Every finding on record at Presbyterian Village, Inc

Based on observation, interview, facility policy review, and document review, it was determined that the facility failed to ensure staff performed hand hygiene while feeding dependent residents to prevent the spread of infection and cross contamination. This failed practice had the potential to spread infection to 4 residents (Resident #18, #21, #32, and #37) of 4 sampled residents observed for dependent dining. The findings include: A review of a facility policy titled, Hand Hygiene Policy and Procedure undocumented date, revealed staff should always perform hand hygiene after contact with a resident's mucous membranes, body fluids or excretions and to cleanse the hands between residents direct contact. A review of a facility policy titled, Infection Prevention and Control Program copyright date 2024, revealed hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. A review of the in-service titled, Disinfection of Hands, dated 01/04/25, revealed all personnel should stop and disinfect hands before passing out the next person's food and drink and may use hand sanitizer x3 (3 times), then use soap and water. During a 40-minute observation on 04/14/25 at 12:34 PM, Activity Director/Certified Nursing Assistant (CNA #4) was assisting with meals for (4) four dependent resident diners; Residents #18, #21, #32, and #37, touched dirty napkins after CNA #4 wiped the faces of Resident #37 and Resident #18, and touched the legs of Resident #32 to wake the resident up to take a bite, without performing hand hygiene between each resident, then continued to feed each resident. During an interview with CNA #4 on 04/14/25 at 1:17 PM, CNA #4 stated she was only supposed to use hand hygiene when she started and finished feeding the residents. CNA #4 stated, I cross contaminated by not using hand sanitizer and could spread infection to other residents. CNA #4 revealed she had not been in-serviced on hand hygiene for feeding residents. During an interview with CNA #5 on 04/14/25 at 1:21 PM, CNA #5 stated, Staff should use hand sanitizer upon entering the room, in between each resident, after touching things or resident, and when finished to prevent spreading infection. CNA#5 revealed she had not been in-serviced at this facility, but she had experience from a previous position. During an interview with the Infection Preventionist Licensed Practical Nurse (LPN #1) on 4/15/25 at 10:19 AM, LPN #1 stated staff should sanitize their hands before they go in and when they leave from residents rooms, after wiping a resident's face and touching anything that could spread infection to other residents. A review of the in-service titled, Hand Hygiene, dated 04/16/25, revealed staff should use hand sanitizer before and after passing out resident meal trays and in between each tray. During an interview with the Medical Director (MD) 04/16/25 at 9:53 AM, the MD stated, Staff should perform hand hygiene at least 3 times with resident contact-before, during and after and if they touch anything else they need to hand hygiene again. She confirmed it was difficult during assist feeding of resident, but hand hygiene must be followed to prevent spread of infection while feeding multiple residents, especially if you were touching anything other than the spoon handle. She stated, By performing hand hygiene it prevents transmission of many diseases. During an interview with the Director of Nursing (DON) on 04/17/25 10:56 AM, the DON stated it was important for staff to use hand hygiene between residents to prevent spread of infection and it should be done between each resident while feeding residents especially if they touched the actual body. The DON stated competencies were done annually, on hire, and when the need arose. During an interview with the Administrator on 4/17/25 at 11:47 AM, the Administrator stated hand hygiene was important to do to prevent cross contamination, and must be done during assistive feeding, especially if touching anything other than spoon handles.

Based on observation, interviews, and record review, the facility failed to ensure a physician's order for applying compression stockings/leg wraps was being followed for 1 (Resident #40) of 1 resident reviewed requiring compression stocking or legs wraps. The findings include: A review of a Resident Summary indicated the facility admitted Resident #40 with a diagnosis of hypertension (high blood pressure) that included edema (swelling). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/31/2025, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) of 8, which indicated the resident was moderately impaired for their daily decision making. A review Resident #40's Physician Orders for the month of 04/2025, revealed an order dated 01/31/2024, to apply compression stockings daily prior to resident getting out of bed for edema. Another order dated 10/16/2024, indicated to wrap both legs from toes to knees daily for edema. A review of Resident #40's medications listed on Physician Orders revealed an order dated 03/13/2025, for a water pill [generic diuretic] to decrease edema. Review of Resident #40's Physician Orders updated on 04/16/2025, revealed that the physician prescribed another diuretic [name brand diuretic] to help decrease the edema. A review of Resident #40's Care Plan dated 02/07/2025, revealed interventions to apply compression stockings and to notify the doctor if edema increases. On 04/14/25 11:30 AM, Resident #40 was observed sitting in their recliner with legs elevated. Edema was noted to both legs and no compression stockings or wraps were on the resident. On 04/15/25 12:33 PM, Resident #40 was observed sitting in their recliner with legs elevated. Edema was noted to both legs and no compression stockings or wraps were on the resident. On 04/16/25 8:35 AM, Resident #40 was observed sitting in their recliner with legs elevated. Edema was noted to both legs and no compression stockings or wraps were on the resident. On 4/16/2025 at 7:37 AM, during an interview, Resident #40 stated their legs were hurting due to the swelling. Resident #40 was asked if anyone had wrapped their legs or applied compression stockings. The resident stated it had been a few weeks. Resident #40 stated they would like for their legs to either be wrapped or have the compression stockings applied. During an interview on 04/16/25 at 7:49 AM, Certified Nursing Assistant (CNA) #2 stated she had applied Resident #40's compression stockings on 04/03/2025. CNA# 2 stated Resident #40 requested later during the day to have the compression stockings removed. CNA# 2 stated she removed them, and she reported it to the charge nurse but that it was not documented anywhere. CNA #2 was asked if she had asked Resident #40 if they wanted the compression stockings on and CNA#2 stated she had not. During an interview on 04/15/2025 at 8:00 AM, with Restorative Certified Nursing Assistant (RCNA) # 6, she was asked if she had ever applied or asked Resident #40 about applying the compression stockings. RCNA#6 said she had not. During an interview on 04/16/25 at 8:28 AM, Licensed Practical Nurse, (LPN) #3 reviewed the Medication Administration Record (MAR) for Resident #40 to see if there was an order for the compression stockings or the wrap. She stated there was no order, therefore she would not be the one to wrap them. LPN#3 stated an order for compression stockings or leg wraps would be on the Treatment Administration Record (TAR) and the treatment nurse would be responsible for ensuring the stockings or wraps were applied. On 04/16/25 at 8:35 AM, during an interview with LPN #1, she reviewed the TAR and said there were no orders for compression stocking or leg wraps. LPN#1 stated the orders would not be on the TAR. LPN #1 reviewed the Physician Orders for Resident #40 and stated the compression stockings or wraps should be applied. At 8:45 AM, LPN #1 entered Resident #40's room and asked the resident if anyone had offered to apply the compression stocking or wraps. Resident #40 said no one had attempted but the resident would allow the wraps to be applied. LPN#1 stated she would notify the doctor about the legs swelling. On 04/16/25 at 9:45 AM, during an interview with the Director of Nursing (DON) she stated that the orders for the compression stockings and the wrap were overlooked and were entered as an ancillary order rather than a doctor's order. The DON stated the order should be on the MAR, and the nurses should apply them daily. On 04/16/25 at 9:53 AM, during an interview with the Medical Director (MD), she stated the compression stockings or wraps should be applied or offered daily to Resident #40 but if the resident refused, staff should educate the resident and offer again later. The MD stated she believed nurses should have a tracking record and interventions for treatments ordered. The MD stated she was not aware that the wraps or compression stockings had not been applied or offered. The Medical Director ordered for the resident to receive a fluid pill [Name brand diuretic] to help decrease the edema. On 04/16/25 at 10:36 AM, during an interview with the DON, this surveyor requested copy of the facility ' s policy on following physician orders and for applying compression stockings/wraps. The DON presented a copy of a policy titled Antiembolytic Stockings Policy and Procedure. The policy indicated the purpose of the policy was to provide support for lower extremities, to aid return circulation from lower extremities, to prevent embolus (blood clots) formation, to reduce pain, and to reduce edema.

Based on observation, interview and record review, the facility failed to ensure that the facility kitchen and food storage areas were maintained in a clean, sanitary manner. This had the potential to affect 65 residents receiving their meals from the facility kitchen. The findings are: On 02/05/2024 at 10:01 AM, the can opener in the kitchen had a build-up of a sticky green and brown residue that could be removed with a towel. On 02/08/2024 at 10:17 AM, a can of celery soup located in the kitchen's dry storage area was observed to have a dent on the seam of the can. On 02/08/2024 at 10:25 AM, the freezer used to store boxes of meat in the kitchen's cold storage area was observed to have sticky brown and black debris on the racks used to store boxes of frozen meat, as well as the floor of the freezer. On 02/08/2024 at 10:26 AM, the freezer labeled Vegetable Freezer in the kitchen's cold storage area was observed to have a sticky, green substance on the shelves in the door of the freezer. On 02/08/2024 at 10:27 AM, the freezer used to store desserts in the kitchen's cold storage area was to have a sticky red fluid covering portions of the floor of the freezer. On 02/08/2024 at 10:29 AM, the can opener in the kitchen had a sticky, green and brown substance on the base. A piece of a can label was attached to the blade of the can opener. On 02/08/2024 at 10:31 AM, an alcove attached to the kitchen that was used to store sheet pans and coffee cups had an accumulation of debris built up in the corners of the room. On 02/08/2024 at 10:32 AM, the alcove attached to the kitchen housing the dishwasher had debris on floor and built up in the corners of the room. On 02/08/2024 at 10:32 AM, the main kitchen was observed to have debris built up in each corner of the room and under the appliances used to prepare meals. On 02/08/2024 at 10:34 AM, a support pole was observed mounted to the preparation table. The base of the pole had a buildup of grease and debris coating it. On 02/08/2024 at 10:36 AM, the ventilation hood located over the oven and deep fryer had a buildup of grease and debris that appeared 3/8 of an inch thick over the appliances. On 02/08/2024 at 10:39 AM, the two Heating, Ventilation, and Air Conditioning (HVAC) vents in the ceiling of the kitchen that were located above the food preparation area were observed to have a buildup of dust and debris. On 02/08/2024 at 12:11 PM, Dietary #1 confirmed the equipment used to prepare and store food intended to be served to residents in the facility should be kept clean and free of debris to avoid the possibility of contamination and foodborne illness. Dietary #1 confirmed the canned goods should be inspected upon delivery to ensure no damage was present to prevent the possibility of contamination. Dietary #1 confirmed the accumulation of debris observed on the floors, preparation table, and ventilation hood was not the result of a single day's use of the kitchen and had accumulated over time. Dietary #1 confirmed the importance of maintaining the kitchen and equipment in a clean and orderly manner. On 02/08/2024 at 2:43 PM, the Administrator confirmed the kitchen and the equipment used to prepare food for the residents should be maintained in a clean and orderly manner to prevent contamination and foodborne illness. The Administrator was informed of the issues observed and stated, That's not acceptable. A policy titled; Food Safety Requirements was provided by the Administrator on 02/08/2024 at 12:50 PM. It documented, Food will also be stored, prepared, distributed, and served in accordance with professional standards for food service safety .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination .Staff shall follow facility procedures for dishwashing and cleaning fixed cooking equipment . A policy titled, Food Receiving and Storage was provided by Dietary #1 on 02/08/2024 at 12:55PM. It documented, Foods shall be received and stored in a manner that complies with safe food handling practices .When food is delivered to the facility it will be inspected for safe transport and quality before being accepted . A policy titled, Food Preparation and Storage was provided by Dietary #1 on 02/08/2024 at 12:55PM. It documented, Dietary Employees shall prepare and serve food in a manner that complies with safe food handling practices .Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .

Based on observation, interview and record review, the facility failed to ensure that staff used proper hand hygiene to prevent the potential for cross contamination for 3 (Residents #5, #21, and #46) sampled residents. The facility also failed to implement a Legionella plan to prevent the potential for waterborne pathogens, and the facility failed to flush capped off water valves to reduce the potential for waterborne pathogens. This failed practice had the potential to affect all 63 residents. The findings are: 1. Resident 21 had a diagnosis of unspecified dementia, unspecified severity, without behavior/psychosis/mood. According to the Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/04/23 Resident #21 scored 04 (0-7 indicates severely impaired cognition) on Brief Interview of Mental Status (BIMS) and is always incontinent of bowel and bladder. a. On 02/05/24 at 10:38 AM, the Surveyor observed Certified Nursing Assistant (CNA) #5 take a package of open wipes off of Resident A's bed to provide incontinent care to Resident #21 (Bed B). CNA #5 wiped Resident #21 with his/her right hand then with the right hand pulled a wipe from the pack. CNA #5 continued this process several times. CNA #5 applied clean a brief after Resident #21 refused a shower. b. On 02/08/24 at 01:23 PM, Surveyor asked CNA #1, the wipes left in the resident's room, are they strictly for that resident? CNA #1 voiced he/she would rather not answer. c. On 02/08/24 at 01:25 PM, CNA #1 approached the Surveyor and stated, Yes. The Surveyor asked, after opening wipes for a resident are they only used for that resident? CNA #1 stated, Yes. The Surveyor, can you tell me why that is? CNA #1 stated, Because of cross contamination. d. On 02/08/24 at 01:30 PM, the Surveyor asked the Director of Nursing (DON), the open wipes that remain in a resident's room, are they specific to that resident? The DON stated, Yes. The Surveyor asked, why is that? The DON stated, For infection control purposes. The Surveyor asked, is it standard practice to remove a pack of unopened wipes from the resident in Bed A and use them to provide care to the resident in Bed B? The DON stated No, it is not standard practice. 2. Resident #46 had a diagnosis of Vascular Dementia, Unspecified Severity. According to the Significant Change MDS with an ARD of 11/24/23 documented Resident #46 scored 04 (0-7 indicates severely impaired cognition) on a BIMS and required substantial/maximal assistance with sit to stand. a. On 02/05/24 at 11:30 AM, the Surveyor observed CNA #3 and #4 lock Resident #46's wheelchair prior to placing a lift pad under Resident #46 ' s arms. CNA #3 and #4 removed the soiled incontinence pad and CNA #3 placed it in trash. CNA #3 and #4 both removed gloves and CNA #3 donned clean gloves without washing or sanitizing hands. CNA #3 performed incontinent care for Resident #49 then disposed of the dirty wipes in the trash. Resident #46 was then placed on the shower chair. CNA #3 with the same gloves used to perform incontinent care of Resident #46 removed the lift pad, placed it on top of the lift, and parked the lift in the hallway. b. On 02/05/24 at 11:50 AM, the Surveyor asked CNA #3, how many residents on this hall use the stand-up lift? CNA #3 stated Two [Residents #46 and #5]. The Surveyor asked, how often do you change the lift pad? CNA #3 stated, Two to three times a week. The Surveyor asked, how many times did you change your gloves during incontinence care? CNA #3 stated, Two times. When I went in the room and when I noticed something on them. The Surveyor asked, are you saying you changed your gloves when you initially went in the room? CNA #3 stated, Oh, you said change glove. I changed them one time. The Surveyor asked, when did that glove change take place? CNA #3 stated, Toward the beginning. The Surveyor asked, is there something that should occur between glove changes? CNA #3 stated, Hand washing. The Surveyor asked, did you wash your hands after removing dirty gloves but before applying clean gloves? CNA #3 stated, No. The Surveyor asked, after you applied clean gloves did Resident 46 have any incontinent care to be performed? CNA #3 stated, A little bit. The Surveyor asked after you applied clean gloves, you resumed incontinent care for Resident 46, with dirty gloves you removed the lift pad, placed the lift pad over the lift, and parked the lift in the hallway to be reused. How do you know if you contaminated the lift pad with your gloves? CNA #3 stated, I guess you wouldn't know unless you looked. The Surveyor asked, did you look? CNA #3 stated, No ma'am. The Surveyor asked, what could potentially be a negative outcome? CNA #3 stated, Someone else could touch and get their hands dirty and it's unsanitary. c. On 02/09/24 at 01:30 PM, the Surveyor asked the Director of Nursing (DON), if a staff member used a stand-up lift to stand a resident that was incontinent of bowel and the staff member provided care to that resident and after care was provided the staff member used the gloves she provided care with and removed the lift pad and place it in the hallway to be reused, is that standard practice? The DON stated, No. The Surveyor asked, what issue could that cause? The DON stated, Infection control. d. On 02/08/24 at 02:41 PM, the Infection Preventionist provided the Surveyor with a binder which included a policy titled Infection Control Policy and Procedures: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A policy titled hand washing documented Purpose: Hand hygiene is a simple and effective method for preventing the spread of pathogens, such as bacteria and viruses, which cause infections. pathogens can contaminate the hands of a staff person during direct contact with residents or contact with contaminated equipment and environmental surfaces within close proximity of the resident. Failure to clean contaminated hands can result in the spread of these pathogens to residents, staff (including the person whose hands were contaminated), and environmental surfaces. To protect our residents, visitors, and staff, our facility promotes hand hygiene practices during adl care activities and when working in rotations within the facility. 47916 3. On 02/06/2024 11:37 AM, the Infection Preventionist (IP]) provided the Infection Prevention Policies and Procedures manual containing a policy titled Infection Control Policy and Procedure documented, .Purpose: To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. a. On 02/07/2024 at 01:30 PM, the Surveyor asked Maintenance #1, for a water flow diagram of the facility showing hot and cold-water distribution. Maintenance #1 said he did not have a flow diagram and asked what it was. The Surveyor asked if Maintenance #1 was familiar with legionella and how did maintenance check for waterborne illnesses. Maintenance #1 stated I am not familiar with legionella. I think it is from stagnant water He said he did not know what Legionella caused. When asked what testing maintenance does, Maintenance #1 said ph, water temperatures are checked, and he also does visual inspections. The Surveyor asked if disinfection levels are checked? The Maintenance Supervisor said he did not know. Maintenance said they are on city water and if the city contacted him and said they tested positive for legionella he would work with the city to shut down the water, use their emergency water source, and would ask for assistance in testing and treating for legionella. To his knowledge they have not had any cases of legionella. b. On 02/07/2024 at 01:45 PM, the Surveyor pointed out an area on the south side of 3rd floor and Maintenance #1 identified it as valved off water. The Surveyor asked how often they flush the valved off water and Maintenance #1 said, We, haven't. The Surveyor accompanied maintenance to the South end of 2nd floor, and he pointed out another area of valved off water. Maintenance #1 said there had been [named] water dispensers removed from these areas and that is why the water was valved off there. The Surveyor asked if the facility flushes the water in unoccupied rooms and Maintenance #1 told the surveyor maintenance flushes the empty rooms about once a week. The Surveyor asked Maintenance #1 if they had a Water Management Team and the Maintenance #1 said, No . well, I guess me and the Plant Manager. The Surveyor asked how often the water management program was reviewed, and Maintenance #1 said annually. c. 02/07/2024 at 02:10 PM, the Surveyor asked for a copy of the Legionella Water Management Program. The Surveyor asked Maintenance #1 if he had any logs showing when water was flushed. Maintenance #1 told the Surveyor he did not have any documentation. d. On 02/07/2024 at 02:30 PM, Maintenance #1 provided a policy titled, Legionella Water Management Program, which documented, .Policy Statement Our facility is committed to the prevention, detection, and control of water-born contaminants, including Legionella. Policy Interpretation and Implementation. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services .5. The water management program includes the following elements: b. A detailed description and diagram of the water system in the facility, including the following: (l) Receiving; (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. 2. Map the water system- the facility shall develop and keep on file a diagram to demonstrate the flow of water within the facility. The flow diagram shall include basic information on the following. Area where municipal water is received into the building, Areas of cold-water distribution, Areas where water is heated and stored, Areas of Hot Water distribution, Area where wastewater is discarded . Maintenance #1 provided a policy titled Water Infection Control Risk Assessment by the CDC documenting, .Introduction A water infection control risk assessment (WICBA) is a critical component of water management programs (WMP) in healthcare settings. WMP team members can use a WCRA to evaluate water sources, modes of transmission, patient susceptibility, patient exposure, and program preparedness .Instructions .Step 2: identify potential water sources, considering the examples on the next page. Each row of the WICRA table may be used for a unique exposure, or set of like exposures, in a location (e.9., sink, hopper, shower, fountain, ice machine) . Water Management program Flow Description: Water enters the property of [Facility] --, via municipal six-inch (6 [inch]) line. Water continues via six-inch line for fire-suppression and reduces to a three-ich @ 1 line for cold water supply. There is back flow prevention throughout the system including between the cold-water distribution and the city water main, and between the fire suppression system. Cold water is distributed to the kitchen, laundry, ice machine, water fountains, and all sinks, toilets, and showers throughout the building. Cold water is heated via [named] kitchen dishwasher and laundry washers are heated to 140F [Fahrenheit] Patient rooms, showers and whirlpool are heated to 110F. The Hot water is distributed via localized water heaters via a direct(nor-recirculating) line. Due to localized water heater, we have two mixing valves mixing valves throughout the building. All wastewater, whether hot or cold, is discarded through the sanitary sewer line. e. On 02/08/2024 at 02:00 PM, the Director of Nursing (DON) was asked who was on the Water Management Team. The DON said the Infection Preventionist (IP), Maintenance #1, Plant Manager, and the Administrator. The Surveyor asked why it was important to have a water management team to prevent Legionella and the DON said to prevent respiratory infections. The Surveyor asked the DON how often dead end or valved off water should be flushed. The DON said she is not familiar and that would be a question for Maintenance #1, or the Plant Manager. f. On 02/09/24 at 08:00 AM, the DON was asked to provide minutes or log in for the Water Management Team meetings. g. On 02/09/24 at 08:06 AM, the Administrator provided the Water Management Team meeting minutes, and the Surveyor observed three documented meetings. i) On 10/16/2023, the Administrator, IP, Plant Manager, Maintenance #1, and CNA #1 met and gave the management policy and procedure to the team for review and consideration. ii) On 11/15/2023, the meeting was postponed until January due to the holiday activities. iii) On 01/24/2024, the Administrator, IP, Maintenance #1, and CNA #1 discussed removing the portable water fountains on 2nd and 3rd floor due to nonuse on January 12, 2024.

Based on observation, interview, and record review the facility failed to ensure the environment was free of accident hazards by making sure lift pads/slings were free of fraying, rips, or tears to prevent accidents, or falls. This failed practice had the potential to affect 1(Residents #43) requiring mechanical lift transfer, with the potential to affect 4 sampled (Residents #3, #16, #31, and #43) requiring lift assistance on the 3rd floor. The facility failed to ensure that staff used appropriate transfer devices to aid in the transfer of Resident #40 in the transfer from the recliner to the wheelchair. This failed practice had the potential to affect 7 sampled (Resident #7, #8, #220, #53, #28, #59, #21) of 12 on the 2nd floor who required assistance for transfers without a lift. The findings are: 1. Resident #43 with a diagnosis of retention of urine, major depressive disorder, and lower back pain. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2023 documented a Brief Interview for Mental Status (BIMS) of 15 (13-15 indicates cognition is intact). Resident #43 was independent with eating, had independent bed mobility, supervised transfers, extensive dressing assistance, and total dependent on assistance for toileting. a. A care plan (dated 02/05/2024) documented, .Resident #43 has the risk for injuries from falls as resident has history of falls, use of antidepressant medication . Insure that adaptive devices are within reach and in good repair .Assists with transferring as needed . b. On 02/05/24 at 10:17 AM, the Surveyor observed a blue lift pad resting in a chair across from the foot of the bed that appears to be coming loose and was hanging on by threads. c. On 02/06/24 at 08:15 AM, the Surveyor observed a blue lift pad resting in a chair across from the foot of the bed. A nylon strap appears to be hanging by threads. d. On 02/06/24 at 09:35 AM, the Surveyor asked the Certified Nursing Assistant (CNA) Lead #1 to look at Resident ' s blue lift pad and pointed out a nylon strap hanging by the threads. The Surveyor asked if the lift pad is still safe to use on Resident #43. CNA #1 said this lift pad should be removed from commission because the strap is coming off. The Surveyor asked if Resident #43 is the only resident using this lift pad and was told No, we use this one on all lift residents and remove it if it is soiled, or not safe to use. The Surveyor asked if the lift pads go through the laundry, and he said, Yes, we do launder the lift pads. CNA #1 said this lift pad is not safe to use and could cause someone to fall. e. On 02/07/2024 at 10:00 AM, the Surveyor asked the Director of Nursing (DON) what system is in place that staff follow to ensure lift pads are safe to use on the floor. The DON said staff are educated to remove lift pads if there are tears or rips. The Lead (CNA #1) spot checks them. The Surveyor asked if the facility launders lift pads. The DON said they launder lift pads, but they do not go through the dryer. The Surveyor asked why the facility would expect staff to remove lift pads with tears or rips, and the DON stated, Because of the danger of someone being dropped. f. On 02/09/2024 at 10:40 AM, the Administrator provided a policy titled Safe Resident Handling/Transfers documenting, .Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident ' s condition and mobility, the use of mechanical lifts are a safer alternative and should be used .Compliance Guidelines: .5. Handling aids may include gait belts, transfer boards, and other devices . 7. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy . 11. Staff will be educated on the use of safe handling / transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur .16. Slings will be laundered according to manufacturer's instructions and any damaged, broken or unsafe slings will be removed from service and replaced. 48977 2. Resident #40 had a diagnosis of Parkinsonism, and a History of Falling. According to the Quarterly MDS with an ARD of 1/15/24 Resident #40 scored 10 (8-12 indicates moderate impairment) on a BIMS. a. The care plan with a start date of 1/26/24 documented, .Category:11 Fall - History/Risk .P (Problem) [Resident #40] has the risk for injuries R/T [related to] use of antianxiety, antidepressant medications. He does have a DX [Diagnosis] Parkinson which may increase his risk for falls . b. On 02/05/24 at 11:58 AM, the Surveyor was standing outside an open door and observed Certified Nursing Assistant (CNA) #5 transferring Resident #40 from recliner to wheelchair without a gait belt. Resident #40 was wearing stretchy sweatpants at the time of transfer. CNA #5 grabbed the seat of Resident #40 sweatpants and pulled the resident down into wheelchair from a standing position. Resident #40 appeared unsteady on his/her feet and was grabbing and holding on to the foot of the bed while CNA #5 pulled on the seat of pants. There was a triangle shaped area created by the recliner, wheelchair, and foot of bed. CNA #5 was positioned behind wheelchair and was reaching over the wheelchair to transfer Resident #40. c. On 02/05/24 at 12:00 PM, the Surveyor asked CNA #5, do you normally use the back of a resident's pants to transfer them? CNA #5 stated, No, [Resident #40] usually sits for me. The Surveyor stated to CNA #5 I noticed that the resident was leaning forward. The Surveyor asked CNA #5, what could you have done to help Resident #40 if he/she had started to fall? CNA #5 stated, I would have lowered [Resident #40] to the floor. The Surveyor asked CNA #5 do you all use gait belts to assist with transfers? CNA #5 stated Yes, but I don't have it. d. On 02/08/24 01:30 PM, the Surveyor asked the Director of Nursing (DON), what is the best way to transfer a resident who does not require a lift? DON stated, With a gait belt. The Surveyor asked the DON, why is that the best way? DON stated, For safety. e. On 02/08/24 10:57 AM, Administrator provided Surveyor with a policy titled Ambulation, Gait Belt Policy and Procedure Purpose that documented, Purpose: 1. To assist resident to achieve maximum function. 2. To provide assistance to residents as necessary.6. To reduce risk of falls and injury .

Based on observations, interviews and record reviews, the facility failed to ensure a posting of a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups in a form and manner accessible and understandable to residents and resident representatives. This failed practice had the potential to affect all 13 Residents in the secured unit. The findings are: 1. On 02/07/24 at 03:11 PM, during rounds on the secure unit, the Surveyor observed there were no signs posted for the Office of Long-Term Care (OLTC) or Ombudsmen with the contact information of the state authority for the residents that resided on the unit. a. On 02/07/24 at 03:15 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1, can you tell me where the phone number for the OLTC is posted? LPN #1 stated Oh, I have it in my binder. The Surveyor asked, what about the Ombudsman, where is that information posted? LPN #1 said the information was up front outside of the secured unit. The Surveyor asked, if a resident wanted to call the OLTC (Office of Long Term Care) or Ombudsman how would they get the information? LPN #1 stated They can ask me, and I will give them the number. The Surveyor asked, what if they wanted to contact OLTC or Ombudsmen confidentially? LPN #1 stated, Oh, that I don't know baby, they wouldn't. b. On 02/08/24 at 01:30 PM, Surveyor asked Director of Nursing (DON), If a Resident in the secured unit wanted the contact information for OLTC and/or Ombudsman without the knowledge of staff, how would they get that information? DON stated, The family have that information. Most of the Residents are not cognitively intact or talk on a phone. We have that information back there now. c. On 02/09/24 at 8:30 AM, the Administrator provided the Surveyor with a policy titled Resident Rights and Quality of Life Policy and Procedures documented, .Residents have the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility. Resident's rights will be explained to the responsible party or legal representative. A resident has the right: .26. To seek immediate access to any of the following: a. Any representative of the Secretary of the U.S. Department of Health and Human Services. b. Any representative of the State. c. The Resident's individual physician. d. The State's long-term care ombudsman. e. The agency responsible for the protection of and advocacy system for mentally ill or developmentally disabled individuals .

Based on observation, interview and record review, the facility failed to ensure a leg strap was in place to prevent injury or trauma from pulling on the catheter tubing. This failed practice affected 1 (Resident #43) and had the potential to affect 1 (Resident #43) on 3rd floor requiring a foley or indwelling catheter. The facility failed to ensure that 1 (Resident #7) of 2 sampled (Residents #7, #55) received the appropriate care for an indwelling catheter. This failed practice had the potential to cause UTI (urinary tract infection), trauma and or damage to the bladder. The findings are: 1. Resident #43 with a diagnosis of retention of urine, hematuria, and obstructive and reflux uropathy. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/2023 documented on a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognition is intact). Resident #43 is independent with eating, has independent bed mobility, supervised transfers, extensive dressing assistance, and total dependent on assistance for toileting. a. A Physician Orders dated 01/19/2024 documented, Catheter 16fr [French] every shift for Retention of Urine . b. A Care Plan dated, 02/05/2024 documented, Resident #43 has the presence of a foley catheter, he does have a diagnosis of urinary retention . A. Keep tubing free of kinks .A. Secure catheter to leg to avoid tension on the urinary meatus . c. On 02/05/24 at 10:17 AM, the Surveyor observed Resident #43's foley draining to gravity without a leg strap, and no privacy bag was in place. d. On 02/06/24 at 08:15 AM, the Surveyor observed Resident #43's foley draining to gravity in a blue bag, and no leg strap. e. On 02/06/24 at 02:42 PM, the Surveyor asked Certified Nursing Assistant [CNA] #2 to accompany the Surveyor to Resident #43's bedside. Resident #43 gave permission for CNA #2 to look at the catheter tubing, CNA #2 said the Resident is missing a leg strap. The Surveyor observed catheter tubing extending out of the bottom of Resident #43's brief, resting on the left leg. The Surveyor asked if there is any time that a resident would not be expected to wear a leg strap. CNA #2 said he/she did not know a lot about catheters and does not usually do catheter care but understood a leg strap comes with the catheter kit. The Surveyor asked what the purpose of a leg strap was, and CNA #2 said maybe to keep it from pulling. f. On 02/07/2024 at 10:15 AM, the Surveyor spoke with the Director of Nursing (DON) and asked what procedures are used to maintain or protect a catheter after placement. The DON said there is no policy, but they would want staff to stabilize the catheter to keep it from being pulled. The Surveyor asked how they would stabilize the catheter, and the DON said by attaching the catheter bag to the bed or using a leg band or strap. The Surveyor asked if there was any time a resident with a catheter would not require a leg strap and the DON said if they refuse to wear one. The Surveyor asked if catheters are allowed to touch the floor, and if catheters are to be covered and why they would put a catheter in a bag. The DON said it is for privacy, and the catheter should not touch the floor due to germs. The Surveyor asked who is responsible for making sure catheters are properly maintained. The DON told the Surveyor that the charge nurse is ultimately responsible, and managers round daily to check on residents. The DON said I guess it is really everyone's responsibility. If a Certified Nursing Assistance [CNA] moves a bed or something they should make sure the catheter is not touching the floor. 48977 2. Resident #7 had a diagnosis of Dysuria, Retention of Urine, and Acute Kidney Failure. The Admission MDS with an ARD of 01/22/24 documented Resident #7 scored 05 (0-7 indicates severely impaired cognition) on a BIMS and had an indwelling catheter (suprapubic). a. The care plan with a start date of 1/19/24 documented, .Category:6 Urinary/Indwelling Catheter .(P)[Problem] [Resident #7] has presence of suprapubic catheter. He does need staff assistance with toileting needs . (G)[Goal] To minimize risk of complications r/t [related to] foley catheter and to have toileting needs met with staff assistance daily over the next review . (A) [Action] check for needs during rounds and prn [as needed], assist with toileting prn, offer and encouragee [encourage] fluids as ordered . b. On 02/05/24 at 02:37 PM, the Surveyor observed Resident #7 self-propelling in a wheelchair in the hall. Resident #7 was propelling the wheelchair back and forth, in a rocking motion with the indwelling catheter tubing dragging on the floor just behind the wheel of the wheelchair. c. On 02/06/24 at 10:15 AM, the Surveyor observed Resident #7 self-propelling in a wheelchair in the hallway and the indwelling catheter tubing was dragging the floor. d. On 02/08/24 at 01:30 PM, the Surveyor asked the Director of Nursing (DON), what is the proper way to store an indwelling catheter when a resident is up in the wheelchair? The DON stated, Off the floor, in a privacy bag, draining below the bladder. The Surveyor asked, why should the catheter not touch the floor? The DON stated, Infection control purposes. e. On 02/08/24 at 02:30 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1, can you explain to me the proper way to store an indwelling catheter when a resident is up in the wheelchair? CNA #1 stated Through the pants leg, under the wheelchair, and in the privacy bag. The Surveyor asked, should any part of the indwelling catheter touch the floor? CNA #1 stated, No. The Surveyor asked why not? CNA #1 stated, Cross contamination. f. On 02/07/24 at 10:15 AM, the Director of Nursing voiced that the facility did not have a policy for catheter care.

Based on observation, record review, and interview, the facility failed to ensure 2 of 2 clothes dryers remained free from the lint buildup to decrease the potential for fire and loss of laundry services for 1 of 1 laundry room. This failed practice had the potential to affect all 60 residents as documented by the Resident Census and Conditions of Residents provided by the Administrator on 11/7/22 at 10:09 a.m. The findings are: 1. On 11/08/22 at 12:54 PM, a tour of the laundry was conducted by this Surveyor and Laundry Staff #1. The Surveyor asked, How often do you clean your lint screens in the dryer? She answered, I clean them twice a day with the vacuum cleaner or I sweep them off. Someone from Maintenance comes once a month to clean the back of the dryers. She opened the bottom of the left dryer to expose the lint screen. The Surveyor asked her to remove the lint screen. She stated, I didn't even know those come off. Laundry Staff #2 removed the lint screen to expose a moderate amount of lint build up approximately 1/4 inches thick on the inside of the screen and around the edges of the screen, and approximately 2 inches thick buildup of lint around the edges of the receptacle that held the screen. Laundry Staff #1 obtained a broom and began to sweep the lint from the screen, where a pile of lint buildup approximately 6 by 6 inches long and approximately 4 inches tall accumulated on the floor of the laundry room. Laundry Staff #2 opened the bottom of the right dryer and removed the lint screen from the right dryer to expose approximately 1/4 inches of lint build up on the inside of the screen and around the edges of the screen, and approximately 2 inches thick buildup of lint around the edges of the receptacle that held the screen. 3. On 11/8/22 at 1:10 PM, the Surveyor asked Laundry Staff #1, What could happen if there is lint build up in your dryer? She answered, Fire. 4. On 11/8/22 at 02:13 PM, the Surveyor asked the Administrator, Who is responsible for cleaning the lint screens in the dryers? He answered, The laundry staff. They clean it every hour or so. The Surveyor asked, What could happen if there was a buildup of lint in the dryers? He answered, They could overheat or catch fire if there was enough of it. 2. The facility policy titled, Fire Safety and Prevention, provided by the Administrator on 11/8/22 at 2:13 p.m. documented, .Keep filters on heating systems, dryers, etc. [etcetera] free of lint .

Based on record review and interview, the facility failed to ensure the Binding Arbitration Agreement provided for the selection of a neutral arbitrator or a venue is convenient to all parties for 3 (Residents #45, #5 and #48) of 3 sampled residents who signed Binding Arbitration Agreements upon admission since September 16, 2019. The findings are: 1. The Binding Arbitration Agreements for Residents #45, #5 and #48 provided by the Administrator on 11/07/22 at 11:46 AM, contained no mention in the Agreements that discussed the selection of a venue which is convenient for both parties. The Agreements documented, .the party may initiate arbitration through [Mediator/Arbitrator Business and Address], if for any reason the matter has not been resolved in mediation . 2. On 11/07/22 at 2:56 PM, the Surveyor asked the Administrator for the facility policy on Binding Arbitration Agreements. 3. On 11/07/22 at 3:39 PM, the Administrator stated, We don't have a policy for Arbitration. They are working on a new agreement as we speak . 4. On 11/08/22 at 12:02 PM, the Surveyor asked the Administrator, How do you ensure that the resident or his/her representative has an equal role in selecting a neutral arbitrator? He answered, It will be one that we both agree upon. We will get their input and they can bring us their selection. The Surveyor asked, What is your process for selecting a neutral arbitrator? He answered, We will give a list of the ones we have heard of and ones they have heard of and decide between the 2 parties. The Surveyor asked, How do you ensure that the resident or his/her representative has an equal role in selecting a convenient venue? He answered, We will look at what is convenient to where they live and do what is most convenient for them and the resident. The Surveyor asked, What is your process for selecting a convenient venue? He answered, The neural arbitrator will also help select a venue. The Surveyor asked, When a resident or his/her representative do not agree with the arbitrator and/or venue, what are the next steps? He answered, We will continue to discuss until we find a common agreement. The Surveyor asked, How do you ensure the resident or his/her representative is provided an opportunity to select the arbitrator and venue agreed upon by both parties? He answered, They know upon admission they have the right to choose if the need arises. The Surveyor asked, When, and under what circumstances, do you approach residents or their representatives about selecting an arbitrator or venue? He answered, If there is a disagreement we can't agree upon and we feel the need for arbitration. The Surveyor asked, What information do you provide residents or their representatives regarding specific arbitrators or arbitration services companies? He answered, We will provide a list of arbitrators and their locations, and we will also let them know they can choose their own. 5. On 11/08/22 at 3:30 PM, the Administrator provided a document titled Arbitration Agreement which did not document that the facility would ensure that the resident or his/her representative had an equal role in selecting a convenient venue. The Surveyor asked, Is this new? He answered, Yes.

Based on record review and interview, the facility failed to ensure the QAA (Quality Assessment and Assurance) Committee developed and implemented appropriate plans of actions to correct identified deficiencies with Accident Hazards, and with distributing and serving food in a sanitary manner. This failed practice had the potential to affect all 60 residents who resided in the facility as identified on the Resident Census and Conditions of Residents provided by the Administrator on [DATE] at 10:09 a.m. The findings are: 1. The Centers for Medicaid and Medicare Services (CMS) 2567 dated [DATE] documented, Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered and sealed; expired food items were promptly removed from stock and discarded; kitchen equipment was maintained in clean and sanitary condition; ice machines were maintained in clean and sanitary condition; and dietary staff washed their hands and changed gloves before handling clean equipment or food items, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen . The facility must ensure that . The resident environment remains as free of accident hazards as is possible . 2. The 2020 Quality Assurance and Performance Improvement (QAPI) Plan, provided by the Administrator on [DATE] at 11:38 a.m. documented, The QAPI Team will decide what data to monitor . Areas to consider may include . state survey results and deficiencies . 3. The Centers for Medicaid and Medicare Services (CMS) 2567 dated [DATE] documented, .Based on observation and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of excessive lint build-up to decrease the potential for fire for the residents who resided in 1 of 1 facility . Providers Plan of Correction . 4- The plant manager /designee will make observation rounds 1 weekly x [times] 8 weeks to ensure the floor behind the 2 dryers located in the laundry was free of any lint build up and there was no lint build up on the back of the 2 dryers' motors. 5- Any negative findings will be corrected immediately and reported to the administrator/designee 1 x weekly. The administrator will forward all negative findings to the QA&A committee 1 x monthly for further recommendations . 4. The Centers for Medicaid and Medicare Services (CMS) 2567 dated [DATE] documented, Based on observation and interview, the facility failed to ensure kitchen employees washed their hands before handling clean trays or food items and maintained sanitary practices while serving lunch and failed to ensure food items stored in the freezer and /or refrigerator were dated, labeled or not expired to prevent potential foodborne illness for residents who received meals from 1 of 1 kitchen . Providers Plan of Correction . HAND WASHING . Step #4 The dietary manager/designee will observe dietary staff serving food to the residents 2 x weekly x 8 . Any negative findings will be corrected immediately. Step #5 The Dietary manager/designee will report all negative findings to the administrator for his weekly QAPI (Quality Assurance and Performance Improvement)/QA&A review. The administrator will forward all negative findings to the QA&A Committee 1 x monthly for further recommendations . 5. On the current survey the facility failed to ensure excessive lint buildup was removed in the dryers and food was distributed and stored and served in a sanitary manner resulting in repeat deficient practices. 6. On [DATE] at 10:06 a.m., the Surveyor asked the Administrator, How does the QAA committee know when a deviation from performance or a negative trend is occurring? He answered, By interviewing with staff, staff bringing information, and looking at quality measures, grievances, rounds. We all bring issues to the meeting if not sooner. The Surveyor asked, How does the QAA committee decide which issues to work on? He answered, We prioritize by safety concerns, then resident care, and so forth. The Surveyor asked, How long will the QAA committee monitor the issues that it has corrected? He answered, Long enough to know the issue is in compliance. Usually two cycles of committee meetings. We meet every two months at least. The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? He answered, Not that I am aware of. Well, we are aware of repeated dietary deficiencies. And the last time it wasn't the dryer, it was the lint behind the dryer, so I've been monitoring the lint behind the dryer. The Surveyor asked, Is the committee monitoring to ensure corrective action has been implemented? He answered I walk through often. I have stopped bringing it up to the committee in the past couple of months. The Surveyor asked, Does the committee revise interventions if results have not yielded the expected improvement? He answered, Yes and we will be doing that this time too.

Based on observations, interviews, and review of a facility policy, it was determined that the facility failed to cover residents' food during delivery from Dining Area #1 to Dining Area #2. This had the potential to cause food born illness for 15 of 16 residents who ate in Dining Area #2. Findings included: A review of a facility policy titled, Assistance with Meals, revised March 2022, revealed, The food services department will deliver food carts to appropriate areas. Nursing staff will remove food trays from the food cart and deliver the trays to each resident's room. Further review of the policy revealed, All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The policy had no guidance regarding covering food on meal trays. On 11/08/2022 at 2:42 PM, during an interview with the Administrator, he stated this was the only policy the facility had and confirmed it did not address food being covered during transport. On 11/07/2022 at 12:47 PM, during a dining observation, residents who were independent were eating in Dining Area #1. Residents who needed assistance with eating were seated in Dining Area #2. Observation revealed food was plated from a steam table in Dining Area #1 and staff were observed carrying the uncovered plated food down a resident hallway to Dining Area #2. The staff delivered 16 total trays to residents and only one tray was covered while being transported to Dining Area #2. On 11/07/2022 at 1:28 PM, during an interview with Certified Nursing Assistant (CNA) #1, she stated if staff were transporting meal trays down a hallway to deliver to residents, the trays should be covered, and the cups should have lids. She stated she had delivered trays from Dining Area #1 to Dining Area #2 without the food being covered. However, CNA #1 stated the food should have been covered. On 11/07/2022 at 1:37 PM, during an interview with CNA #2, she stated any time food trays were delivered to residents in their rooms, the food was covered. However, CNA #2 stated the food did not need to be covered during transport from Dining Area #1 to Dining Area #2. She stated she had delivered food from Dining Area #1 to Dining Area #2 and the food was not covered. On 11/07/2022 at 1:44 PM, during an interview with CNA #3, she stated food was supposed to be covered with lids if staff transported the meal down a resident hallway. CNA #3 confirmed the hallway from Dining Area #1 to Dining Area #2 was a resident hallway. She stated she had delivered uncovered food trays from Dining Area #1 to Dining Area #2 but stated the food should have been covered. On 11/08/2022 at 8:06 AM, during an interview with the Director of Nursing (DON) and Administrator, the DON stated meal trays should be covered. The Administrator stated the two dining areas had always been considered one area.

Based on observations, interviews, and review of a facility policy, it was determined that the facility failed to ensure that each resident was involved in developing the care plan for 1 (Resident #33) of 6 sampled residents reviewed for care plan meeting attendance. Findings included: A review of a facility policy titled, Care Planning, revised March 2022, revealed, The resident, the resident ' s family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident ' s care plan. A review of a Profile Face Sheet indicated the facility admitted Resident #33 with diagnoses that included pneumonia, type 2 diabetes, and mild cognitive impairment. A significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of Resident #33's Care Plan, dated 09/09/2022, revealed the resident had behaviors such as resisting care at times and a history of throwing coffee at staff. There was nowhere on the care plan which addressed the resident not being practicable for the development of the care plan. A review of Resident #33's Care Plan Conference Summary, dated 01/11/2022, revealed that was the last care plan conference that was held with the resident in attendance. On 11/07/2022 at 1:56 PM, during an interview with Resident #33, the resident stated they had not participated in a care plan meeting. On 11/09/2022 at 2:40 PM, during a follow-up interview, the resident stated they wanted to be invited to their care plan meetings. On 11/09/2022 at 11:39 AM, during an interview with the MDS Coordinator, she stated she sent out a letter every quarter to the resident's family. The letter instructed the family to contact the Resident Services Supervisor to set up a meeting. She stated she sent the letter to the resident's family member and not to the resident. On 11/09/2022 at 11:39 AM, during an interview with the Resident Services Supervisor, she stated if the resident's family did not respond to the invitation letter and set up a meeting, nothing happened at that point. The last care plan meeting that the resident attended was held on 01/11/2022. On 11/09/2022 at 2:13 PM, during a follow-up interview, the Resident Services Supervisor stated if the resident's family had not set up a care plan meeting the resident would not have been invited to the care plan meeting. On 11/09/2022 at 12:10 PM, during an interview with the Director of Nursing (DON), she stated there should be a care plan meeting quarterly and verified that the resident ' s last documented care plan meeting that the resident attended was held on 01/11/2022. On 11/09/2022 at 2:23 PM, during an interview with the Administrator, he stated they invited all parties to the care plan meetings and the resident should be invited to their care plan meeting. He stated Resident #33 had behaviors at times, and the care plan meeting discussions caused agitation. The Administrator acknowledged the last care plan meeting held with the resident was on 01/11/2022.

Based on observation, record review and interview, the facility failed to ensure staff sanitized their hands when they entered the building as per the facility's infection control policy and procedures and properly wore their face masks to keep their mouth and nose covered to prevent potential spread of COVID-19 or other infectious illnesses for the staff and residents of 1 of 1 facility. The findings are: 1. On 8/06/21 at 8:21 AM, Housekeeper #1 walked into the facility, filled out the COVID-19 screening questionnaire, and walked toward the patient care area. She did not sanitize her hands. She was holding a N95 mask up to her face with her hands. The mask wasn't strapped around her head. 2. On 8/06/21 at 8:22 AM, the Groundskeeper walked into the facility, filled out the COVID-19 screening questionnaire, and walked toward the patient care area. He did not sanitize his hands. 3. On 8/06/21 at 8:23 AM, Screener #1 was asked, Can you tell me why [Housekeeper #1] didn't have her mask on properly? She stated, I was going to give her one, but I don't have any up here. She was asked, Can you tell me why [Housekeeper #1] and the groundskeeper didn't sanitize their hands? She stated, I don't know; I didn't check. 4. On 8/06/21 at 8:50 AM, Certified Nursing Assistant (CNA) #2 was sitting at the kiosk on Hall 300, documenting. Her mask was pulled below her chin. At 8:51 AM, CNA #2 was asked, Can you tell me why you have your mask below your chin? She pulled her mask up over her nose and stated, My nose was sweating, so I pulled it down for a second. 5. On 8/06/21 at 10:49 AM, the Minimum Data Set (MDS) Coordinator was asked, What is the screening process when you enter the building? She stated, You have to check in at the front office; you have a screen questionnaire; and you check the temp [temperature]. If you have an elevated temperature, you can't come in. She was asked, Should you sanitize your hands as soon as you enter the building? She stated, Oh yes, and they do have automated hand sanitizer available. She was asked, Why is it important that you sanitize your hands before entering the building? She stated, To decrease the spread of infection, and decrease the risk of spreading infection. She was asked, How do you properly wear a mask? She stated, You have to cover your mouth, your nose, and your chin too. She was asked, When should a mask be properly worn? She stated, The whole time you're in the facility. 6. On 8/06/21 at 11:09 AM, Licensed Practical Nurse (LPN) #1 was asked, What is the screening process when you enter the building? She stated, We have to have our temperature checked and sign in. When we leave out of the building, we have to do the same thing every time. She was asked, Should you sanitize your hands as soon as you enter the building? She stated, Yes, they have sanitizer on the table down there. She was asked, Why is it important that you sanitize your hands before entering the building? She stated, Because you've been in the car and just came from home. You can't wash your hands from the car to the building. She was asked, How do you properly wear a mask? She stated, Squeeze it on your nose at the top, and it covers your nose and your mouth. She was asked, When should a mask be properly worn? She stated, All the time you are in the building. 7. On 8/06/21 at 11:30 AM, CNA #1 was asked, What is the screening process when you enter the building? She stated, They always check the temperature, and sanitize your hands. She was asked, Why is it important that you sanitize your hands? She stated, To kill the germs. You don't know what you have touched. She was asked, How do you properly wear a mask? She stated, Make sure your nose and mouth are covered. She was asked, When should a mask be properly worn? She stated, Before I get out of the car, and keep it pulled up all the time when I'm in the building. 8. On 8/06/21 at 12:46 PM, the Director of Nursing (DON) was asked, When should staff sanitize their hands? She stated, Before they provide care, meal service when passing trays, before and after providing care. She was asked, Should staff sanitize their hands when they enter the building? She stated, Yes ma'am, before we sign in at the door. She was asked, When should staff have their masked pulled up to cover their nose and their mouth? She stated, Upon entry to the facility, and if they don't have one, they should be provided with one. In the patient care areas, hallways, and patient rooms. She was asked, Why is it important that staff sanitize their hands upon entrance into the building and have their mask covering their nose and mouth? She stated, For the hand sanitizer, we are touching a pen that everybody touches, and we are on the outside. The mask is to prevent the Coronavirus, and we are the ones coming in. 9. The facility's Infection Control Policy, revised 3/4/2021, documented, .all visitors and staff will be screened per CDC [Centers for Disease Control] recommendations .All visitors and staff will use alcohol based hand sanitizer and don a face mask upon entering .All employees are to wear surgical masks while in the facility, as long as surgical masks are available .

Based on record review and interview, the facility failed to ensure residents' medical records contained documentation to indicate whether residents did or did not receive a pneumococcal vaccination and that residents and / or their representatives were provided with education on the benefits and possible side effects of pneumococcal immunization for 2 (Residents #2 and #3) of 5 (Residents #1, #2, #3, #4, and #5) sampled residents whose medical records were reviewed for pneumococcal vaccination information. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. An immunization consent form signed by the resident's responsible party on 8/16/12 documented, .Immunization Act of 1999, states that every resident of a nursing home must annually have a flu shot and a pneumonia vaccine once . The form had a handwritten check mark next to, Permission is given to participate in the immunization program . b. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/13/21 documented the resident was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status and was offered and declined the pneumococcal vaccine. d. As of 8/6/21 at 2:30 PM, the resident's medical record did not contain documentation of a pneumococcal vaccine administered to the resident or education provided to the resident or responsible party regarding the benefits and possible side effects of the pneumococcal vaccine. 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Nursing Home Resident Consent for Vaccination form signed by the resident on 3/19/19 documented, .I consent to administration of the pneumonia vaccine . b. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . c. The quarterly MDS with an ARD of 6/8/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a brief interview for mental, did not receive the pneumococcal vaccine and was not offered the vaccine. d. As of 8/6/21 at 2:40 PM, the resident's medical record did not contain documentation of a pneumococcal vaccine administered to the resident or education provided to the resident or responsible party regarding the benefits and possible side effects of the pneumococcal vaccine. 3. On 8/06/21 at 2:31 PM, the Director of Nursing (DON) was asked where the documentation of pneumococcal vaccines and education was located for Residents #2 and #3. She stated, The lady that keeps up with it is not here. The last time State was here, they gave them the book. It wasn't in the charts then. She was asked if she was aware of the reason the vaccination information was not documented in the residents' medical records. She stated, No ma'am, they keep them in a book. 4. On 8/06/21 at 2:40 PM, the DON was asked who was responsible for making sure the residents received pneumococcal vaccines if they wanted them and that the vaccinations were documented in the medical records. She stated, The nurses give the vaccines and document it on the MAR [Medication Administration Record] that they gave it. 5. The facility's policy titled, Vaccinations of Residents, provided by the Administrator on 8/06/21 at 2:45 PM, documented, .All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated, or the resident has already been vaccinated . Provision of such education shall be documented in the resident's medical record . All new residents shall be assessed for current vaccination status upon admission . If vaccines are refused, the refusal shall be documented in the resident's medical record . Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated .

Based on observation and interview, the facility failed to ensure kitchen employees washed their hands before handling clean trays or food items and maintained sanitary practices while serving lunch and failed to ensure food items stored in the freezer and /or refrigerator were dated, labeled or not expired to prevent potential foodborne illness for residents who received meals from 1 of 1 kitchen. The failed practice had the potential to affect 51 residents who received meals from the kitchen (total census: 51), according to lists provided by the Administrator on [DATE] at 4:15 PM. The findings are: 1. On [DATE] at 11:37 am, there were twelve 40-ounce bags of frozen peppers and onions with an expiration date of [DATE] stored in the 3-door freezer. 2. At 11:40 am, in a two-door freezer, the following items did not have a date: 4 bags of frozen yellow squash and 4 bags of frozen broccoli florets. 3. On [DATE] at 11:45 am, the large deep freezer contained three 40-ounce bags of frozen peppers and onions with an expiration date of [DATE]. There were 4 bags of frozen pancakes with no date. There were two bags of frozen baby baker potatoes with an expiration date of [DATE]. There were 5 bags of frozen French fries with an expiration date of [DATE]. There were 6 bags of frozen sweet potato fries with an expiration date of [DATE]. There were 2 bags of frozen cut red potatoes with an expiration date of [DATE]. There was 1 bag of frozen hash browns with an expiration date of [DATE]. 4. On [DATE] at 11:54 am, the following items were stored in the walk-in refrigerator: There were two bags of whipped topping with no date. There was one bag of honey ham with no date. There were 3 Ziplock bags of red and yellow bell peppers with no open date or label on it. There was one Ziplock bag of shredded carrots with no open date or label. There was one Ziplock bag of cabbage with no open date or label on it. There was one Ziplock bag of parmesan cheese with no date or open label on it. 5. On [DATE] at 12:10 pm, the Dietary Manager was asked, Should the food items be labeled or dated? Dietary Manager stated, Yes. The Dietary Manager was asked, Should the expired foods still be in the freezer? Dietary Manager stated, No, I will get them discarded now. 6. On [DATE] at 11:46 pm, Dietary Aide #2 entered the kitchen, walked over to the food prep table and picked up a paper towel. She then walked into the employee break room and stood over the air conditioner. Dietary Aide #2 came back into the kitchen, picked up trays, and began to place them on the meal cart. She did not wash her hands prior to handling the trays. 7. On [DATE] at 12:15 pm, as Dietary Aide #1 prepared plates for the main floor, he held the plate in his left hand and against his abdomen while preparing the tray. On [DATE] at 1:29 pm, Dietary Aide #1 was asked, Should you hold the plates against your stomach while preparing the plate? Dietary Aide #1 stated, No, my left arm is weak because I had a stroke when I was 9 months old. Dietary Aide #1 was asked, Why should you not hold the plate against your stomach? Dietary Aide #1 stated, I can get stuff off my shirt onto the plate. 8. On [DATE] at 2:10 pm, the facility provided a policy titled, Food Receiving and Storage. The policy documented, Food shall be received and stored in a manner that complies with safe food handling practices . All foods stored in refrigerator or freezer will be covered, labeled, and dated. 9. On [DATE] at 2:10 pm, the facility provided a policy titled, Preventing Foodborne Illness-Food Handling. The policy documented, Food will be stored prepared, handled and served so that the risk of foodborne illness is minimized . 3. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .

Based on observation, interview and record review, the facility failed to ensure a call light was placed within reach to enable residents to call for assistance when needed for 1 (Resident #32) of 17 (Residents #41, 32, 39, 40, 24, 3, 2, 32, 301, 6, 44, 20, 26, 17, 27, 25 and 252) sampled residents who resided on the 200 Hall. The findings are: Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), with an assessment reference date of 06/04/21 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS) and required limited assistance with activities of daily living. a. On 07/12/21 at 11:38 AM, Resident #32 was lying on his bed, asleep on his right side. The resident was fully dressed on top of the blanket. His call light was on the floor under the bed. b. On 07/13/21 at 09:45 AM, Resident #32 was in his bed, asleep on his right side. The resident's call light was on the floor under the bed, in the same position as the previous day. c. On 07/15/21 at 10:42 AM, Resident #32 was in his bed, asleep on his right side. The resident's call light was on the floor under the bed. d. On 07/15/21 at 08:46 AM, Certified Nursing Assistant (CNA) #1 was asked where a resident's call light should be located. She stated, Within their reach. She was asked if the resident could use his call light and she stated he could use it. e. On 07/15/21 at 08:50 AM, CNA, #2 was asked where a resident's call light should be located. She stated, Within their reach. I usually clip it to their blanket or sheet. f. On 07/15/21 at 8:58 AM, Licensed Practical Nurse (LPN) #1 was asked where a resident's call light should be located. She stated, Within their reach. g. On 07/15/21 at 03:20 PM, the Assistant Director of Nursing (ADON) was asked where a resident's call light should be located. She stated, It should be within their reach. If they are in bed it should be clipped to their linen or if they are up in their chair, then it is clipped to their person.

Based on observation and interview, the facility failed to ensure 2 of 2 clothes dryers remained free of excessive lint build-up to decrease the potential for fire for the residents who resided in 1 of 1 facility. This failed practice had the potential to affect all 51 residents due to the potential for the interruption of laundry services, according to the Resident Census and Conditions of Residents form dated 07/12/21. The findings are: 1. On 07/16/21 at 09:05 am, there were 2 electric dryers in the clean area of the laundry room. Dryer #1 had lint built up on the motor, approximately ¼-inch-thick and Dryer #2 had lint built up on the motor approximately ¼-inch-thick. There was an approximately 1-inch thick by 2-foot-wide area of lint buildup on the floor behind the dryer and approximately 1 inch thick on the exhaust hose. Laundry Employee #1 was asked, What do you see? She stated, Lint. She was asked who is responsible for cleaning behind the dryers and she stated, Maintenance is. She was asked how often they clean it and she stated, Monthly. 2. On 07/16/21 at 09:22 am, the Maintenance Supervisor was asked how often the dryer vent compartment and behind the dryers were cleaned. He stated, We do that monthly and when needed. It's been about a month, so it is time for us to do that. The surveyor showed him pictures of lint behind the dryer and he stated, Yes, it needs to be done again. We will get on it today.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required blended diets for 2 of 2 meals observed. This failed practice had the potential to affect 5 residents who received blended diets, as documented on the Diet list provided by the Administrator on 7/15/21 at 4:15 pm. The findings are: 1. On 7/13/21 at 10:33 AM, the Dietary Cook placed 7 pieces of [MEDICATION(S)] bread into the robocoupe, placed 1/3 pan of cooked meatloaf into the robocoupe, placed beef base with water into the robocoupe and blended into a pureed mixture. She added 1/2 cup of calorie and protein supplement to the robocoupe during the mixing process. After pureeing the food, she emptied the contents of the robocoupe into a pan, covered it with aluminum foil and placed it on the steam table. The consistency of the meatloaf was not smooth and had unblended pieces of meat which created a lumpy consistency. 2. On 7/13/21 at 10:44 AM, the Dietary Cook, placed the cooked mixed vegetables into the clean robocoupe. She added 1/2 cup calorie and protein powder supplement and 1/2 the broth from the cooked vegetables. She pureed the vegetables, removed the vegetables from the robocoupe and placed it in a pan, covered the pan with aluminum foil and placed the pan on the steam table. The vegetables had a thin, watery consistency. 3. On 7/14/21 at 12:05 PM, the Dietary Cook pureed pork loin for the lunch meal. The consistency of the pork loin was not smooth and had unblended pieces of meat, which created a lumpy consistency. 4. On 7/16/21 at 9:43 AM, the Dietary Cook was asked, What consistency should a pureed meal look like? The Dietary Cook stated, It should look like a form kind of like baby food and should be thick but not too thick and not chewy so the resident can be able to swallow it. 5. On 7/16/21 at 9:51 AM, the Dietary Manager was asked, What consistency should a pureed meal look like? The Dietary Manager stated, It should be pudding like. The Dietary Manager was asked, Is it okay for meat to have lumps in it? The Dietary Manager stated, No, it should be pudding like.

Based on observation, interview, and record review, the facility failed to ensure facial hair was regularly removed to maintain good grooming and personal hygiene for 1 (Resident #24) of 7 (Residents #3, 24, 41, 39, 40, 2, and 32) sampled residents who resided on the 200 hall and were dependent on staff assistance for shaving, according to a list provided by the Administrator on 07/15/2021 at 4:00 PM. The findings are: Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an assessment reference date of 05/21/2021 documented the resident scored 9 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status and required limited assistance of one person for bathing. a. The Comprehensive Care Plan dated 5/28/21 documented, [Resident #24] has had a decline in his selfcare functioning level . Assist with ADLs [activities of daily living] prn [as needed], check for needs during rounds and prn . b. On 07/12/21 at 11:34 AM, the resident's mid to lower jaw was covered in facial hair, approximately 1/8 to 1/4 inches long. The resident was asked if he preferred a beard instead of being shaved. The resident stated, It would be nice if I could get that about once a week. The resident reported that he thought his shower days were Monday, Wednesday, and Friday; however, he did not always get a shave on those days. c. On 07/15/21 at 08:50 AM, Certified Nursing Assistant (CNA) #2 was asked if she was aware of this resident ever refusing care. She stated, No .sometimes if I come in and they weren't shaved the day before, I will do it. d. On 07/15/21 at 08:46 AM, Certified Nursing Assistant (CNA) #1 was asked how many times per week the residents received a bath or shower. CNA #1 reported the residents were given a bath or shower three times a week, on a Monday, Wednesday Friday schedule or a Tuesday, Thursday, Saturday schedule, and that the task was assigned for day and evening shifts. When asked if this was also the time when shaving took place she stated, Yes, most of the time, but not always. How often a resident is shaved is up to them, and occasionally, there will be a family that performs the shaving. The CNA reported there were no family members who performed shaving for Resident #24. When asked what the procedure is if a resident refuses a shave or other type of care, she stated, We tell the nurse. e. On 7/15/21 at 08:58 AM, Licensed Practical Nurse (LPN) #1 was asked how often the residents were given a bath or shower. She stated, Three times per week. When asked if that was the time shaving normally took place, she stated, Yes. When asked how information was communicated from one shift to another concerning the completion of this task she stated, The CNAs put it in their computer. f. On 07/15/21 at 03:20 PM, the Assistant Director of Nursing (ADON) was asked how often a resident was to be shaved. She stated that shaving should be completed on the resident's shower days. When asked if a resident who was showered on Wednesday should present as clean shaven on Thursday, she stated, Should be, yes.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator and freezer were covered and sealed; expired food items were promptly removed from stock and discarded; kitchen equipment was maintained in clean and sanitary condition; ice machines were maintained in clean and sanitary condition; and dietary staff washed their hands and changed gloves before handling clean equipment or food items, to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 55 residents who received meals from the kitchen (total census: 55), as documented on the Diet List provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 10:42 a.m., Dietary Employee #1's facial hair was not covered by a beard / mustache guard. a. On [DATE] at 10:43 a.m., seven (7) containers of spices stored on a rack in the kitchen were not dated. The Surveyor took a photograph of the spices at this time.) b. On [DATE] at 10:44 a.m., two (2) cartons of chocolate milk stored on a shelf in the refrigerator had an expiration date of [DATE]. c. On [DATE] at 10:45 a.m., a package of sliced cheese was stored on a shelf in the refrigerator. The package of cheese was uncovered. Dietary Employee #1 was asked, Should it be covered? She stated, Yes. d. On [DATE] at 10:48 a.m., two (2) packages of coleslaw were stored on a shelf in the refrigerator. The packages of coleslaw were not dated. e. On [DATE] at 10:49 a.m., one brick of swiss cheese was stored on a shelf in the walk-in freezer. The brick of swiss cheese was not dated. Dietary Employee #1 was asked, Should these all be dated? She stated, Yes. f. On [DATE] at 12:08 p.m., Dietary Employee #1 placed the pans of food on the steam table in the Main Dining Area on the 200 Hall. He washed his hands, applied gloves, and removed the aluminum foil and plastic wrap from the pans. He placed scoops and spoons in the food at 12:10 p.m. and the first lunch meal tray was served. Dietary Employee #1 touched the tray cart, plastic wrap, and aluminum foil approximately 6 to 8 times without changing gloves and touched the inner aspect of the plate he was portioning food on to serve to the residents. g. On [DATE] at 1:56 p.m., the ice scoop holder for the 300 Hall had a yellow brown substance down one side. At 1:58 p.m., the ice scoop holder on the 200 Hall was lying down without a lid on it on the hydration cart. The ice scoop was in the holder and was lying on the shelf of the hydration cart. The auto ice machine on the ground floor's back cover had dried spots on it. The tray had a white substance at the bottom of it (The Surveyor took photographs of the ice machines and ice scoop holders at this time.) h. On [DATE] at 3:26 p.m., Dietary Employee #3 rinsed the robot coupe, the lid, and the blade with hot water. She placed it back on its base and placed 20 slices of turkey, ham, and cheese into the robot coupe. She pulsed the mixture until it was a chopped consistency. i. On [DATE] at 3:38 p.m., she rinsed the robot coupe, the lid, and the blade with hot water and placed it back on its base. At 3:42 p.m., she added 5 scoops of mixed vegetables with ,[DATE] cup of fortified supplement and blended the mixture. She identified the pureed mixture was too loose and added ,[DATE] cup of potato powder to thicken mixture and blended the mixture to a smooth consistency. At 3:48 p.m., Dietary Employee #3 was asked, Do you always rinse the robot coupe? She stated, Most of the time I do. She was asked, Do you ever place it in the dishwasher? She stated, Do I need to? j. On [DATE] at 3:53 p.m., the Dietary Service Manager was informed about the rinsing the robot coupe. She stated, That's what we do. She was asked for the facility policy for cleaning the robot coupe. 2. A facility policy titled How to Clean a [NAME]ot Coupe Mixer provided by the Dietary Service Manager on [DATE] at 3:55 p.m. documented, .The Blixer should be cleaned after each use or a least once a day . The bowl, blade, and lid can be cleaned in a dishwasher, but robot coupe recommends washing these parts by hand in a sink . a. A facility policy titled [NAME]ot Coupe provided by the Dietary Service Manager on [DATE] at 8:10 a.m. documented, .After usage [NAME]ot Coupe is to be hand washed in the sink due to the dish machine shortening out the blades of the machine and life expectancy of each part . b. On [DATE] at 8:14 a.m., the Dietary Service Manager was asked, Is rinsing the robot coupe the same as washing it? She stated, No.

Based on observation, record review and interview, the facility failed to notify the Physician of ineffective pain management during treatment of [REDACTED].#3 and Resident #5) with pressure ulcers. This failed practice resulted in a pattern of actual harm for 1 (Resident #3) case mix resident. The failed practice had the potential to affect 3 residents with pressure ulcers and assessed with [REDACTED]. 1. Resident #3 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly MDS with an Assessment Reference Date (ARD) of 5/6/14 documented the resident scored 4 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required total assistance of two plus persons for transfer, bed mobility, dressing and bathing; received 51% or more of nutrition via a percutaneous endoscopic tube (PEG tube), had one Stage 3 pressure ulcer and one unstageable pressure ulcer; and had pain daily. a. A Physician order [REDACTED]." b. A Wound/Skin Healing Record dated 5/2/14 documented, "PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing; Pain Location: to coccyx wound; Nature of Pain (specify): when cleaning only or changing drsg (dressing), PAIN: is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Locations: Lt (left) back (wound site); Nature of Pain (specify): Tender to touch ..." A Wound/Skin Healing Record dated 5/9/14 documented, "PAIN: is patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Location: Coccyx wound; Nature of Pain (specify): During drsg change (Lt. back (position shoulder); 'scapula') PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Nature of Pain (specify): Tender to touch area..." c. Nurse's Notes dated 5/16/14 at 1:00 p.m. documented, "EMLA ([MEDICATION NAME] and [MEDICATION NAME] Ointment requested to use c (with) R (resident) to decrease px (pain) during drsg changes. Will continue to monitor ..." A Physician order [REDACTED]. Cleanse left scapula area wound with wound cleaner, apply Calcium Alginate and Santyl, cover with bordered dressing 3 x/ wk and prn." d. A Wound Clinic Physician order [REDACTED]." Nurse's Notes dated 6/6/14, no time on note, documented, "Dr. (name deleted) suggested use of EMLA for wound care but no prescription/hard copy of physician order [REDACTED]." e. On 6/24/14 at 9:10 a.m., Certified Nursing Assistants (CNAs) #4 and #6 provided incontinent care for Resident #3. During care the resident stated, "I'm hurting. My legs are hurting." CNA #4 stated, "I'll tell your nurse." At 9:40 a.m., without being assessed for pain or provided interventions for her complaint of leg pain, the resident was lifted and weighed via a mechanical lift by CNAs #4 and #5. During the process, Resident #3 stated, "My legs hurt; can you give me something for pain?" CNA #4 stated, "We can't give you anything but we will tell your nurse." On 6/25/14 at 9:55 a. m., Licensed Practical Nurse (LPN) #3 who was assigned to Resident #3 on 6/24/14 was asked, "Did anyone tell you yesterday (Resident #3) was hurting?" The LPN stated, "No ma ' am, they told me the lady in the other bed was hurting." f. On 6/24/14 at 10:10 a.m., the Treatment Nurse (LPN#7) provided wound care for the resident. The Treatment Nurse stated, "It's ordered 3 times per week (dressing changes), but I have been changing the dressings every day because of the drainage ". The Treatment Nurse added, "She (Resident #3) was pre-medicated about an hour ago." The June 2014 MAR (Medication Administration Record) for Resident #3 was reviewed. The MAR indicated [REDACTED]. The Narcotic Record documented the resident was administered Hydro/APAP at 12:14 a.m. on 6/24/14. The resident had not received the Hydro/APAP for 9 hours and 56 minutes before the treatment to the pressure ulcers was performed. 1) At 10:18 a.m., during wound care, the Treatment Nurse scrubbed the resident ' s scapula wound, using a 4 x 4 gauze and a Q-tip to cleanse the tunneling area and under the wound edge. Resident #3 flinched and attempted to move her shoulder away from the nurse, stating, "That hurts." The Treatment Nurse stated, "I'm sorry" and continued to scrub the wound. The Treatment Nurse proceeded to apply Santyl to the resident's scapula wound using another Q-Tip. The resident flinched, moved her shoulder and stated, "That hurts." The Treatment Nurse continued to apply the medication to the wound. 2) At 10:30 a.m., the Treatment Nurse began treatment on the resident's sacrum. As the LPN began to scrub the wound bed with gauze the resident stated, "Oh, honey that hurts." The Treatment Nurse stated, "I'm sorry I have to get it clean." Resident #3 stated, "Well, it's clean." The resident flinched and attempted to move away from the nurse who continued to scrub the wound. g. On 6/25/14 at 9:35 a.m. Resident #3 was observed being administered medications by LPN #3. LPN #3 stated, "I usually give her something for pain. The night shift usually gives her something about 5:00 or 6:00 o'clock in the morning. When she first had her wounds she was in a lot of pain, but they have gotten better and they are not so bad now, so we give her medicine as she verbalizes. Any time you go in there and touch her or anything she well say, 'Oh baby I'm hurting', but well the pain is what they say it is. We kind of gauge (the time) when the Treatment Nurse (LPN #7) is going to do her treatment and medicate her before then. LPN #3 was asked, "What does she get?" LPN #3 stated, "She gets [MEDICATION NAME] routine or we can give her prn if she needs it, but she can get [MEDICATION NAME] if she needs it." As the LPN administered the resident's routine medication, LPN #3 asked the resident, "Are you hurting?" The resident stated, "Yes, my butt." The LPN went to the medication cart and got the [MEDICATION NAME]. As she was going to administer it via peg tube the resident stated, "Please don't hurt me, I'm already hurting." The pain medication was administered at 9:50 a.m. h. On 6/25/14 at 10:45 a.m., the Treatment Nurse began treatment on Resident #3s scapula wound. The nurse was scrubbing the Stage III pressure ulcer with wound cleanser and gauze when the Director of Nursing (DON) walked into the room. The DON asked the resident, "How are you doing, it's me Miss (name deleted) you know me?" The resident stated, "That hurts Miss (name deleted)." The DON looked up at the Treatment Nurse and walked out of the room." When the Treatment Nurse placed the Calcium Alginate into the wound bed the resident stated, "Baby that hurts." The Treatment Nurse stated, "I'm sorry." The resident stated, in a distressed voice, "Why are you always saying you're sorry." The resident flinched and attempted to move away from the nurse. After the bordered dressing was applied the resident stated, "You all hurt me baby, hurt me so bad." The Hydro/APAP 7.5 mg, administered 1 hour and 10 minutes before the beginning of the treatment, did not control the resident's pain during wound care to the Stage III and Stage IV pressure ulcers. i. On 6/25/14 at 11:15 a.m., the Treatment Nurse was asked, "How did you know (Resident #3) was pre-medicated for pain yesterday before you did the treatment?" The Treatment Nurse stated, "I had asked, I spoke with (LPN #3)." The Treatment Nurse was asked, "Do you think her pain was controlled during her treatment yesterday?" The Treatment Nurse stated, "Yes, because when it's uncontrolled she would be screaming out." The Treatment Nurse was asked, "When you were cleaning her sacrum wound and she said 'oh that hurts', you replied, 'I'm sorry but I have to clean it' the resident stated, 'Well it's clean', do you think it she was hurting?" The Treatment Nurse stated, "Yes, maybe, she says things repetitively any way, if you even touch her she says she's hurting." The Treatment Nurse was asked, "Do you think flinching and attempting to move away from you while you do the treatment is non-verbal indicators of pain?" The Treatment Nurse stated, "Yes." The Treatment Nurse was then asked, "They (the Wound Clinic) recommended EMLA for (Resident #3's) wounds from on 6/6 (June 6, 2014)? The Treatment Nurse stated, "Yes, but no hard copy was ever sent to us for that." The Treatment Nurse was asked, "Did you request a hard copy?" The Treatment Nurse stated, "Yes, I asked the nurse over there. They said they could send it back with her when she gets back from the wound clinic." The Treatment Nurse was asked, "When was this?" The Treatment Nurse stated, "It was the first couple of weeks of June and (name deleted) our aide was going over there with her and she had mentioned it really worked. Dr.(name deleted) had mentioned that if we wanted it just let him know and he would send it back on the next visit. That was on June 13th, she was supposed to go back June 20th, she didn't because the DON (name deleted) wanted her to start going bi-weekly because they were looking better, because we didn't want her sitting up all that time for her visit. We didn't want her uncomfortable so often and her wounds are looking better." The Treatment Nurse was asked, "Did you follow-up after the 20th, since she didn't go to get a hard copy for the EMLA?" The Treatment Nurse stated, "I didn't because she is getting her prn's daily and that usually takes care of her pain." The Treatment Nurse was asked, "When you started cleaning and packing the wounds and she says, 'Baby you guys hurt me so bad', do you think the prn's are controlling her pain? The Treatment Nurse stated, "No, maybe we need to increase her prn." j. On 6/26/14 at 4:00 p.m., the DON was asked, "Did anyone ever call the wound clinic for the EMLA cream?" The DON stated, "I don't know if she came back. It was not recommended until the 2nd or 3rd visit. I don't know if they thought we were going to put it in the wound or what." The DON was asked, "Could they have told you how they used it?" The DON stated, "Yes." k. On 6/27/14 at 9:30 a.m., the nurse from the Wound Clinic was asked, "On June 6th (6/6/14) the Physician documented, 'May use EMLA for wound care'. Can you tell me how the EMLA is applied?" The Wound Nurse stated, "What we do here is we debride. If the patient is having a lot of pain, we do it before we debride. We put it on 10-15 minutes before wound care. We just dampen gauze with it and place it in the wound and around the wound." The Wound Nurse was asked, "Did the facility staff ever contact you regarding the use of the EMLA, for example how to apply it?" The Wound Nurse stated, "Yesterday (6/26/14) they did, if it was an actual order, that as far as he was concerned if she was having pain with wound care they could use it." The Wound Nurse was asked, "Did they consult you regarding (Resident #3's) pain during wound care? The Wound Nurse stated, "No ma'am." On 6/27/14 at 9:45 a.m., the Physician's Assistant (PA) was asked, "Has the facility notified or consulted you regarding (Resident #3's) pain related to wound care? The PA stated, "No, not specifically to wound care." The PA was asked, "Have they consulted or told you about a recommendation from the wound clinic regarding the use of the EMLA cream related to pain with wound care?" The PA stated, "I don't know anything about that cream but, if it would alleviate her pain we would certainly check into it." 2. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on a BIMS; required extensive assistance of one person for transfer and toilet use; had no pain; and had a Stage 3 pressure ulcer that measured 2 x 2 x 2 centimeters (cm). a. The Resident Care Plan dated 1/8/14 did not document interventions to address pain for this resident. b. A Wound / Skin Healing Record dated 5/2/14 documented, " pain: yes, moaning/crying-sacral tender to touch only when (change) (dressing)." A Wound / Skin Healing Record dated 5/9/14 documented, " pain: yes ... tense." A Wound / Skin Healing Record dated 5/16/14 documented, "pain: yes ... moaning/crying during wound care." A Wound / Skin Healing Record dated 5/23/14 documented," pain: yes ... guarding . . . tense only during wound care." A Wound / Skin Healing Record dated 5/30/14 documented, " pain: yes ... guarding . . . tense, (resident) states, 'Ouch, you're poking me'." A Wound / Skin Healing Record dated 6/6/14 documented, "guarding ... during cleaning wound to sacrum." A Wound / Skin Healing Record dated 6/13/14 documented, " pain: yes ... guarding . . . sacral area." A Wound / Skin Healing Record dated 6/20/14 documented, " pain: yes ..., (resident) states, 'It feels like you're sticking me'." c. Nurse's Notes dated for May 1, 2014 through June 25, 2014 were reviewed. There was no documentation of a physician consultation regarding the resident's documented pain during wound treatments. d. A Physician order [REDACTED]. On 6/25/14 at 10:25 a.m., Treatment Nurse / LPN #7 provided treatment to the resident's healing stage 3 at the sacrum. The resident did not make statements of pain at that time. e. On 6/26/14 at 4:28 p.m., the DON was informed of the resident's documented pain during pressure ulcer treatments and that no documentation of a physician consult regarding the resident's pain was in the resident's clinical record. The DON was asked to provide further evidence of a physician consult if it had been done. As of 6/27/14 at 1:00 p.m., the requested information had not been provided.

Based on observation, record review and interview, the facility failed to ensure that pain was effectively managed after complaints or signs of pain were observed for 3 (Residents #3, #5 and #8) of 5 (Residents #3, #5, #6, #8 and #9) case mix residents with identified pain. This failed practice resulted in a pattern of harm for Resident #3 who had stated pain during wound treatments and a recommendation from a wound clinic for pain management interventions that were not addressed by the facility for a period of greater than 2 weeks. This failed practice had the potential to affect 14 residents who received pain management as documented by the Minimum Data Set (MDS) Coordinator on 6/27/14 at 9:14 a.m. The findings are: 1. Resident #3 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly MDS with an Assessment Reference Date (ARD) of 5/6/14 documented the resident scored 4 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required total assistance of two plus persons for transfer, bed mobility, dressing and bathing; received 51% or more of nutrition via a percutaneous endoscopic tube (PEG tube), had one Stage 3 pressure ulcer and one unstageable pressure ulcer; and had pain daily. a. A Physician order [REDACTED]." b. A Wound/Skin Healing Record dated 5/2/14 documented, "PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing; Pain Location: to coccyx wound; Nature of Pain (specify): when cleaning only or changing drsg (dressing), PAIN: is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Locations: Lt (left) back (wound site); Nature of Pain (specify): Tender to touch ..." A Wound/Skin Healing Record dated 5/9/14 documented, "PAIN: is patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Location: Coccyx wound; Nature of Pain (specify): During drsg change (Lt. back (position shoulder); 'scapula') PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Nature of Pain (specify): Tender to touch area..." c. Nurse's Notes dated 5/16/14 at 1:00 p.m. documented, "EMLA ([MEDICATION NAME] and [MEDICATION NAME]) requested to use c (with) R (resident) to decrease px (pain) during drsg changes. Will continue to monitor ..." A Physician order [REDACTED]. Cleanse left scapula area wound with wound cleaner, apply Calcium Alginate and Santyl, cover with bordered dressing 3 x/ wk and prn." d. A Wound Clinic Physician order [REDACTED]." Nurse's Notes dated 6/6/14, no time on note, documented, "Dr. (name deleted) suggested use of EMLA for wound care but no prescription/hard copy of physician order [REDACTED]." e. On 6/24/14 at 9:10 a.m., Certified Nursing Assistants (CNAs) #4 and #6 provided incontinent care for Resident #3. During care the resident stated, "I'm hurting. My legs are hurting." CNA #4 stated, "I'll tell your nurse." At 9:40 a.m., without being assessed for pain or provided interventions for her complaint of leg pain, the resident was lifted and weighed via a mechanical lift by CNAs #4 and #5. During the process, Resident #3 stated, "My legs hurt; can you give me something for pain?" CNA #4 stated, "We can't give you anything but we will tell your nurse." On 6/25/14 at 9:55 a. m., Licensed Practical Nurse (LPN) #3 who was assigned to Resident #3 on 6/24/14 was asked, "Did anyone tell you yesterday (Resident #3) was hurting?" The LPN stated, "No ma ' am, they told me the lady in the other bed was hurting." f. On 6/24/14 at 10:10 a.m., the Treatment Nurse (LPN#7) provided wound care for the resident. The Treatment Nurse stated, "It's ordered 3 times per week (dressing changes), but I have been changing the dressings every day because of the drainage. " The Treatment Nurse added, "She (Resident #3) was pre-medicated about an hour ago." The June 2014 MAR (Medication Administration Record) for Resident #3 was reviewed. The MAR indicated [REDACTED]. The Narcotic Record documented the resident was administered Hydro/APAP at 12:14 a.m. on 6/24/14. The resident had not received the Hydro/APAP for 9 hours and 56 minutes before the treatment to the pressure ulcers was performed. 1) At 10:18 a.m., during wound care, the Treatment Nurse scrubbed the resident ' s scapula wound, using a 4 x 4 gauze and a Q-tip to cleanse the tunneling area and under the wound edge. Resident #3 flinched and attempted to move her shoulder away from the nurse, stating, "That hurts." The Treatment Nurse stated, "I'm sorry" and continued to scrub the wound. The Treatment Nurse proceeded to apply Santyl to the resident's scapula wound using another Q-Tip. The resident flinched, moved her shoulder and stated, "That hurts." The Treatment Nurse continued to apply the medication. 2) At 10:30 a.m., the Treatment Nurse began treatment on the resident's sacrum. As the LPN began to scrub the wound bed with gauze the resident stated, "Oh, honey that hurts." The Treatment Nurse stated, "I'm sorry I have to get it clean." Resident #3 stated, "Well, it's clean." The resident flinched and attempted to move away from the nurse who continued to scrub the wound. g. On 6/25/14 at 9:35 a.m. Resident #3 was observed being administered medications by LPN #3. LPN #3 stated, "I usually give her something for pain. The night shift usually gives her something about 5:00 or 6:00 o'clock in the morning. When she first had her wounds she was in a lot of pain, but they have gotten better and they are not so bad now, so we give her medicine as she verbalizes. Any time you go in there and touch her or anything she well say, 'Oh baby I'm hurting', but well the pain is what they say it is. We kind of gauge (the time) when the Treatment Nurse (LPN #7) is going to do her treatment and medicate her before then. LPN #3 was asked, "What does she get?" LPN #3 stated, "She gets [MEDICATION NAME] routine or we can give her prn if she needs it, but she can get [MEDICATION NAME] if she needs it." As the LPN administered the resident's routine medication LPN #3 asked the resident, "Are you hurting?" The resident stated, "Yes, my butt." The LPN went to the medication cart and got the [MEDICATION NAME]. As she was going to administer it via peg tube the resident stated, "Please don't hurt me, I'm already hurting." The pain medication was administered at 9:50 a.m. h. On 6/25/14 at 10:45 a.m., the Treatment Nurse began treatment on Resident #3s scapula wound. The nurse was scrubbing the Stage III pressure ulcer with wound cleanser and gauze when the Director of Nursing (DON) walked into the room. The DON asked the resident, "How are you doing, it's me Miss (name deleted) you know me?" The resident stated, "That hurts Miss (name deleted)." The DON looked up at the Treatment Nurse and walked out of the room." When the Treatment Nurse placed the Calcium Alginate into the wound bed the resident stated, "Baby that hurts." The Treatment Nurse stated, "I'm sorry." The resident stated, in a distressed voice, "Why are you always saying you're sorry." The resident flinched and attempted to move away from the nurse. After the bordered dressing was applied the resident stated, "You all hurt me baby, hurt me so bad." The Hydro/APAP 7.5 mg, administered 1 hour and 10 minutes before the beginning of the treatment, did not control the resident's pain during wound care to the Stage III and Stage IV pressure ulcers. i. On 6/25/14 at 11:15 a.m., the Treatment Nurse was asked, "How did you know (Resident #3) was pre-medicated for pain yesterday before you did the treatment?" The Treatment Nurse stated, "I had asked, I spoke with (LPN #3)." The Treatment Nurse was asked, "Do you think her pain was controlled during her treatment yesterday?" The Treatment Nurse stated, "Yes, because when it's uncontrolled she would be screaming out." The Treatment Nurse was asked, "When you were cleaning her sacrum wound and she said 'oh that hurts', you replied, 'I'm sorry but I have to clean it' the resident stated, 'Well it's clean', do you think it she was hurting?" The Treatment Nurse stated, "Yes, maybe, she says things repetitively any way, if you even touch her she says she's hurting." The Treatment Nurse was asked, "Do you think flinching and attempting to move away from you while you do the treatment is non-verbal indicators of pain?" The Treatment Nurse stated, "Yes." The Treatment Nurse was then asked, "They (the Wound Clinic) recommended EMLA for (Resident #3's) wounds from on 6/6 (June 6, 2014)? The Treatment Nurse stated, "Yes, but no hard copy was ever sent to us for that." The Treatment Nurse was asked, "Did you request a hard copy?" The Treatment Nurse stated, "Yes, I asked the nurse over there. They said they could send it back with her when she gets back from the wound clinic." The Treatment Nurse was asked, "When was this?" The Treatment Nurse stated, "It was the first couple of weeks of June and (name deleted) our aide was going over there with her and she had mentioned it really worked. Dr.(name deleted) had mentioned that if we wanted it just let him know and he would send it back on the next visit. That was on June 13th, she was supposed to go back June 20th, she didn't because the DON (name deleted) wanted her to start going bi-weekly because they were looking better, because we didn't want her sitting up all that time for her visit. We didn't want her uncomfortable so often and her wounds are looking better." The Treatment Nurse was asked, "Did you follow-up after the 20th, since she didn't go to get a hard copy for the EMLA?" The Treatment Nurse stated, "I didn't because she is getting her prn's daily and that usually takes care of her pain." The Treatment Nurse was asked, "When you started cleaning and packing the wounds and she says, 'Baby you guys hurt me so bad', do you think the prn's are controlling her pain? The Treatment Nurse stated, "No, maybe we need to increase her prn." j. On 6/26/14 at 4:00 p.m., the DON was asked, "Did anyone ever call the wound clinic for the EMLA cream?" The DON stated, "I don't know if she came back. It was not recommended until the 2nd or 3rd visit. I don't know if they thought we were going to put it in the wound or what." The DON was asked, "Could they have told you how they used it?" The DON stated, "Yes." k. On 6/27/14 at 9:30 a.m., the nurse from the Wound Clinic was asked, "On June 6th (6/6/14) the Physician documented, 'May use EMLA for wound care'. Can you tell me how the EMLA is applied?" The Wound Nurse stated, "What we do here is we debride. If the patient is having a lot of pain, we do it before we debride. We put it on 10-15 minutes before wound care. We just dampen gauze with it and place it in the wound and around the wound." The Wound Nurse was asked, "Did the facility staff ever contact you regarding the use of the EMLA, for example how to apply it?" The Wound Nurse stated, "Yesterday (6/26/14) they did, if it was an actual order, that as far as he was concerned if she was having pain with wound care they could use it." The Wound Nurse was asked, "Did they consult you regarding (Resident #3's) pain during wound care? The Wound Nurse stated, "No ma'am." On 6/27/14 at 9:45 a.m., the Physician's Assistant (PA) was asked, "Has the facility notified or consulted you regarding (Resident #3's) pain related to wound care? The PA stated, "No, not specifically to wound care." The PA was asked, "Have they consulted or told you about a recommendation from the wound clinic regarding the use of the EMLA cream related to pain with wound care?" The PA stated, "I don't know anything about that cream but, if it would alleviate her pain we would certainly check into it." 2. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on a BIMS; required extensive assistance of one person for transfer and toilet use; had no pain; and had a Stage 3 pressure ulcer that measured 2 x 2 x 2 centimeters (cm). a. The Resident Care Plan dated 1/8/14 did not document interventions to address pain for this resident. b. Quarterly Pain Assessments dated 12/27/13 and 4/1/14 documented no pain for this resident. c. Wound / Skin Healing Records documented weekly pressure ulcer assessments without pain on 12/27/13, 1/3/14, 1/10/14, 1/18/14, 1/23/14, 1/30/14, 2/5/14, 2/12/14, 2/24/14, 3/3/14, and 3/12/14. There was no documentation of weekly wound assessments between 3/12/14 and 5/2/14. d. A Wound / Skin Healing Record dated 5/2/14 documented, " pain: yes, moaning/crying-sacral tender to touch only when (change) (dressing)." A Wound / Skin Healing Record dated 5/9/14 documented, " pain: yes ... tense." A Wound / Skin Healing Record dated 5/16/14 documented, "pain: yes ... moaning/crying during wound care." A Wound / Skin Healing Record dated 5/23/14 documented," pain: yes ... guarding . . . tense only during wound care." A Wound / Skin Healing Record dated 5/30/14 documented, " pain: yes ... guarding . . . tense, (resident) states, 'Ouch, you're poking me'." A Wound / Skin Healing Record dated 6/6/14 documented, "guarding ... during cleaning wound to sacrum." A Wound / Skin Healing Record dated 6/13/14 documented, " pain: yes ... guarding . . . sacral area." A Wound / Skin Healing Record dated 6/20/14 documented, " pain: yes ..., (resident) states, 'It feels like you're sticking me'." e. Nurse's Notes dated for May 1, 2014 through June 25, 2014 were reviewed. There was no documentation of a physician consultation regarding the resident's documented pain during wound treatments. f. Medication Administration Records (MARs) dated for the months of April 2014, May 2014 and June 2014 were reviewed. The resident had a physician order [REDACTED]. There was no documentation to verify that Tylenol 325 mg had been administered to the resident on the above noted MARs. g. A Physician order [REDACTED]. On 6/25/14 at 10:25 a.m., Treatment Nurse / LPN #7 provided treatment to the resident's healing stage 3 at the sacrum. The resident did not make statements of pain at that time. h. On 6/26/14 at 4:28 p.m., the Director of Nursing (DON) was asked if the Treatment Nurse / LPN #7 had ever reported the resident's assessed pain. The DON stated, "No." 3. Resident #8 had a [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 5/5/14 documented the resident scored 11 (a score of 8-12 indicates moderate impairment) on a BIMS and required limited assistance of one person for toilet use. a. A Physician order [REDACTED]." b. On 6/24/14 at 12:46 p.m., CNA #3 brought the resident's lunch tray to the room and stated the resident fed herself. The resident did not attempt to eat. At 12:52 p.m., the Activity Director, DON and LPN #6 were in the resident's room when the resident stated, "stomach not right." At 1:03 p.m., the Activity Director, who had been encouraging the resident to eat, stated, "She won't eat, I'm getting her a Sprite." c. On 6/25/14 at 2:00 p.m., LPN #6 provided a copy of the resident's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. LPN #6 stated, "No."

Based on observation, record review and interview, the facility's Nursing Administration failed to ensure that Treatment Nurse/Licensed Practical Nurse (LPN) #7 was monitored during provision of treatments by Assistant Director of Nursing (ADON) or Director of Nursing (DON) to ensure pain during wound treatments was effectively managed for 2 of 2 (Residents #3 and #5) case mix residents with pressure ulcer treatments. The failed practice resulted in a pattern of harm for Resident #3 whose complaints of pain were not responded to in a timely manner and a wound clinic recommendation for wound pain treatment was not put in place. The failed practice had the potential to affect 3 residents with pressure ulcer treatments with identified pain as documented by the Minimum Data Set (MDS) Coordinator on 6/27/14 at 9:14 a.m. The findings are: 1. On 6/27/14 at 9:48 a.m., the Medicare Registered Nurse (RN) provided the job description for the Assistant Director of Nursing (ADON). The job description documented, " ...should possess a working knowledge of state and federal regulations in (state)," and "promote quality delivery of healthcare services..." The job description did not document monitoring of treatments. 2. On 6/27/14 at 11:40 a.m., the facility's physician consultant (OD #1) provided the job description for the DON which documented, " ...The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times," and "schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request," and "Monitor . . . treatment schedules to ensure that . . . treatments are provided as scheduled ...." 3. On 6/27/14 at 11:40 a.m., OD #1 provided the job description for "Treatment Nurse," which documented, " ...The primary purpose of you job position is to provide primary skin care to resident under the medical direction and supervision of the residents' attending physician, the Director of Nursing Services . . . You will also assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident . . . " and in the section Experience, " ...Must have, as a minimum, two (2) years of experience as an LPN/RN..." a. On 6/27/14, the personnel file for Treatment Nurse/LPN #7 was reviewed. LPN #7's application documented a license for practical nursing was issued September 2012 and that the nurse's date of hire was 4/24/14, 19 months after the nurse's LPN license was received. 4. Resident #3 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly MDS with an Assessment Reference Date (ARD) of 5/6/14 documented the resident scored 4 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required total assistance of two plus persons for transfer, bed mobility, dressing and bathing; received 51% or more of nutrition via a Percutaneous endoscopic Tube (PEG tube); had one Stage 3 pressure ulcer and one unstageable pressure ulcer; and had pain daily. a. A Physician order [REDACTED]." A Physician order [REDACTED]." b. A Wound/Skin Healing Record dated 5/2/14 documented, "PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing; Pain Location: to coccyx wound; Nature of Pain (specify): when cleaning only or changing drsg (dressing), PAIN: is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Locations: Lt (left) back (wound site); Nature of Pain (specify): Tender to touch ..." A Wound/Skin Healing Record dated 5/9/14 documented, "PAIN: is patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Pain Location: Coccyx wound; Nature of Pain (specify): During drsg change (Lt. back (position shoulder); 'scapula') PAIN: Is the patient experiencing pain related to wound? Yes; Non-verbal's demonstrated: Grimacing, Moaning/Crying; Nature of Pain (specify): Tender to touch area..." c. Nurse's Notes dated 5/16/14 at 1:00 p.m. documented, "EMLA ([MEDICATION NAME] and [MEDICATION NAME]) requested to use c (with) R (resident) to decrease px (pain) during drsg changes. Will continue to monitor ..." A Physician order [REDACTED]. Cleanse left scapula area wound with wound cleaner, apply Calcium Alginate and Santyl, cover with bordered dressing 3 x/ wk and prn." d. A Wound Clinic Physician order [REDACTED]." Nurse's Notes dated 6/6/14, no time on note, documented, "Dr. (name deleted) suggested use of EMLA for wound care but no prescription/hard copy of physician order [REDACTED]." e. On 6/24/14 at 9:10 a.m., Certified Nursing Assistants (CNAs) #4 and #6 provided incontinent care for Resident #3. During care the resident stated, "I'm hurting. My legs are hurting." CNA #4 stated, "I'll tell your nurse." At 9:40 a.m., without being assessed for pain or provided interventions for her complaint of leg pain, the resident was lifted and weighed via a mechanical lift by CNAs #4 and #5. During the process, Resident #3 stated, "My legs hurt; can you give me something for pain?" CNA #4 stated, "We can't give you anything but we will tell your nurse." On 6/25/14 at 9:55 a. m., Licensed Practical Nurse (LPN) #3 who was assigned to Resident #3 on 6/24/14 was asked, "Did anyone tell you yesterday (Resident #3) was hurting?" The LPN stated, "No ma ' am, they told me the lady in the other bed was hurting." f. On 6/24/14 at 10:10 a.m., the Treatment Nurse (LPN#7) provided wound care for the resident. The Treatment Nurse stated, "It's ordered 3 times per week (dressing changes), but I have been changing the dressings every day because of the drainage. " The Treatment Nurse added, "She (Resident #3) was pre-medicated about an hour ago." The June 2014 MAR (Medication Administration Record) for Resident #3 was reviewed. The MAR indicated [REDACTED]. The Narcotic Record documented the resident was administered Hydro/APAP at 12:14 a.m. on 6/24/14. The resident had not received the Hydro/APAP for 9 hours and 56 minutes before the treatment to the pressure ulcers was performed. 1) At 10:18 a.m., during wound care the Treatment Nurse washed her hands, put on gloves, removed a pillow from behind the resident's back and took off her gloves. Without washing her hands or using alcohol gel, she took a hand full of gloves out of the box and laid them on the resident's bed approximately 6-8 inches from the stage 3 scapula wound. She double gloved and removed the soiled dressing. After taking off the top pair of gloves, she sprayed the wound cleanser into the wound, with the tip of the sprayer approximately 1/4 inch from the wound. The Treatment Nurse then scrubbed the resident ' s scapula wound, using a 4x4 gauze and a Q-tip to cleanse the tunneling area and under the wound edge. Resident #3 flinched and attempted to move her shoulder away from the nurse, stating, "That hurts." The Treatment Nurse stated, "I'm sorry" and continued to scrub the wound. The nurse then dried the edges of the wound with the same gauze used to clean the wound. The Treatment Nurse removed her remaining pair of gloves and without washing her hands she opened the sterile Q-tip package. She touched the cotton tip with her bare hand, and placed the Q-tip into the plastic medicine cup which contained the Santyl. After donning a pair of gloves, from the resident's bed, she placed the Santyl into the wound using the contaminated Q-tip from the medicine cup. The Treatment Nurse proceeded to apply Santyl to the resident's scapula wound using another Q-Tip. The resident flinched, moved her shoulder and stated, "That hurts." The Treatment Nurse continued to apply the medication to the wound. The nurse then opened the sterile package of Calcium Alginate dressing. She tore off a piece and placed it on the wound. She then placed the remainder of the Calcium Alginate dressing back into the opened package. She took off her gloves, applied skin prep around the resident's wound, then opened the sterile border dressing, removed the protective covering and applied the bandage on top of the Calcium Alginate in the wound bed. 2) At 10:30 a.m., the Treatment Nurse began treatment on the resident's sacrum. The Treatment Nurse picked up two pairs of gloves from the bed, put on both pair and removed the soiled dressing from Resident #3's sacrum. She removed the top pair of gloves, sprayed wound cleanser into the wound bed, holding the tip of the sprayer approximately 1/4" from the wound, contaminating the end of the sprayer with cleanser which splashed from the wound bed. As the LPN began to scrub the wound bed with gauze the resident stated, "Oh, honey that hurts." The Treatment Nurse stated, "I'm sorry I have to get it clean." Resident #3 stated, "Well, it's clean." The resident flinched and attempted to move away from the nurse who continued to scrub the wound. The Treatment Nurse then dried the wound edges with the contaminated gauze. She removed her gloves and donned two more pair that had been lying on the bed. After opening the package of Calcium Alginate the Treatment Nurse pulled a pair of scissors out of her pocket and cut the sterile dressing before she applied it to the sacral wound. g. On 6/25/14 at 9:35 a.m. Resident #3 was observed being administered medications by LPN #3. LPN #3 stated, "I usually give her something for pain. The night shift usually gives her something about 5:00 or 6:00 o'clock in the morning. When she first had her wounds she was in a lot of pain, but they have gotten better and they are not so bad now, so we give her medicine as she verbalizes. Any time you go in there and touch her or anything she well say, 'Oh baby I'm hurting', but well the pain is what they say it is. We kind of gauge (the time) when the Treatment Nurse (LPN #7) is going to do her treatment and medicate her before then. LPN #3 was asked, "What does she get?" LPN #3 stated, "She gets [MEDICATION NAME] routine or we can give her prn if she needs it, but she can get [MEDICATION NAME] if she needs it." As the LPN administered the resident's routine medication, LPN #3 asked the resident, "Are you hurting?" The resident stated, "Yes, my butt." The LPN went to the medication cart and got the [MEDICATION NAME]. As she was going to administer it via peg tube the resident stated, "Please don't hurt me, I'm already hurting." The pain medication was administered at 9:50 a.m. h. On 6/25/14 at 10:45 a.m., the Treatment Nurse began treatment on Resident #3s scapula wound. The nurse was scrubbing the Stage III pressure ulcer with wound cleanser and gauze when the Director of Nursing (DON) walked into the room. The DON asked the resident, "How are you doing, it's me Miss (name deleted) you know me?" The resident stated, "That hurts Miss (name deleted)." The DON looked up at the Treatment Nurse and walked out of the room. The nurse completed wound care to the resident's scapula and began wound care to the resident's sacrum. After cleansing the sacral wound the nurse opened the Calcium Alginate, laid it on the wound bed and cut it to size. As she cut the dressing, the tip of the scissors touched the inside of the wound. When the Treatment Nurse placed the Calcium Alginate into the wound bed the resident stated, "Baby that hurts." The Treatment Nurse stated, "I'm sorry." The resident stated, in a distressed voice, "Why are you always saying you're sorry." The resident flinched and attempted to move away from the nurse. The nurse opened a package of sterile gauze. She then placed the gauze on a contaminated field that she then picked up and held in the palm of her hand. She sprayed the gauze with normal saline wound cleanser, folded in the gauze and placed the contaminated side directly on top of the Calcium Alginate. The gauze that had been placed on the Calcium Alginate fell off the site. The Treatment Nurse took off her gloves and without washing her hands, went to the treatment cart in the hall, brought another package of sterile gauze into the room, and without washing her hands, put on a pair of gloves, opened the sterile package, holding the package in the palm of her hand, placed the gauze on the top of the package, sprayed the gauze with the normal saline wound cleanser. She then folded the gauze and placed the contaminated side directly on top of the Calcium Alginate. After the bordered dressing was applied the resident stated, "You all hurt me baby, hurt me so bad." The Hydro/APAP 7.5 mg, administered 1 hour and 10 minutes before the beginning of the treatment did not control the resident's pain during wound care to the Stage 3 and Stage 4 pressure ulcers. k. On 6/25/14 at 11:15 a.m., the Treatment Nurse was asked, "How did you know (Resident #3) was pre-medicated for pain yesterday before you did the treatment?" The Treatment Nurse stated, "I had asked, I spoke with (LPN #3)." The Treatment Nurse was asked, "Do you think her pain was controlled during her treatment yesterday?" The Treatment Nurse stated, "Yes, because when it's uncontrolled she would be screaming out." The Treatment Nurse was asked, "When you were cleaning her sacrum wound and she said 'oh that hurts', you replied, 'I'm sorry but I have to clean it' the resident stated, 'Well it's clean', do you think it she was hurting?" The Treatment Nurse stated, "Yes, maybe, she says things repetitively any way, if you even touch her she says she's hurting." The Treatment Nurse was asked, "Do you think flinching and attempting to move away from you while you do the treatment is non-verbal indicators of pain?" The Treatment Nurse stated, "Yes." The Treatment Nurse was then asked, "They (the Wound Clinic) recommended EMLA for (Resident #3's) wounds from on 6/6 (June 6, 2014)? The Treatment Nurse stated, "Yes, but no hard copy was ever sent to us for that." The Treatment Nurse was asked, "Did you request a hard copy?" The Treatment Nurse stated, "Yes, I asked the nurse over there. They said they could send it back with her when she gets back from the wound clinic." The Treatment Nurse was asked, "When was this?" The Treatment Nurse stated, "It was the first couple of weeks of June and (name deleted) our aide was going over there with her and she had mentioned it really worked. Dr.(name deleted) had mentioned that if we wanted it just let him know and he would send it back on the next visit. That was on June 13th, she was supposed to go back June 20th, she didn't because the DON (name deleted) wanted her to start going bi-weekly because they were looking better, because we didn't want her sitting up all that time for her visit. We didn't want her uncomfortable so often and her wounds are looking better." The Treatment Nurse was asked, "Did you follow-up after the 20th, since she didn't go to get a hard copy for the EMLA?" The Treatment Nurse stated, "I didn't because she is getting her prn's daily and that usually takes care of her pain." The Treatment Nurse was asked, "When you started cleaning and packing the wounds and she says, 'Baby you guys hurt me so bad', do you think the prn's are controlling her pain? The Treatment Nurse stated, "No, maybe we need to increase her prn." l. On 6/26/14 at 4:00 p.m., the DON was asked, "Did anyone ever call the wound clinic for the EMLA cream?" The DON stated, "I don't know if she came back. It was not recommended until the 2nd or 3rd visit. I don't know if they thought we were going to put it in the wound or what." The DON was asked, "Could they have told you how they used it?" The DON stated, "Yes." On 6/27/14 at 9:30 a.m., the nurse from the Wound Clinic was asked, "On June 6th (6/6/14) the Physician documented, 'May use EMLA for wound care'. Can you tell me how the EMLA is applied?" The Wound Nurse stated, "What we do here is we debride. If the patient is having a lot of pain, we do it before we debride. We put it on 10-15 minutes before wound care. We just dampen gauze with it and place it in the wound and around the wound." The Wound Nurse was asked, "Did the facility staff ever contact you regarding the use of the EMLA, for example how to apply it?" The Wound Nurse stated, "Yesterday (6/26/14) they did, if it was an actual order, that as far as he was concerned if she was having pain with wound care they could use it." The Wound Nurse was asked, "Did they consult you regarding (Resident #3's) pain during wound care? The Wound Nurse stated, "No ma'am." On 6/27/14 at 9:45 a.m., the Physician's Assistant (PA) was asked, "Has the facility notified or consulted you regarding (Resident #3's) pain related to wound care? The PA stated, "No, not specifically to wound care." The PA was asked, "Have they consulted or told you about a recommendation from the wound clinic regarding the use of the EMLA cream related to pain with wound care?" The PA stated, "I don't know anything about that cream but, if it would alleviate her pain we would certainly check into it." 5. Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/1/14 documented the resident scored 5 (0-7 indicates severe impairment) on a BIMS; required extensive assistance of one person for transfer and toilet use; had no pain; and had a Stage 3 pressure ulcer that measured 2 x 2 x 2 centimeters (cm). a. The Resident Care Plan dated 1/8/14 did not document interventions to address pain for this resident. b. Quarterly Pain Assessments dated 12/27/13 and 4/1/14 documented no pain for this resident. c. Wound / Skin Healing Records documented weekly pressure ulcer assessments without pain on 12/27/13, 1/3/14, 1/10/14, 1/18/14, 1/23/14, 1/30/14, 2/5/14, 2/12/14, 2/24/14, 3/3/14, and 3/12/14. There was no documentation of weekly wound assessments between 3/12/14 and 5/2/14. d. A Wound / Skin Healing Record dated 5/2/14 documented, " pain: yes, moaning/crying-sacral tender to touch only when (change) (dressing)." A Wound / Skin Healing Record dated 5/9/14 documented, " pain: yes ... tense." A Wound / Skin Healing Record dated 5/16/14 documented, "pain: yes ... moaning/crying during wound care." A Wound / Skin Healing Record dated 5/23/14 documented," pain: yes ... guarding . . . tense only during wound care." A Wound / Skin Healing Record dated 5/30/14 documented, " pain: yes ... guarding . . . tense, (resident) states, 'Ouch, you're poking me'." A Wound / Skin Healing Record dated 6/6/14 documented, "guarding ... during cleaning wound to sacrum." A Wound / Skin Healing Record dated 6/13/14 documented, " pain: yes ... guarding . . . sacral area." A Wound / Skin Healing Record dated 6/20/14 documented, " pain: yes ..., (resident) states, 'It feels like you're sticking me'." e. Nurse's Notes dated for May 1, 2014 through June 25, 2014 were reviewed. There was no documentation of a physician consultation regarding the resident's documented pain during wound treatments. f. Medication Administration Records (MAR's) dated for the months of April 2014, May 2014 and June 2014 were reviewed. The resident had a physician order [REDACTED]. There was no documentation to verify that Tylenol 325 mg had been administered to the resident on the above noted MARs. g. A Physician order [REDACTED]. On 6/25/14 at 10:25 a.m., Treatment Nurse / LPN #7 provided treatment to the resident's healing stage 3 at the sacrum. The resident did not make statements of pain at that time. h. On 6/26/14 at 4:28 p.m., the Director of Nursing (DON) was asked if the Treatment Nurse / LPN #7 had ever reported the resident's assessed pain. The DON stated, "No." 6. On 6/26/14 at 12:55 p.m., the DON was asked to describe the training provided for Treatment Nurse/LPN #7 when she was hired. The DON stated she had no documentation of specialized training for wound treatments, and, "first couple of weeks we (DON and ADON) were with her every treatment," but no check off sheet was documented. The DON stated LPN #7 had been a treatment nurse, "for 2 years before here and trained with (wound/ostomy company) at her previous long term care facility." The DON was asked to call LPN #7's previous workplace and request evidence of that specialized wound training. As of 6/27/14 at 1:00 p.m., no documented evidence had been provided. 7. On 6/26/14 at 3:13 p.m., the ADON was asked if she had observed or monitored LPN #7 during wound treatments after orientation and the ADON stated LPN #7 was not, "receptive, (acted) offended," and made statements, "don't need you watching." The ADON was asked what she did about that and she stated she informed the DON. a. On 6/26/14 at 4:40 p.m., the DON was asked how LPN #7 was monitored during wound treatments and she stated, "(LPN #7) was not receptive," when she attempted to watch treatments. The DON was asked if she routinely monitored LPN #7 during wound treatments and she stated, "not routinely going with (LPN #7) to observe treatments."

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure necessary treatment and services were provided to Resident #1to prevent the development of pressure sores. The facility failed to ensure skin assessments were completed at least once every shift after the application of a removable air cast for 1 (Resident #1) of 1 (Residents #1) case mix residents who had an air cast walking boot in place and 5 (Residents #1 through #5) case mix residents who were identified by the facility to be at risk for the development of skin breakdown. The failed practice resulted in immediate jeopardy which likely caused or could have caused serious harm, injury or death to Resident #1who developed Stage IV pressure sores to the right lower leg/foot and had the likelihood of causing more than minimal harm to 16 residents who were at risk for pressure sores according to a list provided by the Director of Nursing on 3/3/11 at 8:26 a.m. The facility was informed of the immediate jeopardy situation on 3/2/11 at 3:24 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. a. The Resident Assessment Protocol Summary (RAPS) dated 7/29/10 documented, "Resident is at risk for breakdown due to incontinence and impaired mobility." b. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 1/21/11 documented the resident had a staff assessment for mental status which documented the resident had severely impaired cognitive skills for daily decision-making, was totally dependent on staff for activities of daily living, required total assistance for bed mobility, transfers, personal hygiene and toilet use, was incontinent of bowel and bladder, was not at risk for developing pressure ulcers and had no pressure ulcers at the time of this assessment and had 2 venous and arterial ulcers present. c. The Braden Scale for Predicting Pressure Sore Risk form dated 1/21/11 documented a total score of "14" with a total score of 13 - 14 indicating a moderate risk for developing pressure sores. d. The Care Plan dated 1/21/11 documented, " Problem ...Risk for skin breakdown as resident is incontinent of bowel and bladder. At risk for breakdown due to impaired mobility and incontinence. ...Problem ...Resident with history of wound to bilateral legs related to [MEDICAL CONDITION]." e. A Nurse's Note dated 2/21/11 at 11:30 a.m. documented, "Received order for x-ray right tibia and fibula rule out fracture..." f. A Nurse's Note dated 2/22/11 at 2:35 a.m. documented, "Resident returned from ER (emergency room ) on stretcher, attendant x 2, with sitter... Right LE (lower extremity) wrapped with hard cast on... " g. A Nurse's Note dated 2/22/11 at 1:35 p.m. documented, "Appointment made for follow up with (Orthopedic doctor). Appointment at 1:10 p.m. ..." h. A Nurse's Note dated 2/23/11(2/24/11) at 5:30 a.m., documented, "Resident in bed with walker boot on. No problem noted..." i. A Nurse's Note dated 2/24/11 (no time) and signed by the treatment nurse documented, "Resident has walking boot to right LE related to fracture and air is pumped through pillows inside the boot to adjust the compression and accommodate for swelling related to [MEDICAL CONDITION] and trauma. Cap (capillary) refill is less than 3 seconds. No affect of pain when extremity is moved. Verbalized no when asked if she was hurting anywhere. Air deflated, boot removed. No changes in skin integrity related to boot... Boot replaced and pumped air to keep extremity immobilized at ankle..." j. A Nurse's Note dated 3/1/11 (no time) and signed by the Assistant Director of Nursing documented, "Called to room... with (Director of Nursing) to assess right lower leg after air boot (splint for fractures). Large amount brown eschar to inside lower leg, another large area with eschar located laterally caused by pressure from air boot used as splint... (ambulance service) contacted for transport to (hospital)... Areas measure (inside) 10.2 cm (centimeters) x 7.1 cm. Lower area 6.5 cm x 10 cm. (Lateral) 5.6 cm x 6.8 cm..." A Nurse's Note dated 3/1/11 (no time) and signed by the treatment nurse documented, "...Brace to RLL (right lower leg) - cap refill is less than 3 seconds, color is normal for skin tone. Removed brace buckles in front and deflated air. Suspected DTI (deep tissue injury) and possible ecchymosis related to fracture. 2.8 x 3.0 x < (less than) 0.2 cm area of pressure noted to top of foot over the bony prominence of great toe, more proximal to the middle of foot. Ecchymotic area encompassed heel around to encircle calcaneous bilaterally. Skin is dry and scaly and medial side and dry and intact with no flaking on lateral. Area is depleted of fluid related to air tube in boot compressing to stabilize fracture. Sending resident out to ER related to boot causing areas of breakdown and concern of maintaining the healing of bone with the need to reduce the amount of air to elevate pressure areas..." k. On 3/2/11 at 8:30 a.m., Licensed Practical Nurse (LPN) #1 was asked why Resident #1 was not in her room. The nurse stated, "She's in the hospital." When asked why, she stated, "Yesterday evening, that black boot on her fractured leg was removed and there were some sores on her skin." LPN #1 was asked if that was a removable boot. She stated, "Yes." The LPN was asked if there were instructions or orders on how often to take the boot off. She stated, "The only thing I had was a little piece of paper on how to put the boot on. The Director of Nursing (DON) just came and got that." LPN #1 was asked if she had ever taken the boot off and checked the resident's skin. She stated, "No." l. On 3/2/11 at 10:50 a.m., the treatment nurse was asked if there were any orders or clarification on how often the air cast could be removed. She stated, "Initially, the Ortho doctor didn't want to put it in a cast because of swelling and pressure so he put her in this boot. Per the sitter, the boot was to be inflated and you check the tightness by putting your hand down in it. I did capillary refill checks." The treatment nurse was asked if she herself called the doctor and asked for instructions on the boot, since this information was from the sitter. She stated, "No." The treatment nurse was asked if she removed the boot any time other than on 2/24/11. She stated she did not because she was afraid to due to the fracture. The treatment nurse was asked what she observed when the boot was removed 3/1/11. She stated, "I saw a pressure area on top of the foot. It looked kinda like a macerated area. No drainage. I didn't see any eschar." 1). On 3/2/11 at 2:45 p.m., the DON was asked if anyone had called the Orthopedic clinic to find out if the air cast could be removed to provide care to the resident's foot. She stated, "I believe all the information came from the sitter." 2). On 3/2/11 at 3:00 p.m., the Orthopedic clinic was contacted. The physician's nurse was asked about (Resident #1's) air cast and if it was intended to stay on 24 hours a day or was it ok to remove it routinely to check skin integrity. She stated, "Yes it was ok to take it off, wash her foot and put it back on. That's what that kind of boot is for." m. On 3/2/11 at 1:00 p.m., during an interview with the resident in the hospital, the resident's nurse removed the dressing to the right lower leg/foot and revealed a large area of skin breakdown on the lateral side of the right lower leg and foot. The area extended from up above the lateral malleolus to the distal lateral edge of the foot and had areas of black and yellow tissue present along with a blistering appearance in the distal part of the wound. A large dark, purple colored blister was present on the heel and two smaller dark purple areas with a large red peri-wound were present on the bottom of the foot just below the little toe. The resident was carefully positioned toward her back by the nurse so the inside (medial) part of the leg could be viewed. A large black area extended from above the medial malleolus to the distal edge of the foot. A large dark purple fluid filled blister was present at the distal part of the wound on the inner heel. There was also a nickel sized open area on top of the foot that had a yellow slough appearance and a bright red peri-wound that extended approximately 1 cm around the wound. The dressings on the leg revealed a small amount of brownish yellow drainage. No odor was noticed. The resident's nurse stated Resident #1 was receiving [MEDICATION NAME] for the wounds. During the observation of the wounds, the resident's physician entered the room. He observed the wounds and stated, "Those are Stage 4s. They look like they're starting to abscess." He began writing his progress note at that time. n.The hospital Physician's Progress Note dated 3/2/11 documented, "Stage 4 Decubiti." o.The hospital Physician order [REDACTED]." p. The immediate jeopardy was removed and the scope and severity lowered to a "G" when the facility initiated the following plan of removal on 3/2/11 at 4:45 p.m.: 1) On 3/2/11 upon discovery of the negative finding on (Resident #1) with injury to her right foot, the DON/licensed nurse instructed all licensed nurses to perform a body audit on all residents to ensure there were no skin breakdown/deterioration to skin integrity or wounds. Any negative findings will be immediately addressed and notified to the MD for further instructions/order. Completion date 3/2/11. 2) The DON/licensed nurse will make observation rounds to ensure body audits on all residents are completed and negative findings addressed upon discovery. Completion date 3/2/11. 3) The DON/licensed nurse will inservice all licensed staff on skin audits with emphasis on checking resident's wounds for any drainage or deterioration in skin integrity and to notify MD (Medical Doctor) of any negative findings upon discovery. Licensed staff will also be inserviced on assessing and monitoring residents who may have an apparatus such as a cast or splint and calling the physician if there are no care instructions. Inservice started 3/2/11 on all available licensed nurses. Nurses not available or on vacation will be inserviced prior to providing care to the residents. 4) The DON will observe residents who are at a higher risk of developing pressure ulcers due to having special devices 2 x weekly for 30 days or until compliance achieved to ensure body audits were performed by assigned nurse/s and wound condition/new concerns documented and reported to MD upon discovery. Started 3/2/11. 5) Any negative findings by the DON/licensed nurse will be corrected/addressed upon discovery and reported to the Administrator for his weekly review. The Administrator will forward all negative findings to the QA&A (Quality Assessment and Assurance) Committee 1 x monthly for further recommendations and necessary corrective action.

Complaint # was substantiated (all or in part) with these findings: A. Based on observation, record review and interview, the facility failed to ensure supervision was provided to prevent fractures during the delivery of care for Resident #1. The facility failed to ensure interventions were developed and implemented to reduce the risk of fractures during the delivery of care to 1 (Resident #1) of 6 case-mix residents (Residents #1-6) who had an increased risk for fractures due to [DIAGNOSES REDACTED].#1, who sustained a fractured tibia and fibula and had the likelihood of causing more than minimal harm to 16 residents in the facility who had a [DIAGNOSES REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. a. The Care Plan dated 1/21/11 documented, " Problem: Risk for falls as resident is dependent on staff for transfers. ...Approaches ...Two person and mechanical lift." The care plan did not address the residents increased risk of fractures due to osteoporosis. On 3/3/11 at 10:05 a.m., the Care Plan Coordinator was asked why (Resident #1's) care plan did not have specific precautions related to the increased risk of fractures since the resident had a [DIAGNOSES REDACTED]. For example, just because someone has hypertension doesn't mean it needs to be care planned. In the interest of providing consolidated care, I have shortened the care plan." b. A DMS (Division of Medical Services) -762 (Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and Exploitation of Residents in Long Term Care Facilities) documented, "On 2/21/11 at about 10:00 a.m. the treatment nurse observed edema to (Resident #1) lower right foot. Charge Nurse and ADON (Assistant Director of Nursing) were notified. Resident was assessed with [REDACTED]. No signs or symptoms of pain or discomfort. The area was warm to touch but non-tender upon palpation. At 11:30 a.m. family and MD (Medical Doctor) notified, x-ray ordered. At 1410 hrs (2:10 p.m.) x-ray taken. At 1700 (5:00 p.m.) received x-ray result with right lower leg fracture. MD & family notified. At 1900 hrs (7:00 p.m.) resident sent to ER for evaluation. Investigation started. Staff and other cognitive residents were interviewed with no negative findings. The two CNAs (Certified Nurse Assistant #1 and #2) who assisted the resident with transfer stated that on 2/21/11 after breakfast around 9:30 a.m. they took (Resident #1) down from dining room to her room on her w/c (wheel chair) and transferred her from w/c to bed via mechanical lift and put her down to her bed using precaution. After transfer, (CNA #1) gave resident a bed bath. (CNA #1) states that she did not notice anything abnormal with resident's ankle and did not do anything to cause resident an injury or a fracture. Resident was unable to state what happened. Resident is a [AGE] years old white female with Dementia and Osteoporosis with Vitamin D deficiency. Resident needs assistance with all ADLs (Activities of Daily Living) and transfers...Staff were inserviced on proper transfer technique and resident abuse policy... The DON(Director of Nursing)/designee will ensure that resident is transferred properly and safely. Based on the investigation, witness statements and review of resident's medical condition the facility is unable to determine the cause of fracture or any abuse to the resident, however, resident had Osteoporosis and may have twisted and fractured the ankle accidentally during transfer..." 1) On 3/2/11 at 9:30 a.m., CNA #1, who was assigned to (Resident #1) and who transferred the resident from the wheelchair to the bed the morning of 2/21/11, stated during an interview, "(Resident #1) was already up that morning. She had a blanket over her legs. I took her to the dining room, then we put her back to bed. It was her shower day. I gave her a bed bath... Nothing happened during the transfer." CNA #1 was asked if anything unusual happened during the bed bath. She stated, "No." She was asked if she noticed anything strange about the resident's leg during the bed bath. She stated, "No." CNA #1 was asked if the resident appeared to be in any pain. She stated, "No." 2) On 3/2/11 at 10:24 a.m., CNA #2, who assisted CNA #1 with transferring (Resident #1) from the wheelchair to the bed the morning of 2/21/11, stated during an interview, "I set the lift up, locked the wheel. I actually showed CNA #1 how to do her because her skin is so fragile... Nothing happened during the transfer. She had no signs or symptoms of pain." c. A Nurse's Note dated 2/21/11 at 11:30 a.m. documented, "Received order for x-ray right tibia and fibula, rule out fracture." 1) A Nurse's Note dated 2/22/11 at 2:35 a.m. documented, "Resident returned from ER (emergency room ) on stretcher, attendant x 2, with sitter... Right LE (lower extremity) wrapped with hard cast on..." 2) A Radiology Report dated 2/21/11 documented, "There is a recent fracture involving distal tibia and fibula with minimal displacement." d. On 3/1/11 at 10:00 a.m., the Director of Nursing (DON) provided a documented inservice dated 2/22/11 entitled "Transfers." The CNA signature sheet for this inservice documented 7 total signatures. The DON was asked why only 7 CNAs had been inserviced since the incident on 2/21/11. She stated, "Staff is supposed to go through the book, read and sign, but obviously that didn't happen. That's my fault." The DON was asked how the facility had monitored the effectiveness of this inservice. She stated, "Let me check on that." The DON was asked if there were any inservices on Osteoporosis prior to the incident. She stated, "No." On 3/1/11 at 10:45 a.m., the Assistant Director of Nursing (ADON) was asked why only 7 CNAs had been inserviced on transfers since the incident on 2/21/11. She stated, "I do not know." When asked to explain, she stated, "The inservices go in a red book at the Nurse's station for staff to read." The ADON was asked why a staff inservice wasn't done after (Resident #1) sustained such a serious injury. She stated, "I do my spill at the Nurse's station and talk to as many as I can, but then it's placed in the red book and flagged." The inservice did not contain documentation related to transferring residents with Osteoporosis. On 3/1/11 at 11:35 a.m., the Administrator was asked why only 7 CNAs had been inserviced on transfers since the incident on 2/21/11. He stated, "Because everybody is not scheduled every day. Whoever gets scheduled that day gets inserviced." e. On 3/1/11 at 9:30 a.m., the treatment nurse was asked why only 19 people had been inserviced since the incident on 2/21/11 for the inservice dated 2/21/11 and titled " Slow Your Roll." She stated, "They're supposed to go through the red book at the Nurse's station and read it and sign it." The Inservice Education Report dated 2/21/11 and titled Slow Your Roll documented, "... Please keep in mind how fragile our residents have become. Their skin tears like tissue paper... and their bones can crumble and fracture with the slightest bump on the bedrail or wheelchairs during transfer..." f. On 3/2/11 at 9:30 a.m., CNA #1 was asked if she was aware that (Resident #1) had Osteoporosis, or bones that easily fracture. She stated, "No." She was asked if she was aware of any other residents who have Osteoporosis. She stated, "No." CNA #1 was asked if she had ever been shown or trained on how to provide care to prevent potential fractures for someone with Osteoporosis. She stated, " No. " As of 3/2/11 at 9:30 a.m., there was no documentation in CNA #1's file of an inservice since hire date to indicate she had been trained on how to use a mechanical lift or how to provide care to residents with osteoporosis. g. On 3/2/11 at 10:24 a.m., CNA #2 was asked if she was aware that Resident #1 had Osteoporosis. She stated, "No." She was asked if she was aware of any other residents who have that diagnosis. She stated, "No." CNA #2 was asked if she had ever been shown or trained on how to provide care to prevent potential fractures for someone with Osteoporosis. She stated, "No." B. Based on observation, record review and interview, the facility failed to ensure supervision was provided to reduce the risk of injury during transfers for Residents #2 and #3. The facility failed to ensure two staff members assisted during a transfer as documented in the plan of care for 1 (Resident #3) of 4 (Residents #1, 3, 4, and 6) case mix resident who required 2 staff assistance with transfer and the use of a mechanical lift. The facility failed to ensure interventions for transfers were evaluated for their effectiveness and modified as needed or replaced for residents who were non weight bearing and at risk for falls for 1 (Resident #2) of 4 case mix residents (Resident #1, #3, #4 and #6) who were non weight bearing and required the assistance of 2 staff members for transfers. The facility failed to ensure interventions were developed and implemented to reduce the potential for injury for 1 (Resident #2) of 6 (Residents #1 -6) case mix residents who were at risk for skin tears. The failed practices had the likelihood of causing more than minimal harm for 33 residents who required the use of a mechanical lift transfers and 21 residents who required the assistance of 2 staff member for transfers, and who were at risk for skin tears according to a list provided by the Director of Nursing (DON) on 3/3/11 at 9:25 a.m. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 12/24/10 documented a staff assessment for mental status which documented the resident had moderately impaired cognitive skills for daily decision making and required total assistance of two people for transfers. a. The care plan updated 1/25/11 documented, "...At Risk for falls d/t (due to) dependent on staff for transfers and Hx (history) of falls. Interventions: ...Mechanical lift with 2 people." b. The Nurse's Aide's Information Sheet (Care plan) documented, "Locomotion: with 2 assist and lift." c. On 3/1/11 at 1:36 p.m., the resident was in bed. CNA #3 was unlatching the resident's lift pad loops from the mechanical lift. The CNA was the only CNA in the room. CNA #3 was asked did you just transfer the resident by yourself. She stated, "Yes." She was asked if Resident #3 always required the use of a mechanical lift to transfer. She stated, "Yes." She was asked, " Are you required to have 2 people when transferring the resident when using a mechanical lift. " She stated, "I think we are suppose to have 2 people. I just couldn't find anyone." d. On 3/2/11 at 9:30 a.m., the facility provided the mechanical lift manufacturer's guidelines which documented, "...NOTE: Although Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case." e. On 3/2/11 at 10:30 a.m., the "Safe Lifting and Movement of Residents" policy revised December 2007 provided by provided by the Administrator on 3/2/11 at 10:30 a.m. documented, "...3. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques." 2. Resident #2 had [DIAGNOSES REDACTED]. a. An I/A (Incident and Accident) Report dated 9/23/10 at 1:05 a.m. documented, "CNA on round stated she uncovered resident and noticed dry blood on bed sheet. Nurse called to resident room on assessment nurse observed skin tear (S/T) to left (L) (left) upper arm. Intervention: inservice CNAs (R) (resident) has fragile skin, two CNA to assist with ADL..." b. An I/A Report dated 10/17/10 at 4:25 p.m. documented, "...R has a skin tear to the (L) arm. On assessment R (resident) noted to have a skin area of approx. (approximately) 2.1cm (centimeter) x 0.4cm x < (less than) 0.2cm to the (L) lower hand, minimal bleeding noted. Unable to state how she sustained S/T. Interventions: Geri sleeves on resident, inservice on proper transfers and attempt to place in high visibility area." c. An I/A Report dated 12/6/10 documented, "CNA asked nurse to go to shower room, Hospice CNA reported bruise on (Resident #2). (Resident) was found to be leaning to (L) side... Intervention: assist R to bed between meals when lethargic or sleeping in w/c (wheel chair), Inservice on fragile skin, (B) (bilateral) Geri sleeves..." d. An I/A Report dated 12/11/10 at 1:00 a.m. documented, "...found R in bed a large bruise on her left foot... Interventions: will con't (continue) to monitor and report changes, investigation initiated." e. An I/A Report dated 12/25/10 at 6:30 a.m. documented, "This nurse was called by CNA ...to the dayroom to look at (Resident) left foot which was bleeding at the back. This nurse ask Resident when happened. Resident stated, ' I don't know. ' ...Skin tear 3.5cm in length and .5 inch in width was noted to posterior LLL (left lower leg). Inservice staff on fragile skin of this resident, uses w/c (wheelchair) for mobility at times - extreme care with transfers D/T (due to) weeping edema and fragile skin." f. An I/A Report dated 1/15/11 at 7:00 a.m. documented, "Nurse was called to resident's room to look at her upper inner (R) (right) thigh where she has a scratch ...10 meter long and red... R asked what happened, she stated 'I don't know, maybe I scratched it. ' Intervention: Zinc oxide to area until improvement is noticed and trim nails." g. An I/A Report dated 1/27/11 at 7:15 a.m. documented, "CNA dressing R upon removing gown noticed skin tear to Lt (left) forearm (5.2cm length) and dorsal left hand (1.2cm length). Interventions: Tx (treatment nurse) to follow ...protectively wrapped with non-bordered foam ...Inservice to CNAs regarding skin integrity." h. An I/A Report dated 2/5/11 at 6:30 p.m. documented, "CNA came to desk and states resident blouse was stuck to her L arm, when she removed it dry blood was on her blouse and arm. 6.5cm x 1.5cm skin tear noted cleaned and steristrips applied. Interventions: ...pad (L) arm geri chair." i. The care plan updated 2/21/11 documented, "...Start Date: 5/31/10 Use gait belt for all transfers and allow periods of rest during ADL's (activities of daily living)..." The care plan did not address how many staff members to help provide care, did not address the positioning devices or to use a drawsheet. j. On 3/2/11 at 11:30 a.m., the resident was in a geri chair (G/C) next to her bed. The resident was leaning to the left side of the G/C causing pressure to the left underarm and left side of the thoracic region of the chest. A pillow was on the floor next to the G/C, and a square metal bar was extending and protruding from the front section of the left armrest exposing metal edges. There was no cap or padding on the metal bar. The resident was not wearing geri-sleeves. A geri sleeve was found in the G/C on the left side between the resident's left thigh and inside G/C panel. Another geri sleeve was found draped across the left armrest of the G/C. Licensed Practical Nurse (LPN) #2 entered the resident's room while the surveyor was making the observation. LPN #2 was asked why the right armrest was padded and not the left. She was unable to answer. She indicated the resident had a history of [REDACTED]. k. On 3/3/11 at 11:45 a.m., CNA #4 was asked how the staff had been specifically instructed to provide care for (Resident #2) to prevent further skin tears. She stated, "Ms. (Resident #2) was fragile, had to be very gentle with her, she bruises easy. If you try to stand her, make sure another CNA is with you, keep her comfortable, put pillows between her legs and use wedges and drawsheets. " The CNA stated (Resident #2) could bear weight, but it depends on the time of day. l. On 3/3/11 at 1:45 p.m., CNA #5 and CNA #6 were observed transferring the resident from a geri chair to the bed. CNA #5 placed a draw sheet on the bed. The G/C was locked in place. CNA #6 placed a gait belt around the resident's waist. CNA #5 was on the left side of the resident and CNA #6 was on the right side. They placed their hand around the resident ' s upper arms and grabbed from behind the resident's back and pulled the resident's pants as they lifted the resident up. The gait belt was not used to lift the resident. Resident #2 was observed not bearing weight at all. CNA #5 was asked, after the transfer was finished, can she stand on her own or bear weight? CNA #5 stated, "No, she's pretty limp." She was asked how she knew the resident required 2 people to transfer. CNA #5 stated as she referred to the care plan in the resident's closest, her (Resident #2) care plan says one person for transfers. She was asked why she used 2 people. She stated, "I felt we needed two." She was asked, why. She stated, "Because she's so fragile, so weak. I think she needs two. She's declined since I started, she use to could stand." She was asked why she used a gait belt. She stated, "...for security, so you won ' t be chicken winging her." She was informed it was noticed that both CNAs pulled the back of the resident's pants to lift the resident. CNA #5 stated, "I used her pants because I didn't want the gait belt to cut into her ribs, I didn't want to hurt her." She was then asked why would a resident require the use of a mechanical lift for trasnfers. She stated, "Because they can ' t bear weight." m. On 3/2/11 at 10:30 a.m., the facility provided the "Safe Lifting and Movement of Residents" policy. The policy revised December 2007 documented, "...8. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: a. Resident's mobility (degree of dependency) b. Resident's size c.Weight-bearing ability d.Cognitive status." n. On 3/3/11 at 1:15 p.m., the Director of Nursing (DON) was asked in reference to the facility's policy on transfers, when was the last time Resident #2 was assessed for transfers. She stated, "I don't know." The DON was informed of the observation made with CNA #5 and CNA #6 when transferring (Resident #2). The DON was asked if CNA #5 had reported to the nurse the resident's change in condition. The DON was informed the CNA had been asked and had stated she had not reported to the nurse. The DON stated the resident was so small she probably would not fit in the lift pad and indicated she thought that a transfer pad would be best to use. The Assistant Director of Nursing (ADON) was also present during the interview. They were asked when did the facility conduct transfer assessments, if the assessments were conducted quarterly or not. The ADON commented the transfer assessments were conducted, "when there is a slight change in condition, if they've been in the hospital, our CNAs will come and say like, "Mr. So and So is not helping like they use to." According to (Resident #2's) plan of care updated 2/21/11, there was no documentation to indicate the resident had been assessed for transfers since 5/31/10, approximately 10 months ago. 3. On 3/3/11 at 9:40 a.m., the DON stated she worked at the facility from January - December 2010, she left and then came back to the facility on [DATE]. The facility provided multiple inservices on prevention of skin tears and safe transfers dated 12/2/10, 1/3/11, and 1/27/11. The DON was asked how the facility monitored the effectiveness of these inservices. She stated, "...I'm still trying to figure it out. We had demonstrations with return demonstration with a test from January 2010 through December 2010..." The DON indicated they had Risk Management Meetings weekly before (during her prior employment). She stated, " I don't know why we stopped those meetings. All departments were present. We'd go over the I/As (Incident and Accident), document them and care plan them. For some reason they quit them. I can't believe they quit them. Those will be starting back up."