. I need my aides to: use the following assistive devices to be able to better help me: wheelchair most of the time, make sure my important items are within reach, give me non-skid footwear so I don't slip, remind me to wear my glasses, make sure my hearing aids are in and are working, remind me to get up and move slowly, keep my room well lit when I'm up, report signs that I am in pain to my nurse, report any of my behaviors that might cause me harm to my nurse, assist me with transfers or when I walk, remind me to ask for help. I need social services staff to: explain my needs to others, I need activity staff to: notify the appropriate staff if there are any changes in my ability. I need rehab staff to: treat as indicated. I need everyone to: report changes in my abilities to my nurse. My goal is to stay safe while I'm moving about. On 2/9/22, Surveyor reviewed R87's Guidelines for Care and noted the following approaches related to falls which were added prior to R87's 12/31/21 fall which resulted in the left hip fracture: -On 2/5/21: Approach was added under Other: Needs reminders to use call light and wait for assistance, -On 11/16/21, Approach was added under Other: Despite therapy recommendations with education/risk for fall. R87 often will complete own cares/transfers independently. Between 2/7/22 and 2/9/22, Surveyor reviewed R87's EHR related to falls documentation: -On 12/31/21 at 12:00 PM, R87 had a fall that resulted in a broken left hip. R87 went to the emergency room and was admitted . R87 had an Open Reduction and Internal Fixation (ORIF) surgery (a type of surgery that is used to repair broken bones that need to be put back together by use of some form of hardware that holds the bone together so it will heal.) On 12/31/21 at 12:18 PM and 2:42 PM, the falls incident charting was initiated and completed in R87's EHR. Of note under Past Interventions: no falls within past 3 months. New Interventions put in place: Update physician, Pain assessment completed. Interventions: Sent to ER for evaluation of left hip pain. Teaching done: Use of call light re-educated resident. On 1/4/22, R87 returned from the hospital and staff initiated a Short Term Care Plan (STCP) related to falls. This STCP had a goal to be met by 1/7/22. The approaches checked on the STCP are: Non skid footwear, call light within reach, assess and treat pain, allow adequate rest without interruption, bed in low position, items within reach such as fluids and remote. On 1/4/22 at 9:55 AM, Interdisciplinary Team (I-Team) fall team notes indicated: reviewed fall event of 12/31/21. Resident was sent to hospital for further eval and was noted to have left hip fracture. Had surgical repair ORIF on 1/1/22. Per report may return today 1/4/22. Will be TTWB (Toe Touch Weight Bearing) to left leg and needs assist of 2 with stand lift. Upon review of fall, R87 was trying to get calendar down from corkboard. Corkboard is at wheelchair/ height however R87 had a small end table in front of the cork board. R87 had removed the calendar, lost balance and fell . R87 had gotten self back in wheelchair and then has pain worsening to left hip. It is care planned that R87 is to have assistance of 1 with transfers for ambulation but R87 often despite education will do things on own accord. Upon return R87 will need more assistance and Physical/Occupational Therapy in order to recover/heal. Will be completing a change of status assessment related to events and will review/revise plan of care accordingly. On 1/9/22 at 7:30 PM, R87 reported to staff R87 had fallen while attempting to self transfer in the bathroom to brush teeth without staff assistance. Physician was notified. On 1/9/22 at 9:04 PM and 10:09 PM, the falls incident was initiated and completed in R87's EHR. The 10:09 PM incident charting showed interventions were: 15 minute checks 1:1 STCP initiated; Pain assessment completed, Pain medication administered. Teaching Done; Use of call light. The 9:04 PM Incident charting showed: New interventions put in place: Pain assessed, update MD, 15 minute checks, pain medication administered. Surveyor noted these were not new interventions. On 1/9/22 a STCP was initiated related to falls with a goal to improved safety awareness/decreased risk for injury. Goal to be met by 1/12/22. Approaches checked are: Vital signs and neuro checks every 15 minutes X 1 hour, then every 1 hour X 8 hours, then every shift for a total of 72 hours. Interventions checked are: Evaluate proper call light, non-skid socks in bed / evaluate condition of current non-skid socks and proper footwear. The STCP is signed at the line: STCP summarized and Comprehensive Care Plan Updated on 1/13/22. Surveyor noted these are not new interventions from LTCP dated 11/9/21. On 1/10/22 at 12:49 PM, I-Team fall notes indicate: review of fall from last evening 1/9/22. Per report R87 was trying to get to bathroom to brush teeth. R87 states fell and got self back up into recliner and then waited for staff. However call light system was not utilized/on when staff arrived to help. R87 is just back from the hospital stay from prior fall that resulted in left hip fracture needing surgical repair. R87 has a tendency to do things/cares on own despite prior education that staff needs to be with R87 with mobility tasks as his history of falls and poor safety awareness. Has work with therapy in the past as well as currently. Has wt bearing restrictions at this time of TTWB to left leg. Staff transfer R87 with 2 staff and stand aid mechanical lift. PCP (Primay Care Physician) has been updated. Is on 15 minute checks, monitoring pain, keeping call light within reach. IDT aware of recent fall. Plan of care being reviewed during this time already due to change of status post left hip fracture. On 1/13/22, R87's Long Term Care plan (LTCP) was updated. Changes noted from the 11/9/21 LTCP were: In the past I have fallen, last falls noted: 12/31/21 and 1/9/22; and the addition of R87's change in transfer method after return from the hospital: I need staff to assist me with transfers by using mechanical lift. Surveyor noted there were no new interventions to reduce fall risk added to this LTCP. On 1/21/22 at 1:13 PM, R87 had a fall while attempting to transfer from recliner to wheelchair. Physician was notified. On 1/21/22 at 1:39 PM and 3:26 PM, the falls incident charting was initiated and completed in R87's EHR. The 1:39 PM charting shows: Interventions initiated 15 minute checks monitor via STCP. Teaching done. Instructed resident on use of call light. The 3:26 PM charting shows: New interventions put in place: Pain assessed, monitor via STCP: Plan: Monitor via STCP, Continue with current care plan, Monitor for pain/injury. Surveyor noted there were no new interventions put in place to reduce further fall risk. On 1/21/22 a STCP was initiated related to falls with a goal to improved safety awareness / decreased risk for injury. There is no date for the goal to be met. Approaches: Vital signs every shift X 24 hours; monitor for residual injuries, monitor for complaints of pain, 15 minute safety checks X 24 hours, monitor for unsafe behavior, monitor for changes in gait/ROM, update MD/Nurse Practioner as needed. There are no new interventions checked. There is a signature on the line: STCP Summarized and Comprehensive Care Plan Updated with a date of 1/22/22. Surveyor noted there was no update to the comprehensive (LTCP care plan on 1/22/22). On 1/26/22 at 9:39 AM, I-Team fall notes indicated: noted event on 1/21/22 about 1 PM. Had attempted to self transfer from wheelchair to recliner chair and fell . Denied any injury. This is R87's 3rd fall in last month. 12/31/21 fell with hip fracture, then again on 1/9/22 trying to self transfer). R87 is still own decision maker however has poor safety awareness and often thinks can do things on own. R87 has always needed supervision per therapy recommendations prior the fracture and would still self transfer despite recommendations. Since the hip fracture / surgery, R87 is transfer of 2 assist. Continues with Physical / Occupational Therapy as ordered for rehab on left hip. Education has been given each time and is reminded to call for assistance. STCP have been in place along with 15 minute checks. R87 does not always use call light. This last event, call light was in reach but did not use. Did have appropriate shoes on. Plan of care was followed. On 2/2/22, a STCP was initiated after a hospital stay from 1/31/22 to 2/2/22 in which R87 had a left hip replacement. This STCP had a goal of improved safety awareness/decreased risk for injury. Decreased mobility, Increased weakness, poor safety awareness, unaware of physical limitations. There is no date for the goal to be met by. The last date the shift section is filled out is 2/6/22. There is also no signature or date under the STCP summarized and Comprehensive Care Plan Updated. There is a handwritten note WBAT (Weight Bearing as Tolerated to LLE (Left Lower Extremity)). On 2/8/22, R87's LTCP (Long Term Care plan) was updated. The only update noted on the care plan was: In the past I have fallen. Last falls noted: 12/31/21 and 1/9/22, 1/21/22. No novel interventions to reduce fall risk were added to this care plan. On 2/9/22 at 8:36 AM, Surveyor interviewed Registered Nurse Supervisor (RNS-F) who indicated generally when there is a fall, the nurse does an assessment and charts the incident. Then RNS-F reviews the whole event and that gets charted under I-team notes. RNS-F indicated RNS-F would look at what interventions the nurse initiated in the STCP and if those interventions are appropriate to continue. If there were none, RNS-F indicated RNS-F does look at should anything be done differently. RNS-F indicated that part of the nurse charting in ECS is to have to put what was on the current care plan and what interventions were in place. RNS-F indicated after R87's first fall, R87 was put on 15 minute checks. RNS-F indicated staff are trying to be in there more often and anticipating R87's needs. RNS-F indicated staff document the 15 minute checks initially after the event and then the documentation stops after a few days, but staff are still going in and checking. RNS-F also verified 15 minute checks are on the care plan, though usually after 3 days, staff stop documenting the 15 minute checks. RNS-F revealed after the 2nd fall, R87 was back on 15 minute checks for a few days. RNS-F indicated after the 3rd fall, R87 was given education and R87 is still in therapy as well. RNS-F indicated any additional falls interventions should get added to both the LTCP and to the Guidelines for Daily care. On 2/9/22, Surveyor re-reviewed R87's LTCP and Guidelines for daily care and did not note an approach of 15 minute checks on the care plan. On 2/09/22 at 2:1 [TRUNCATED]

Based on observations and staff interviews, the facility did not ensure food was stored in accordance with food safety standards. This had the potential to affect 108 residents. Food/drink stored in the unit kitchenettes did not have date labels indicating when the product was to be used by nor when the product was opened. In addition, some food items stored in the unit kitchenettes were past manufacturer use-by dates. Findings: Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food), Date Marking. (B) Except as specified in (D) to (F) of this section, refrigerated, ready-to-eat (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section. (1) The day the original container is opened in the food establishment shall be counted as Day 1. Facility policy titled Household Storage of Food and Beverages dated [DATE] read as follows: Residents, families and visitors may bring in personal food/beverage items for the resident to store in the household refrigerators. Residents may store their personal food/beverage items in their household refrigerator provided the item is contained and labeled with their name and a date. Unlabeled or undated food will be discarded. Labeled and dated food will be discarded after 3 days, or after the indicated use-by date. It is the resident's responsibility to discard spoiled or outdated food items; if it is not discarded by the resident, the staff will discard it to prevent foodborne illness. Facility policy titled Date Marking Food dated [DATE] read as follows: Purpose: To provided practical information to implement food code date marking requirements that apply to ready-to-eat, potentially hazardous foods. Date marking is a process assuring the food is discarded before bacteria can cause foodborne illness. Performed By: Food and Nutritional Services Department. - Date marking foods time starts with the day of preparation OR the day the container is opened. - Refrigerated, ready-to-eat, potentially hazardous food prepared and held for more than 24 hours must be marked to indicate the date by which the food must be consumed or discarded within 7 days. The date marked is the last day the product can be consumed safely. - Use manufacturer's expiration date or use-by date, for product with this information. Use date mark system for products after opening, but not to exceed manufacturer's expiration or use-by date. - When foods are mixed together, the date of the oldest food becomes the new date for the mixed food. On [DATE] at 8:32 AM, Surveyor interviewed Dietary Manager (DM)-P. DM-P indicated the facility followed the Wisconsin (WI) Food Code. DM-P indicated each nursing unit in the facility contained a kitchenette of which the housekeeping staff and hospitality aides monitored the refrigerators. In addition, the Food and Nutrition Services staff check the kitchenettes twice a week and restock food/drink items at that time. On [DATE] at 9:33 AM, the Surveyor observed Parkside 1-South Unit. The following was noted: Cupboards: A piece of homemade-type bread in a plastic bag. A patch of mold-like substance was noted to be growing on the bread. No handwritten or manufacturer date labels. An 18 ounce (oz) bag of aged cheddar popcorn, opened with no date label. (Unable to locate manufacturer expiration date on bag). A 9-,d+[DATE] oz bag of Cool Ranch Doritos not opened, with a manufacturer Guaranteed fresh until [DATE]. There was a handwritten resident first name on the bag. A 9-,d+[DATE] oz bag of Nacho Cheese Doritos opened, no open date label, with a resident's first name on the bag. A plastic container of Crystal Light powdered drink packets; 3 of 6 packets remaining. Manufacturer use-by date of [DATE]. A 64 oz bag of popcorn seeds opened. Manufacturer use-by date is [DATE] Refrigerator: A 16 oz container of [NAME] French Onion dip opened, no open date label. A reusable plastic container with what appeared to be leftover beef stroganoff, no labels, no dates on the container. A reusable plastic container with a resident names on it, which appeared to contain leftover chili, no date labels. A reusable container of cheese slices with a resident's name written on it and a date of ,d+[DATE] on it. No manufacturer expiration dates noted as cheese was removed from the original container. A reusable container which had a resident's name on it of strawberries and blueberries with a handwritten date of ,d+[DATE]. No manufacturer dates as food was removed from the original container. A to-go type container with what appeared to have spaghetti and fettuccini - half eaten, with no date labels. A resident first name and room number written on it. On the Island Countertop: Bin 1: Five brown sugar packets .46 oz removed from original bulk container, no manufacturer expiration dates on them. Seven hot chocolate powder packets .73 oz removed from original bulk container, no manufacturer expiration dates on them. Twelve [NAME] tea packets removed from original bulk container, no manufacturer expiration dates on them. Thirty plus sugar and sweetener packets removed from their original bulk container, no manufacturer expiration dates on them. Bin 2 : Nine peanut butter containers ,d+[DATE] oz and 20 jelly packets with no manufacturer expiration dates on them; removed from their original bulk container. Inside the bin was a piece of cardboard which was taped to side of the container which read Regular [DATE] and Diet [DATE] Six dining room tables also contained a turntable in center with brown sugar, peanut butter, jelly, sugars/sweeteners with no manufacturer expiration date labels. Refrigerator #2: A to-go type plastic container with what appeared to be Chicken Alfredo; no date labels or other labels. An open bottle of Italian Dressing labeled [DATE]. (Per facility-provided list of when to discard food, salad dressing is to be discarded 3 months after opening.) A store-bought 36 oz cheese cake (half gone), no date labels, with a resident first name and room number written on container. Surveyor noted a sign on the outside of the refrigerator which read: Reminder - label all food items. On [DATE] at 12:10 PM, Surveyor interviewed Director of Food and Nutritional Services (FNS)-O. FNS-O indicated the Food and Nutrition Services staff monitor and restock the food pantries on Monday and Thursday for the unit kitchenettes. FNS-O indicated that nursing staff and Food and Nutrition Services staff share the responsibility of monitoring the kitchenettes. FNS-O explained the night shift Certified Nursing Assistants (CNAs) are responsible for cleaning out the refrigerators each night. FNS-O confirmed CNAs are also responsible for cleaning out the cupboards of expired food items or unlabeled foods. FNS-O explained that personal food items must have resident name and room number on the item/container. FNS-O confirmed open dating is required as well. Food/drink item that are not dated or expired items should be thrown out per FNS-O; explaining that homemade type foods should be discarded after three days. On [DATE] at 12:24 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated not being sure if it is CNAs who are to monitor the kitchenettes for unlabeled/expired foods. DON-B indicated, it was the CNAs in the past, but not sure if they still do this; it (the process) may have transitioned since COVID. On [DATE] at 7:56 AM, Surveyor returned to Parkside 1-South Unit All of the items noted above, still remained except the Beef Stroganoff. The above listed items, still were without date labels. The Cool Ranch Doritos were noted to now be past their manufacturer use-by date. On [DATE] at 8:06 AM, Surveyor observed the kitchenette on Lakeside 100 unit and noted the following: Refrigerator #6: An 8 oz opened bag of shredded mozzarella cheese, no open date. A 12.25 oz jar of butterscotch-flavored topping. No open date. A resident name was written on the jar. Two boxes with spouts which were opened of liquid coffee. No open date. Refrigerator #1: A 24 oz sugar-free syrup, opened with a handwritten label of [DATE] (date has not occurred yet). Cupboards: A honeybun packaged roll, hardened, removed from original container. No manufacturer expiration dates. A box of snack bars with 4 bars left labeled with a resident name and room number with a hand written date of ,d+[DATE]; manufacturer expiration date of [DATE]. A box of honey buns with no manufacturer expiration date, 4 of 16 left. Hand-written label says [DATE] with a resident name written on the box. The box appears to have come from a bulk packaged box. One soft baked fruit bar with a manufacturer sell-by date of [DATE]. One individual apple Nutrigrain bar with no manufacturer expiration date on it nor handwritten dates. Two .73 oz packets of hot chocolate. No manufacturer expiration dates. No written labels/dates. A bag with powdered sugar in it; manufacturer best-by date of [DATE] and a handwritten date of [DATE]. On countertop: A 15 oz hazelnut coffee creamer (powdered) with a resident name on it, no open date. A 15 oz Coffee Mate opened; no date labels. A 1 oz bag of animal crackers, no date labels. A shaker of Cinnamon and sugar mix with hand-written label of [DATE]. Not in original container; therefore, no manufacturer expiration dates. Five .73 oz packets of hot chocolate, no manufacturer expiration dates. No written date labels. On [DATE] at 8:33 AM, Surveyor interviewed Unit Nurse Supervisor (NS)-H. NS-H indicated it is ultimately the Food and Nutrition Services staff's responsibility to get rid of unlabeled and expired food from the refrigerator and cupboards. NS-H indicated that night shift CNAs may also go through them (cupboards/refrigerator). On [DATE] at 12:45 PM, Surveyor interviewed DON-B and Nursing Home Administrator (NHA)-A. DON-B indicated it is a joint effort to clean the kitchenette of unlabeled/expired foods. NHA-A confirmed date labeling is the responsibility of whoever opens the food item. On [DATE] at 12:55 PM, Surveyor again observed Parkside Unit 1 refrigerator; the items noted above remained, with no date labels. The moldy bread in cupboard was now gone.

Based on observation, record review and interview, the facility did not ensure medication was administered by competent licensed staff for 1 Resident (R) (R85) of 5 residents observed during medication administration. Certified Nursing Assistant (CNA)-D consistently administered topical medication to R85. Findings include: On 2/9/22, Surveyor reviewed R85's medical record. R85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R85's Minimum Data Set (MDS) assessment dated [DATE] stated R85's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R85 had no cognitive impairment. On 2/9/22 at 8:05 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare medications to be administered to R85. Prior to preparation of R85's oral medications, CNA-D was observed giving LPN-E a tube of [MEDICATION(S)] (medication used to treat pain locally by topical application on skin). CNA-D stated to LPN-E, [R85] likes it ([MEDICATION(S)]) on every morning. On 2/9/22 at 8:12 AM, Surveyor observed LPN-E administer [MEDICATION(S)] to R85. During application of [MEDICATION(S)], CNA-D was instructing LPN-E on where to apply the [MEDICATION(S)] which included R85's left shoulder and left hip areas. During application of [MEDICATION(S)], R85 indicated how much R85 liked CNA-D and that CNA-D was the staff that usually administered [MEDICATION(S)] to R85's shoulder and hip. On 2/9/22 at 8:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Infection Preventionist (IP)-C. When questioned if facility allowed CNAs to administer topical medications, IP-C stated, They (CNAs) should not be (applying medication topically). NHA-A and IP-C verified CNA-D was not a Certified Medication Aide. On 2/9/22 at 9:13 AM, Surveyor interviewed CNA-D who, when questioned if CNA-D applied [MEDICATION(S)] to R85 on a regular basis, stated, I do put it ([MEDICATION(S)]) on (R85) every time I work. CNA-D indicated CNA-D worked full-time Monday through Friday each week as a Restorative Aide for several months. CNA-D indicated CNA-D walked with R85 twice daily, once in the morning and once in the afternoon. CNA-D indicated CNA-D always applied [MEDICATION(S)] to R85's shoulder and hip prior to R85's morning walk. CNA-D indicated CNA-D watched a Registered Nurse apply R85's [MEDICATION(S)] once and has been administering [MEDICATION(S)] to R85 ever since. CNA-D could not recall when that observation occurred. CNA-D verified CNA-D received no paperwork from facility regarding education of [MEDICATION(S)] application.

Based on observation, record review and interview, the facility did not ensure resident medical records contained accurate and complete documentation for 1 Resident (R) (R85) of 5 residents observed during medication administration. Certified Nursing Assistant (CNA)-D consistently administered topical medication to R85. Doses administered by CNA-D were not consistently included in R85's medical record. Findings include: On 2/9/22, Surveyor reviewed R85's medical record. R85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R85's Minimum Data Set (MDS) assessment dated [DATE] stated R85's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated R85 had no cognitive impairment. On 2/9/22 at 8:05 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare medications to be administered to R85. Prior to preparation of R85's oral medications, CNA-D was observed giving LPN-E a tube of [MEDICATION(S)] (medication used to treat pain locally by topical application on skin). CNA-D stated to LPN-E, [R85] likes it ([MEDICATION(S)]) on every morning. On 2/9/22 at 8:12 AM, Surveyor observed LPN-E administer [MEDICATION(S)] to R85. During application of [MEDICATION(S)], CNA-D was instructing LPN-E on where to apply the [MEDICATION(S)] which included R85's left shoulder and left hip areas. During application of [MEDICATION(S)], R85 indicated how much R85 liked CNA-D and that CNA-D was the staff that usually administered [MEDICATION(S)] to R85's shoulder and hip. On 2/9/22 at 8:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Infection Preventionist (IP)-C. When questioned if facility allowed CNAs to administer topical medications, IP-C stated, They (CNAs) should not be (applying medication topically). NHA-A and IP-C verified CNA-D was not a Certified Medication Aide. On 2/9/22 at 9:13 AM, Surveyor interviewed CNA-D who, when questioned if CNA-D applied [MEDICATION(S)] to R85 on a regular basis, stated, I do put it ([MEDICATION(S)]) on (R85) every time I work. CNA-D indicated CNA-D worked full-time Monday through Friday each week as a Restorative Aide for several months. CNA-D indicated CNA-D walked with R85 twice daily, once in the morning and once in the afternoon. CNA-D indicated CNA-D always applied [MEDICATION(S)] to R85's shoulder and hip prior to R85's morning walk. CNA-D indicated CNA-D watched a Registered Nurse apply R85's [MEDICATION(S)] once and has been administering [MEDICATION(S)] to R85 ever since. CNA-D could not recall when that observation occurred. CNA-D verified CNA-D received no paperwork from facility regarding education of [MEDICATION(S)] application. 2/9/22 at 11:28 AM, Surveyor reviewed R85's Treatment Administration Record (TAR) for the months of January 2022 and February 2022 which contained the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ ([MEDICATION(S)]) [MEDICATION(S)] Sodium 1% (percent) Gel topical apply to affected area (s) as needed q.i.d. (four times daily) . for Pain . R85's TAR indicated R85 received [MEDICATION(S)] one to two times most days. Documentation of Monday through Friday morning administration was missing on the following dates: 1/3,1/4, 1/5, 1/6, 1/10, 1/11, 1/12, 1/13, 1/20, 1/24, 1/25, 1/27, 2/4, 2/7 and 2/8. On 2/9/22 at 1:21 PM, Surveyor interviewed NHA-A who verified all medication doses should be documented. NHA-A verified R85's TAR indicated missing dose documentation for [MEDICATION(S)] administered by CNA-D.

Based on record review and staff interview, the facility did not consult with the resident's physician when there was a significant change in the resident's physical and/or mental status, or when there was a need to alter treatment significantly in 1 Resident (R) (R1) of 3 sampled residents reviewed for notification to the physician. The facility did not contact R1's physician when R1 had a change of condition with increased anxiety/restlessness, when R1 would not keep R1's [CONDITION(S)] (continuous positive airway pressure) mask on, and when R1's O2 (oxygen) sats (saturation) level (amount of oxygen in blood) dropped to 50 to 54 percent. R1 passed away at the facility. Findings include: The facility notification of change in condition policy, dated August 2017, indicated the resident's physician will be notified promptly of any significant accident, injury, or adverse change in resident's condition. The facility will immediately consult with the resident's physician when there is a significant change in the resident's physical, mental or psychosocial status such as a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications to include recurrent periods of [CONDITION(S)], or when there is a need to alter treatment significantly. The need to alter treatment significantly means a need to stop a form of treatment because of adverse events or commence a new form of treatment to deal with a problem. In the case of a competent individual, the facility must still contact the resident's physician. 1. On 1/24/22, the Surveyor reviewed the closed medical record of R1. R1 was admitted to the facility in November of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was DNR (do not resuscitate). R1's admission MDS (Minimum Data Set), dated 11/12/21, indicated R1's cognition was 15 out of 15 (the higher the score, the more cognizant). R1 did not have any mental status changes, R1 had shortness of breath with exertion and when lying flat, R1 had oxygen therapy and used [CONDITION(S)] while a resident. R1 required extensive assistance of two plus staff for bed mobility, transfer and locomotion. R1 did not ambulate. R1's plan of care with a date of 11/18/21, indicated R1 used oxygen when wearing [CONDITION(S)] at night because R1 liked not to be SOB (short of breath) because R1 had [CONDITION(S)] and CHF. The approaches, dated 11/18/21, indicated R1's vital signs were to be monitored, lab results reviewed, oxygen provided as needed, apply [CONDITION(S)] as ordered with oxygen, report any shortness of breath, report any confusion/behaviors, and update my physician with any changes or concerns. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2 L (liters) on at HS (at bedtime) and off in AM (before midday). Another physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 10:15 AM, the facility sent a notification to P (Psychiatrist)-H regarding R1. The notification indicated R1 was started on [MEDICATION(S)] 1 mg BID on 1/6/22. R1 was noted to be delirious and with increased fatigue on 1/10/22. R1's [MEDICATION(S)] was held on 1/11/22 in the AM and PM. R1's progress note with a date of 1/11/22 at 1:30 PM, indicated R1 had increased lethargy yesterday and today. R1 was also experiencing low O2 sats this morning and O2 was applied. R1 was evaluated by APNP (Advanced Practice Nurse Prescriber)-G and [MEDICATION(S)] was held. R1 remains tired this afternoon. R1 expressed feeling confused and stated I'm lost. On 1/11/22, R1 was seen by APNP-G for a compliance visit. Per the note from APNP-G, R1 was doing well until this morning. R1 was noted to be confused, hallucinating and extremely tired. R1 stated I feel off but could not elaborate. Due to fatigue, APNP-G was unable to understand R1. APNP-G documented the assessment and plan was lethargy, etiology unknown. New medication changes included the addition of [MEDICATION(S)] and scheduled [MEDICATION(S)]. Poor oral intake yesterday. Concentrated urine this morning. Likely dehydrated. Hold [MEDICATION(S)] this morning due to lethargy. Will order labs. R1 doesn't look like active heart failure. R1's progress note with a date of 1/11/22 at 1:47 PM, indicated new orders were received and noted to complete a CBC (complete blood count) with diff, CMP (comprehensive metabolic panel) and BNP (brain natriuretic peptide) to be completed 1/12/22. R1's emergency contact was notified of R1's pending lab orders and of R1 being more sleepy. On 1/11/22 at 10:28 PM, CNA (Certified Nursing Assistant)-D documented R1 was having restless, fidgety and anxious physical movements times nine (9). R1 was reassured, redirected and reoriented. The outcome was unchanged. On 1/11/22 at 10:30 PM, CNA-D documented R1 was screaming at staff times two (2). Screaming/disruptive sounds times 10. Redirected, reassured and reoriented. R1 was yelling out loud disturbing others. The outcome was unchanged. On 1/12/22 at 1:34 AM, RN (Registered Nurse)-E documented upon assessment, R1 was not currently exhibiting any respiratory signs or symptoms or respiratory complications. At 1:37 AM, RN-E documented R1's O2 saturation was 90 percent on O2: 2L [CONDITION(S)]. On 1/12/22 at 2:47 AM, RN-E documented upon assessment, R1 was not currently exhibiting any respiratory sings or symptoms or respiratory complications. At 2:50 AM, RN-E documented R1's O2 saturation was 91 percent on O2: 2L [CONDITION(S)]. On 1/12/22 at 3:39 AM, CNA-C documented R1 had four (4) hours of sleep. On 1/12/22 at 3:41 AM, CNA-C documented R1 was having restless, fidgety and anxious physical movements 10 plus times. R1 was having trouble falling, staying, or sleeping 10 plus times. R1 was having trouble concentrating on things 10 plus times. R1's position was changed, R1 was reassured, redirected, reoriented, provided with a 1:1 talk, and toileted. The information was reported to the nurse. The outcome was worsened. On 1/12/22 at 3:50 AM, CNA-C documented R1 was screaming disruptive sounds not directed towards others 20 plus times. R1 was having delusions (misconceptions or beliefs that are firmly held, contrary to reality) 20 plus times and R1 was having hallucinations (perceptions of the presence of something that is not actually there, auditory/visual) 20 plus times. R1's position was changed, R1 was toileted, R1 was reoriented, redirected and reassured. Additionally, R1 was provided with a 1:1 talk, offered a snack and offered fluids. The information was reported to the nurse. The outcome was unchanged. On 1/12/22 at 4:20 AM, RN-E documented R1 had a short-term care plan for increased anxiety, R1 slept and had no behavior issues. Will continue to observe and assess. On 1/12/22 at 5:30 AM, RN-E documented R1 did not have a blood pressure, respiratory rate or apical pulse. At 5:32 AM, RN-E placed a call to the physician on call. On 1/12/22 at 7:51 AM, RNSS (Registered Nurse Shift Supervisor)-F documented RNSS-F went in R1's room around 5:15 AM to complete R1s lab draw. R1's face was gray in color. Extremities were warm and skin was clammy. R1 was not breathing. R1 had white foam surrounding R1's lips and mouth. On 1/24/22 at 11:55 AM, the Surveyor interviewed RNSS-F via telephone regarding R1. RNSS-F verified RNSS-F went in R1's room at approximately 5:10 AM to 5:15 AM and realized R1 had passed away. R1's [CONDITION(S)] mask was on and was connected to O2. RNSS-F stated RN-E on the night shift on 1/11/22 and 1/12/22, RN-E had reported R1 slept and did not have any behaviors. CNA-C and CNA-D reported behaviors of being awake all night, crying out, and trying to get out of bed. The one time the CNAs called for RN-E to assess R1's change of condition, RN-E was in RNSS-F's office. With so many differences in charting, RNSS-F didn't feel RN-E completed a change of condition assessment for R1 when needed. RNSS-F started an investigation. At the start of the shift, RN-E should have completed a full set of vitals on R1. At 2:00 AM to 2:30 AM, CNA-C and CNA-D took R1's O2 sats and the percent was 50 something. RN-E stated it was not a correct reading. RNSS-F then stated R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-E could have called the physician to see if the [MEDICATION(S)] would help. R1 suffered the last few hours of the night. Had maybe four (4) hours of sleep all night. The [MEDICATION(S)] could have calmed R1. On 1/24/22 at 12:23 PM, the Surveyor interviewed RN-E via telephone. RN-E stated R1's death was unexpected. RN-E stated R1 was assessed at the beginning of the shift. Near the beginning of the shift, R1 rolled on right side while in bed and legs were between the bed and wall. The CNAs sent a text to RN-E because RN-E was on the other unit. It took CNA-C, CNA-D and RN-E to put R1's legs back in bed. RN-E checked on R1 again at approximately 2:30 AM to 2:45 AM, RN-E completed an assessment on R1 and R1 had no issues after CNA-C advised RN-E of getting an odd reading when O2 sats were completed for R1. RN-E stated if the batteries were dying on the O2 meter, you would get a low reading. RN-E indicated RN-E did not remember the percent CNA-C got when taking R1's O2 sats, but after changing the battery, RN-E got a reading of 91 percent. RN-E stated RN-E did not observe R1 having any anxiety. On 1/24/22 at 2:00 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding the investigation for R1. NHA-A stated RN-E had conflicting charting. R1 was restless all night and R1's [CONDITION(S)] was not on. RN-E did not notify RNSS-F with R1's change of condition when R1 was trying to get out of bed. Maybe R1 was restless, maybe not. Probably was restless. On 1/24/22 at 2:51 PM, the Surveyor interviewed NHA-A regarding R1. NHA-A stated RN-E did not report R1's change in condition to RNSS-F per facility policy. Additionally, NHA-A stated the CNAs would not have reported R1's restlessness if it didn't occur. On 1/25/22 at 9:17 AM, the Surveyor interviewed APNP-G regarding R1. APNP-G stated the order was to hold [MEDICATION(S)] on the morning of 1/11/22. R1 did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I only held the morning dose because (R1) was so lethargic. I wondered if (R1) was dying because of (R1's) presentation. (R1) was usually worse with yelling out and anxious in the PMs to nights. Definitely would have increased the [MEDICATION(S)] ([MEDICATION(S)]) to every two (2) hours if I had known he was restless/anxious again and ordered [MEDICATION(S)] to help with breathing. Wish I had been notified to increase (the [MEDICATION(S)]) but (R1) still had the orders they could have used. On 1/25/22 at 6:01 PM, the Surveyor interviewed CNA-D via telephone. CNA-D stated the PM shift reported R1 was yelling out hello, hello. At the beginning of the shift, R1 was trying to climb out of bed by the window. Reported to RN-E to get help. Around 2:30 PM, CNA-C and CNA-D reported the low O2 saturation to RN-E. RN-E stated the other meter wasn't working and RN-E was able to have R1 complete deep breathing to get R1's O2 sats to a normal range. On 1/26/22 at 10:03 AM, the Surveyor interviewed CNA-C via telephone. CNA-C verified CNA-C was R1's primary CNA on 1/11/22 and 1/12/22 night shift. CNA-C stated R1 was very restless and anxious starting at 10:30 PM. At one point, R1 tried crawling out of bed. RN-E came to assist put R1 back in bed. R1 was taking off the [CONDITION(S)] mask. R1 was very uncomfortable, thrashing around and distraught. CNA-C elevated the head of the bed to help with R1's breathing. RN-E was made aware of the concerns. At approximately 2:00 AM to 2:30 AM, CNA-C texted RN-E that R1's O2 sats were not good ranging from approximately 52 percent to 62 percent and asked RN-E if CNA-C should put the [CONDITION(S)] mask back on because R1 kept removing it or if could leave it off and just use oxygen. RN-E stated the [CONDITION(S)] had to be on. R1's back of the head was soaked. R1 felt warm, not clammy. Looked ashy in color. CNA-C took R1's temperature. R1 did not have a fever. CNA-C texted RN-E again to advise RN-E something was not right with R1 and R1 would need to be assessed. RN-E stated RN-E would be back on the unit from another unit in a few minutes. RN-E did not go by R1 right away and commented RN-E found an order to bump up R1's oxygen to 4L. RN-E bumped up the oxygen, then dropped the oxygen to 2L after getting R1's O2 sats up to like 92 percent. RN-E did not go back in R1's room. CNA-C had another resident across the hall from R1 that needed to be checked on every 15 minutes so CNA-C would check on R1 at the same time. Finally, at approximately 4:30 AM, R1 wasn't restless trying to remove the [CONDITION(S)] mask and only moaned. At 4:45 AM, R1's chest was rising when checked on. CNA-C was advised R1 had passed away by RN-E and RNSS-F. CNA-C was asked to write a statement and stated R1's change of condition was not reported to RNSS-F as required per facility policy. The comprehensive incident investigation verified the statements made by CNA-C, CNA-D and RNSS-F. The investigation indicated RN-E was in RNSS-F's office when RN-E was notified via text 911 to R1's room. RN-E did not report anything abnormal to RNSS-F so RNSS-F assumed R1 was fine. RNSS-F checked RN-E's charting to find R1's vitals were within normal limits and no behaviors were charted. RN-E was interviewed twice during the investigation. Due to a comprehensive chart review and further investigation, the facility believes it is likely that R1 was restless and may have had a decrease in O2 saturation during the night shift on 1/11/22 and 1/12/22. Despite RN-E reporting R1's vitals and behavior were within normal limits throughout the shift, the facility believes that was not assessed, charted, or reported to RNSS-F per policy by RN-E.

Based on record review and staff interview, the facility did not ensure all alleged violations involving allegations of abuse/neglect were thoroughly investigated involving 1 Resident (R) (R1) of 3 sampled residents. CNAs (Certified Nursing Assistants) reported a change of condition to an RN (Registered Nurse). The RN did not report the change of condition to the RN supervisor or R1's physician. R1 passed away. The facility did not conduct a thorough investigation of the allegation of possible abuse/neglect when the facility did not interview other residents and did not educate nurses on reporting change of condition to the RN supervisor and physician. Findings include: The facility policy entitled Resident Condition Report Procedure with a date of 7/2/15, indicated the Resident Condition Report provides daily twenty-four hour written communication of acute resident concerns and significant changes to specified individuals of the interdepartmental team such as the NHA (Nursing Home Administrator) and RNSS (Registered Nurse Shift Supervisor). Staff nurses will assess acute resident conditions and concerns on the neighborhoods and verbalize acute resident conditions and neighborhood concerns to the RNSS in a prompt manner. The facility policy entitled Abuse, Neglect, Exploitation and misappropriation of Resident Property with a date of June 2017, indicated each resident will be free from abuse/neglect. It is the policy of the facility that reports of abuse/neglect are promptly and thoroughly investigated. Staff should report all concerns immediately to the RNSS. The RNSS will complete an incident report. Interview residents involved and residents who could have been affected immediately to determine any injury or psychosocial harm. Employees accused of alleged abuse/neglect will be immediately removed from the facility and will remain removed pending the results of a thorough investigation. 1. On 1/24/22, the Surveyor reviewed the facility comprehensive incident investigation regarding R1. The date of incident was documented as 1/12/22. The report indicated RNSS (Registered Nurse Shift Supervisor)-F went into R1's room at 5:10 AM on 1/12/22 to draw R1's ordered lab work. RNSS-F found R1 gray in color and with white foam around lips/mouth. A sternal rub was completed with no response. Heart and lung sounds were assessed to find absence of sounds. R1 had no pulse or blood pressure. An investigation was initiated because of the conflicting reports and documentation from the CNAs and the RN. CNA-C and CNA-D reported R1 was restless, trying to get out of bed and calling out all shift, which was a change of condition from being lethargic. RN-E reported R1 slept and had no behavioral concerns throughout the night. Additionally, the CNAs reported a low oxygen saturation of 50 to 54 percent and would not leave [CONDITION(S)] (continuous positive airway pressure) mask with oxygen on. RN-E reported oxygen saturations in the 90 percent range. The summary of findings indicated, after a comprehensive chart review and further investigation, the facility believes it is likely that R1 was restless and may have had a decrease in oxygen saturation during the night shift on 1/11/22 to 1/12/22. RN-E was immediately suspended pending investigation. Despite RN-E reporting R1's vitals and behavior were within normal limits throughout the shift, the facility believes that was not properly assessed, charted or reported to RNSS-F per policy by RN-E. The self-report did not include documentation that the incident had been thoroughly investigated, as other residents were not interviewed or assessed to determine if nurses assessed and reported when a resident would have a change of condition according to standards of practice. Additionally, nurses were not educated on notifying the RN supervisor or physician when a resident had a change of condition. On 1/24/22 at 11:56 AM, the Surveyor interviewed RNSS-F via telephone. RNSS-F verified the above statements made on the comprehensive incident investigation. RNSS-F stated it was felt RN-E had not completed a change of condition assessment. Neglectful. RNSS-F verified RNSS-F did not interview any other residents about change of condition or abuse/neglect, and did not provide education to any nurses regarding abuse/neglect/ reporting change of condition to the RN supervisor or the physician. On 1/24/22 at 4:05 PM, the Surveyor interviewed NHA (Nursing Home Administrator)-A regarding interviewing other residents about a change of condition assessment or abuse/neglect to determine if the nurses assessed any changes of condition properly. Additionally, NHA was asked if the nurses were educated regarding facility policy related to change of condition notification to RN supervisor and physician, and regarding abuse/neglect. NHA-A stated other residents were not interviewed and staff were not educated on notifying the RN supervisor or physician with a change of condition in a resident because there was nothing concerning with other nurses so the only nurse to be educated will be (RN-E) when/if (RN-E) returns to employment.

Based on record review and staff interview, the facility did not ensure all allegations of abuse/neglect were reported to the State Survey and Certification Agency for 1 Resident (R) (R1) of 3 residents reviewed for abuse/neglect allegations. CNAs (Certified Nursing Assistants) reported a change of condition to an RN (Registered Nurse). The RN did not report the change of condition to the RN supervisor or R1's physician. R1 passed away. The allegation of potential abuse/neglect was not reported to the State Agency. Findings include: The facility policy entitled Resident Condition Report Procedure with a date of 7/2/15, indicated the Resident Condition Report provides daily twenty-four hour written communication of acute resident concerns and significant changes to specified individuals of the interdepartmental team such as the NHA (Nursing Home Administrator) and RNSS (Registered Nurse Shift Supervisor). Staff nurses will assess acute resident conditions and concerns on the neighborhoods and verbalize acute resident conditions and neighborhood concerns to the RNSS in a prompt manner. The facility policy entitled Abuse, Neglect, Exploitation and misappropriation of Resident Property with a date of June 2017, indicated each resident will be free from abuse/neglect. Once the facility administration becomes aware of any alleged violations that are considered reportable, the facility will make an initial report immediately or within the allotted time frames (24 hours) to the designated State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days of the incident or the date the facility became aware of the incident. 1. On 1/24/22, the Surveyor reviewed the closed medical record of R1. R1 was admitted to the facility in November of 2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was DNR (do not resuscitate). R1's admission MDS (Minimum Data Set), dated 11/12/21, indicated R1's cognition was 15 out of 15 (the higher the score, the more cognizant). R1 did not have any mental status changes, R1 had shortness of breath with exertion and when lying flat, R1 had oxygen therapy and used [CONDITION(S)] (continuous positive airway pressure) while a resident. R1 required extensive assistance of two plus staff for bed mobility, transfer and locomotion. R1 did not ambulate. On 1/24/22, the Surveyor reviewed the facility comprehensive incident investigation regarding R1. The date of incident was documented as 1/12/22. The report indicated RNSS-F went into R1's room at 5:10 AM on 1/12/22 to draw R1's ordered lab work. RNSS-F found R1 gray in color and with white foam around lips/mouth. A sternal rub was completed with no response. Heart and lung sounds were assessed to find absence of sounds. R1 had no pulse or blood pressure. An investigation was initiated because of the conflicting reports and documentation from the CNAs and the RN. CNA-C and CNA-D reported R1 was restless, trying to get out of bed and calling out all shift, which was a change of condition from being lethargic. RN-E reported R1 slept and had no behavioral concerns throughout the night. Additionally, the CNAs reported a low oxygen saturation of 50 to 54 percent and would not leave [CONDITION(S)] mask with oxygen on. RN-E reported oxygen saturations in the 90 percent range. The summary of findings indicated, after a comprehensive chart review and further investigation, the facility believes it is likely that R1 was restless and may have had a decrease in oxygen saturation during the night shift on 1/11/22 to 1/12/22. RN-E was immediately suspended pending investigation. Despite RN-E reporting R1's vitals and behavior were within normal limits throughout the shift, the facility believes that was not properly assessed, charted or reported to RNSS-F per policy by RN-E. On 1/24/22 at 11:56 AM, the Surveyor interviewed RNSS-F via telephone. RNSS-F verified the above statements made on the comprehensive incident investigation. RNSS-F stated it was felt RN-E had not completed a change of condition assessment. RN-E could have called R1's physician to ask if [MEDICATION(S)] (anti-anxiety) would help as R1 had an order to be given as needed or to see if R1 should be sent to the ED (emergency department). R1 suffered the last few hours of the night. Could have calmed R1. Neglectful. On 1/24/22 at 2:51 PM, the Surveyor interviewed NHA-A regarding reporting allegations of abuse/neglect. NHA-A stated RN-E did not report R1's change of condition to RNSS-F per policy. The CNAs wouldn't have reported the restlessness if it didn't occur. On 1/24/22 at 4:25 PM, the Surveyor interviewed NHA-A regarding reporting allegations of abuse/neglect. NHA-A verified the allegation of abuse/neglect made by other staff regarding RN-E not assessing R1's change of condition was not reported to the State Agency within 24 hours and a follow up investigation was not submitted to the State Agency within five days because RN-E denied the allegations made by the CNAs. NHA-A then stated NHA-A didn't feel neglect because (RN-E) denied the allegations about R1.

Based on observations, record review, and interviews, the facility did not ensure staff wore appropriate Personal Protective Equipment (PPE), utilized appropriate PPE removal techniques, or performed appropriate hand hygiene for 1 Resident (R) (R1) who was under contact and droplet precautions. These practices had the potential to affect all 12 residents on R1's unit at the facility. Hospitality Aide (HA)-D did not wear appropriate PPE while attending to R1's needs on 11/29/21. CNA (Certified Nursing Assistant)-E did not utilize appropriate PPE removal and did not perform appropriate hand hygiene following removal of PPE after attending to R1's needs on 11/29/21. Registered Nurse (RN)-F did not utilize appropriate PPE removal and did not perform appropriate hand hygiene following removal of PPE after attending to R1's needs on 11/29/21. Findings include: Facility provided policy titled Covid-19 . (a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) Policy and Procedure dated 11/21 (November 2021) stated, Purpose: To implement infection control and prevention practices to prevent and control the transmission of Covid-19, regardless of vaccination status or level of vaccination coverage in the facility . Required PPE for 14-day monitoring of residents newly admitted , returning from a hospital stay, acute signs of respiratory illness or sustained direct contact with confirmed case . Staff caring for these residents should wear the following when caring for these residents: N95 Mask, eye protection, gown and gloves . On 11/29/21, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's medical record contained nursing progress notes including the following: ~ 11/19/21: .cough: occasional nonproductive, and occasional tracheal congestion that is cleared by coughing . ~ 11/29/21: 14 day Covid monitoring, Altered Lung Sounds . Lung Sounds: upon auscultation all lobes are clear upper and lower, however the left lower base is a little diminished, Tracheal congestion present, Isolation precautions: Airborne precautions . CXR (chest xray) scheduled for tomorrow . On 11/29/21 at 8:47 AM, Surveyor observed signs by R1's room door which indicated R1 was on Covid-19 monitoring precautions, what PPE to wear which included gown, gloves, eye protection and N95 respirator mask, and how to put on/take off PPE. Surveyor observed three plastic 3-drawer storage units and one storage cart on wheels outside R1's room which contained PPE. The drawers of the 3-drawer storage units were clear (see-through). Some of these drawers were observed to be empty. Surveyor observed staff wearing surgical masks and eye protection throughout the unit. On 11/29/21 at 9:13 AM, Surveyor observed R1's call light indicator was activated. On 11/29/21 at 9:17 AM, Surveyor heard coughing coming from R1's room. On 11/29/21 at 9:20 AM, Surveyor observed HA-D enter R1's room wearing the same surgical mask and eye protection HA-D wore throughout the unit and without changing to appropriate PPE as indicated on the sign by R1's room door. HA-D was observed to pick up R1's used meal tray and place the used meal tray on a cart in the hall outside R1's room. HA-D was observed reentering R1's room, wash off R1's over-bed table and reposition R1's over-bed table closer to R1. HA-D was then observed performing hand hygiene as HA-D exited R1's room. On 11/29/21 at 9:22AM, Surveyor interviewed HA-D who, when questioned what PPE HA-D was supposed to wear to enter R1's room, stated, Supposed to use a gown and I didn't. When questioned if there was any other PPE HA-D was to use, HA-D indicated gloves should have also been worn. When questioned again if there was any other PPE HA-D was to use, HA-D stated, Don't think I needed foot protectors. On 11/29/21 at 9:23AM, Surveyor observed CNA-E enter R1's room. Prior to entry, CNA-E put on a gown, replaced CNA-E's surgical mask with an N-95 respirator mask and put on gloves. CNA-E wore the same eye protection CNA-E had worn throughout the unit. CNA-E was heard asking R1 what R1 needed and R1 was heard to indicate R1 needed to use the toilet. On 11/29/21 at 9:27 AM, Surveyor observed CNA-E exit R1's room. CNA-E's gown and gloves had already been removed inside R1's room. CNA-E was wearing CNA-E's N-95 respirator mask and the same eye protection worn throughout the unit. CNA-E was observed to pick a glove off the hall floor, walk down the hall (passing behind R2 who was sitting at a table eating in the dining area), place the glove from the floor in a garbage container, then walk into the attached kitchenette and wash CNA-E's hands. CNA-E was observed to remove CNA-E's N-95 respirator mask (in the center of the hall where the hallway leading to R1's room begins) and without performing hand hygiene, remove a surgical mask from CNA-E's uniform pocket and place that surgical mask on CNA-E's face. CNA-E was observed to place the N-95 respirator mask into a paper bag from the supply cart outside R1's room. On 11/29/21 at 9:29 AM, Surveyor interviewed CNA-E who indicated CNA-E should have taken the N-95 respirator mask off when exiting R1's room. CNA-E verified the surgical mask CNA-E was currently wearing had been placed in CNA-E's pocket by CNA-E and was the same surgical mask CNA-E had worn throughout the unit prior to entering R1's room. CNA-E stated, Supposed to have surgical masks in the carts but there aren't any. CNA-E did not know how long the cart was without surgical masks. On 11/29/21 at 9:34 AM, Surveyor observed RN-F enter R1's room with medications. RN-F put on a gown, replaced RN-F's surgical mask with an N-95 respirator mask and put on gloves. RN-F wore the same eye protection RN-F had worn throughout the unit. Upon entry, RN-F was heard to say to R1, Still got that cough? On 11/29/21 at 9:40 AM, Surveyor observed RN-F exit R1's room. RN-F's gown and gloves had already been removed inside R1's room. RN-F was observed to perform hand hygiene, use sanitizing wipes to sanitize vital sign equipment, and again perform hand hygiene. RN-F opened the top drawer of the wheeled storage cart. Surveyor observed there were surgical masks with ties (not elastic loops) stored in the opened top drawer. RN-F stated, I don't like the tie ones and walked to the nurse station still wearing RN-F's N-95 respirator mask. In the nurse station, RN-F was observed to remove RN-F's N-95 mask and, without performing hand hygiene, apply a new surgical mask (with elastic loops) from a box at nurse station, remove keys from RN-F's pocket, unlock and open medication room door, then perform hand hygiene prior to entering data into computer on medication cart. On 11/29/21 at 9:43 AM, Surveyor interviewed RN-F who verified RN-F should not have worn RN-F's used N-95 respirator mask through the unit outside of R1's room and should have performed hand hygiene after removing N-95 respirator mask before applying clean surgical mask. On 11/29/21 at 10:00AM, Surveyor interviewed Infection Preventionist (IP)-C who indicated R1 was vaccinated against Covid-19 with one-dose vaccine in the hospital on 11/19/21 and was placed on 14-day monitoring upon admission to facility on 11/19/21 for symptom monitoring per facility policy. When questioned what PPE staff should wear when in R1's room, IP-C indicated staff should wear gown, gloves, N-95 respirator mask, and eye protection whenever in R1's room. IP-C indicated staff may wear the same eye protection throughout the unit but should sanitize eye protection upon exiting R1's room. Following discussion of the previously stated Surveyor observations, IP-C verified HA-D should not have entered R1's room without proper PPE. IP-C verified CNA-E should have not stored surgical mask in CNA-E's uniform pocket, should not have worn N-95 respirator mask on unit outside of R1's room and should have performed hand hygiene after removal of N-95 respirator mask. IP-C verified RN-F should not have worn N-95 respirator mask on unit outside of R1's room and should have performed hand hygiene after removal of N-95 respirator mask. IP-C indicated staff were supposed to check isolation supply carts and refill as needed from infection control storage closets located on each unit. On 11/29/21 at 10:55 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated facility was considered to remain in outbreak status due to one staff member who tested positive for [CONDITION(S)]-CoV-2 (the virus that causes Covid-19) on 11/29/21. NHA-A indicated R3 was placed in droplet and contact precautions on 11/29/21 for being exposed (to the staff member who tested positive on 11/29/21) prior to that staff member developing symptoms, being tested and leaving facility. R3 resided on a different unit than R1 and R2. On 11/29/21, Surveyor reviewed facility provided resident vaccination rate of 91% and staff vaccination rate of 70%.

Based on record review and staff interviews, the facility did not ensure adequate monitoring of drug regimens for 2 residents (Resident (R) 6 and R5) of 24 sampled residents. R6 had a physician's orders [REDACTED]. R6's most recent DISCUS (Dyskinesia Identification System: Condensed User Scale) assessment was completed on 8/31/16. R6's [MEDICATION NAME] was discontinued on 10/6/16 and resumed on 1/25/17. A DISCUS assessment was not completed at that time to rule out tardive dyskinesia (TD), a side effect of certain antipsychotic and other medications that includes stiff, jerky uncontrollable movements of the face and body. R5 had a physician's orders [REDACTED]. R5's [MEDICATION NAME] was decreased on 10/07/16 and then increased on 10/19/16. A DISCUS assessment was not completed at that time to rule out TD. Findings: The National Alliance on Mental Illness, in a 2014 web based article, defined TD as one of the most disturbing potential side effects of antipsychotic medications. Tardive (late) Dyskinesia (bad movement) is a movement disorder that occurs over months, years and even decades. TD is a principle concern of first generation antipsychotic medication but has been reported in second generation antipsychotic medication and needs to be monitored for all people who take these medications. Facility policy; Subject: TARDIVE DYSKINESIA MONITORING PROCEDURE, dated 06/21/12 Purpose: To regularly and systematically assess for Tardive Dyskinesia in the resident who is receiving antipsychotic, [MEDICATION NAME]. To monitor those residents who are known to have been previously on these medications. EQUIPMENT REQUIRED: Dyskinesia Identification System Condensed User Scale (DISCUS) in ECS (electronic charting system). 2. RN Neighborhood Nurse is responsible to: a. Admission DISCUS assessment in ECS. b. Upon initiation of order for antipsychotic, [MEDICATION NAME], or [MEDICATION NAME]. c. Every month for three (3) months after discontinuation of medication was used for more than thirty (30) days. 1) If Tardive Dyskinesia present, continue to monitor monthly. 2) If no Tardive Dyskinesia, then in one year. d. Every three (3) months during therapy for [MEDICATION NAME]. e. Every six (6) months during therapy for [MEDICATION NAME] and [MEDICATION NAME]. f. As directed by the pharmacy consultant or physician. 1. On 2/6/17, Surveyor reviewed the medical record of R6. The resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. R6's most recent MDS (Minimum Data Set), dated 12/14/16, documented R5 was severely cognitively impaired, had physical behavior and received over 55% or greater of nutrition via tube feeding. Upon review of R6's medical record, Surveyor observed physician's orders [REDACTED]. Also observed was physician assistant documentation, dated 2/2/17 indicating [MEDICATION NAME] was discontinued September 2016 because of increased risk of tardive dyskinesia and [MEDICATION NAME] was restarted one week ago (1/25/17) related to increased episode of vomiting, agitation and indication of abdominal discomfort. Surveyor observed a DISCUS assessment dated [DATE]. The DISCUS indicated R6 was receiving 15 mg of [MEDICATION NAME] daily. The DISCUS had a total score of 7, a decrease in score of 8 documented on the DISCUS dated 5/25/16. The DISCUS was performed to assess for increased signs and symptoms of tardive dyskinesia. On 2/9/17 at 11:30 a.m., Surveyor interviewed RNMGR (Registered Nurse Manager)-F regarding R6's most recent DISCUS assessment. RNMGR-F indicated a DISCUS should have been completed in January (2017) when R6's [MEDICATION NAME] was restarted. RNMGR-F indicated the DISCUS was completed on 2/7/17 after Surveyor brought the issue to RNMGR-F's attention. 2. On 2/07/17, Surveyor reviewed the medical record of R5. The resident was admitted to the facility with [DIAGNOSES REDACTED]. R5's most recent MDS assessment dated [DATE], documented R5 was cognitively impaired and had delusions, [MEDICAL CONDITION] and behaviors. R5's antipsychotic/anti-anxiety medication plan of care, dated 6/28/16 contained interventions to monitor for drug side effects, update staff psychiatrists with changes in mood and/or behaviors and/or bothersome side effects and administer [MEDICATION NAME] according to written informed consent and monitor for drug side effects. Upon review of R5's medical record, Surveyor observed a physician's orders [REDACTED]. Surveyor observed a DISCUS assessment, dated 6/15/16. The DISCUS indicated R5 was receiving 50 mg of [MEDICATION NAME] daily. The DISCUS had a total score of 1 indicating R5 was not experiencing signs and symptoms of tardive dyskinesia. Upon further review of R5's medical record, Surveyor noted R5's [MEDICATION NAME] was decreased from 25 mg twice daily to 12.5 mg daily on 10/07/16. R5's [MEDICATION NAME] was then increased to 25 mg daily on 10/19/16 after R5 was noted to have increased behaviors and agitation. On 2/07/17 at 3:50 p.m., Surveyor interviewed RNMGR (Registered Nurse Manager)-F regarding R5's most recent DISCUS assessment. RNMGR-F indicated a DISCUS should have been completed in October (2016) when R5's [MEDICATION NAME] was increased. RNMGR-F was unable to locate R5's October 2016 DISCUS or any subsequent DISCUS assessment prior to 2/07/17.

Based on observation, staff interviews and record review, the facility did not operationalize an infection control program under which it prevents infections in accordance with current standards of practice for 4 residents (Resident (R)13, R25, R26 and R6) of 20 resident observations for which hand hygiene was indicated. Staff did not appropriately cleanse hands during the provision of catheter care for R13. RN (Registered Nurse)-C did not wash/sanitize hand after administration of medications and eye drops to R25 and before assisting R26 with discontinuing nebulizer treatment. RN-D did not appropriately sanitize prior to entering R6's room and after discontinuing R6's nebulizer treatment. Findings include: The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the Centers for Disease Control and Prevention entitled, Guideline for Hand Hygiene in Health Care Settings indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. The facility's policy HAND HYGIENE PROCEDURE FOR EMPLOYEE, dated 11/09/11, indicated PURPOSE: To reduce the transmission of pathogenic microorganism to residents and staff in health care settings. INDICATIONS FOR HAND WASHING AND HAND ANTISEPSIS: A. When hands are visibly dirty or contaminated use soap and water. B. Hands not visibly soiled, you may use an alcohol-based hand rub for routinely cleaning of hands in all other clinical situations. It is recommended to wash hands with soap and water after 8-10 application of gel. C. Wash hands before and after having direct contact with patients. D. Wash hands before applying gloves and after removing gloves . The facility's 5/7/12 policy, INDWELLING CATHETER CARE, listed PROCEDURE: 1. Wash hands before and after handling indwelling catheter, tubing, drainage bags and leg bags. 1. Surveyor reviewed R13's medical record from 2/6-2/9/17. The [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment, dated 12/7/16 indicated R13 had a BIMS (Brief Interview for Mental Status) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS further indicated R13 and was dependent upon staff for total assistance with bed mobility, toileting and hygiene. On 2/7/17, at 1:15 p.m., Surveyor observed CNA (Certified Nursing Assistant)-A provide catheter care for R13. After emptying the resident's urinary catheter leg bag, CNA-A removed gloves and washed hands. CNA-A then manipulated the resident's catheter bag with bare hands, adjusting the cap on the drain port and secured the drainage bag to R13's leg. With the same soiled hands, CNA-A touched the resident's face, clothing, brief, pillows, bedding, call light and bed control before washing hands. On 2/7/17, at 1:20 p.m., Surveyor interviewed CNA-A, who confirmed the above observations and verified hands should have been washed after touching the resident's catheter bag. On 2/7/17, at 1:35 p.m., Surveyor interviewed RN (Registered Nurse)-B who confirmed staff are expected to wash hands after manipulating a catheter bag and before touching other items in the room. 2. On 2/6/17 at 4:35 p.m., Surveyor observed RN-C administer medication and eye drops for R25. RN-C administered medications without concern. After administration of eye drops, RN-C removed gloves and, without sanitizing/washing hands, entered R26's room. RN-C then put on gloves without washing/sanitizing hands, turned off the nebulizer (breathing treatment), rinsed nebulizer equipment and placed it on a towel. RN-C then removed gloves, left R26's returned to medication cart, took R25's eye drops out of their pocket and put the eye drops back into the medication cart drawer before sanitizing hands. Immediately following the above observation Surveyor interviewed RN-C regarding hand hygiene. RN-C verified not washing/sanitizing hand after removing gloves, between residents and/or tasks and not performing any hand hygiene until after returning R25's eye drops to the medication cart. RN-C indicated it is the facility's policy to wash/sanitizes hands after change gloves, between tasks and residents. 3. On 2/7/17 at 9:15 a.m., Surveyor observed RN-D administer nebulizer treatment for [REDACTED]. At 9:33 a.m., RN-D sanitized hands before leaving nurses station, touched door handle, entered R6's room, closed the door, turned off nebulizer machine, removed mask from R6, rinsed and cleaned the nebulizer equipment placing on clean towel, touched R6's door, the nurses station door and medication room door before sanitizing hands. Immediately following the above observation Surveyor interviewed RN-D regarding hand hygiene. RN-D verified touching multiple surfaces prior to entering R6's room, then removing the nebulizer mask from R6, cleansing the nebulizer equipment, leaving R6's room and touching multiple surfaces prior to sanitizing hands in the medication room before sanitizing hands. On 2/7/17 at 2:15 p.m., Surveyor interviewed DON (Director of Nursing)-E regarding hand hygiene. DON-E indicated it was the facility's policy to wash/sanitize hands before contact with residents, after glove changes, between tasks, and always between residents.

Based on observation, staff and resident interviews, and record review, the facility did not ensure pressure injury prevention devices were in place for 2 residents (Resident (R)7 and R6) of 15 residents reviewed for skin risk. R7 had a history of [REDACTED]. The facility did not float R7's heels, refer R7 to therapy for an assessment of devices to redistribute pressure in R7's recliner, and did not document risk/benefit education for R7, alternate device trials, or care plan how to respond to refusals of standard interventions. R6 had a history of [REDACTED]. The facility did not consistently float R6's heels while in bed as indicated in the resident's plan of care and did not document alternative device trails. Findings include: National Pressure Ulcer Advisory Panel (NPUAP) 2014 Quick Reference Guide documents, Repositioning for Preventing Heel Pressure Ulcers: 1. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called 'floating heels'. 1.1 Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows. 2. The knee should be in slight (5 to 10 degree) flexion. Seating Support Surfaces to Prevent Pressure Ulcers: 1. Use a pressure redistributing seat cushion for individuals sitting in a chair whose mobility is reduced. NPUAP March 2014, The NPUAP selected 'Quality of Care Regulations' Made Easy documents, Risk Factors: Many studies and professional documents identify risk factors that increase a resident's susceptibility to develop or to not heal pressure ulcers. Examples of these risk factors include, but are not limited to: · Impaired/decreased mobility and decreased functional ability; · Co-morbid conditions, such as end stage [MEDICAL CONDITIONS] disease or diabetes mellitus; · Drugs such as steroids that may affect wound healing; · Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency; · Resident refusal of some aspects of care and treatment; · Cognitive impairment; · Exposure of skin to urinary and fecal deficits; and · A healed ulcer. The history of a healed pressure ulcer and its stage (if known) is important since areas of healed State III (3) or IV (4) pressure ulcers are more likely to have recurrent breakdown. 1. From 2/6/17 through 2/9/17, Surveyor reviewed R7's medical record which documented: ~ [DIAGNOSES REDACTED]. ~ Admission Minimum Data Set (MDS) assessment documents was admitted with a stage 2 pressure injury. ~ Wound Rounds note, dated 3/9/16, documents had a stage 2 pressure injury on the sacrum (triangular bone directly above coccyx/tailbone) and a right heel blister with stage 1 persistent redness. ~ Wound Rounds note, dated 3/16/16, documents sacrum advanced to stage 3, blister still present on right heel. ~ Wound Rounds note, dated 4/20/16, documents both areas healed and disengagement of the wound team. ~ Short Term Care Plan - Impaired Skin Integrity, dated 3/4/16 documents had an open area to coccyx superficial 2 centimeters (cm) by 1 centimeter, a blister to the right heel, and incisions to left hip. Interventions included use pillows for positioning, assess skin integrity daily, especially over boney (sic) prominences, assess need for pressure reducing devices in w/c (wheelchair), chairs, bed, etc., consult Dietary, PT/OT for high-risk residents. ~ extended Short Term Care Plan - Impaired Skin Integrity, dated 3/16/16 documents had a stage 3 pressure injury to the coccyx, a blister to the right heel, and left hip surgical incisions. Interventions included previous interventions on 3/4/16 care plan and these additions: Elevate (off load) heels while in bed - pillows, educate resident r/t (related to) 'off loading', shifting weight, etc. Encourage self-compliance, APM (Alternating Pressure Mattress), Update Wound Care Team with new or worsening areas, and update MD (Medical Doctor) as needed. ~ Certified Nursing Assistant (CNA) guidelines, print dated 1/7/17 documents R7 needs extensive assistance of 1-2 staff for bed mobility and transfers with manual lift does not bear weight. Surveyor noted CNA guidelines did not address pressure redistribution in all seated surfaces or floating heels. ~ comprehensive care plan for skin, last pre-survey update 8/8/16, documents an intervention of pressure relieving device(s) for chair, assess skin daily, encourage fluids as needed, specialty mattress, monitor fragile coccyx, [MEDICATION NAME] per order, incontinence product use per day and night, no mattress pad on bed. ~ comprehensive care plan additions to skin care plan, dated 2/8/17 after skin integrity questions were asked of facility staff included, Encourage to elevate feet off bed, assist with hygiene and general skin care, keep skin clean and dry, barrier cream to peri-area as needed, encourage and assist to reposition, inspect skin q.shift, elevate heels off of bed. ~ 2/9/17 (after skin integrity questions were asked of facility staff) - Therapy referral made documenting, Resident states uncomfortable when sitting in recliner/wc. Please eval (evaluate) for seating & positioning and safety of cushion placement in recliner. ~ 2/9/17 (after skin integrity questions were asked of facility staff) - education was provided to resident regarding the risks of skin breakdown. ~ Braden Assessments, dated 11/16/17 and 2/8/17, document a score of 16 (low risk). On 2/8/17 at 9:15 a.m., Surveyor observed CNA-I and CNA-J transfer R7 from an electric wheelchair to R7's bed. CNA-I and CNA-J provided extensive assistance with positioning and placed one pillow behind R7's knees. CNA-I and CNA-J verified R7's heels were in full contact with R7's mattress and indicated R7 preferred to be positioned with a pillow under the knees. At that time, R7 indicated being comfortable with a pillow under the knees. On 2/8/17 at 10:20 a.m., Surveyor interviewed Registered Nurse (RN)-K regarding R7's heels. RN-K verified R7 previously had a pressure injury on the right heel and heel pressure injury prevention was not addressed on R7's care plan but should be. RN-K indicated the facility has alternate devices to utilize besides a pillow but no alternate devices had been utilized for R7 since R7 moved to the unit three to four months ago. RN-K indicated CNAs did not communicate R7's preference for a pillow under the knees to RN-K and RN-K denied providing any education to R7 regarding protecting R7's heels from pressure. On 2/8/17 at 3:03 p.m., Surveyor interviewed RN/Wound Care Certified (WCC)-L regarding R7. RN-WCC-L verified R7 was admitted with pressure injuries on the sacrum and right heel. RN/WCC-L indicated R7 was not always compliant or wanted to free float heels. RN/WCC-L denied being involved with R7 since R7's pressure injuries healed on 4/20/16. RN/WCC-L was uncertain whether or not risk/benefit education was documented but indicated education occurred. RN/WCC-L indicated an expectation of CNAs to communicate to their local nurse if a resident prefers not to have interventions. On 2/9/17 at 9:55 a.m., Surveyor observed R7 sitting in a recliner with two pillows under the legs. R7's heels were free floating. At that time Surveyor interviewed R7 who verified having a comfortable leg position. Surveyor observed and R7 verified R7 did not have a pressure redistribution cushion between the recliner and R7's self. R7 said, I have a bony butt and verified the recliner may be more comfortable with a cushion. R7 denied ever being offered a recliner cushion by the facility. On 2/9/17 at 10:02 a.m., Surveyor interviewed RN-D regarding a cushion in R7's recliner. RN-D read R7's care plan and verified the care plan did not mention a cushion for the recliner. RN-D CNA-N, and Surveyor observed R7 in the recliner. CNA-N indicated R7 did not have a cushion in the recliner and it was not a practice to move R7's wheelchair cushion to the recliner. RN-D indicated a plan to request a physical therapy consult. On 2/9/17 at 10:49 a.m., RN/WCC-L indicated to Surveyor that R7 did not have a recliner upon admission but when R7 changed from short-term to long-term stay, the recliner was moved to the facility for R7's use. RN/WCC-L emphatically stated, We healed (R7) and indicated R7 had no current issues and would not necessarily need a cushion in the recliner because the cushion might be too high and create a positioning issue. However, RN/WCC-L was not sure a therapy screen was completed for recliner positioning and cushion use. On 2/9/17 at 11:05 a.m., Surveyor interviewed Certified Occupational Therapy Assistant/Rehabilitation Coordinator (COTA/RC)-O regarding R7. COTA/RA denied receiving a therapy referral prior to today (2/9/17) for recliner positioning or pressure redistribution cushions. COTA/RA-O indicated R7 previously had a therapy referral for feeding and occasionally declined devices but COTA/RA-O still expects a referral if R7 uses a recliner and would also expect follow-up if R7 refused a recliner device so a new device could be recommended. On 2/9/17 at 1:13 p.m., Director of Nursing (DON)-E indicated to Surveyor that R7's skin was healed, R7 may be at increased safety risk if a cushion was placed in the recliner, and a belief that prevention interventions were no longer needed because R7's skin is currently intact. DON-E indicated R7 sits in the recliner for limited amounts of time usually less than one hour at a time. DON-E further indicated there was no documentation to submit to the survey team congruent with Surveyor 's request for a timeline of interventions or devices attempted and refusal documentation. DON-E indicated it was not the practice of the Inter-Disciplinary Team (IDT) to document decision making if IDT decides whether or not to initiate different devices and interventions. 2. On 2/6/17, Surveyor reviewed the medical record of R6. The resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. R6's most recent MDS assessment, dated 12/14/16, documented R6 was at risk for pressure injury development, was frequently incontinent of bowel and bladder required total assist of 2 staff for transfer and all ADL's (Activities of Daily Living). The resident also had a history of [REDACTED]. R6's potential for impairment of skin integrity plan of care dated 11/06/15, included interventions for pressure relieving devices for bed, chair, use pillows for positioning, elevate heels off bed, resident can become agitated and restless and pillows may need to be repositioned. Documentation on 1/30/16 R6 had a superficial slit to coccyx measuring 2 cm. The wound round note dated 2/3/16 indicated an open area due to moisture measuring 1.2 cm length by 0.2 cm width by less than 0.1 cm depth. Documentation on 3/10/16 indicated R6 had a new 1 cm slit noted to the upper coccyx. On 2/7/17 at 9:40 a.m., Surveyor observed CNA-G and CNA-H provide incontinence care and repositioning for R6. Prior to provision of incontinence care, R6's left heel was free floated and right heel was in direct contact with mattress. After provision of incontinence care, CNA-G and CNA-H repositioned R6 and when completed R6's left heel was free floated and the right heel was in direct contact with the mattress. CNA-G indicated we don't always float both heels because of comfort. CNA-G then free floated both of R6's heels. At 1:35 p.m., Surveyor observed R6 both heels were free floated. R6 was observed by Surveyor on the following dates/times: ~ 2/8/17 at 7:50 a.m. and 10:40 a.m., R6's left heel free floated and right heel was in direct contact with mattress. On 2/8/17 at 10:45 a.m., Surveyor interviewed CNA-G regarding activities R6 enjoyed. CNA-G indicated R6 was last checked and changed for incontinence and repositioning at 9:30 a.m. ~ 2/9/17 at 7:35 a.m., 8:55 a.m., 9:20 a.m., and 10:35 a.m., R6's left heel free floated and right heel was in direct contact with mattress. On 2/9/17 at 11:30 a.m., Surveyor interviewed RNMGR (Registered Nurse Manager)-F regarding R6's heel being free floated. RNMGR-F indicated that R6's heels should both be free floated according to the resident's care plan. RNMGR-F further indicated the most recent Braden scale (assessment use to for the prediction of pressure injury risk), dated 1/18/17 indicated R6 had a score of 12 placing the resident at high risk for the development of pressure injury.

Based on observation, staff interview and record review, the facility did not ensure that 1 resident (Resident (R)13) of 3 residents reviewed for catheter cares, received the appropriate treatment and services to prevent urinary tract infections. During an observation of catheter care, staff elevated R13's urinary catheter drainage bag above the level of R13's bladder. Findings include: HICPAC (Healthcare Infection Control Practices Advisory Committee) 2009 Guideline For Prevention Of Catheter Associated Urinary Tract indicates: III.B (1) Keep the collecting bag below the level of the bladder at all times . The facility's policy Indwelling Catheter Care, dated 5/7/12, indicated: PURPOSE: Provide guidelines for handling and caring for indwelling catheters . PROCEDURE: .4. To prevent backflow of urine, keep the drainage bag below the level of the resident's bladder at all times . Surveyor reviewed R13's medical record from 2/6-2/9/17 and it included the following: The [DIAGNOSES REDACTED]. R13's care plan, dated 3/27/16, indicated the resident had a physician order [REDACTED]. The MDS (Minimum Data Set) assessment, dated 12/7/16, indicated R13 had a BIMS (Brief Interview for Mental Status) score of 8/15, which indicated moderate cognitive impairment. The MDS further indicated R13 and was dependent upon staff for total assistance with bed mobility, toileting and hygiene. On 2/7/17, at 1:15 p.m., Surveyor observed CNA (Certified Nursing Assistant)-A provide catheter cares for R13, while the resident was reclined on bed. With gloved hands, CNA-A pushed up the elastic-banded pant leg of R13, exposing the urinary drainage leg bag and tubing secured to R13's leg, which CNA-A loosened. CNA-A opened the drainage port of the bag, wiped it with an alcohol pad and placed the port near the collection container. However, none of the visible urine in the bag drained out while the bag was lying flat on the bed. CNA-A attempted to lower the port by moving it to the edge of the bed, but the length of tubing did not allow the bag to hang over the bed to utilize gravity to assist the drainage of the bag. CNA-A then lifted the bag above the level of R13's bladder and opened the port, which allowed approximately 300 cc (cubic centimeters) of yellow urine to flow into the collection container. Urine visible in the tubing was observed to move backwards as the lowest point of the drainage bag was elevated 6 to 8 inches above the level of R13's bladder. CNA-A cleansed the port, removed gloves and performed hand hygiene. On 2/7/17, at 1:44 p.m., Surveyor interviewed CNA-A, who confirmed the above observations and verified R13's catheter bag should not be lifted above the level of the bladder. On 2/7/17, at 1:35 p.m., Surveyor interviewed RN (Registered Nurse)-B who confirmed staff should not lift a catheter drainage bag above the level of the resident's bladder.

Based on interview, and record review, the facility did not ensure staff immediately informed a resident's physician when a change in the resident's physical condition occurred for 1 (resident #18) of 24 sampled residents. On 10/25/13, staff became aware of a new open area to resident #18's toe. The facility did not notify the resident's physician until 11/27/13. Findings include: According to the [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 9/9/13 indicated resident #18 was cognitively impaired, was dependant on staff for transfers, did not ambulate, was dependant on staff for hygiene, was frequently incontinent of bowel and bladder, and was at risk for developing pressure ulcers. A Braden pressure ulcer assessment completed 9/4/13 indicated resident #18 was at "high risk" for pressure ulcer development. Resident #18's care plan printed 11/27/13, indicated that the facility had multiple pressure ulcer prevention interventions in place including a pressure reducing mattress, floating heels in bed, pressure reducing cushion to wheel chair seat, repositioning every two hours, and protective boots in the bariatric geri-chair. A "Skin Check Sheet" dated 10/25/13 indicated resident #18 had a "sore" on a toe on the right foot. The form was signed by a CNA (Certified Nursing Assistant) and a RN (Registered Nurse). A podiatry exam form dated 10/29/13 indicated the resident had an area of "eschar" to the second toe on the right foot. A "Skin Check Sheet" dated 11/1/13 indicated resident #18 had a "small red spot" to the left foot and to the "second toe, right foot". This form was signed by a CNA and a nurse. On 11/27/13 at 8:30 a.m., surveyor # interviewed RN-B regarding resident #18. RN-B verified that she was not aware of the documentation indicating resident #18 had an open area. In addition, RN-B verified there had been no monitoring, assessments, or treatments done to this area. On 11/27/13 at 10:50 a.m., surveyor # interviewed RNUM (Registered Nurse Unit Manager)-A regarding resident #18. RNUM-A verified that she was not aware of resident #18's pressure ulcer until today and the resident's primary physician had been faxed today. In addition, RNUM-A verified that the evening shift nurse was aware of the open area, as she had signed the skin check forms, and that the nurse should have updated the physician immediately. On 11/27/13 at 11: 05 a.m., surveyor # interviewed WCCRN-C regarding resident #18. WCCRN-C verified that she had not been informed of resident #18's pressure ulcer until today, after surveyor # was asking questions about it. WCCRN-C verified the area on the resident's right foot is a pressure ulcer and could have occurred from the resident's bedding. WCCRN-C also verified resident #18's physician was not updated until today; indicating the physician should have been updated when the area was first observed on 10/25/13. On 11/27/13 at 1:40 p.m., surveyor # interviewed DON (Director Of Nursing)-D regarding resident #18. DON-D verified the open area to resident #18's toe was missed by staff. DON-D agreed the resident's physician should have been updated when staff became aware of the resident's open area in October, so it could have been monitored and treated appropriately.