Every finding on record at Rennes Health and Rehab Center-Weston

Based on observation, interview and record review, the facility did not ensure proper food handling practices related to thawing raw meat were followed to prevent the outbreak of foodborne illness for 26 of 82 residents. Facility did not use proper thawing method for frozen pork chops. Policy and procedure titled Food Preparation and Service last revised in August of 2014 reads in part, Submerging the item in cold running water. Guidelines from Agriculture, Trade, and Consumer Protection Subpart 3-501.13 last registered in November 2024, reads in part, Completely submerged under running water .With sufficient water velocity to agitate and float off loose particles in an overflow. The FDA Food Code states the following: 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking. On 05/14/25 at 8:23 AM, Surveyor observed pork chops, which appeared to be thawed, in a pan of water placed in the small sink of the prep table. Pork tenderloins were partially red/partially browning in color. Surveyor observed the pork chops sitting in still water, not running water. On 05/14/25 at 8:49 AM, Surveyor observed pork chops in the same water. This was not cold running water. Surveyor interviewed Dietary Manager (DM) S and [NAME] T. DM S stated the pork chops were thawing and had been taken out of the freezer that morning. [NAME] T stated [NAME] T had taken the pork chops out of the freezer when [NAME] T got to work that morning. On 05/15/25 at 7:50 AM, Surveyor interviewed DM S. DM S stated that [NAME] T may have run the pork tenderloins underwater prior to Sureyor's observation but wasn't positive. DM S stated [NAME] T would most likely have rinsed the pork chops before cooking them. [NAME] T reported the pork chops were partially frozen in the middle when he took them out of the still water. The pork chops were then breaded and cooked and served to 26 residents. Cooked internal temp was recorded at 193 degrees. On 05/15/25 at 9:34 AM, Surveyor interviewed Director of Corporate Food Services (DCFS) U. DCFS U stated DCDS U was informed by [NAME] T the water had been running until about 8:00 AM that morning and it was shut off due to [NAME] T leaving the kitchen. At that time the pork was left in the sitting water. Surveyor determined the facility did not follow safe and appropriate thawing methods for frozen pork, which had the potential for contributing to foodborne illness.

Based on observation, interview and record review, the facility did not implement comprehensive person-centered care plan approaches for 1 of 1 sampled resident (R), (R46) by ensuring fall intervention approaches were in place to meet a resident's medical, nursing, and psychosocial needs which are identified. This is evidenced by: The facility policy, titled Falls and Fall Risk, managing policy statement states, Based on previous evaluations and current data, the staff will identify interventions related to the residents from falling and to try to minimize complications from falling. 6. Staff will identify and implement relevant interventions .to try to minimize serious consequences or falling. R46 was admitted to the facility on [DATE] and has diagnoses of unspecified dementia, mild, with psychotic disturbance with delirium and adult failure to thrive. R46's admission Minimum Data Set (MDS) assessment, dated 01/25/25, indicated a Brief Interview for Mental Status (BIMS) score of 9/15 (mildly impaired) and had a fall in the last month prior to admission and the last 2-6 months prior to admission. R46's fall risk care plan, dated 01/22/25, with a target date of 04/22/25, has interventions approaches dated 01/23/25 of Call don't fall sign placed in room and on 04/14/25 added autolocking brakes to wheelchair. On 05/13/25 at 11:42 AM, Surveyor observed no Call before you fall sign or autolocking brakes on wheelchair for R46. On 05/14/25 at 10:03 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding fall interventions for R46 of signage and brakes. CNA G pulled a CNA care card out of uniform pocket and confirmed that R46 is supposed to have a Call don't fall sign and autolocking brakes on wheelchair to prevent falls. On 05/14/25 at 11:00 AM, Surveyor interviewed Director of Nursing (DON) B regarding fall interventions for R46. DON B stated the sign was found in the resident's drawer and believes R46 does not have usual wheelchair and is investigating on what may have happened.

Based on observation, interview and record review, the facility did not ensure it was free of medication error rates of 5% or greater. There were 2 errors in 29 opportunities that affected 2 out of 7 residents (R), (R20, R53) included in the medication pass task, which resulted in an error rate of 6.9%. -R5's prescribed topical medication was used for R20. -R53's lidocaine patch was not removed after 12 hours, as ordered. Findings: Example 1 The facility's policy, Administering Medications read in part, 3. Medications must be administered in accordance with the orders. The licensed nurse shall follow the five Rights for medication pass: Right Resident, Right Medication, Right Time, Right Dose, Right Route. 5. The individual administering medications must verify the resident's identity before giving the resident his/her medication. On 05/12/25 at 3:50 PM, Surveyor observed Registered Nurse (RN) F completing medication administration for R20. RN F reported she could not administer R20's prescription topical diclofenac sodium gel to both knees, as the medication was not in the medication cart. RN F stated she would update R20's primary care provider (PCP) and the pharmacy to order more. RN F stated she would make a progress note reflecting these actions. On 05/13/25, Surveyor reviewed R20's progress notes, and noted there was not a record indicating RN F updated PCP and pharmacy of R20's medication being unavailable on 05/12/25. Surveyor reviewed R20's medication administration record (MAR) and noted: -05/12/25 PM shift, RN F documented diclofenac sodium gel was not administered due to medication being unavailable. -05/13/25 AM shift, R20's MAR indicated RN C administered R20's diclofenac sodium gel as ordered. On 05/13/25 at 10:20 AM, Surveyor interviewed RN C. RN C stated she did administer R20's diclofenac sodium gel on this date, as ordered. RN C looked in the medication cart for R20's gel, for several minutes. RN C did locate R20's gel and Surveyor noted the tube of diclofenac sodium gel appeared to be new and the dosing card included did not appear to be used. RN C stated she borrowed R5's Voltaren gel (brand name for diclofenac gel) as she was unable to locate R20's diclofenac gel. RN C acknowledged she should not have used R5's medication for R20, as this was not the right resident. On 05/13/25 at 10:32 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported licensed nursing staff should not use another resident's medication, and she would expect staff to contact the resident's provider for direction. DON B stated she would provide re-education to nursing staff immediately. Example 2 On 05/13/25 at 7:27 AM, Surveyor observed Registered Nurse (RN) C administer medications to R53 which included: Lidocaine 4% Patch (2 patches) on daily to lower back, remove after 12 hours On 5/13/25 at 7:29 AM, Surveyor observed RN C remove one patch from R53's lower back which was left on from previous day and not removed per physician orders. RN C removed glove, performed hand hygiene, put on a new glove, and applied two new patches to R53's lower back. Surveyor reviewed R53's medication administration record (MAR) for Lidocaine patch order which reads: Lidocaine adhesive patch, medicated; 4%; amount: 2 patches; topical Apply daily, remove 12 hours after applying ON AM, OFF HS Surveyor reviewed R53's MAR, which indicated the patches from the previous day had been removed by Licensed Practical Nurse (LPN) Q, who was not available for interview. On 05/14/25 at 12:31 PM, Surveyor interviewed LPN R. LPN R stated if orders indicate lidocaine patches are to be placed one time daily and removed after 12 hours, the MAR would prompt the nurse to remove patch on PM shift. LPN R stated patches are on for 12 hours and off for 12 hours. The facility did not ensure physician order for Lidocaine patch was followed as ordered.

Based on observation, interview and record review, the facility did not maintain infection control practices to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (R) reviewed (R57). - R57's Foley catheter collection bag was observed placed above bladder level allowing backflow which can contribute to infections. On 05/13/25, half of R57's Foley catheter bag was lying on the floor uncovered. This is evidenced by: The facility policy titled, Catheter Care, Urinary indicates the following, . 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder . 11. Be sure the catheter tubing and drainage bag are kept off the floor. R57 was admitted to the facility on [DATE] with diagnoses including surgical aftercare following surgery on the urinary system, urogenital implants, urinary tract infection, lobulated, fused and horseshoe kidney, sepsis, kidney stones, enlarged prostate with lower urinary tract symptoms, obstructive and reflux uropathy, and feeling of incomplete bladder emptying. R57's care plan, dated 4/2/25, includes the following: Problem: Resident requires an indwelling urinary catheter R/T obstructive and reflux uropathy Approach: Keep catheter system a closed system as much as possible, Position bag below level or the bladder and use a catheter strap. On 05/12/25 at 1:25 PM, Surveyor observed R57 being brought to the dining room by spouse with R57's catheter bag placed on lap above bladder level during lunch. Surveyor asked Licensed Practical Nurse (LPN) E if they see anything concerning with R57. LPN E stated that R57's catheter bag is on his lap and explained R57 just returned from an appointment with the urologist, and no one must have seen it yet. LPN E added LPN E will take care of the catheter right away. Surveyor reviewed the nursing progress note dated 05/12/25 at 12:41 PM, (which was 1 hour and 16 minutes before the observation) stating R57 returned to the facility from his appointment. The note was entered by LPN E. On 05/13/25 at 7:38 AM, Surveyor observed R57's Foley catheter drainage bag clipped to bottom of the wheelchair with 1/2 of the bag uncovered and resting on the floor. Surveyor interviewed Certified Nursing Assistant (CNA) L and asked who provided morning care for R57. CNA L said CNA L and CNA M provided care for R57. Surveyor asked CNA L if CNA L noticed anything wrong with R57's catheter bag. CNA L said, Oh yes. It is supposed to be in the bag on the back of the wheelchair. CNA L immediately sanitized hands, donned gown and gloves, and placed the catheter bag in the privacy bag on the back of R57's wheelchair. On 5/13/25 at 2:49 PM, Surveyor interviewed Infection Preventionist (IP) O and asked what the expectation would be for staff regarding managing Foley catheters. IP O vocalized staff should place the Foley catheter bags below the bladder level to prevent backflow and infection. The catheter bag is to be in privacy bag off the floor, and place resident on Enhanced Barrier Precautions (EBP). Surveyor discussed the observations, and IP O stated she will start providing education right away. On 05/15/25 at 8:20 AM, Surveyor interviewed DON B who said DON B was made aware of the catheter concerns and the facility has already begun educating staff

Based on observation, interview and record review, the facility did not ensure proper hand hygiene with food handling in accordance with professional standards for food service safety. This has the potential to affect all 24 residents in the south dining room out of 64 residents residing in the facility. The dietary aide touched multiple contaminated surfaces with gloved hands, did not remove her gloves or wash her hands, and used her gloved hands to serve garlic bread on resident plates. Findings: The facility policy titled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, states in part . 7. Employees must wash their hands: d. Before coming in contact with any food surfaces; f. After handling soiled equipment or utensils; h. After engaging in other activities that contaminate the hands. 10. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 12. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves dies not substitute for proper handwashing. On 04/01/24 at 12:05 PM, Surveyor observed Cook R serving meals in the south dining room. Surveyor observed Cook R wearing single-use disposable gloves. Surveyor observed Cook R, with gloved hands, touch serving utensils, plates, counter top, meal tickets, and plate lids, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed Cook R did not remove gloves or wash her hands. Surveyor observed Cook R, with same gloved hands, walk to the cooler located at the back of the kitchen, open the cooler door, obtain a can of soda, walk to the steam table, place can of soda on tray, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed Cook R did not remove gloves or wash her hands. Surveyor observed Cook R, with same gloved hands walk to the cooler located at the back of the kitchen, open the cooler door and obtain a plastic container with food, walk to the steam table, open a drawer and obtain a serving utensil, place items on the countertop, and with gloved hands pick up garlic bread and place on a resident plate to be served. Surveyor observed Cook R did not remove gloves or wash her hands. Surveyor observed Cook R, with same gloved hands continue to plate garlic bread with gloved hands without changing gloves or washing her hands, on four plates. On 04/01/24 at 12:25 PM, Surveyor interviewed Cook R. Cook R stated it is her normal practice to pick up food items with gloved hands, But I have been touching things, so I shouldn't. Surveyor observed Cook R remove her gloves and wash her hands. Cook R donned new gloves. On 04/01/24 at 12:27 PM, Surveyor interviewed Corporate Food Service Director S. Corporate Food Service Director S confirmed using contaminated gloves to pick up food items is not the facility's practice, and usually utensils, such as tongs, are used.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 5 residents (R) reviewed (R36) who is unable to carry out activities of daily living independently, receives the necessary services to maintain good nutrition, repopositioning with personal hygiene and oral hygiene. This is evidenced by: R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. According to this assessment, R36 has a Brief Interview of Mental Status (BIMS) of 3/15, indicating severe cognitive dysfunction, no behaviors such as rejection of care, verbal, physical or other actions in response to stimulation directed at self or others. For ADL functions, R36 requires partial to moderate assistance with oral hygiene and ambulation and substantial to maximum assistance with toileting hygiene, dressing of upper and lower body, personal hygiene, rolling right to left in bed, moving from a sitting to lying and a lying to sitting position, moving from a sitting to a standing position and transfers. R36 requires supervision and touch assistance with eating. Positioning/pesonal hygiene: Care Plan 1. At risk for impaired skin integrity related to decreased mobility. (Start date 12/11/23) Interventions for this plan included: - Encourage physical activity, mobility and range of motion to maximal potential. (Start date 12/11/23) - Reposition every 2-3 hours and as needed (Start date 12/11/23) Observation On 4/2/24 from 6:26 AM - 7:12 AM, Surveyor observed care provision for R36 by Certified Nursing Assistant (CNA) N. R36 has no current pressure injuries. Once cares were completed, at 7:12 a.m., CNA N left R36's room with R36 positioned in the wheelchair in front of the television. R36 remained in the room until 8:10 AM, when she was propelled to the dining room for the morning meal. R36 remained in the dining room until 8:44 AM, when staff propelled R36 to a small activity room/television room in preparation for activity of nail care. Nail care started at 9:18 AM by Activity Aide (AA) O and Activity Director (AD) P. R36 was placed at a table away from the nail care table. R36 was noted to be sitting up straight but slightly leaned to the right side. Both legs were off the footrests and positioned on the floor. At 10:43 AM, a strong odor of feces was noted emanating from R36. At 10:57 AM, AA O began nail care for R36. The nail care was completed at 11:30 AM, at which time AA O noted the feces odor and propelled R36 to the resident's room and alerted staff of the toileting need. This was at 11:30 AM. At 11:31 AM, CNA N assisted R36 to the bed and provided the incontinence cleansing. Surveyor verified with CNA N at this time that no further cares were completed following the earlier morning ADL cares. When asked why no cares were provided after meal service, CNA N stated, I did her cares then she went to breakfast and then she was in an activity. I didn't do anything, but now I am going to change her. Surveyor asked CNA N what the repositioning schedule was for R36. CNA N stated, I think it's every two hours. This was a time period of 4 hours 19 minutes in which no staff approached to offer or encourage repositioning or personal hygiene for R36. At 4:40 PM, Surveyor interviewed CNA J and CNA K regarding ADL provision on the evening shifts. When asked about R36's repositioning and toileting needs, both staff stated R36 was to be repositioned and checked for toileting needs every two hours. On 04/02/24 at 4:54 PM, Surveyor interviewed Director of Nursing (DON) B regarding R36's care needs and asked what the expectation of repositioning and toileting and personal hygiene was for R36. DON B stated R36 was to be repositioned or cued to reposition every 2-3 hours. At that time personal hygiene would be provided if R36 was incontinent. On 4/3/24 at 7:46 AM, Surveyor approached CNA G and interviewed regarding the needs of R36. CNA G is a primary dayshift caregiver for R36. CNA G stated they are to reposition and offer toileting to R36 every two hours. On 4/3/24 at 8:07 AM, Surveyor approached CNA F and interviewed her regarding R36's Restorative Nursing Program (RNP) for ADLs. CNA F is another primary caregiver for R36 on the dayshift. CNA F stated that repositioning and toileting with personal hygiene should be offered to R36 every two hours. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding her expectation of staff in regard to R36's needs. When asked about R36's repositioning needs, UM M stated her expectation is that R36 be repositioned every 2-3 hours. Oral care ST completed a Dietary/Staff Communication Guide dated 12/11/23 and again on 1/5/24. According to these, R36 was to take small bites with 1-2 swallows with each bite. Staff were to encourage to clear throat, cough and re-swallow as needed and to check for pocketing. Staff were also to complete oral cares following meals. On 4/1/24 at 12:00 PM, Surveyor observed initial entrance meal service for R36 for the noon meal. R36 was seated at a table with five other residents with two staff assisting these four others. From 12:12 PM - 12:36 PM, Surveyor observed R36's noon meal. At 12:44 PM, AA O noticed that R36 hadn't eaten anything. AA O pulled up a chair to R36's right side, sat down and began to feed R36 the meal. AA O offered R36 a beverage with R36 choosing cranberry juice. AA O fed R36 the meal, finishing at 1:18 PM and accepting approximately 25% of the meal. There was no oral care provided following this meal. On 4/2/24, Surveyor observed the morning meal service. R36 was propelled into the dining room and placed at the table with four other residents at 8:10 AM. R36 remained in the room until 8:10 AM, at which time R36 was propelled to the dining room for the morning meal. R36 was in the dining room until 8:44 AM, at which time was propelled to the small activity room across from the dining room, for an activity of nail care. Surveyors continued to observe R36 in this activity. There was no oral care provided following the meal to clear potential food from the pockets of R36's cheeks, as directed. Surveyor observed meal service on 4/2/24 for the noon meal. R36 was propelled into the dining room at 12:22 PM and positioned at the table with the same four residents noted on earlier observations. R36 was served the meal at 12:23 PM. R36 completed the meal at 1:06 PM, at which time, staff assisted to lay down for a nap. No oral care was provided following this meal. Meal Assist According to the Comprehensive Care Plan developed for R36, the following plans were noted by Surveyor: 2. Nutritional Status: At nutrition risk related to therapeutic, mechanically altered diet due to hypertension and dysphagia. (Start date 12/11/23, last revised 3/18/21) The goal for this problem was No significant weight loss from 130 pounds. Consume 50% or more most meals and tolerate least restrictive diet. Interventions included: - Beverages in mugs with lids (Start date 2/21/24) - Assisted devices: lipped plate and built up utensils (start date 2/20/24) - House supplements three times daily with meals (Start date 12/11/23) - Per ST: Direct supervision, 1-2 swallows per small bite, alternate solids/liquids, clear throat/cough, then re-swallow, oral cares after meals, clear mouth between bites, verbal and physical cues to eat slowly. (Start date 12/11/23) CNA care card (last updated 4/2/24) identified R36 as requiring the following (not all-inclusive): - dining: built up utensils, all beverages in mugs with lids and straws. House supplement three times daily - encourage to participate in activities/meals Observation 1 On 4/1/24 at 12:00 PM, Surveyor observed initial entrance meal service for R36 for the noon meal. R36 was seated at a table with five other residents with two staff assisting these four others. R36 received her meal at 12:12 PM by AD P, which consisted of pasta with marinara sauce, ground chicken, peas, garlic bread and a brownie. There were no beverages served to R36 at that time. R36 was served the main entree on a lipped plate with regular, standard utensils. There were two staff also at the table; Nurse Manager (NM) D was assisting R44 and R12 and CNA C was assisting R32 and R17. R32 was directly to R36's right side and R17 was directly across the table from R36. From 12:12 PM - 12:36 PM, R36 repeatedly looked around the room and around the table at the other residents eating and being assisted. R36 made no attempts to feed self. Still, no beverages were supplied during this time. Neither staff seated at the table prompted, cued or encouraged R36 to eat. At 12:44 PM, AA (Activity Aide) O noticed that R36 hadn't eaten anything. AA O pulled up a chair to R36's right side, sat down and began to feed R36 the meal. R36 observed to sit unassisted with meal for 32 minutes with no staff interaction or encouragement to eat. There was no encouragement or cues given to R36 to eat independently. Observation 2: On 4/2/24, Surveyor observed the morning meal service. R36 was propelled into the dining room and placed at the table with four other residents at 8:10 AM. These four other residents were the same as noted at the noon observation 4/1/24. At 8:15 AM, R36 was given 8 ounces of cranberry juice, served in a regular beverage glass. Two staff assisted the four other residents at the table; NM D was assisting R44 and R12 and CNA E sat between R32 and R36 and assisted R32 with the meal. At 8:22 AM, R36 was served the meal on a lipped plate with regular/standard utensils. The meal served with this observation was biscuits and gravy and oatmeal with brown sugar. R36 made few attempts to feed herself during this meal, frequently looking around at the table at other residents being assisted by staff. R36 also picked up the glass of juice twice and took sips. At 8:28 AM, CNA E finished assisting R32 and began to assist R36, as CNA E noted R36 was not making attempts to feed herself. R36 finished her meal at 8:44 AM, being fed by CNA E. R36 was not encouraged or cued in self-feeding. Observation 3: Surveyor observed meal service on 4/2/24 for the noon meal. R36 was propelled into the dining room at 12:22 PM and positioned at the table with the same four residents noted on earlier observations. R36 was served the meal at 12:23 PM which consisted of chopped chicken fried steak, mashed potatoes with gravy, mixed vegetables, a slice of bread and a marshmallow fluff for dessert. R36 was given 8 ounces of apple juice served in a sippy cup. R36 made no attempts to eat the meal but did occasionally pick up the sippy cup and take a drink of the juice. No staff encouraged or offered assistance until 12:46 PM, when NM D sat beside R36 to assist with the meal. This was 23 minutes in which no cues or encouragement were given to R36 to eat independently. On 4/2/24 at 4:04 PM, Surveyor interviewed Staff H, who is the director of rehabilitation. Speech Therapy (ST) Q was not on duty on this date. Staff H spoke with ST Q on the telephone and reviewed ST documentation. Staff H stated R36 was seen by ST 12/1/23 - 12/8/23 and then again 12/11/23- 1/19/24 and made recommendations for R36 to be on mechanically soft diet with thin liquids, served in a covered mug with a straw on 2/20/24. Staff H stated there were directions of supervision with the meal and directives on swallowing. Staff H stated the RNP was to be implemented 1/25/24. On 4/3/24 at 10:39 AM, Surveyor interviewed ST Q regarding the plan that was to be implemented for meal service. ST Q stated that she recommended the oral care after meals as R36 was a relatively new stroke patient and impulsive, so required cues to slow down with eating and staff to provide oral cares, as she could be pocketing food and didn't want R36 to be laid down and then risk choking on any food that may still be in the mouth. ST Q stated the food was to be cut into bite sized pieces and R36 was to be cued to alter solids and liquids and swallow as needed. R36 required direct supervision with the meal. ST Q stated this plan was to be implemented as of 1/25/24. The ADL assistance was not offered in relation to assistance with meals with the recommended tools for self-feeding, oral cares following meals, and assistance with repositioning and toileting needs.

Based on observations, record review, staff interview and policy review, the facility failed to ensure 1 of 3 residents (R) R36 reviewed for limited mobility, received restorative services as needed to address limited mobility, to maintain or improve mobility for the goal to reach the maximum practicable independence. R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. Surveyor reviewed the most recent Minimum Data Set (MDS) assessment completed for R36, which was a quarterly assessment with an assessment reference date of 3/7/24. According to this assessment, R36 has a Brief Interview of Mental Status (BIMS) of 3/15, indicating severe cognitive dysfunction, no behaviors such as rejection of care were noted. R36 was identified as having impaired visual function and moderate difficulty with hearing. R36 has unclear speech but usually understands others and is usually understood. R36 has limited range of motion for both upper and lower extremities that affect the right side of the body. R36 has limited range of motion for both upper and lower extremities that affect the right side of the body. For activities of daily living (ADL) functions, R36 requires partial to moderate assistance with oral hygiene and ambulation and substantial to maximum assistance with toileting hygiene, dressing of upper and lower body, personal hygiene, rolling right to left in bed, moving from a sitting to lying and a lying to sitting position, moving from a sitting to a standing position and transfers. The MDS documents R36 received restorative in dressing and grooming during the seven days of the assessment observation. R36 was seen by Physical Therapy (PT) 12/11/23-1/25/24. On 1/24/24, PT initiated a Restorative Nursing Program (RNP) to be carried out by nursing staff that directed care giving staff on the following: 1. Ambulation: Ambulate twice daily in 400 hallway with FWW (full wheeled walker), assist of 1 (contact guard assist) and w/c (wheel chair) directly behind. Give cues/assist as needed for maintaining straight path. Ambulate from her room to beauty salon, give seated rest break, then ambulate from beauty salon back to her room. 2. Dressing/Grooming: Resident to complete grooming tasks while seated in w/c in front of sink with setup of supplies and verbal cues. Complete UB (upper body) dressing with maximum assist. Encourage resident to assist with ADL's as much as possible. R36 was seen by Occupational Therapy (OT) 12/12/23-1/25/24. The most recent RNP developed by OT was dated 2/20/24 and directed staff .patient able to manage standard mug; nosey cup and sippy cup no longer needed . According to the comprehensive care plan developed for R36, the following plans were noted by Surveyor: 1. Restorative: Self-Care Deficit related to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side. The goal written for this problem was Resident will maintain current level of function with grooming and UB (upper body) dressing to reduce risk of functional decline. (Start date 12/11/23, last revised on 3/21/24). Interventions for this plan included: - Dressing per RNP: Complete UB dressing with maximum assistance while seated in wheel chair in front of sink with supplies set up in front of her. (Start date of 1/27/24) - Provide verbal cues to initiate task and encourage her to be as independent as possible. Assist as needed. (Start date of 1/27/24) - Dressing and grooming per therapy recommendations. (Start date 12/11/23) 3. Restorative: Impaired physical mobility with risk for falls related to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side. (Start date 12/11/23, last revised on 3/21/24) Surveyor then reviewed restorative documentation completed monthly for R36 and noted the following: - 02/25/2024 . Restorative: Resident admitted [DATE] . Had new RNP established 1/24/23 for ambulation and dressing/grooming. Goal is to maintain ambulation distances and ability to walk with FWW to reduce risk of functional decline. She is very inconsistent with ambulation. Transfers and ambulation with 1 A (assist) ww (wheeled walker). WC (wheel chair) following during ambulation. She needs cueing to maintain straight walking path . Has met goal only sporadically since being implemented . Had 2 falls in January which did not impact her ability to participate in ambulation. Will initiate nursing documentation on how she is tolerating and if refusing why? Dressing/grooming goal is to maintain current level of function with grooming and UB dressing to reduce risk of functional decline. Staff must anticipate needs. ADLS are completed while seated in WC in front of sink with supplies set up within her reach. Needs verbal cueing and encouragement for her to assist as much as she is able to. Has met goal daily. POC (plan of care) updated. - 02/26/2024 Staff reports that resident is difficult to stand up. Needing 2A to ambulate. Resident did ambulate short distance within her room this shift. - 03/24/2024 Restorative: Resident has RNP for ambulation and dressing/grooming. Goal is to maintain ambulation distances and ability to walk with FWW to reduce risk of functional decline. She is very inconsistent with ambulation. Transfers and ambulation with 1 A ww. WC following during ambulation. She needs cueing to maintain straight walking path. Dressing/grooming goal is to maintain current level of function with grooming and UB dressing to reduce risk of functional decline. Staff must anticipate needs. ADLS are completed while seated in WC in front of sink with supplies set up within her reach. Needs verbal cueing and encouragement for her to assist as much as she is able to. Has met goal daily. ADL goal has been met 5-7 days and ambulation has improved and been more consistent this past month. POC Reviewed. Surveyor reviewed ambulation documentation for the hours of awake for the past three months and noted the following: - January 25-31st (RNP was to be implemented 1/25/24): Attempts made for ambulation were 3 times, all other times were documented as refused. This was 7 days with twice daily ambulation orders or 14 opportunities. - February 1-29th: 29 days or 58 opportunities Ambulation completed 24 times, several entries documented as refusals or not observed and one time documented as combative. - March 1-31st: 31 days or 62 opportunities: Ambulation completed 24 times, with 22 refusals documented. There also were unknown documented x1, not observed documented x 2, unavailable documented x2 and no information documented x1. The following observations were made by Surveyor: Restorative Services On 4/2/24 at 6:13 AM, Surveyor observed R36 in bed with the room dark. At 6:26 AM, Surveyor observed Certifiied Nursing Assistant (CNA) N enter R36's room to provide ADL cares. CNA N stated she has worked for the facility for two weeks but has been a CNA for a long time. The following was noted: - Upon entrance to the room, Surveyor noted R36 to be in bed as noted above. No staff have entered the room prior to this. - CNA N gently awakened R36 and explained that she was going to assist her to get up for the day. - CNA proceeded to wash R36's face, removed the pajama top and completed washing of the hands, arms, chest and arm pits. CNA N then proceeded to catheter and perineal cleansing. - Following the bathing, CNA N dressed R36 all while R36 was still in the bed. During the bathing and dressing, R36 followed directions with ease for rolling right and left in the bed. - CNA N then assisted R36 to sit on the side of the bed and placed a gait belt around the resident's waist and pivot transferred her to the wheelchair. No full wheeled walker was used with this transfer. - Once R36 was positioned in the wheelchair, CNA N brushed R36's hair and completed oral care, brushing R36's teeth. These tasks were not completed by the sink. Instead, they were completed for R36 by the bed. - CNA N then positioned R36 in front of the television in the room. CNA N attached the call light over the resident's right side lap and then left the room at 7:12 AM. Of concern with this observation is that R36 was not encouraged or directed to participate in the ADL cares, as OT and PT recommended to maintain or maximize functional abilities. Instead, CNA N performed all the cares for R36, not allowing for some independence by the resident. Also, no ambulation was offered or attempted with this observation. R36 was not given the opportunity to refuse. At 9:18 AM, Surveyor interviewed CNA N regarding care provision of R36. Surveyor asked CNA N if R36 was to be ambulated. CNA N stated, It depends on the day. Sometimes she will but sometimes she gets anxious and won't. [R36] uses the walker and generally just walks in the room. We pivot her from the bed to the chair, but that's about all. [R36] will tell you if she doesn't want to do it. Surveyor asked if there is a restorative plan to encourage R36 to be as independent and functional as able. CNA N stated that she wasn't sure if there was a plan, stating, . We just do everything for her. Surveyors continued to observe R36 to observe for ambulation opportunities. R36 was assisted to the morning meal at 8:10 AM. Following the meal, R36 was placed into a small activity room in which nail care was in progress. R36 remained in this activity until 11:30 AM, at which time was propelled to her room, assisted with incontinence care and placed into bed for a nap. R36 was assisted up into the wheelchair for the noon meal at 12:20 and propelled in the wheelchair to the main dining room. R36 remained at the meal until 1:06 PM, at which time, was placed into bed for a nap. At 4:04 PM, Surveyor interviewed staff H, who is the Director of Rehabilitation, and Certified Occupational Therapy Assistant (COTA) I regarding R36's ADL RNPs. Both indicated that RNPs were written for R36 to ambulate twice daily in 400 hallway with wheeled walker and to provide dressing and grooming tasks in the wheelchair, set up at the sink and to be given verbal cues for self-care. COTA I stated that she worked with R36 to ambulate in the room, while PT worked with walking in the hallway. R36 was still in bed napping at 4:40 PM. At 4:40 PM, Surveyor approached CNA J and CNA K regarding restorative services on the evening shifts. CNA J and CNA K had no knowledge that they were to ambulate R36. CNA I did indicate that on occasion, she places R36 at the sink to do some cares. Both staff stated R36 was to be repositioned every 2 hours. Together, CNA I and Surveyor went to check the computer kiosk for what was written for R36's ADLs. CNA I verified they were to ambulate R36 and set her up at the sink for provision of self-grooming tasks. At 4:54 PM, Surveyor interviewed Director of Nursing (DON) B regarding the carrying out of RNPs written by therapies for resident functional maintenance and maximizing individual abilities. DON B stated the CNAs should follow the programs if it related to ADLs, sometimes the nurses implement them. The staff should follow the plan, but if a resident refuses, the staff should notify the nurse, who then would implement charting. If the refusals continue, a referral back to therapy would be completed. Of concern is staff did not offer or encourage R36 to ambulate as directed in the RNP. On 4/3/24 at 7:46 AM, Surveyor approached CNA G and interviewed regarding the needs of R36. CNA G is a primary dayshift caregiver for R36. CNA G also stated that she does not ambulate R36. CNA G stated she wasn't aware that they were to ambulate R36 until last week. CNA G stated she felt it was a little scary to try to ambulate R36, that even pivot transfers can be scary at times. CNA G stated she informed therapy of this but was told they are to encourage R36 to ambulate, that the resident is able and needs verbal cues. CNA G also stated that she does not place R36 at the sink to conduct self-grooming tasks, stating, . we do all her grooming . At 8:07 AM, Surveyor approached CNA F and interviewed her regarding R36's RNP for ADLs. CNA F is another primary caregiver for R36 on the dayshift. CNA F stated it is sometimes hard to ambulate R36 in the hallway but does ambulate R36 to the bathroom. CNA F stated that R36 will often refuse to walk in the hallway but are to encourage R36 to do so. CNA F also stated that she has never placed R36 at the sink to conduct self-grooming tasks and that she has to do all the grooming for the resident. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding her expectation of staff in regard to implementing ADL RNPs completed by therapies. UM M is the manager of the 400 hall, in which R36 resides. UM M stated the process is that a resident is evaluated and treated by therapies. Therapies then writes RNPs for floor staff to implement. The plan is communicated to floor staff onto bright green sheets that are placed on a white board, which is hanging behind the nursing desk. All staff are aware of these boards and are expected to read the RNPs prior to shift to be aware of any potential changes with any residents. UM M stated her expectation is that staff implement the plans written.

Based on observations, interviews and record reviews, the facility did not ensure hand hygiene was conducted appropriately for 1 of 1 care observations (R36). This is evidenced by: The CDC had outlined the following indications for hand washing and the wearing of gloves: A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water. B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items. C. Decontaminate hands before having direct contact with patients . F. Decontaminate hands after contact with a patient's intact skin. G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled. H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. J. Decontaminate hands after removing gloves . The CDC continues to direct healthcare workers with the technique of hand hygiene: . E. Change gloves during patient care if moving from a contaminated body site to a clean body site . R36 has medical diagnoses that include but are not limited to hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage affecting right dominant side, aphasia, metabolic encephalopathy, anxiety disorder, depression and encephalomalacia. On 4/2/24 at 6:13 AM, Surveyor observed R36 in bed with the room dark. At 6:26 AM, Surveyor observed Certified Nursing Assistant (CNA) N enter R36's room to provide ADL cares. The following was noted: - CNA N gently awakened R36 and explained that she was going to assist her to get up for the day. - CNA N sanitized her hands and donned a pair of gloves. CNA N washed R36's upper body and underarms. - R36 was then directed to roll onto her right side. CNA N removed the pajama bottoms and proceeded to complete catheter care then front perineal cleansing. CNA N then directed R36 to roll onto the right side and CNA N provided buttock and anal cleansing. R36 was then directed onto the back. CNA N removed the gloves, and without sanitizing or washing her hands, donned a fresh pair of gloves. CNA N then proceeded with the following: - put socks, a clean brief and slacks on R36; - rolled R36 right and left to pull up and adjust the slacks; - emptied the two basins of water in the bathroom toilet and rinsed them in the sink; and - placed all the soiled linens into a plastic bag. CNA N then removed the gloves and again, without sanitizing or washing her hands, proceeded with the following: - adjusted the bed level to low; elevated the head of the bed to 60 degrees; - opened the closet door and put away clothing hangers; - opened the dresser drawer in search of a gait belt; - pulled the wheelchair up to the side of the bed and locked the brakes; - assisted R36 to sit up on the side of the bed, guiding the resident's arms and back in the process and holding R36's hands to assist her to sit up straight; - placed the gait belt around R36's waist and tightened the buckle; - lowered the bed height more so that R36's feet were on the floor; - placed her arms around R36's waist/back area and assisted R36 to a stand, then pivot transferred R36 to the wheelchair; - placed the indwelling Foley catheter drainage bag into a protective pouch located under the wheelchair seat; - placed the foot pedals of the wheelchair onto the chair and then placed each of R36's legs/feet onto these for support; and - moved the wheelchair by the arm rests away from the bed. CNA N then removed the gloves. CNA N still did not sanitize or wash her hands. CNA N entered the bathroom closet to retrieve a comb, not finding it, went to the nightstand and opened the top drawer and removed a brush. CNA N then proceeded to brush R36's hair. CNA N then donned a pair of gloves and picked up a tube of Cere Ve moisturizing lotion and lotioned R36's face. CNA N removed the gloves, and without sanitizing or washing her hands, donned a fresh pair of gloves. - CNA N then removed soiled linens from the bed and made up R36's bed. - CNA N then entered the bathroom and set up a toothbrush with toothpaste, approached R36 and covered the resident's chest with a towel and proceeded to brush R36's teeth, gave R36 a sip of water to rinse and spit into an emesis basin. CNA N then removed the gloves, placed the towel that was over R36's chest into the plastic bag of linens and then without washing or sanitizing, donned another new pair of gloves and placed hearing aids into each of R36's ears. CNA N then wiped off R36's eyeglasses and placed them on the face. CNA N then positioned R36 in the wheelchair in front of the television and set up the over-the-bed table to R36's right side. On this table, CNA N placed a box of kleenex, a covered mug with water, the remote control for the television and a small bag of cookies. CNA N placed the call light cord over R36's lap. CNA N then removed the gloves and sanitized her hands and left the room at 7:12 AM. On this same date at 9:18 AM, Surveyor interviewed CNA N regarding the above procedure and techniques. Surveyor asked CNA N what knowledge she had regarding hand hygiene. CNA N replied that hand hygiene was the best way to keep germs away and she should wash hands frequently, sanitize or wash her hands after removing gloves. The observation was explained to CNA N with no sanitizing or washing her hands with the removal of the gloves, especially following perineal and buttock cleansing. CNA N stated, Yeah, I should have after I took off the gloves. Yeah, so all tasks afterwards were considered dirty. OK. On 4/3/24 at 8:18 AM, Surveyor interviewed Unit Manager (UM) M regarding various topics including the expected practice of hand hygiene with cares. UM M stated, I would expect them [staff] to sanitize and glove when entering the room, and with cares, whenever doing something like peri-care, take off the gloves and sanitize their hands. Surveyor explained the observation made on 4/2/24 with CNA N. UM M stated, Yeah, she should have sanitized her hands after pericare and put on new gloves .

Based on observation, interview, and record review, the facility did not ensure appropriate source control is worn by unvaccinated staff to mitigate transmission of infections such as COVID-19, which has the potential to affect all 64 residents. CNA-D did not follow the facility policy and procedure for mitigation strategies for staff who are not fully vaccinated. On 02/16/2022 at approximately 8:30AM, Surveyor observed CNA-D come out of a resident room wearing goggles and a regular surgical mask. On 02/16/2022 at approximately 9:00AM Surveyor observed CNA-D (Certified Nursing Assistant) wearing goggles and a regular surgical mask while in a patient care area hallway. This is evidenced by: On 02/16/2022 at approximately 8:30AM, Surveyor interviewed CNA-D regarding infection control as CNA-D was listed on the facility vaccination spreadsheet as an unvaccinated staff with an exemption. Surveyor asked CNA-D how they received education regarding the COVID-19 vaccine. CNA-D responded that there was education laying around the building. Surveyor inquired as to what the process was to obtain a vaccination exemption. CNA-D stated that there was a form available online that they had to fill out. It was then sent to the NHA and approved. CNA-D further stated that they were required to test for COVID-19 2x a week. Surveyor asked what kind of PPE (Personal Protective Equipment) they were required to wear as an unvaccinated staff. CNA-D stated that they were only required to wear an N95 mask in COVID positive rooms, but could wear a regular mask otherwise. On 2/16/2022, Surveyor interviewed ADON (Assistant Director of Nursing,) who is also the IP (Infection Preventionist) at the facility, regarding the expectations for PPE and unvaccinated staff. ADON stated that the policy is that unvaccinated staff need to wear a KN95 mask at all times, not a regular surgical mask. They are expected to change from KN95 mask to an N95 mask when entering COVID-19 positive room. On 2/16/2022, Surveyor interviewed CNA-E, who is an unvaccinated staff with an exemption regarding infection control. CNA-E stated that they received training on infection control through the training program Relias, employee education books at nurses station, and that managers supplied training to staff as needed. When asked what PPE should be worn, CNA-E reported that unvaccinated staff needed to wear KN95 masks and that vaccinated staff would wear surgical mask. All had to follow directives given on isolation room doors. On 2/16/2022, Surveyor interviewed PT (Physical Therapist) regarding infection control. PT stated that they received education from the Relias computer training, that audits were conducted, emails were sent to employees that required a read and sign response, and that the facility held a skills fair yearly. PT stated that vaccinated staff wore surgical masks and that unvaccinated staff with approved exemptions were to wear KN95 masks. On 2/16/2022, Surveyor reviewed the facility policy titled, Rennes Health & Rehab Center-Covid-19 Vaccine Requirements. Under the portion of the policy that speaks to employees who are unvaccinated with an approved exemption, it states: Must comply with current Rennes Health & Rehab Center guidance on PPE use, which includes use of KN95 or higher, or as determined by the facility IDT team. On 2/26/2022, Surveyor reviewed the education that employees are required to sign and read regarding the policy in place for unvaccinated staff. Employees were required to sign and read an education form on the Topic of Staff with Approved Exemption. The form states that the employee, Must comply with the current Rennes Health &Rehab Center guidance on PPE use, which includes the use of KN95 or higher, or as determined by the facility IDT team. On 2/16/2022, Surveyor reviewed the letter sent to employees with exemption request approval. The second bullet points read: Must comply with current guidance on PPE use, which includes use of a KN95 mask or higher. On 2/16/2022, Surveyor reviewed the schedule for CNA-D since 1/27/22 when vaccination rule came into effect. CNA-D had worked 9 shifts on 3 different units since the rule began.

Based on observation interview and record review, the facility did not ensure 2 of 6 sampled residents with pressure injuries (R1 and R52) received the necessary care and services to prevent the development and promote healing of a pressure injury. R52 was admitted with an upper left humerus fracture and wore a shoulder immobilizer. The facility did not implement any interventions to offload the elbow despite R52's limited mobility. R52 began to complain of pain in the elbow on 12/3/18. On 12/12/18, R52 was found to have an unstageable pressure injury to the left elbow. R52's unstageable left elbow pressure injury subsequently deteriorated to a stage IV pressure injury with exposed periosteum (membrane layer covering bone) potentially requiring surgical closure. R1 was admitted to the facility with a DTI (Deep Tissue Injury) on the left heel, and vulnerable skin on the right heel. Despite that, R1 was observed wearing shoes potentially causing increased pressure to an existing DTI. This is evidenced by: Example 1: R52 had current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) was dated 11/12/18 indicated R52: ~ Had a BIMS (Brief Interview for Mental Status) score of 10, indicating a moderate cognitive impairment; ~ Required extensive assistance of 2 or more staff persons for bed mobility, transfers, bathing, dressing, grooming, and using the bathroom; ~ Limited assistance of 2 or more staff persons for walking; ~ Ate independently with supervision; ~ Was at risk for pressure injuries; and ~ Had no pressure injuries. R52's skin care plan dated 11/5/18 includes approaches, .Assess resident for pressure risk factors. Treat, reduce, eliminate risk factors .Conduct a systematic skin inspection daily with care and weekly with bath. Pay particular attention to the bony prominences .Report any signs of breakdown .Repositioning Q (every) 2-3 hours .Check skin under immobilizer brace daily .Pressure redistribution mattress and w/c (wheel chair) cushion . An admission skin assessment dated [DATE] indicated R52 had bruising to left arm and no pressure injuries. Surveyor reviewed R52's physician orders. On 11/6/18 a physician's orders [REDACTED]. Surveyor completed a review of R52's nursing notes and noted the following. ~ 11/8/18, .no skin issues under immobilizer . ~ 11/11/18, .free from redness, irritation under immobilizer . ~ 11/16/18, .skin free from issues . ~ 12/2/18, .skin free from issues . On 12/3/18 a nursing note indicated FM-P (Family Member) contacted the facility regarding R52's complaints of increased pain. The facility in response contacted the physician who ordered an increased dose of R52's pain medication. On 1/30/19 at 1:15 PM Surveyor spoke with FM-P. Surveyor asked FM-P about R52's pain. FM-P stated she contacted the facility due to R52's complaints of more pain in the left elbow. FM-P indicated R52's increased pain was shortly before R52's pressure injury had been identified. New pain was a significant finding. Pain typically precedes the development of a pressure injury. There was no indication the facility thoroughly assessed R52's left arm including the left elbow to determine the cause of increased pain. Nursing notes continue. ~ 12/5/18, .skin free from irritation . ~ 12/6/18, .skin free from irritation . ~ 12/8/18, .skin free from irritation . There were no further nursing notes describing the status of R52's skin until 12/12/18. ~ 12/12/18, .Resident was seen on weekly wound rounds r/t (related to) scab present on L (left) elbow. During assessment writer noted intact scab to boney (sic) prominence on L elbow. Stage II, dark in color, no drainage noted. No [MEDICAL CONDITION] noted surrounding scab, skin noted to be blanchable. Scab measuring 1.7cm x 1cm (1.7 centimeters by 1.0 centimeters) .Received order to skin prep Q (every) shift. Interventions .pad wheelchair arm rests. Check immobilizer for proper placement and fit. Request for LAL (Low Air Loss) mattress . This was the first notation of any type of skin problems on R52's left elbow. A dark scab was indicative R52's wound potentially started as a DTI (Deep Tissue Injury) not recognized by the facility until it evolved into eschar (dead tissue). A DTI is caused from prolonged pressure causing injury to subcutaneous tissue. It typically appears as a deep bruise or blood filled blister. As a DTI evolves it can have the appearance of a dark scab. In addition, the pressure injury as described could not be accurately staged. Until 100% (percent) of a wound base can be visualized it is considered an unstageable wound. The wound should have been staged as an unstageable pressure injury or DTI and not a stage II pressure injury. On 12/14/18, the facility updated R52's skin care plan. This was done after R52 developed a pressure injury. The care plan indicated R52 had developed a pressure injury to the left elbow and included approaches of .Conduct a systematic skin inspection weekly on wound rounds and scheduled bath shower day .air mattress .padded WC (wheel chair) arm rests .Wound team will follow until resolved . Nursing notes continue: ~ 12/19/18, .weekly wound rounds .During assessment writer noted intact scab to boney (sic) prominence on L elbow. Stage II, dark in color, no drainage noted. [MEDICAL CONDITION] noted to arm surrounding scab, skin noted to be blanchable. Scab measuring 1.4cm x 1cm (1.4 cm x 1.0 cm), open area noted surround the edges of the scab. Entire area measuring 1.6cm x1.6cm . This was indicative the pressure injury on R52's left elbow had deteriorated. The wound was again not staged accurately. The physician was contacted and order Santyl a [MEDICATION NAME] agent. The facility also received orders to refer R52 to the wound clinic. ~12/28/18, .weekly wound rounds r/t scab present on L elbow .noted .slough present in wound bed, no scab noted, surrounding skin noted to be blanchable and intact, Stage II, dark in color, no drainage noted. [MEDICAL CONDITION] noted to arm surrounding scab. Open area measuring 1.8cm x 0.8 (1.8 cm x 0.8 cm) . According to the wound note R52's wound was now covered with slough (devitalized tissue). The wound note was incomplete and did not specify what percent of slough was present in R52's wound bed. The facility continued to inaccurately stage R52's pressure injury. ~ 1/9/19, .weekly wound rounds r/t scab present on L elbow .L elbow measuring 1cm x 1cm x 0.4cm at 12 o'clock (1.0 cm x 1.0 cm x 0.4 cm in depth) . Wound bed white in color, surrounding skin intact and blanchable . The wound note indicated R52's unstageable wound continued to deteriorate. The wound was now showing depth at the 12 o'clock position. The wound note was incomplete and did not describe any further details regarding the wound bed. ~ 1/16/19, .weekly wound rounds r/t scab present on .L elbow measuring 1.2cm x 0.8cm, the area noted at 12 o'clock measures 0.2cm x 0.2cm x 0.3. Wound bed pink in color, wound bed noted to have more [MEDICATION NAME] tissue present than last week. Surrounding skin intact and blanchable . On 1/17/19 R52 was seen in the wound clinic. The wound clinic note did not describe any wound characteristics of R52's left elbow pressure injury. The wound clinic note indicated a culture was obtained. Results of the culture indicated there was no infection in R52's wound. ~ 1/23/19, .weekly wound rounds r/t scab present on L elbow .measuring 1.1cm x 0.7cm, tunneling at 12 o'clock measuring 0.3cm. Skin at the base of the wound edge noted to be more macerated .Wound bed pink in color, surrounding skin intact . The facility's wound notes continued to lack specific information regarding the characteristics of R52's wound. It is critical to document detailed and accurate wound characteristics in order to ensure appropriate treatment in order to promote healing. Surveyor completed a review of R52's medication and treatment records since 11/6/18. From 11/6/18 through 12/12/18 R52's record indicated licensed staff had viewed and inspected the skin under R52's immobilizer daily. On 1/28/19, the facility updated R52's care plan to include .Requires extensive assistance for bed mobility. Turn and reposition every .1-2 hours . On 1/30/19 at 8:45 AM Surveyor observed RN-Q (Registered Nurse) and RN-F complete a dressing change on R52's left elbow wound. RN-Q measured R52's wound at 1.5 cm x 1.4 cm x 0.4 cm. The wound base was noted as pale pink with white colored tissue covering approximately 30% of the most proximal point of the wound. Undermining was noted at the 9 o'clock position measured by RN-Q at 0.4 cm and at the 3 o'clock position which measured at 0.2 cm. The most distal end of the wound had an area of blue/black tissue measuring approximately 0.2 cm. The wound was surrounded by approximately 0.2 cm of whitish raised tissue. Surveyor was unable to determine if the white tissue in the base of the wound was bone or cartilage. Surveyor asked RN-Q if the area was bone. RN-Q was not sure. On 1/29/19 at 12:05 PM Surveyor spoke with CNA-I (Certified Nursing Assistant). CNA-I indicated she worked on the unit where R52 resides. CNA-I indicated R52 had an immobilizer when she was first admitted . CNA-I stated R52 wore the immobilizer at all times except when they did cares. Surveyor asked CNA-I about R52's pressure injury. CNA-I indicated she did not know how it developed. CNA-I indicated she did see it sometime in (MONTH) and recalled the area being red. CNA-I stated they had not seen the wound right away and it had been missed due to its location. 01/29/19 at 12:17 PM Surveyor spoke with CNA-J. CNA-J indicated she worked full time on the unit where R52 resides. CNA-J also indicated she took care of R52 every day she worked. CNA-J indicated R52 had an immobilizer on when first admitted to the facility. CNA-J stated she took the immobilizer off when she worked in order to complete care. CNA-J stated she recalled R52's left elbow looking red and sore. CNA-J also indicated R52 complained of pain in the area. CNA-J stated after the nurses started doing treatments on it they used a soft pillow under R52's elbow. 01/29/19 at 4:41 PM Surveyor spoke with RN-K. RN-K indicated she worked full time on the unit where R52 resides. Surveyor asked RN-K about R52's left elbow pressure injury. RN-K indicated R52 has had it for a while. RN-K stated she did not know how R52 developed the wound. RN-K stated she had done a skin check prior to R52 developing the wound and had not noted any skin issues. On 1/30/19 at 9:30 AM Surveyor spoke with RN-R. According to R52's MAR (Medication Administration Record) RN-R worked 12/10/18, 12/11/18, and 12/12/18 on the unit where R52 resides. Surveyor asked RN-R about R52's pressure injury. RN-R indicated she never saw a wound or scab on R52's elbow. RN-R indicated the first time she was aware of the wound was after the treatment had started. On 01/29/19 at 4:57 PM Surveyor spoke with RN-L. RN-L indicated she was the clinical manager on the unit where R52 resides and is also the facility wound nurse. Surveyor asked RN-L about R52's wound. RN-L stated R52 had been admitted from home after a fall with in which R52 sustained a left humeral fracture. RN-L stated R52 had an immobilizer in place and R52 could not move her arm when in the immobilizer. Surveyor asked if the immobilizer covered R52's elbow. RN-L indicated no. RN-L indicated R52's wound was brought to her attention by OT (Occupational Therapy), but could not recall who in OT. RN-L indicated she initially observed the area on R52's left elbow as an intact black-brown non-blanchable scab. RN-L stated she looked at possible causes for the development of the wound and felt R52's pressure injury may have been caused by pressure from resting R52's left elbow on something in R52's wheel chair. RN-L stated after the development they placed sheep skin on the arm rests of R52's wheel chair and placed a specialized air mattress. RN-L indicated the wound was stable at first, but then started to deteriorate when the edges of the wound started to lift. RN-L stated they used several different treatments and eventually got orders for R52 to be seen in the wound clinic. RN-L indicated she felt R52's wound was still not improving. Surveyor asked RN-L why the wound was not identified until it was an unstageable wound. RN-L indicated she did not know. RN-L indicated she did investigate the occurrence and talked with the nurses. RN-L stated all the nurses she spoke with were unaware of the scab. On 1/30/19 at 7:30 AM Surveyor spoke with COTA-M. COTA-M indicated she was the person who identified R52's wound. COTA-M indicated she worked with R52 most days and assisted R52 with bathing, dressing, and grooming. COTA-M indicated she identified the wound on 12/12/18. COTA-M indicated according to her documentation she noted as an open sore on the posterior elbow which measured approximately 0.5 cm. COTA-M indicated when she was assisting R52 with cares R52 complained of pain in her left elbow. COTA-M indicated when she investigated the source of R52's pain she found the wound. COTA-M indicated she had not seen it earlier due to its location and the amount of pain R52 had with any movement of the arm. COTA-M indicated she felt the wound was due to pressure. On 1/30/19 at 9:10 AM Surveyor spoke with NP-N (Nurse Practitioner) from the wound clinic. NP-N indicated she saw R52 only once on 1/17/19. NP-N stated she saw R52 at the request of the facility for a non-healing wound. NP-N indicated when she saw R52 on 1/17/19 R52's wound was a stage IV pressure injury and measured 1.4 cm x 0.8 cm x 0.5 cm with tunneling measuring 0.8 cm from the 2 o'clock position to the 4 o'clock position. NP-N indicated she also noted the white tissue in the base of R52's wound. NP-N indicated she was not sure if it was bone or not. NP-N indicated there was no infection. NP-N indicated due to the nature of the wound and its location she may refer R52 to the orthopedic clinic for surgical closure. NP-N stated she was scheduled to see R52 on 1/30/19. Surveyor asked NP-N to inform Surveyor of her findings. On 1/30/19 at 11:40 AM Surveyor again spoke with NP-N. NP-N indicated she assessed R52's wound on 1/30/19 and noted it to be a stage IV pressure injury. NP-N stated the wound measured 1.0 cm x 0.8 cm x 0.4 cm. NP-N indicated there was also 1.1 cm tunneling from the 10 o'clock position to the 2 o'clock position. NP-N indicated she felt the white tissue as noted in R52's wound was periosteum (membrane layer covering bone). NP-N indicated due to the nature of R52's wound and location she requested a surgical consult for surgical closure of R52's wound. Example 2: R1 had current [DIAGNOSES REDACTED]. The most current MDS was dated 1/14/19 and indicated R1: ~ Had a BIMS (Brief Interview for Mental Status) score of 3 indicating a severe cognitive impairment; ~ Required limited to extensive assist 1-2 for all aspects of care; ~ Did not walk; and ~ Had 1 DTI present on admit. R1's skin care plan was dated 1/7/19. The care plan had the following approaches. ~ 1/7/19, .Elevate heels off bed or use heel protectors .Position with pillows . ~ 1/9/19, .Float heels when in bed . ~ 1/29/19, .Blue boots .when resident is in bed . There were no interventions to direct staff on what type of footwear R1 should wear. On 1/28/19 at 12:23 PM R1 was noted in the dining room. R1 had shoes on both feet. On 1/29/19 at 9:08 AM R1 was noted to have shoes on both feet. Shoes have the potential to increase pressure to R1's already existing left heel DTI. On 1/30/19 at 9:43 AM Surveyor observed R1's heels with the assistance of RN-O. R1 was noted to be wearing gripper socks which RN-O removed. Surveyor observed a DTI on R1's left heel measuring approximately 2.0 cm x 3.0 cm. The DTI had the appearance of a flat intact blood blister with defined wound margins. Surveyor asked RN-O about R1 wearing shoes. RN-O stated R1 should not be wearing shoes due to the possible increased pressure. RN-O stated R1 should wear gripper socks.

Based on observations, interviews and record reviews, the facility did not ensure 1 of 1 residents reviewed for potential restraint or assistive device use (R12), was comprehensively assessed for both safety and the need for the device. R12 was using a right sided lap tray while up in her wheelchair. The facility did not: - comprehensively assess the need for the device, whether safety or positioning, or other alternative and least restrictive devices; - obtain a physician order [REDACTED].>- identify a medical symptom for its use; - identify the use of the device in the care plan with directives to staff to provide device-free periods; and - complete ongoing monitoring of the device to determine whether the device continued to be safe for R12 or its continued need. This is evidenced by: R12 was admitted to the facility for rehabilitation and strengthening following a hospitalization as a result of a fall. Medical Diagnoses for R12 include, but are not limited to [MEDICAL CONDITION] and Collapse, Orthostatic [MEDICAL CONDITIONS] and generalized weakness. The most recent completed MDS (Minimum Data Assessment) dated 10/28/18 indicates R12 has BIMS (Basic interview of Mental Status) score was 4/15, indicating impaired cognitive abilities; requires extensive assistance of 1-2 staff with all cares; is non-ambulatory; and had no range of motion limitations. R12's current care plan and CNA (Certified Nursing Assistant) care card do not address the use of any device. The facility also completed CP's for Comfort dated 1/31/18 and for Pain dated 2/22/18. Neither of these CP's identified the use of the device for either restraint or positioning. A review of R12's medical record including progress notes and physician communication do not address the use of any device. On approximately 2/13/18, R12 was evaluated by Occupational Therapy (OT) who placed a lateral support device to R12's wheelchair. The reason for the device was to prevent R12 from leaning to the right. Surveyor observed R12 during meals on 1/29/19 and 1/30/19. R12 was noted to have a right sided lap tray affixed to her wheelchair. On 1/30/19 at 8:03 AM, Surveyor spoke with R12. R12 responded with yes and no answers. Surveyor asked R12 if she knew why she had the lap table. R12 indicated that she did not know. R12 denied any pain or discomfort and was able to raise her right arm up and down. Surveyor asked R12 if she could remove the table. R12 moved her fingers along the edges of the tray table, but was unable to move the device. She could not grasp what she needed to do to remove the tray. On 1/29/19 at 9:11 AM Surveyor interviewed CNA-A regarding the device and R12's abilities. CNA-A stated R12 had a stroke and uses the tray to support her arm. She was unsure when it was placed. She stated that R12 uses a sit to stand for transfers, needs much help with cares, and doesn't really make attempts to do anything on her own anymore. A review of R12's medical record found no [DIAGNOSES REDACTED]. On 1/29/19 at 9:22 AM, Surveyor interviewed CNA-C regarding her knowledge of the device. CNA-C stated that R12 had the lap tray before she started working for the facility in October. She further stated that R12 was transferred with a mechanical lift and required extensive help with all her cares. On 1/30/19 at 8:17 AM, the Surveyor interviewed LPN-D regarding her knowledge of the lap tray used by R12. LPN-D was R12's primary nurse during the entire survey and stated that she generally works R12's hall. LPN-D stated that she started working for the facility in (MONTH) (YEAR). She recalled R12 leaning to her right when sitting in the wheelchair and believed the device was placed to prevent that from happening. She stated staff had previously tried to use pillows and blankets for the leaning. LPN-D did not know who initiated the lap tray but believed that it may have been therapy, stating That is the normal process anyway. Therapy would assess and make a recommendation for a device. On 01/30/19 at 7:44 AM, the Surveyor met with the NHA. The NHA stated they were unable to locate an assessment for the use of R12's lap tray. He stated an assessment had been completed yesterday (1/29/19), and provided the Surveyor with this assessment. He further stated the facility is working on obtaining a physician order [REDACTED]. When asked what the normal process is for device placement, the NHA stated, The typical process is we would get an order for [REDACTED]. The NHA did not know when the device was placed on R12's wheelchair, or who was responsible for doing so, as no information was found in R12's Medical Record. On 1/30/19 at 10:36 AM, the Surveyor met with OTR-H (Occupational Therapist), the DON, The facility VPO-G (Vice President of Operations), and RNC-F (Regional Nurse Consultant to discuss the lap tray as well as the expected procedures to follow prior to placement of any device, whether restraint or assistive. OTR-H indicated a previous OT evaluation was done in which a lateral support was placed to R12's right side in the wheelchair. OTR-H stated the normal process would be therapy department would receive a physician order [REDACTED]. She will monitor R12 throughout the day to determine fatigue levels, posture and positioning. OTR-H stated she removed the tray table today to see how R12 manages without it. She indicated she updated LPN-D, who would be responsible to also monitor throughout the day. The DON was asked what the normal process was for any device placement. The DON stated first an assessment should be completed to determine need. After the assessment, a therapy evaluation is conducted, and based on therapy recommendation, the physician is updated and orders the device. The care plan is updated and staff informed. The resident is then monitored on-going.

Based on observation and interview, the facility did not ensure the storage of all biologicals were stored under proper temperature controls in a cooler in 1 of 2 medication rooms. This has the potential to affect all 75 residents residing in the facility. The cooler in the South Medication Room contained 12 vials of influenza vaccine. The cooler was not kept within adequate temperature range. There was no documentation of staff monitoring the temperatures of the cooler. The medication refrigerator in the South Medication Room contained an open vial of influenza vaccine. The open vial did not have an open date on the vial. This is evidenced by: On 10/18/17 at approximately 1:10 p.m., Surveyor reviewed the South Medication Room with Registered Nurse (RN) H and observed the following: There was a small cooler sitting on the counter that contained 12 vials of influenza vaccine which would 120 doses. The thermometer inside the cooler indicated the temperature was 52 degrees Fahrenheit (F). RN H was unaware of where staff documented the temperature of the cooler. RN H indicated that the night shift nurses are responsible for monitoring the temperatures of the refrigerators. RN C, who is also the Unit Manager came to assist. RN C verified with Surveyor that the interior of the cooler was not cold to the touch and the thermometer was reading over 50 degrees. RN C was also unable to locate any documentation that staff were monitoring the temperatures of the cooler. The influenza vaccine package stated the vaccine was to be stored between 36 and 46 degrees F. The medication refrigerator in the South Medication Room contained an open vial of influenza vaccine. The open vial did not contain an open date on the vial. RN H verified there was no open date on the vial. RN H stated that it was the facility policy to date the vial when it is open. On 10/18/17 at approximately 1:30 p.m., Surveyor explained and showed the Director of Nursing (DON) the cooler in the South Medication Room. The DON stated that the vaccines should not have been stored in that cooler and that they should have been placed in the medication refrigerator. The DON indicated that the vaccines would have to be disposed of.

Based on family and staff interviews and record review, the facility did not consistently implement written restorative programs to maintain or enhance 2 of 4 resident's (R2 and R10) functional abilities. R10 was admitted to the facility following a fall at home, sustaining a [MEDICAL CONDITION]. Following physical therapy services, she was released to floor staff restorative programming for Activities of Daily Living training as well as chair exercises to enhance and maintain her current level of functioning. There is no evidence these chair exercises are being completed. R2 has restorative programs for dressing and grooming, as well as active range of motion. There is no evidence this program is followed as directed by Occupational Therapy. This is evidenced by: Example 1: R10 was admitted to the facility on [DATE] after hospitalization for a periprosthetic fracture around an internal prosthetic left hip joint. While in the facility, R10 received both Physical Therapy (PT) and Occupational Therapy (OT) services. The goal was to increase R10's strength to facilitate independence with functional mobility. On 10/6/17, R10 was released from PT services with directives given to floor staff on a Restorative Nursing Program (RNP) which included chair exercises. The PT Discharge Summary dated 10/12/17 states prognosis is Excellent with participation in RNP. On 10/17/17 at 4:45 p.m., Surveyor spoke with Family-J, R10's Activated Power of Attorney. Family-J stated he desired to take R10 back home with him, which was the previous living arrangement. He noted progress with R10's abilities when she was receiving therapy services, but since that has stopped, Family-J stated that R10 has more laziness. He noted that R10 sleeps a lot, and that he was unsure of what to expect or what he should do. He stated that he hasn't seen progress in R10, as he would expect. Surveyor reviewed R10's CNA (Certified Nursing Assistant) Care Card and Comprehensive Care Plan. The CNA Care Card is updated daily, as needed with any changes in the provision of care. According to both documents, R10 is to receive Restorative Nursing Program of Active Range of Motion and dressing/grooming exercises. On 10/18/17 at 9:26 a.m., Surveyor asked CNA-F if there were any exercise plans in place for R10 that CNA staff are to complete. CNA-F stated that R10 receives her morning cares from night shift and if there were any plans, the exercises would be completed with morning cares. She was unaware of any detailed exercise plans for R10. On 10/18/17 at 12:26 p.m., Surveyor spoke with the Physical Therapy Assistant (PTA) responsible for R10's RNP for bedside exercises. PTA-K stated that Physical Therapy had worked with R10 after a left [MEDICAL CONDITION], to improve strengthening and functional abilities. The goal was to attempt previous level of independence. PTA-K stated R10 was discharged from PT services on 10/6/17 with referral to floor staff on a FMP (Functional Maintenance Plan) to continue bedside exercises for the lower extremities. PTA-K stated that she directed staff on details of how to perform each exercise and how often. She stated her recommendations were to complete each exercise daily, at least five days per week. Surveyor requested a copy of the FMP for R10. In reviewing, Surveyor noted the description states, Lower body and trunk exercises RNP completion. Attached were pictures and instructions for 6 different exercises staff were to assist R10 to complete. The PT Discharge Summary which was electronically signed and dated 10/12/17 by PTA-K and the Physical Therapist, states, .seated LE (lower extremity) and trunk exercises to increase strength to facilitate independence with functional mobility tasks. Under the section of prognosis, was documented, Excellent with participation in RNP. Surveyor then requested the documentation of the exercise program. In reviewing, there has been no documentation of the exercises being completed. The only program being documented was for Activities of Daily Living. On this same date at 1:35 p.m., Surveyor interviewed UM-C (Unit Manager) who is responsible for R10. UM-C stated that she did update R10's CNA Care Card and Care Plan regarding the completion of bedside exercises but that she failed to open the RNP into the computer Point of Care (P(NAME)) which would have given the CNA staff an area to document the completion of the exercises. She further stated the plans are written by OT or PT and submitted to her. UM is responsible to update the information on the care plans, make a copy to place into a binder that is left in the residents rooms for CNA staff to refer to, then a copy of the plan is placed in her file as well as at the nursing desk. She stated she has no way to ensure it was being completed by staff as it was not opened up in the P(NAME) charting. Example 2: R2 has medical [DIAGNOSES REDACTED]. R2 spends the majority of her days and nights in bed with repositioning competed by staff. R2's Brief Interview for Mental Status (BIMS) score is 15/15, indicating R2 is alert and oriented and cognitively intact. On 10/16/17 at 12:05 p.m., Surveyor interviewed R2. Included in the interview were questions relating to exercising, as R2 spends the majority of her time in her bed, per her choice. R2 stated staff used to give her exercises in bed but it does not happen often anymore. She stated she sometimes has a lot of pain and hasn't been feeling well lately. She further stated, the girls help me with all my bathing and dressing . and assist her as needed when she requests. R2 has a FMP (Functional Maintenance Plan) dated 3/25/16 which directs staff to Please complete ROM (Range of Motion) following attached exercise program. Attached to the program, and located in R2's room in a red binder, are detailed exercises to her legs that staff are to complete twice daily. This exercise program has a hand written date of 11/25/15. On 10/17/17 Surveyor requested documentation of the restorative program for R2 from the Unit Manager-G (UM), responsible for R2. On 10/18/17 at 10:18 a.m., Surveyor appraoched CNA-K (Certified Nursing Assistant), as she just completed cares on R2, and asked her what she all assisted R2 with for morning cares. CNA-K explained the basic cares and that she completed all bathing, dressing and grooming for R2. Surveyor then asked if R2 had an exercise program in place that she was to assist her with. CNA-K stated, I couldn't tell you. I didn't do any. On 10/18/17 Surveyor received the restorative documentation from UM-G. Upon review from the dates of 8/28/17-10/18/17, Dressing/Grooming program: R2 was to complete upper body cares. Initially when the program was written, R2 was getting up in a wheelchair and performing these cares at the sink. Being that she has been in bed for a lengthy time frame, there is no indication that she has been performing these self cares in bed. At the time it was written, she was performing upper body bathing, dressing and grooming independently. Currently, staff provide these cares with extensive assistance. Documentation: ~ Not Performed was documented on the day shift 1 time and on the evening shift 4 times ~ Unanswered was documented on the dayshift 33 times and on the evening shift 33 times Active Range of Motion Program: ~ Unanswered was documented on the dayshift 19 times and on the evening shift 19 times On 10/18/17 at 10:52 a.m., Surveyor spoke with UM-G (Unit Manager) who is responsible for R2. UM-G stated that floor nurses are responsible to ensure CNA staff are completing the restorative programs. Any refusals by the resident should be documented in the nursing progress notes. When asked what documentation of Unanswered indicates on the Point of Care documentation, which is where CNA staff document the provision of the exercise and restorative programs, UM-G stated, It means that either it was not completed or the CNA did not document that they did it. On 10/18/17 at 1:18 p.m, Surveyor asked the Director of Nursing (DON) if the program is still current. The DON reviewed and researched and stated that it is indeed still current.

Based on observation, staff interviews and record review the facility did not consistently implement nutritional approaches and adaptive devices and mealtime approaches to promote good nutrition and prevent further weight loss for 2 of 6 residents reviewed for weight (R1 and R5). R5 is to have weighted utensils at mealtimes, is to receive her meal early to allow time to feed herself, use a two handled sippy cup for liquids and a supplement (liquid or thrive ice cream) at all meals. These approaches were not consistently implemented as observed by the Surveyor. R1 feeds herself her meals in her room. Even though R1 is on Hospice services and weight loss is expected, staff do not consistently encourage or cue R1 to eat. Observations were made of 3 meals in which meal trays were given to R1 but no staff had entered during the meal time to assist or encourage R1 to eat. This is evidenced by: Example 1: R5 was admitted to the nursing home on 12/19/16 following a right [MEDICAL CONDITION]. R5 is currently receiving Hospice Care as of 01/18/2017. Surveyor review of R5's current Minimum Data Set assessment dated [DATE], indicates the following: extensive assistance for eating, weight 94#, yes to weight loss and not on a MD (physician) prescribed weight loss program. Review of R5's occupational therapy discharge notes dated 01/18/17, indicates that caregiver's and resident were trained on use of weighted utensils for successful self feeding. Review of R5's diet card given to the surveyor by RD/DM-E (Registered Dietcician/Dietary Manager) reveals the following approaches for all meal times: house supplement all 3 meals, 2 handled sippy cup, trays early to allow time for self feeding, assist if eats less than 50%, direct supervision, weighted utensils, provide verbal cues and physical assistance as needed. On 10/17/17 beginning at 8:10 a.m., Surveyor observed R5 at the breakfast meal in the dining room. At 8:15 a.m., R5 was observed to receive apple juice in two handled sippy cup, which she picked up in her right hand and drank from. It wasn't until 8:50 a.m., R5 received a bowl of cream of wheat cereal which staff put brown sugar on. Staff also placed R5's diet card with all of the approaches at the table by her. Many of the other residents had already eaten their meal and left the dining room. R5 was observed to have regular utensils, not weighted built up handled utensils (spoon). R5 picked up the spoon and began to eat her cream of wheat. R5 ate 100% of the cream of wheat and drank all of the apple juice in the sippy cup. R5 was not offered any more food to eat or any more to drink. No supplement was given to R5 at the meal. R5 was not allowed to start her meal early. At 9:10 a.m., R5 was wheeled from the dining room by staff. On 10/17/17 at 12:10 p.m., Surveyor observed R5 at the lunch meal in the dining room. At 12:27 p.m., R5 was still waiting for her food. All other residents were eating their meals and some were already leaving the dining room. R5 was given a 10 ounce one handled covered container of lemonade with a straw in it. At 12:35 p.m., R5 was given her meal of pureed meat, pureed green beans and chocolate pudding. A 6 ounce vanilla supplement was given to her a in regular glass and a straw. R5 diet card with all of her approaches were also placed on the table by R5. Staff were observed to review the diet card. Mashed potatoes were on the menu, but R5 did not receive mashed potatoes. No weighted built up utensils were given to R5. CNA-I (Certified Nursing Assistant) sat down next to R5 and began to feed R5. CNA-I was observed to review R5's diet card with the meal time approaches. R5 was not allowed the opportunity to feed herself. R5 drank all of the supplement, 1/4 of the meat and less than 1/4 of the green beans and all of the chocolate pudding. R5 was never given mashed potatoes. At 1:10 p.m., CNA-F said that R5 was fed last because she needs direct supervision for meals. CNA-F said that they have 3 tables of residents that need direct supervision. On 10/17/17 beginning at 5 p.m., Surveyor observed R5 in the dining room for supper. R5 had a two handled sippy cup with a red liquid in it. It was identified as a mix of cranberry juice and orange juice. R5 was observed to pick the cup up and drink from it. R5 was given her meal early. R5's diet card with all of the approaches was also placed on her table by R5. R5 received pureed chicken pot pie. R5 was not given weighted handled utensils for self feeding. Staff were observed to feed R5. No supplement or thrive ice cream was observed. Surveyor ceased observation at 5:30 p.m. RD/DM-E was observed present in the kitchenette in the dining room for all of the meals. On 10/18/17 at 7:05 a.m., Surveyor spoke with RN/UM-C (Registered Nurse/Unit Manager). RN-C said that R5 is at nutritional risk and has had significant weight loss. RN-C said that R5 should be given a supplement at all 3 meals, should be asked if she wants more food. RN-C said that R5 should be given her meals early and that R5 likes to try to feed herself. RN-C said that R5 should have weighted handled utensils and a two handled sippy cup for meals because of shakiness/tremors of her arms/hands. On 10/18/17 at 8:55 a.m., Surveyor spoke with COTA-B (Certified Occupational Therapy Assistant). COTA-B said R5 should be using weighted handled utensils and a double handled sippy cup at all meal due to tremors. COTA-B said that R5 is able to feed herself and should be given her meal earlier to allow this as it takes her time to eat. On 10/18/17 at 10:20 a.m., Surveyor spoke with RD/DM-E (Registered Dietician/Dietary Manager). RD/DM-E said that he supervises the kitchen and the kitchen staff. RD-E said that R5 is at nutritional risk and the goal is to prevent further weight loss. RD-E said that R5's usual body weight is around 120 pounds. RD-E said that R5 should be given a supplement at all 3 meals, weighted utensils, direct supervision, given meal earlier to allow her the opportunity to feed herself. RD-E said that R5 likes to eat potatoes and if R5 eats all of something staff should be offering her more food or asking her if she wants something else. Example 2: R1 has medical [DIAGNOSES REDACTED]. R1 is currently on Hospice and feeds herself meals after staff set-up in her room. R1's height is documented as being 61 inches tall. During the initial tour of the facility on 10/16/17 at 9:05 a.m. with UM-G (Unit Manager), Surveyor was told R1 was experiencing weight loss and that she eats in her room. The UM stated staff are expected to provide encouragement for R1 to eat. According to a Dietary documentation dated 4/3/17, R1's Usual Body Weight (UBW) was between 105-110 # (Pounds) or an average of 107.5#. In reviewing R1's weights, Surveyor noted on 2/18/17, R1's weight was 109#. On 10/1/17 R1's weight was down to 93#. During this timeframe, R1 requested to stop receiving Ensure supplements. Surveyor observed R1 during lunch on 10/16/17. R1 received her meal of ground pork with gravy, mashed potatoes with gravy, a cheesecake dessert, and 8 ounces of chocolate milk at 12:25 p.m. At 1:06 p.m., the tray was removed. R1 ate approximately 25% of her solids with this meal. During the entire meal, no staff entered to offer cues or encouragement to R1 to eat. On 10/17/17 during breakfast, R1 was served 2 small donuts, a ham and egg Frittata, hot chocolate and apple juice at 8:35 a.m. At 9:15 a.m., staff removed R1's tray. Intake for this meal was approximately 80% of the Frittata and 1 of the 2 small donuts. During this meal, no staff entered to offer encouragement or cue R1 to eat. On 10/18/17 during breakfast, UM-G provided R1 with 1 slice of toast, orange juice and a cup of coffee at 8:05 a.m. At 8:26 a.m., R1 had eaten the toast, about 2 ounces of the 4 ounce glass of orange juice and her coffee. During this time frame, no staff had entered R1's room to offer additional food items or assistance or cues. On 10/18/17 at 10:40 a.m., Surveyor spoke with CNA-N about residents who eat in their rooms. CNA-N stated staff are to check on residents that eat in their rooms, and if not eating, to encourage them to eat.

Based on record review and interview, the facility did not ensure 2 (R9 and R12) of 15 sampled residents' medication regimens were free from unnecessary drugs. R9 and R12 were treated with a broad spectrum antibiotic for a urinary tract infection [MEDICAL CONDITION]. R9 and R12 did not meet McGeer's criteria for a urinary tract infection. R9 was also being treated for [REDACTED]. This is evidenced by: According to the Centers for Disease Control (CDC), Antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics when followed over a year. Similar to the findings in hospitals, studies have shown that ,[DATE]% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from [MEDICAL CONDITION], increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. The CDC states: [MEDICAL CONDITION] (C. difficile) is an important cause of infectious disease death in the United States. [DIAGNOSES REDACTED]icile was estimated to cause almost half a million infections in the United States in 2011. Approximately 83,000 of the patients who developed [DIAGNOSES REDACTED]icile experienced at least one recurrence and 29,000 died within 30 days of the initial diagnosis. The facility standard for Urinary Tract Infections is MC Geer's, which states: UTI without indwelling catheter (both criteria 1 and 2 must be present) 1. At least 1 of the following sign or symptom subcriteria a. Acute dysuria or acute pain, swelling, or tenderness of the testes, epidiymis, or prostate b. Fever or leukocytosis (refer to constitutional criteria) and at least 1 of the following localizing urinary tract criteria 1. Acute costovetebral angle pain or tenderness 2. Suprapubic pain 3. Gross hematuria 4. New or marked increase in incontinence 5. New or marked increase in urgency 6. New or marked increase in frequency c. In the absence of fever or leukocytosis, the 2 or more of the following urinary tract subcriteria 1. Suprapubic pain 2. Gross hematuria 3. New or marked increase in incontinence 4. New or marked increase in urgency 5. New or marked increase in frequency 2. One of the following microbiologic subcriteria a. At least 100,000 cfu/ml of no more than 2 species of microorganisms in a voided sample b. At least 100 cfu/ml of any number of organisms in a specimen collected by a straight catheter Note: UTI should be diagnosed when there are localizing [MEDICAL CONDITION] signs and symptoms AND a positive urine culture result. Example 1: R9 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. R9 has a history [MEDICAL CONDITION] to the large intestine. R9 had a physician's orders [REDACTED].>[MEDICATION NAME] 125 milligram (mg) capsule, by mouth, four times a day for 14 days ([DATE] - [DATE]) [MEDICATION NAME] 500 mg, by mouth, two times a day for 10 days ([DATE] - [DATE]) Review of R9's medical record indicated the following: [DATE] - .admitted on oral antibiotic [MEDICATION NAME] due to [MEDICAL CONDITION] DX (diagnosis) . [DATE] - .Resident had formed stool. Continue on [MEDICATION NAME] per MD orders. Removed from contact isolation . [DATE] - .Resident placed on contact isolation at this time as she was noted to have watery loose stools . [DATE] - .Resident was started on [MEDICATION NAME] 500mg TID (three times a day) x 14 days . [DATE] - Spoke with infection control nurse, and received permission to remove resident from contact precautions no loose stool noted in over 24 hours [DATE] - Resident noted to have a thick yellow coating on tongue. Dr. (Physician's name) contacted. Order given to start [MEDICATION NAME] swish and swallow QID (four times a day) x 10 days. The thick yellow coating on the tongue would be thrush or a [MEDICAL CONDITION]. The CDC describes [MEDICAL CONDITION]: [MEDICAL CONDITION] lives in the mouth, throat, and the rest of the digestive tract without causing any problems. Sometimes, [MEDICAL CONDITION] multiply and cause an infection if the environment inside the mouth, throat, or esophagus changes in a way that encourages its growth. This can happen when a person's immune system becomes weakened, if antibiotics affect the natural balance of microbes in the body, or for a variety of other reasons in other groups of people. [DATE] - CONTACT: New orders received from (Nurse Practioner's name), NP for CBC (Complete Blood Count), BMP (Basic Metabolic Panel) and UA (Urine Analysis) due to increased weakness. The medical record contained no documentation of localized [MEDICAL CONDITION] signs or symptoms to indicate a UTI. [DATE] - Resident noted to have incontinent stool this morning and then x 2 small stools the rest of the shift. Brown in color and on the liquid side. Initiated standing order for stool for [DIAGNOSES REDACTED] and obtained this afternoon. [DATE] - .Stool sample tested positive for [MEDICAL CONDITION], awaiting MD orders. UA obtained on noc (night) shift, results to .NP . [DATE] - Physician order [REDACTED].>[DATE] - .Received new orders from Dr. (Physician's name) to start [MEDICATION NAME] BID (two times a day) x 10 days. [DATE] - .Resident started on [MEDICATION NAME] PO (by mouth) BID (two times a day) for UTI . [MEDICATION NAME] is a broad-spectrum antibiotic of the fluoroquinolone class. It is active against both Gram-positive and Gram-negative bacteria. R9's temperatures were reviewed the week prior to starting the broad spectrum antibiotic for an UTI. From [DATE] - [DATE] R9's temperatures ranged from 97.4 degrees Fahrenheit (F) to 98.8 degrees F. These temperatures are within normal limits and do not indicate a fever. On [DATE] at approximately 7:30 a.m., the Director of Nursing (DON), who was also identified by the facility as being the Infection Control and Prevention nurse, told Surveyor that R9's symptoms were that she was not progressing in therapy and had complaints of not feeling well. The DON stated that they use McGeer's criteria as only a guide, but it isn't specific for everybody. On [DATE] at approximately 9:15 a.m., Surveyor spoke to R9. R9 is responsible for self and cognition is intact according to the Minimum Data Set (MDS) assessment dated [DATE]. Surveyor asked R9 if she had a history of [REDACTED]. Diff infection. On [DATE] at approximately, 10:30 a.m., the DON provided Surveyor with the facility's Mc Geer's criteria. The DON stated that according to the record, R9 did not meet the McGeer's criteria for a UTI. The American College of [MEDICATION NAME] documents by(NAME)M. Surawicz, MD, MACG, University of(NAME)School of Medicine - Published [DATE]. Updated [DATE]: Diarrhea is a frequent side effect of antibiotics, occurring ,[DATE]% of the time. It usually gets better when the antibiotics are stopped. [MEDICAL CONDITION] infection (CDI) is due to a toxin-producing bacteria that causes a more severe form of antibiotic associated diarrhea. The disease ranges from mild diarrhea to severe colon inflammation that can even be fatal. CDI usually occurs when people have taken antibiotics that change the normal colon bacteria allowing the [DIAGNOSES REDACTED]icile bacteria to grow and produce toxins .Wise antibiotic policies, by using narrow-spectrum agents when directed and avoiding unnecessary use of broad spectrum antibiotics, are key in the prevention of CDI . R9 was admitted to the facility with a [DIAGNOSES REDACTED] infection. R9's medical record revealed the [DIAGNOSES REDACTED] infection has been recurring as resident's symptoms would go away and then return. R9 was treated with an unnecessary broad-spectrum antibiotic for a UTI without having localized symptoms of a UTI. This broad spectrum antibiotic increases R9's risk with [DIAGNOSES REDACTED] infection as it does not allow for the normal bacteria to grow back in the intestines. Example 2: R12 was initially admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. R12 was sent to the hospital on [DATE] for symptoms of a possible stroke. R12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R12's MDS assessment, dated [DATE], indicated that R12 had a urinary tract infection. Review of R12's medical record indicated the following: [DATE] - .readmitted .post hospitalization [MEDICAL CONDITION](stroke) with right sided weakness and [MEDICAL CONDITION] .She is alert and oriented to self and family, and knows that she is at Rennes. A right facial droop is noted, along with RUE (right upper extremity) and RLE (Right Lower Extremity) weakness .Yes and NO questions are easiest for her to answer, she can say single words . [DATE] - .Resident does have c/o (complaints of) pain to LLE (Left Lower Extremity) and did receiving (sic) oral [MEDICATION NAME] . [DATE] - .She is requiring total assist for all ADLS (Activities of Daily Living) and is two assist with Hoyer for transfers . [DATE] - CONTACT: Gave Dr. (physician's name)'s RN (nurse's name) an update on resident's depressed mood and making comments about wanting to die. Also updates that food and fluid intake is very poor. (Nurse's name) will discuss with Dr. (physician's name) and contact us with any new orders. [DATE] - Resident with poor appetite again today and refusing fluids. She did have small emesis x 1 about 1.5 hours after receiving pain medication and states that her stomach still feels upset . [DATE] - CONTACT: Dr. (physician's name) updated on poor intake of food/fluids since re-admission on Nursing [DATE] and of small emesis following breakfast on [DATE]. Nurse also inquired about scheduled pain medication. Dr. (physician's name) wrote orders for: CBC, UA, ESR, CMP, GGT, [MEDICATION NAME], KUB. These are a variety of labs including a urinalysis. [DATE] - .UA collected at this time . [DATE] - .Orders received earlier in day to [MEDICATION NAME]([MEDICATION NAME], a broad-spectrum antibiotic) BID (two times a day) for DX (Diagnosis) of UTI .Has [MEDICAL CONDITION] - unable to determine if pain/irritation present w/ (with) urination .Is afebrile (without a fever) at this time. This note indicates that R12 was not able to tell the nurse if she was having pain or irritation with urination. The above notes indicate R12 was able to answer yes or no questions and on [DATE] was able to let the nurse know she was having pain in her left lower leg. There were no localized [MEDICAL CONDITION] signs or symptoms documented in R12's medical record to indicate R12 had a urinary tract infection. Surveyor reviewed R12's temperatures from [DATE] - [DATE]. R12's temperatures ranged from 97.7 degrees F - 98.9 degrees F, which are within range and do not indicate a fever. R12's White Blood Cell (WBC) count on [DATE] was 7.6. This is within normal range and does not indicate leukocytosis. On [DATE] at approximately 10:30 a.m., the DON told Surveyor that this was an elevated WBC for R12. R12's lab report, on [DATE], indicated a WBC count of 8.3, which is higher than the 7.6. On [DATE] at 10:30 a.m., the DON told Surveyor that R12's indications for a UTI were: acute weakness, poor appetite and lethargy. Surveyor verified with the DON that R12 had returned from the hospital following a stroke on [DATE], which is less then a week from the start of the antibiotic. The DON agreed that R12 did not meet McGeer's criteria, but that the facility only uses McGeer's as a guide. The DON stated R12 was not eating and was lethargic. That R12 was treated prior for E-coli in the urine and it was still present. On [DATE] at approximately 8:30 a.m., Surveyor spoke to R12's son. R12's son indicated that R12 had been amazingly healthy her whole life. Surveyor asked if R12 had a history of [REDACTED]. R12's son stated that R12 had never been hospitalized for [REDACTED]. R12 received an unnecessary broad spectrum antibiotic for a UTI without any localizing urinary signs or symptoms.

Based on staff interview and record review, the facility did not ensure a four-year full background check was completed for 1 of 8 employee records reviewed for background checks. Maintenance Supervisor (MS)-A's last full background check was completed on 5/3/12. MS-A's Background Information Disclosure (BID) was signed as completed on 4/28/16. The Department of Justice (DOJ) response and the Integrated Background Information System (IBIS) letters were not completed until requested on 8/29/15, during the current survey. Findings include: Facility's policy titled Abuse Prohibition Policies and Procedures with revision date of 8/16/16, documents Background checks shall be repeated every four years for employees who have access to residents. On 8/29/16, Surveyor selected a sample of eight facility employees from the list of employees provided by the facility. MS-A's background check, DOJ response and IBIS letter were dated 8/29/16. On 8/29/16 at 3:01 p.m., Surveyor interviewed Nursing Home Administrator (NHA)-F regarding MS-A's background check. NHA-F verified obtaining MS-A's DOJ response and IBIS letter today (8/29/16). NHA-F indicated MS-A's prior DOJ response and IBIS letter were dated 5/3/12. NHA-F verified background checks are to be completed every 4 years and MS-A's background check had been missed when the facility completed an audit.

Based on observations, interviews and record reviews, the facility did not maintain an Infection Control Program to help prevent the development and transmission of disease and infection. The deficient practices have the potential to affect all residents of the facility. There was no evidence that appropriate precautions were implemented when symptoms of ARI (acute respiratory illness) presented. Precautions should have been initiated until the cause was known to prevent transmission to staff, visitors, and other residents. Several residents were observed entering the dining room for meal service, propelling their own wheelchairs or walking with walkers. Staff did not offer or assist residents with hand hygiene prior to eating their meals. This is evidenced by: Example #1: In a memo dated 10/16/13, the Department of Health Services outlined to Long Term Care Facilities (LTCF), and others, the reporting, prevention, and control of acute respiratory illness outbreaks in LTCFs. Included in this memo, facilities were to incorporate droplet precautions for residents manifesting acute respiratory illness (ARI), defined as illness characterized by any two or more of the following symptoms: ~ Fever; ~ Cough (new or worsening, productive or non-productive); ~ Rhinorrhea (runny nose) or nasal congestion; ~ Sore throat; ~ Myalgia (muscle aches) greater than the resident's normal. The memo also defined pneumonia as new or increased pulmonary infiltrates. This memo directs facilities to place residents with ARI into precautions from onset until 24 hours after resolution of fever or symptoms. It also directs facilities to implement precautions (both droplet and contact) immediately if displaying signs and symptoms of ARI and to not wait until the cause is determined. On 6/3/15, Surveyor # reviewed the facility's Infection Control Program. Included in this review was the facility surveillance tracking. In reviewing this information Surveyor # noted the monthly infection logs were not separated by units, instead they included residents from all units. The logs also did not separate out each infection. This makes it difficult to observe quickly if an outbreak is occurring within the facility. Also noted were 12 residents displaying symptoms, as defined above, of respiratory illness and were not placed on isolation precautions until the known cause of the illness was known. These were: ~On 8/19/14, Resident #10 manifested a productive cough with vanilla pudding color and textured sputum. There were no precautions initiated to prevent transmission of a potential pathogen. ~On 9/3/14, Resident #22 was admitted to the facility following hospitalization and treatment for [REDACTED].#22 manifested increased shortness of breath (SOB). On 9/10, her lung sounds were diminished and required a decongestant for congestion and production of clear phlegm. On 9/12/14, Resident #22 had a cough with congestion, an earache, clear sputum, and nasal drainage. There were no droplet precautions initiated. ~On 9/21/14, Resident #23 manifested a temperature of 99.9 degrees, a productive cough with thick light green sputum, congestion, and weakness, which resulted in a fall. The cough and green sputum continued on 9/22/14 as well as SOB with activity. A chest x-ray was obtained. Later in the day the sputum became a thick brownish green and she developed nasal and head congestion. The x-ray revealed probable pneumonia. There were no precautions initiated. ~Resident #24 was placed on antibiotics on 10/8/14, following a doctor appointment for audible congestion with a cough producing a pale yellow sputum. He also had wheezes throughout the posterior lung fields and SOB with rest and activity. He was diagnosed with [REDACTED]. Again, on 2/11/15, Resident #24 manifested a fever of 101.1, SOB, chills, a productive cough of white sputum and skin paleness. A chest x-ray revealed pneumonia on 2/12/15. No precautions were initiated with the first symptoms. ~On 11/5/14, Resident #25 was admitted from another nursing home with an occasional loose productive cough of a greenish brown mucous. He had lower lung lobe crackles and increased fatigue .the past few days. A chest x-ray was completed and indicated positive infiltrates, or pneumonia. Precautions were not implemented. ~On 2/7/15, Resident #25 displayed audible nasal congestion with a hoarse dry cough. On 2/8/15, this cough became loose with a pale green sputum production and a low grade temperature of 99.5 degrees. A chest x-ray was obtained on 2/9/15 which revealed right lower lobe pneumonia. Precautions were not implemented. ~On 4/26/15, Resident #25 complained of weakness, aching all over and being tired. There were audible crackles in both upper and lower lung fields. He had an occasional non-productive cough. A chest x-ray revealed right lower lobe and right middle lobe pneumonia. On 4/30/15, the sputum was documented as being green. There were no precautions in place for Resident #25's illness. ~On 11/10/14, Resident #26 manifested increased redness to her eyes with a yellow pus. There were no precautions placed for potential conjunctivitis, or pink eye. Resident #26 was seen two days later by the physician's assistant and ruled out conjunctivitis, however, prescribed an antibiotic ointment [MEDICATION NAME]. ~Resident #6 was admitted to the facility on [DATE] with ESBL (extended spectrum beta lactimase) in her urine. She was placed on contact precautions as a result. However, on 11/17/14, Resident #6 developed increased sleepiness, fatigue and lethargy, with a .gurgly sounding. congestion. A chest x-ray was obtained and Resident #6 was diagnosed with [REDACTED]. The congestion continued, along with crackles and nonsensical statements, unusual for the resident. Her oxygen saturation dropped to 86% on 2 liters of oxygen. On 11/18/14, she was sent to the emergency room and diagnosed with [REDACTED]. ~On 11/19/14, Resident #27 complained of increased sleepiness. His lung sounds were diminished in the bases of both lungs and the upper lobes of the lungs had occasional crackles that cleared with a cough. On 11/20/14, Resident #27 developed a lot of chest congestion, difficulty breathing on 2 liters of oxygen with a saturation of 86% at rest, and intermittent fever and non-productive cough. A paracentesis was conducted and the removal of 2 liters of fluid was done without any improvement to his breathing ability. He was placed on antibiotic therapy. No precautions were implemented. ~On 12/9/14, Resident #28 was admitted to the facility following hospitalization for lung cancer with metastasis to the brain. He entered the facility on intravenous antibiotics for a MRSA plus infection to the chest port. This is according to the infection log. According to the CDC (Center for Disease Control), MRSA is a methicillin resistant staphylococcus aureus bacteria that is resistant to many antibiotics. In the community most MRSA infections are skin infections. In medical facilities MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections. Contact precautions were not initiated. ~On 12/19/14, Resident #29 was admitted with positive MSSA (methicillin susceptible staphylococcus aureus) to a non-healing wound on her left ankle. According to the CDC, MSSA should be under contact precautions. There were no indications the facility placed Resident #29 into precautions. ~On 3/26/15, Resident #30 manifested a raspy cough with clear sputum and complaints of feeling tired. On 3/27/15, the cough and sputum continued. On 3/28/15, she developed a poor appetite, and on 3/29/15 she became tachycardic (rapid heart rate) with a pulse rate of 104 and a body temperature of 101.1. Her oxygen saturation was 86% and she had a productive cough with a thick clear sputum. She was documented as being congested and wheezy. A chest x-ray was obtained and revealed pneumonia. There were no precautions implemented. ~On 4/2/15, Resident #19 displayed a decreased appetite and increased sleepiness. The following day, on 4/3, she complained of not feeling well. She had rales in her upper lung lobes with an occasional dry non-productive cough. She also developed nasal drainage. In the evening of that same day the cough became productive of a white sputum. She also had wheezing. A chest x-ray revealed possible fluid overload/congestive heart failure or pneumonia. She was sent to the emergency room for evaluation. On 4/8/15, Resident #19 returned to the facility with a [DIAGNOSES REDACTED]. Precautions were not implemented prior to the facility's knowledge of the cause. On 6/3/15 at 4:14 p.m., Surveyor # spoke with the Director of Nursing (DON) regarding infection control. The DON stated the facility generally does not place residents into precautions for pneumonia-like symptoms. Example #2: DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. Included in the memo is the following: Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing to include but not limited to; before eating.Nursing home feeding assistants are trained to assist residents to wash their hands before eating. On 6/3/15 at 3:30 p.m., Surveyor # spoke with RN-M (Registered Nurse) regarding the expectations of staff and resident hand hygiene. RN-M stated residents were to have their hands either washed or sanitized before each meal and that sanitizer stations were available for use at the dining room entrance for this purpose. She also stated the facility supplies disposable hand sanitizing wipes as well. There are two entrances to the main dining room. Located at each entrance is a portable automatic Purell Alcohol Hand Gel dispenser. ~On 6/2/15 at 7:42 a.m., Surveyor # observed Resident #4 receive morning cares by CNA-K (Certified Nursing Assistant) and CNA-L, who was training. There was no hand hygiene included in the bathing process. Once cares were completed, Resident #4 was ambulated to the main dining room with the use of his cane. He was then seated at the table and served his beverages. At 8:09 a.m., Resident #4 was removed from the dining room in order to have his mouth assessed by the nurse. He returned, ambulating with a cane and staff at 8:38 a.m. There was no washing of his hands or sanitizing prior to Resident #4 being served his meal at 8:42 a.m. Resident #4 feeds himself. ~On 6/2/15 at 8:00 a.m., Resident #31 propelled himself into the main dining room in his wheelchair. He was served his meal at 8:20 a.m., and feeds himself. He was not given the opportunity or encouragement to wash or sanitize his hands prior to eating. ~On 6/2/15 at 8:02 a.m., Resident #1 entered the main dining room in his wheelchair, which he was self-propelling. He was served his meal at 8:20 and feeds himself. Resident #1 was not given the opportunity or encouragement to wash or sanitize his hands prior to eating. ~On 6/2/15 at 8:06 a.m., Resident #32 was ambulated into the main dining room by staff with his walker. He was then seated at the table and served his meal. There was no encouragement by staff to wash or sanitize his hands prior to feeding himself his meal. ~On 6/2/15 at 8:07 a.m., Resident #33 entered the main dining room, self-ambulating with a walker. She was served her meal at 8:08 a.m. without any encouragement from staff to wash or sanitize her hands. ~On 6/2/15 at 8:15 a.m., Resident #34 propelled herself into the main dining room in her wheelchair. She was served her meal at 8:20 a.m., and fed herself. She was not encouraged to wash or sanitize her hands prior to the meal. ~On 6/2/15 at 8:18 a.m., Resident #35 entered the main dining room, propelling himself in his wheelchair. He was served his meal at 8:21 a.m. and fed himself. He was not encouraged to wash or sanitize his hands prior to the meal. ~On 06/02/15 at 7:45 a.m. Surveyor # observed the breakfast meal in the dining room. Resident #7 was observed self propelling her wheelchair across the dining room. Resident #7 was served breakfast and not offered hand hygiene. Resident #7 was observed picking her sausage links up with her hands and holding her French toast with one hand and stabbing it with her fork with the other hand to pick it up from her plate.

Based on record review, interviews, and a random observation during the Medication Observation task, 1 resident was allowed to self-administer without an assessment and determination that this was a safe practice. Staff allowed Resident #16 to self administer [MEDICATION NAME] without an assessment. This is evidenced by: Resident #16 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #16 has a physician's orders [REDACTED]. On 06/02/15 at 9:08 a.m., Surveyor # observed RN-A (Registered Nurse) dispense 17 grams of [MEDICATION NAME] in a glass of cranberry juice. RN-A left the glass of [MEDICATION NAME] and juice on Resident #16's breakfast tray and encouraged Resident #16 to finish the [MEDICATION NAME] and juice mixture. RN-A left the room after Resident #16 had drank approximately half of the glass of [MEDICATION NAME] and juice. On 03/26/15, the facility completed a self administration assessment for Resident #16. The assessment determined Resident #16 was safe to self administer only 2 physician ordered inhalers ([MEDICATION NAME] and [MEDICATION NAME]) and not the [MEDICATION NAME]. On 06/02/15 at 9:20 a.m., Surveyor # interviewed RN-A regarding the above observation. RN-A confirmed she had left the [MEDICATION NAME] mixed in cranberry juice on Resident #16's breakfast tray only half consumed. RN-A stated Resident #16 was able to self administer the [MEDICATION NAME]. On 06/03/15 at 3:15 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding the above observation. The DON stated when residents are admitted to the facility, the nurse completes a self administration assessment at the resident's request. The DON further stated, if the resident is deemed safe to self administer a care plan is developed and the resident is allowed to do so. The DON stated nurses are required to ensure medications have been taken prior to leaving the room. On 06/04/15 at 10:35 a.m., the DON stated residents have the right to self administer medications once the resident has been deemed safe to do so. The DON stated the facility does not pursue a physician order [REDACTED].

Based on observation, record review and interview, the facility did not ensure that 1 of 2 residents with [DEVICE]s (gastric tubes) was provided services to prevent complications. RN-A (Registered Nurse) administered medications into Resident #13's [DEVICE] without first confirming placement of the [DEVICE]. Current standards of practice dictate to check placement of the [DEVICE] prior to medication administration to avoid complications such as gastric erosion and aspiration. This is evidenced by: On 06/02/15, Surveyor # requested and reviewed the facility's policy titled Administering Medications through an enteral tube. The policy reflected current standards to check [DEVICE] placement prior to medication administration. Resident #13 was admitted to the facility on [DATE] following the partial removal of the esophagus and the placement of the gastric tube. Review of the care plan titled At nutritional risk. initiated on 05/26/15, instructed staff to check placement and patency of the [DEVICE]. Review of an abdominal x-ray taken on 05/26/15, noted Resident #13 had a [DEVICE] present in the stomach. Review of physician orders [REDACTED].#13 was to receive [MEDICATION NAME] 1 packet twice daily via [DEVICE]. On 06/02/15 at 9:28 a.m., Surveyor # observed RN-A administer [MEDICATION NAME] via Resident #13's [DEVICE] without checking placement. RN-A mixed 2 teaspoons of [MEDICATION NAME] with 90 mls (milliliters) of sterile water. RN-A flushed Resident #13's [DEVICE] with 15 mls of sterile water, then administered the [MEDICATION NAME] mixture, followed by another 15 mls of sterile water to flush the [DEVICE] after the medication. RN-A did not check placement of Resident #13's [DEVICE] at any point during the administration of medications. On 06/02/15 at 9:35 a.m., Surveyor # interviewed RN-A regarding the above observation. RN-A stated Resident #13 was a new admission with a new [DEVICE] due to [MEDICAL CONDITION] surgery. RN-A stated it was not necessary to check placement of the [DEVICE] because Resident #13 has had x-rays to confirm placement of the [DEVICE]. RN-A stated Resident #13 received a 12-hour feeding via the [DEVICE] which began at 7:00 p.m. daily. On 06/03/15 at 3:15 p.m., Surveyor # interviewed the DON (Director of Nurses) regarding the [DEVICE] observation with Resident #13. The DON stated all nurses should know to check the placement of the [DEVICE] prior to medication administration or starting the feeding. The DON stated it was the facility policy to do so based on current standards of practice.

Based on observation, interview and product documentation review, the facility did not provide an environment free of accident hazards for 2 residents. Resident #17 was observed in the beauty salon using 2.5 liters of liquid oxygen while seated elbow to elbow next to Resident #18 who was under a Comfort Aire hair dryer. There was a third resident and the hair stylist in the salon at that time. This is evidenced by: During the initial tour which began on 06/01/15 at 9:10 a.m., Surveyor # walked past the beauty salon at 9:50 a.m. and observed Resident #17 seated elbow to elbow next to Resident #18. Resident #18 was seated under a bonnet style hair dryer, which was running on the medium heat setting. Resident #17 had a portable liquid oxygen tank standing on the seat of his 4 wheeled walker with oxygen tubing to his nose. Surveyor # observed the oxygen tank was approximately 3/4 full and the oxygen was running at 2.5 liters/minute via a nasal cannula. There was a third unknown female resident who was also in the beauty salon with HS-C (Hair Stylist) setting her hair. HS-C and the third female were approximately 8-9 feet away from Resident #17 and #18. Surveyor # remained in the beauty salon for a minimum of 5 minutes until HS-C asked Resident #17 to stand and walk across the room to another chair. Resident #17 walked approximately 7 feet to another chair. Resident #17 was now approximately 7 feet away from any ignition source. HS-C then began cutting Resident #17's hair. Surveyor # left the beauty salon and returned at 10:10 a.m. and observed Resident #17 ambulating down the 400 hallway toward the nurses' station and dining areas. Resident #17 continued to use oxygen and had a fresh haircut. On 06/01/15 at 12:30 p.m., Surveyor # returned to the unoccupied beauty salon to measure the distance from the ignition sources (hair dryers) to the oxygen source. There were three portable Comfort Aire bonnet style hair dryers against the wall. The distance between hair dryer #2 (which was occupied by Resident #18) and hair dryer #3 (which was occupied by Resident #17) was 12 inches. The approximate distance from Resident #17's nasal cannula and the ignition source was 12 inches. The approximate distance from Resident #17's oxygen tank and the ignition source was 18-24 inches. The facility used Collins Comfort Aire hair dryers. Listed under the manufacturer's IMPORTANT SAFETY INSTRUCTIONS for the Comfort Aire hair dryers was 9. Do not use outdoors or operate where aerosol (spray) products are being used or where oxygen is being administered. On 06/01/15 at 2:45 p.m., Surveyor # interviewed HS-C and AD-E (Activity Director) regarding safe beauty salon practices. HS-C stated Resident #17 entered the beauty salon to arrange a haircut appointment. HS-C stated Resident #17 was seated on the chair next to Resident #18. HS-C confirmed Resident #18 had the hair dryer on a medium setting. HS-C stated she should have instructed Resident #17 to sit in the chair across the room from Resident #18 because of the safety concerns with oxygen dependent residents. AD-E stated residents with oxygen are scheduled at the beginning or the end of the day when other residents are not likely to be under the hair dryers. AD-E also stated when oxygen dependent residents need to use the hair dryer, the setting should be on low temperature with the oxygen tank placed at least 5 feet away from the hair dryer. (This only applies to storage of tanks and not tanks being actively used.) AD-E also stated hand held blow dryers should never be used on oxygen dependent residents. On 06/01/15 at 11:15 a.m., Surveyor # interviewed Resident #18 regarding beauty salon services. Resident #18 stated other oxygen dependent residents are present in the beauty salon with hair dryers running. The Surveyor asked if any staff had informed Resident #18 of safety concerns regarding oxygen use in the beauty salon. Resident #18 stated she had not been informed of any safety concerns. On 06/01/15 at 11:21 a.m., Surveyor # interviewed Resident #17 regarding oxygen use in the beauty salon. Resident #17 stated he has been to the beauty salon three times since admission for haircuts. Resident #17 confirmed he was seated next to Resident #18 while the oxygen was running. The Surveyor asked if any staff had informed Resident #17 of safety concerns regarding oxygen use in the beauty shop and Resident #17 stated he had not been informed of any safety concerns. Surveyor # requested a list of all residents who currently use oxygen. The facility provided a list of 16 residents with active oxygen orders as of 06/01/15. Surveyor # requested a list of all interviewable and reliable residents. The SSD (Social Service Director) provided Surveyor # with a list that included Resident #17, #18, #6, #19, and #20 as interviewable and reliable residents. On 06/01/15 at 3:40 p.m., Surveyor # interviewed Resident #19 regarding oxygen use in the beauty salon. Resident #19 stated she uses oxygen all of the time. Resident #19 stated HS-C has used a hand held blow dryer on her to style her hair while the oxygen was in place and running. Resident #19 stated she did not use the hood style hair dryer. On 06/01/15 at 3:44 p.m., Surveyor # interviewed Resident #6 regarding oxygen use in the beauty salon. Resident #6 stated she uses oxygen all of the time. Resident #6 stated she went to the beauty salon weekly, usually on Wednesdays, and was always placed under the hood style hair dryer with the oxygen in place. The Surveyor asked if any staff had informed Resident #6 of safety concerns regarding oxygen use in the beauty shop. Resident #6 stated she had not been informed of any safety concerns. On 06/01/15 at 3:49 p.m., Surveyor # interviewed Resident #20 regarding oxygen use in the beauty salon. Resident #20 stated she used oxygen all of the time. Resident #20 stated she goes to the beauty salon every Wednesday. Resident #20 stated HS-D removes the oxygen when Resident #20 uses the hair dryer. Resident #20 stated HS-D informed her of the potential danger of a spark from the hair dryer and the oxygen could cause a fire. According to the NHA, the nearest fire extinguisher to the beauty salon was 41 feet away. On 06/02/15 at 9:45 a.m., Surveyor # interviewed RTV-J (Respiratory Therapy Vendor) via telephone. RTV-J stated their company follows the recommendations set forth in the DQA (Division of Quality Assurance) memo which read oxygen dependent residents should not be in the beauty salon close to an ignition source. RTV-J stated if oxygen dependent residents are in the beauty salon, the oxygen source should be at least 5 feet away from any ignition source such as hair dryers. RTV-J stated the oxygen source can be the tank or the cannula. RTV-J stated their company recommends oxygen should not be used near an ignition source. The Surveyor reiterated RTV-J's statements in the presence of Surveyor # and # . RTV-J referenced DQA memo 12-005. The directives in DQA memo 12-005 includes: Using electric hair dryers near oxygen use is potentially dangerous. Sparks can be caused by problems with the hair dryer, the cord or with a loose electrical connection. In addition, electric dryers produce hot air which can be dangerous in an oxygen-enriched environment. The U.S. Consumer Product Safety Commission warns consumers not to operate an electric hair dryer where aerosol or spray products are being used, or where oxygen is being administered. Most manufacturers' product labels for electric hair dryers carry warnings to not use electric hair dryers where oxygen is in use. On 06/03/15 at 11:30 a.m., Surveyor # interviewed HS-D regarding safe practices in the beauty salon. HS-D stated in the past, she had used the hair dryer on a low setting for residents using oxygen.