Every finding on record at Salem Place Nursing and Rehabilitation Center, Inc

Based on observation, interview, and facility policy review, the facility failed to ensure dietary staff practiced good hand washing to prevent potential cross contamination, Dairy products were maintained frozen to prevent the growth of bacteria, and hot food items were maintained at above 135 degrees Fahrenheit on the steam table while awaiting service to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 84 residents who received meals from 1 of 1 kitchen, as indicated by a list provided by the Dietary Manager on 8/15/2024 at 8:30 AM. The findings are: 1. On 8/13/24 at 5:16 PM, Dietary [NAME] (DC) #5 was wearing gloves on his hands when he pulled his pants up, contaminating the gloves. Without changing gloves and washing his hands, he picked up chicken patties, buns, lettuce, tomatoes, and tarter tots, and placed them on the plates to be served to the residents for supper meal. DC #5 was asked what he should have done after touching dirty objects and before handling food items. DC #5 stated, I should have changed gloves and washed my hands. 2. On 8/13/24 at 5:29 PM, after the lunch meal service Dietary Aide (DA) #6 was pushing a cart that contained a deep bowl with 4 cartons of vanilla ice cream, 3 cartons of strawberry ice cream, 2 cartons of chocolate ice cream, one carton of whole milk, and one cartoon of 2% milk to the walk-in freezer. DA #6 was asked to check to see if the ice cream was frozen. DA #6 opened one carton of vanilla ice cream, and stated, No, they are melted. DA #6 was asked to check the temperature of the milk. She did, and stated, It was 50 degrees Fahrenheit. DA #6 was asked if thawed ice cream should be refrozen. DA #6 stated, No. 3. On 8/13/24 at 5:41 PM, the following observations were made on a shelf in the storage room: a. An opened gallon of soy sauce, the manufacture's speciation on the gallon specified to refrigerator after opening. b. There were 6 bags of coffee in a pan with an expiration date of 1/20/2024. 4. On 8/14/24 at 10:59 AM, Dietary [NAME] (DC) #7 lifted the trash can lid and threw away an empty glove box into the trash, contaminating the gloves. Without washing her hands, DC #7 picked up strawberries that had been rinsed with water and placed them on the cutting board. DC #7 then sliced the strawberries and placed them in individual bowls. She then removed rinsed fresh grapes from a deep bowl and placed them in individual bowls to be served to the residents for a noon meal. DC #7 was about to cover the bowls of fruits with lids, when she was stopped. DC #7 was asked what she should have done after touching dirty objects and before handing fruits. DC #7 stated, I should have removed the gloves and washed my hands. 4. On 8/14/24 at 12:02 PM, Dietary Aide #8 checked the temperatures of the hot food items that had been placed on the serving line on the steam table in preparation for the noon meal service. The temperatures were: a. Pureed yams - 100 degree Fahrenheit. b. Pureed bread with a little water - 100 degree Fahrenheit, c. Hamburger - 100 degree Fahrenheit. d. Plain pork lion - 125 degree Fahrenheit. The above food items were not reheated before being served to the residents. 5. A facility policy titled, Hand Washing, initiated 3/27/2012 indicated hands should be washed before and after putting gloves on and after touching dirty objects.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to 8 affect residents who received regular diets from 1 of 1 kitchen according to a list provided by the Dietary Manager on 8/15/2024. The findings are: 1. On 8/13/24, a facility supper meal menu indicated residents on mechanical soft diets were to receive 3 ounces of chicken with bun and 1/2 cup of chopped lettuce with tomatoes. Residents on pureed diets were to receive two #8 scoops (#8 scoop is 1/2 cup) of pureed breaded chicken with bun. 2. On 8/13/24 at 5:51 PM, the following observations were made during supper meal service: a. Dietary [NAME] (DC) #5 used a #16 scoop (1/4 cup or 2 ounces) to serve a single portion of ground breaded chicken to the residents on mechanical soft diets, instead of 3 ounces. b. Used a 2-ounce spoon to serve a single portion of chopped lettuce with tomatoes to the residents on mechanical soft diets, instead of 4 ounces c. DC #5 used a #8 scoop (1/2 cup) to serve a single portion of pureed breaded chicken with bun, instead of two #8 scoops. At 5:53 PM, DC #5 was asked what scoop size he had used to serve pureed burger and ground meat and how many servings he gave to each resident. DC #5 confirmed that he had used #16 scoop (1/4 cup) to serve a single portion to the residents on mechanical soft and used a #8 scoop (1/2 cup) to serve a single serving each to the residents on a puree diet. Dietary [NAME] #5 was asked if he looked at the menu before serving supper meal and stated, NO. 3. On 8/14/24 at 11:22 AM, Dietary [NAME] (DC) #7 used a 4 -ounce spoon to place 6 servings of brussels sprouts into a blender and pureed, instead of 7 servings. At 11:25 AM, DC #2 poured the pureed vegetables into a pan and placed it into the warmer. 4. On 8/14/24 at 11:34 AM, DC #7 used a 4-ounce spoon to place 6 servings of candy yam into a blender, added melted butter and pureed. At 11:37 AM, DC #2 poured the pureed candy yam into a pan and placed it in the warmer to serve it to 7 residents who required pureed diets. 5. On 8/14/24 at 11:42 AM, DC #7 placed 6 slices of bread into a blender, added a little water, thickener and pureed, instead of 7 servings. 6. On 8/14/24 at 11:44 AM DC #7 poured the pureed bread into a pan, covered the pan with foil and placed it in the warmer. The DC #7 stated, I just added a little water.

Based on observation, record review, and interview, the facility failed to ensure meals were served in a method that maintained nutritive value and taste that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 7 residents who receive their meal from 1 of 1 kitchen, as documented. on a list provided by Dietary Manager on 8/15/2024 at 8:30 AM. The findings are: 1. Review of a facility titled recipe for pureed herbed pork loin initiated on 2/20/2024, indicated for 10 residents to use ten 3 ounce herbed pork loins and add 1.25 cups of water or stock. 2. On 8/14/2024 at 10:58 AM, Dietary [NAME] (DC) #7 placed 6 thick slices of pork lion into a blender, added 2 cups of water, instead of 1.25 cup, and pureed. At 11:01 AM, DC #7 poured the pureed meat into a pan and placed it in the oven. 3. Review of a facility titled recipe for pureed brussels sprouts initiated on 2/20/2024, indicated for 10 residents use 10.5 cups of brussels sprouts, three tablespoons plus 2 teaspoons of food thickener. Process until smooth using 1 teaspoon food thickener per serving. A note at the bottom stated the amount of thickener may vary relative to liquid content of cooked vegetable. On 8/14/24 at 11:22 AM, DC #7 used a 4 ounce spoon to place 6 servings of brussels sprouts into a blender, added 2 cups of water and pureed, instead of no fluids. 4. On 8/14/24 at 12:31 PM, during an interview DC #7 was asked how much water she had used in the pureed pork lion, pureed brussels sprouts, and pureed bread. DC #7 stated, I used 2 cups water for both pureed meat and pureed vegetables. I just put a little water in the pureed bread. 5. On 8/15/24 at 8:08 AM, during an interview DC #7 was asked to describe how food items pureed with water would taste. DC #7 stated, Both pureed meat and pureed vegetables would taste nasty, and pureed bread would be bland.

Based on observation, interview, and record review, it was determined the facility failed to ensure a discharge Minimum Data Set (MDS) assessment to accurately reflect the residents discharge status for 1 (Resident #13) sampled resident. The findings are: Facility provided the Resident Assessment Instrument (RAI) assessment for discharge instructions on 8/15/2024 and was reviewed. The instructions indicated a discharge assessment must be completed when a resident is discharged from the facility and the resident is not expected to return to the facility within 30 days; must be completed within 14 days after discharge date , must be submitted within 14 days after the MDS completion date, and for unplanned discharges. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/19/2024 indicated Resident #13 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. During a closed record review, the surveyor was unable to locate an MDS Discharge Summary for Resident #13. In an interview on 8/15/2024 at 8:38 AM, the Administrator stated the MDS Coordinator was responsible for the MDS discharge assessments, and that medical records staff fill in when needed. She also stated a discharge could have been overlooked when the MDS Coordinator was previously out on leave. In an interview on 8/15/24 at 10:09 AM, MDS Coordinator #9 said a notification appears in the system to indicate that an MDS discharge is overdue, and that medical records staff fill in when the MDS Coordinator is out of the office. 48630

Based on record review, and interview, the facility failed to ensure the influenza and/or pneumococcal immunizations were administered and/or offered and documented for 4 (Resident #18, Resident #19, Resident #60, and Resident #64) of 5 (Resident #18, Resident #19, Resident #60, Resident #64, and Resident #92) sampled residents reviewed for the compliance of immunizations. The findings are: On 8/14/24 at 3:09 PM, the Administrator provided a form titled, Immunizations, Influenza, Pneumococcal and Covid 19. It indicated that the influenza, pneumococcal, and the Covid 19 immunizations will be administered unless medically contraindicated. The immunization policy indicated that the immunizations will be documented in the medical record when administered or refused. On 8/14/24 at 10:47 AM, review of Resident #64's Physician Orders indicated Resident #64 was admitted on [DATE]. There was no documentation that Resident #64 received the pneumonia or influenza immunization. The immunizations were reviewed in the immunization tab on the electronic record. There was no documentation that the resident's representative, or the resident consented or declined the immunization. On 8/14/24 at 10:49 AM, review of Resident #18's Physician Orders indicated Resident #18 was admitted on [DATE]. There was no documentation Resident #18 received the influenza immunization. The immunizations were reviewed in the immunization tab on the electronic record. There was no documentation that the resident's representative, or the resident consented or declined the immunization. On 8/14/24 at 10:52 AM, review of Resident #60's Physician Orders indicated Resident #60 was admitted on [DATE]. There was no documentation Resident #60 had received the pneumonia, or influenza immunization. The immunizations were reviewed in the immunization tab on the electronic record. There was no documentation that the resident's representative, or the resident consented or declined the immunization. On 8/14/23 at 10:58 AM, review of Resident #19's Physician Orders indicated Resident #19 was admitted on [DATE]. There was no documentation indicating the resident had received the influenza immunization. The immunizations were reviewed in the immunization tab on the electronic record. There was no documentation that the resident's representative, or the resident consented or declined the immunization. On 8/15/24 at 9:30 AM, during an interview, Resident #18 did not remember if the influenza or the pneumococcal immunizations were offered when the resident was admitted . Resident #18 did not remember taking the influenza or the pneumococcal immunizations. On 8/15/24 at 9:35 AM, during an interview, Resident #60 did not remember if the influenza or the pneumococcal immunizations were offered when the resident was admitted . Resident #18 did not remember ever taking the influenza or the pneumococcal immunizations. On 8/15/24 at 9:53 AM, Licensed Practical Nurse (LPN) #10 indicated the department head nurses administer the influenza or the pneumococcal immunizations to the residents, documents the results on a form, and gives the results to the Director of Nursing (DON). She indicated that she doesn't know when the influenza or the pneumococcal immunizations were offered. She indicated that the immunizations should be documented in the electronic record if a resident refuses. On 8/15/24 at 10:05 AM, Certified Medication Technician (CMT) #1 indicated the DON usually administers the influenza or the pneumococcal immunizations. She indicated that the DON has the form with the immunizations documented. She indicated that it should be documented if a resident refuses a vaccine. On 8/15/24 at 10:13 AM, Registered Nurse (RN) #4 indicated the floor nurse or any department head nurse administers the influenza or the pneumococcal immunizations. She indicated the immunizations are documented on a piece of paper and given to medical records. She indicated the Influenza Vaccine is offered in September and October, and the Pneumococcal Vaccine is offered on admission. She indicated that the residents are educated if they refuse to take the vaccine, and the refusal is documented. On 8/15/24 at 10:29 AM, the Administrator indicated the nursing staff is responsible for administering the influenza and the pneumococcal immunizations. She indicated the immunizations should be documented under the immunization tab in the electronic record. The Administrator indicated the Influenza vaccine is offered during the flu season, and the Pneumococcal vaccine is offered on admission. She was asked the reason Resident #60, Resident #64, Resident #18, and Resident #19, did not have the influenza, and/or the pneumococcal immunization documented in the clinical records. She stated, To be completely honest I'm not sure where the ball got dropped. I don't know if a pass employee took it.

Based on observation, interview, and record review, the facility failed to ensure hazards were removed from resident areas as evidenced by medications left at the bedside for 1 (Resident #64) of 1 resident; and a handrail on the Rehab hallway had an end-cap cover on the end of the handrail to prevent exposure of rough edges. Findings include: 1. A review of the facility's undated policy titled, Medications, Oral, indicated staff were to remain at the bedside until all medications are swallowed. A review of the Admission Record, indicated the facility admitted Resident #64 with diagnosis that included fracture around internal prosthetic joint. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/2024, revealed Resident #64 had a Brief Interview of Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment. During an observation on 08/12/2024 at 10:46 AM, Resident #46 had a medication cup with one green pill and one yellow pill located on the resident's overbed table. During a concurrent observation and interview on 08/12/2024 at 11:24 AM, Licensed Practical Nurse (LPN) #2 stated she administered the resident's medications this morning and did not observe the resident take them. LPN #2 confirmed there was a medicine cup with two pills present on the resident's bedside table. LPN #2 stated that during medication administration the staff are supposed to observe the resident take the prescribed medication to ensure it is taken as prescribed. During an interview on 08/15/2024 at 10:48 AM, the Assistant Director of Nursing (ADON) stated that the nurse administering the resident's medications should ensure the medications are swallowed prior to leaving room, and medications should never be left at the bedside because another resident could take the medication and the nurse needs to ensure the medications are taken. 2. During an observation on 08/13/24 at 10:38 AM, a handrail on the left side of the Rehab Hallway near the therapy room was missing the end-cap. The exposed end of the rail had the potential to cause skin tears if a resident were to use this area to hold the handrail for balancing or to hold themselves up. On 08/14/2024 at 8:30 AM, the same observation was made of the missing end cap of the handrail. During an interview on 8/15/24 at 8:55 AM, the Maintenance Supervisor stated he checks the handrails once a month. The Maintenance Supervisor s they do not keep a maintenance log or work orders for the handrails, he just walks around each month and checks and repairs any issues. The Maintenance Supervisor stated the facility checks to ensure the handrails are in good working condition and tight in case a resident grabs a handrail. At 9:05 AM, The Maintenance Supervisor and the surveyor walked over to the handrail with the missing endcap. The Maintenance Supervisor observed the handrail with the missing cap and stated, Oh no, that is not good, it is sharp and could cause a skin tear or a bruise. 48630

Based on observation, interview, and record review, the facility failed to ensure all medications were safely stored and secured in to prevent accidental ingestion and or injury, as evidenced by a tube of anti-fungal medication left at Resident #15's bedside. The findings are: 1. Resident #15 had a diagnosis of brain bleed, heart failure and stroke, as indicated in the Physician's Orders dated August 12, 2024. a. Review of the Care Plan dated 07/23/24, Resident #15 had impaired cognitive function/dementia or impaired thought processes with a Brief Interview for Mental Status (BIMS) score of 6 severely impaired. b. On 08/13/24 at 9:33 AM, the surveyor observed a tube of anti-fungal medication lying on the residents over bed table. A review of the information located on the back of the tube indicated the active ingredient was Miconazole Nitrate 2% (antifungal medication). On the back of the tube was warnings for external use only; keep out of reach of children; and if swallowed, get medical help or contact a Poison Control Center right away. c. On 08/14/24 at 8:20 AM, the surveyor observed a tube of anti-fungal medication lying on the Resident #15's over bed table. 2. On 08/14/24 at 10:31 AM, the surveyor conducted an interview with Registered Nurse (RN) #4 and asked why Resident #15 used the anti-fungal cream. RN #4 stated Resident #15 used the anti-fungal cream as a lotion due to redness around the groin area and that Resident #15 did not have an order for the anti-fungal cream. 3. On 8/14/24 at 11:19 AM, the surveyor interviewed the Assistant Director of Nursing (ADON). The ADON confirmed that the anti-fungal cream used at the facility had medication in it and should be stored in the treatment cart and a physician ' s order is required and it should not be left at Resident #15's bedside to prevent other residents from getting into it. 4. Review of the facility policy titled, Medication Storage in the Facility indicated under Storage of Medications that medications and biologicals are to be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier and is only accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 5. On 08/14/24 at 12:58 PM, the Assistant Director of Nursing (ADON) provided the surveyor with a Safety Data Sheet (SDS) for Clinical Antifungal Ointment. Review of the SDS sheet indicated the ointment can cause eye irritation and to get medical advice/attention. The eyes should be rinsed cautiously with water for several minutes. The skin should be washed with water and get medical attention if it persists. If inhaled one should get fresh air. If ingested consult a physician. 48630

Based on observations, interviews, and facility policy review, the facility failed to ensure a laundry linen delivery cart on W Hall was covered during delivery of clean personal laundry to prevent the possible spread of harmful bacteria. Findings include: On 08/14/2024 at 2:47 PM, during an interview, the Laundry and Housekeeping Supervisor stated the facility did not have a policy for the delivery of clean resident laundry. During an observation on 08/12/2024 at 12:14 PM, a linen cart was parked against the wall on W Hall with the cover open and laid on top of the cart. Laundry Employee #11 was going in and out of resident rooms delivering laundry from the opened linen delivery cart. During an observation on 08/12/2024 at 12:16 PM, Laundry Employee #11 was observed pushing the linen cart down the W Hallway with the front cover open and continued to pass out resident's laundry. During an observation on 08/12/2024 at 12:33 PM, there was a clean linen laundry cart on the other end of W Hall with the front cover open, exposing the resident's clean laundry as Laundry Employee #11 continued to take laundry to each resident's room. During an interview on 08/14/2024 at 2:41 PM, Laundry Employee #3 stated they had been trained to deliver laundry in a covered transport cart or a rolling basket with a cover placed over the top to prevent germs, bacteria, and particles from landing on the resident's clean clothing. During an interview on 08/14/2024 at 2:38 PM, the Housekeeping and Laundry Supervisor stated when delivering laundry, the cart should always be covered. When removing laundry from the cart, the cover should be opened and closed to protect the remaining clothes on the cart from germs, bacteria, and particles in the air. Also, by closing the cart it prevents non-staffed individuals and residents from accessing the linen cart.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to notify the ombudsman of a hospital transfer for 1 (Resident #95) of 1 resident reviewed for hospitalization . Findings include: A review of Progress Notes revealed Resident #95 had been sent to the hospital for low blood pressure and abdominal cramping on 6/12/2024. A review of Emergency Transfers from the Facility document sent to the ombudsman provided by the Business Office Manager revealed Resident #95 had not been included on the list. During an interview on 08/15/2024 at 8:57 AM, the Business Office Manager confirmed by reviewing the list with the surveyor that Resident #95 was not included and should have been to reflect the hospital transfer and the ombudsman should have been notified. During an interview on 08/15/2024 at 9:05 AM, the Administrator confirmed the hospital transfer and reviewed the provided list with the surveyor and stated Resident #95 should have been included on the list sent to the ombudsman to notify of the hospital transfer. On 08/15/2024 at 9:05 AM, the Administrator stated the facility did not have a policy for ombudsman notification of hospital transfers.

Based on observation, record review and interview, the facility failed to ensure call lights were within reach to enable residents to call for any necessary assistance for 1 (Resident #1) of 3 sample mix residents. The findings are: Review of Resident #1's care plan dated 06/03/2020 showed encourage Resident to use the bell to call for assistance. During observation on 10/26/2023 at 9:49 AM, the Surveyor observed Certified Nurse Aide (CNA) #1 clip Resident #1's soft call light to the right side of the bed on the quarter siderail and position the Resident onto his left side with a blue wedge placed behind him for positioning. During observation on 10/26/2023 at 11:38 AM, Resident #1 was in bed on his left side with a blue wedge behind him, and his soft call light clipped onto the right side of the bed on the quarter siderail. During interview on 10/26/2023 at 11:39 AM, CNA #1 confirmed based on the placement of the call light and Resident #1's current position in bed, he could not reach the call light. During interview on 10/26/2023 at 11:41 AM, Registered Nurse #1 confirmed based on the placement of the call light and Resident #1's current position in bed, he could not reach the call light.

Based on observation, interview, and record review, the facility failed to ensure sufficient number of nursing staff to provide care and services to respond to resident's needs in a timely and dignified manner for 1 (Resident #15) of 1 sampled resident. This failed practice had the potential to affect all 82 residents who resided in facility according to the Resident Census and Conditions of Residents provided by the Administrator on 08/07/23 at 11:38 AM. The findings are: 1. On 08/08/23 at 8:40 AM, Resident #15 was sitting in a recliner in his room. A red light was on the call light panel in the room. Resident #15 stated, I turned my light on eight minutes ago. I need help to go to the bathroom. They don't realize I need help. If I could do it myself, I would. A sign on the wall behind Resident #15's bed read. Upon exiting this room . Make sure residents call light is in arm's reach at all times. a. On 08/08/23 at 8:51 AM, the Surveyor heard the call light going off outside Resident #15's room and heard staff out in the hallway outside of the resident's room. b. On 08/08/23 at 8:55 AM, Resident #15 stated, I don't think they are going to answer it and it's going to be too late. Resident #15 picked up the call light lying next to his left leg and pushed the button multiple times. The call light panel on the wall in the resident's room was red and continuous. c. On 08/08/23 at 8:57 AM, Resident # 15 stated, I'm getting close to having a bowel movement. I'm passing gas now and when it stops my bowels start and it's getting very close. The Surveyor asked, Do you have to have help to go to the bathroom? Resident #15 stated, Yes, because I might fall. d. On 08/08/23 at 9:02 AM, Resident #15 stated, I guess they aren't going to come in here. Resident #15 was fidgeting in the recliner. e. On 08/08/23 at 9:13 AM, the Surveyor asked Resident #15, How does it make you feel when you need help, and it takes them a long time to come. Resident #15 stated, I feel helpless. I can't help myself and they won't help me. f. On 08/08/23 at 9:14 AM, Licensed Practical Nurse (LPN) #2 entered the room and administered medication to Resident #15's roommate. LPN #2 did not acknowledge the call light going off. g. On 08/08/23 at 9:15 AM, LPN #2 acknowledged Resident #15 by stating, I'll be back with your medications. LPN #2 did not acknowledge the call light. h. On 08/08/23 at 9:17 AM observed Resident #15 in bed, crying, quoting a Bible verse. i. On 08/08/23 at 9:20 AM, Resident #15 stated, Did [LPN #2] have to go to China to get that medicine. The Surveyor asked Resident #15 if it was like this all the time that you have to wait this long for help. Resident #15 stated, Yes, they are going to have a mess to clean up, I can tell you that. Resident #15 kept looking at the clock on wall. j. On 08/08/23 at 9:22 AM, Resident #15 stated, They are supposed to check on me every two hours and they don't do it. Resident #15's call light was still on. k. On 08/08/23 at 9:25 AM, LPN #2 entered the room to administer medications to Resident #15. LPN #2 did not acknowledge the call light. LPN #2 asked Resident #15, Are you having a good day so far? Resident #15 stated No. l. On 08/08/23 at 9:31 AM, LPN #2 entered Resident #15's room to administer medications again. LPN #2 asked Resident #15, Are you hurting this morning? Resident #15 stated, No, I'm hurting to go to the bathroom. My call light has been on for over an hour. LPN #2 stated, I'll get someone to help me get you to the bathroom. Resident #15 stated, It will take two people. m. On 08/08/23 at 9:33 AM, Certified Nursing Assistant (CNA) #6 entered Resident #15's room. LPN #2 stated, [Resident #15] needs to go to the bathroom. CNA #6 stated, Ok I'll get him. A few seconds later CNA #8 entered the room. n. On 08/08/23 at 9:34 AM, CNA #6 told CNA #8 that Resident #15's roommate needed to be positioned. CNA #6 and CNA #8 assisted the roommate with adjusting the resident in bed. CNA #6 exited from behind the privacy curtain, and went to the bathroom to her wash hands, CNA #8 followed. CNA #6 and CNA #8 returned to the roommate and pulled the privacy curtain. CNA #6 then exited the room. Resident #15 was left in his recliner with the call light still going off. o. On 08/08/23 at 9:39 AM, CNA #6 reentered the room and went to the roommate and started changing the resident's brief. Resident #15's call light was still going off and he had not been assisted to the bathroom. p. On 08/08/23 at 9:41 AM, Resident #15 is grimacing with eyebrows furrowed. The Surveyor asked Resident #15, Are you doing ok? Resident #15 shook his head and stated No. I need to go to the bathroom. I needed to go for over an hour. CNA #6 and CNA #8 heard Resident #15, and both stated, We'll be right there and get you to the bathroom. Resident #15 was sitting on the edge of the recliner rocking back and forth, the Surveyor could hear Resident #15's stomach rumbling and growling. q. On 08/08/23 at 9:47 AM, CNA #6 asked Resident #15, Are you doing alright? Resident #15 stated, No. I'm disappointed. I had my call light on for over an hour. CNA #6 applied a gait belt around Resident #15 and assisted him to the bathroom using a wheelchair. 2. On 08/08/23 at 9:58 AM, the Surveyor asked CNA #6 who was assigned to Resident #15. CNA#6 replied, Myself, and two others. The Surveyor asked how often residents were checked. CNA #6 replied, Every two hours and as needed. The Surveyor asked when a call light should be answered. CNA #6 replied, As soon as you can. The Surveyor asked who was responsible for answering a call light. CNA #6 replied, CNAs and the nurses. CNA #6 stated 1 hour was an unacceptable length of time for Resident #15 to get assistance to go to the bathroom. 3. On 08/08/23 at 10:02 AM, the Surveyor asked CNA #8 who was assigned to Resident #15. CNA #8 replied, Three of us on the hall. The Surveyor asked how often residents were checked. CNA #8 replied, Every two hours. The Surveyor asked when a call light should be answered. CNA #8 replied, As soon as possible. The Surveyor asked who was responsible for answering a call light. CNA #8 replied, All of us. 4. On 08/08/23 at 1:26 PM, the Surveyor asked CNA #6 to describe the reason Resident #15's roommate was assisted before he was helped to the bathroom. CNA #6 stated they were in the process of doing rounds and she started with Resident #15 roommate. 5. On 08/08/23 at 1:27 PM, during an interview on 08/08/2023 at 1:27 PM, CNA #8 stated, Resident #15's roommate was changed first because we were in the process of doing our rounds. 6. On 08/08/23 at 1:36 PM, the Surveyor asked LPN #2 how many CNAs were assigned to care for Resident #15. LPN #2 replied, Three. LPN #2 was asked, At 9:33 AM, you told [CNA #6] that [Resident #15] needed to go to the bathroom. When should the CNAs have assisted [Resident #15]? LPN #2 replied, [CNA #6] should have asked [Resident #15] right then. The Surveyor asked how often residents were checked. LPN #2 replied, Every 2 hours and as needed. The Surveyor asked when a call light should be answered. LPN #2 replied, When available. Fifteen minutes would be way too long. The Surveyor asked who was responsible for answering a call light. LPN #2 replied, Whoever is available, CNAs and nurses. 7. On 08/09/23 at 9:21 AM, the Surveyor asked Resident #46, How long does it take staff to answer your call light after you push it? Resident #46 stated, It used to take a long time, but I threw a fit about it. I sat with [Resident #25] for four hours to get a pain pill the other night when the nurse had three halls by herself. The day before yesterday, I saw an aide sitting in the pool table room hiding and one was sleeping. I'm awake at all hours of the day and night, so I see and hear all kinds of things. But it doesn't do any good to say anything, because they won't do anything. The CNAs are not supervised. 8. On 08/09/23 at 9:22 AM, the Surveyor asked Resident #25, How long does it take staff to answer your call light after you push it? Resident #25 stated, When it's more than 20 minutes, I don't expect them to come at all. [Resident #46] watches out for me. The Surveyor asked, How does it make you feel when you have to wait for a long time for help from staff? Resident #25 stated, I just give up. I don't even try again. 9. On 08/09/2023 at 4:25 PM, the Surveyor asked Resident #15, Have you ever had a bowel movement or urinated on yourself because the staff took too long to answer your light? Resident #15 replied, Yes. 10. On 08/08/23 at 2:28 PM during the medication storage observation, the narcotic count was inaccurate. LPN #1 said she usually signs out the narcotics after medication pass, because of my workload, and further stated, I take shortcuts and that's not good practice. The Surveyor asked, How many residents are you responsible for? LPN #1 replied, Thirty-five or more, and that's too many for one nurse.

Based on observation, interview, and record review, the facility failed to ensure a multi-resident use glucometer was disinfected after use to prevent potential spread of infection for 2 (Residents #19 and #236) of 2 sampled residents; staff followed clean technique during the administration of medications to prevent potential infection for 3 (Residents #19, #41 and #236) of 3 sampled residents who received medications from Licensed Practical Nurse (LPN) #2. The findings are: On 08/09/23, the following observations were made during medication pass by Licensed Practical Nurse (LPN) #2 on the Rehab Hall: 1. Resident #236 a. On 08/09/23 at 11:44 AM, LPN #2 used an alcohol prep pad to wipe the top of the glucometer and then sat the glucometer on top of the medication cart. b. On 08/09/23 at 11:45 AM, LPN #2 applied gloves. LPN #2 did not perform hand hygiene. c. On 08/09/23 at 11:46 AM, LPN #2 cleaned Resident #236's right middle finger with an alcohol prep pad and pricked the finger. d. On 08/09/23 at 11:47 AM, LPN #2 exited Resident #236's room and placed the lancet and blood glucose strip in a sharps container attached to the medication cart. LPN #2 removed her dirty gloves. LPN #2 did not perform hand hygiene. e. On 08/09/23 at 11:48 AM, LPN #2 used an alcohol prep pad and cleaned the glucometer and placed the glucometer on top of the medication cart. LPN #2 removed a vial of Insulin and rolled the insulin in between hands. LPN #2 removed a clean pair of gloves from the box of gloves on the medication cart and applied the gloves. LPN #2 did not perform hand hygiene. f. On 08/09/23 at 11:50 AM, LPN #2 injected 3 units of Insulin to Resident #236's left arm. LPN #2 exited the room and placed the used insulin syringe into the sharps container and removed her dirty gloves. LPN #2 did not perform hand hygiene. 2. Resident #41 a. On 08/09/23 11:55 AM, LPN #2 pulled medications for Resident #41. LPN #2 did not perform hand hygiene prior to, during, or after medication administration. 3. Resident #19 a. On 08/09/23 at 12:02 PM, LPN #2 used an alcohol prep pad to wipe the top of the glucometer and placed the glucometer on top of the medication cart. LPN #2 applied clean gloves. LPN #2 did not perform hand hygiene prior to applying the clean gloves. b. On 08/09/23 at 12:04 PM, LPN #2 administered medications to Resident #19. LPN #2 did not perform hand hygiene prior, during, or after medication administration. c. On 08/09/23 at 12:05 PM, LPN #2 cleaned Resident #19's right middle finger with an alcohol prep pad, pricked the finger. LPN #2 exited the room, placed the lancet and blood glucose strip in the sharps container, then removed the dirty gloves and typed on the lap top. LPN #2 did not perform hand hygiene after removing the dirty gloves. d. On 08/09/23 at 12:07 PM, LPN #2 used an alcohol prep pad and wiped the glucometer, then placed it on top of the medication cart. LPN #2 pulled 13 units of insulin into an insulin syringe and applied clean gloves. LPN #2 did not perform hand hygiene before applying clean gloves. e. On 08/09/23 at 12:09 PM, LPN #2 cleaned Resident #19 right upper posterior arm and injected 13 units of insulin. LPN #2 exited the room, placed the used syringe in the sharps container and removed her dirty gloves. LPN #2 did not perform hand hygiene. 4. On 08/09/23 at 12:34 PM, the Surveyor asked LPN #2 when hand hygiene is performed. LPN #2 replied, Before and after entering the residents room. The Surveyor asked, Are you supposed to perform hand hygiene before and after medication administration and checking blood sugars? LPN #2 replied, Yes, you should, even with gloves on. The Surveyor asked what the glucometer manufacturer's guidelines recommend using to clean the glucometer. LPN #2 replied, I'm not real sure. I use alcohol pads. The Surveyor asked if that glucometer was used on all the residents. LPN #2 replied, Just the Rehab Hall. The Surveyor asked how many residents on the Rehab Hall used that glucometer. LPN #2 replied, Ten residents. The Surveyor asked were you trained on cleaning the glucometers. LPN #2 replied, No, I haven't had any training or inservices. 5. On 08/10/23 at 6:34 AM, the Surveyor asked LPN #5 when hand hygiene is performed. LPN #5 replied, All day, after everything you touch. The Surveyor asked when the glucometers are cleaned. LPN #5 replied, After every use. The Surveyor asked what the glucometers are cleaned with. LPN #5 replied, Bleach wipes. 6. The Glucometer (Blood Glucose Monitoring System) Manufacturer's Guidelines provided by the Assistant Director of Nursing (ADON) on 08/09/23 at 1:24 PM documented, .Caring for your system to minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . Cleaning and Disinfecting: .The meter should be cleaned and disinfected after use on each patient. This Blood Glucose Monitoring System may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed . We have validated [Germicidal Disposable Wipes] for disinfecting the . meter . 7. A facility policy titled, Handwashing/Hand Hygiene, provided by the Administrator on 08/09/23 at 1:44 PM documented, This facility considers hand hygiene the primary means to prevent the spread of infections 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 4. An alcohol-based hand rub may be used if no visible soiling. 5. Hand hygiene is the final step after removing and disposing of personal protective equipment. 6. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observation and interview, the facility failed to ensure food items stored in the two door ice cream freezer were properly sealed to prevent freezer burn dietary employees used clean utensils when preparing food to maintain food quality and dietary employees used clean utensils when preparing meals to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 82 residents who received meals from the kitchen (total census: 82), as documented on a list provided by the Dietary Manager on 08/11/23 at 9:50 AM. The findings are: 1. On 08/07/23 at 10:00 AM, during the initial tour of the kitchen, the following observations were made in the two door ice cream freezer: a. An opened box of approximately 24 single serving cups of vanilla ice cream, with ice cream dripped down the side of the cup and ice cream smears on the box. The Surveyor asked the Dietary Assistant Manager why the ice cream containers look like that. She stated, It looks like they have thawed and been refrozen. b. An opened ziplock bag containing approximately 15 to 20 tator tots with ice crystals on the tator tots and in the bottom of the bag. c. An opened ziplock bag containing approximately 10 chicken strips. d. An opened ziplock bag containing approximately 8-10 biscuits with ice crystals on the biscuits and in the bottom of the bag. The Surveyor asked the Dietary Assistant Manager if the bags should be left open. She stated, No, I'll throw those away. 2. On 08/09/23 at 10:27 AM, Dietary Employee (DE) #1 was preparing pureed lasagna. She placed approximately 48 ounces of lasagna with sauce into a processor and blended it. She took a plastic spatula and stirred the contents, then placed the spatula on the stainless steel countertop. DE #1 blended the lasagna into a smooth pudding like consistency, then using the plastic spatula from the counter, she dumped the contents into a metal bowl and placed a foil sheet on top. She took all 3 metal bowls and placed them in the oven. a. On 08/09/23 at 10:45 AM, the Surveyor asked DE #1 if she should use the spatula in the lasagna after laying it on the counter. She stated, No, I should have used a clean one. 3. The facility policy titled, Food Storage, provided by the Dietary Manager on 08/10/23 at 1:00 PM documented, Policy: Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines. Procedure: .All food not in original containers are to be labeled and dated and stored in NSF [National Sanitation Foundation] approved containers .

Based on observation, interview, and record review, the facility failed to ensure wheelchair arm rests were free of rips and tears for 2 (Residents #1 and #2) of 2 sampled residents and failed to ensure the flooring was free of rips and tears. The findings are: 1. Resident #2 ' s Care Plan with a revision date of 05/24/22 documented, The resident has potential impairment to skin integrity . Identify/document potential causative factors and eliminate/resolve where possible . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . a. On 08/07/23 at 10:33 AM, Resident #2 observed sitting in room. The left wheelchair arm rest was peeling with foam exposed. b. On 08/07/2023 at 1:11 PM, Resident #2 observed sitting in wheelchair in the dining room. The left wheelchair arm was peeling with foam exposed. 2. Resident #1's Care Plan with a revision date of 06/11/21 documented, The resident has potential/actual impairment to skin integrity . Identify/document potential causative factors and eliminate/resolve where possible . Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface . a. On 08/07/23 at 10:46 AM, Resident #1's left wheelchair arm rest was split with rough edges and foam exposed. b. On 08/07/23 at 1:21 PM, Resident #1's left wheelchair arm rest was split with rough edges and foam exposed. c. On 08/07/23 at 1:26 PM, Resident #1 was observed in a wheelchair in the hall. Resident #1's left arm rest was split with rough edges and foam exposed. 3. On 08/09/23 at 10:30 AM, a rip approximately 1.5 feet in length was observed in the floor tile in Room W7. The ripped hole was covered with clear tape that was curling on the sides. 4. On 08/10/23 at 9:46 AM, the Surveyor asked Certified Nursing Assistant (CNA) #6 how is it reported if something needed to be fixed. CNA #6 replied, We use a Work Order form. We fill it out and place it on the clip board outside the Maintenance Office. The Surveyor asked CNA #6 to describe the left arm rest on Resident #1's wheelchair. CNA #6 replied, It has cracks and it's peeling. The Surveyor asked her to describe the ripped area in the floor tile in Room W7. CNA #6 replied, It's ripped and taped. The Surveyor asked how long the floor had been like that. CNA #6 replied, I don't know. The Surveyor asked if the arm rests on Resident #1's and Resident #2's wheelchair and the rip in the floor tile in Room W7 had been reported. CNA #6 replied, I don't know. I haven't noticed it. 5. On 08/10/23 at 9:52 AM, the Surveyor asked Maintenance #1 if something needs to be fixed how is it reported. Maintenance #1 replied, With a work order. There are some at the Nurses Stations and outside the Maintenance Office. They fill it out and put it in a box and I fix it. The Surveyor asked who could fill the work orders out. Maintenance #1 replied, Anyone can fill out a work order. The Surveyor asked if he kept logs of what was fixed and when it was fixed. Maintenance #1 replied, Sometimes I keep them and then get rid of them. The Surveyor asked if Resident #1's left wheelchair arm rest had been reported as needing to be fixed. Maintenance #1 replied, No, it hasn't been reported. The Surveyor asked if he replaced Resident #2's left wheelchair arm rest. Maintenance #1 replied, Yes. The Surveyor asked when he replaced Resident #2's left wheelchair arm rest. Maintenance #1 replied, Yesterday. The Surveyor asked him to describe the ripped floor tile in Room W7. Maintenance #1 replied, It was coming up and we taped it down. The Surveyor asked when the floor tile became ripped. Maintenance #1 replied, It's been like that for a while. The Surveyor asked if there was a reason why it hadn't been fixed yet. Maintenance #1 replied, I forgot about it.

Based on record review and interview, the facility failed to ensure the completion of the quarterly resident assessments within 14 days of the Assessment Reference Date (ARD) and submitted no later than an additional 14 days after completion to meet requirements for 6 (Residents #9, #19, #31, #36, #55 and #58) of 6 sampled residents whose Quarterly Assessments were reviewed. The findings are: During resident record review, the following quarterly assessments were not completed within the regulatory time frame: 1. Resident #9's Quarterly Assessment with an ARD of 06/19/23 was still in progress. 2. Resident #19's Quarterly Assessment with an ARD of 06/14/23 had a completion date of 08/07/23. 3. Resident #31's Quarterly Assessment with an ARD of 06/11/23 had a completion date of 08/07/23. 4. Resident #36's Quarterly Assessment with an ARD of 06/12/23 was still in progress. 5. Resident #55's Quarterly Assessment with an ARD of 06/12/23 had a completion date of 08/07/23. 6. Resident #58's Quarterly Assessment with an ARD of 6/10/23 had a completion date of 08/07/23. 7. On 08/11/23 at 9:35 AM, the Surveyor asked the MDS Coordinator who was responsible for completing the MDS. She stated, Myself and [Rehab MDS Coordinator]. The Surveyor asked when the MDS should be completed. She stated, Upon entry, when a resident had a significant change, Quarterly and Annually. The care areas should be completed within 14 days. 8. On 08/11/23 at 9:58 AM, the Surveyor asked the MDS Coordinator if there was a facility policy on completing the MDS. She stated, No, we use the RAI [Resident Assessment Instrument] Manual. 9. The RAI Manual documents the Quarterly assessment is a non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. The ARD must be not more than 92 days after the ARD of the most recent assessment of any type.

Based on record review and interview, the facility failed to ensure comprehensive care plans were revised quarterly, to accurately identify care area needs and provide care for 4 (Residents #13, #40, #46 and #130) of 22 (Resident #1, #3, #5, #7, #8, #9, #10, #13, #16, #18, #19, #23, #27, #29, #31, #32, #36, #40, #41, #43, #46, #55, #57, #58, #67, #69, #71, #75, #77, #78, #130, #180 and #236) sampled residents whose care plans were reviewed. The findings are: 1. A review of Resident #13's resident profile in the electronic medical record noted diagnoses of Unspecified Dementia, Chronic Obstructive Pulmonary Disease (COPD), Heart Failure and Acute Kidney Failure. a. A Physician Order dated 05/24/23 documented the resident was to receive Lasix, a diuretic medication one time a day related to acute kidney failure. b. A Physician Order dated 08/01/23 documented the resident was to receive Sertraline (an antidepressant medication) one time a day related to other recurrent depressive disorders and Hydrocodone-Acetaminophen (an opioid pain reliever) every 8 hours as needed for pain. c. A review of Resident #13's Care Plan noted an admitted [DATE]. There were no revisions noted. The Care Plan did not address goals or interventions for dementia, COPD, heart failure or the need for use of opioids, diuretics, or antidepressants. 46723 2. A review of Resident #40's Care Plan, last revised on 02/04/20 noted the resident had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and noted a care plan for altered respiratory status. The care plan noted an intervention of oxygen at 1 liter per minute. a. A review of Physicians Order dated 05/08/20 documented Resident #40 was to receive oxygen (02) at liters 2 Liters per minute via nasal cannula as needed. 39316 3. Resident #46 had a Physicians Order dated 09/21/20 documented Resident #46 was to receive oxygen (O2) at 2 liters per minute via nasal cannula as needed. a. A Physicians Order dated 06/05/23 documented the resident was to have a CPAP (Continuous Positive Airway Pressure) applied at bedtime and was to be removed in the morning. b. Review of the Care Plan noted an admitted [DATE] and noted diagnoses of asthma and sleep apnea. The care plan failed to address the use of oxygen therapy and CPAP. 4. A review of Resident #130's Physicians Order dated 08/08/23 documented Resident #130 had an indwelling catheter. a. A review of the Care Plan failed to address the use of an indwelling catheter. 5. On 08/09/23 at 2:30 PM, the Administrator stated, We do not have a care plan policy, we use the Resident Assessment Instrument (RAI) manual. 6. On 08/11/23 at 9:35 AM, the Surveyor asked the Minimum Data Set (MDS) Coordinator who was responsible for completing the MDS. She stated, Myself and [Rehab MDS Coordinator]. The Surveyor asked her to look at Resident #13's Care Plan, and asked if medications such as diuretics, opioids, and antidepressants should be addressed on the care plan. She stated, Yes. 7. On 08/11/23 at 9:36 AM, the Surveyor asked the MDS Coordinator to look at Resident #46's Care Plan and asked if the use of O2 and a CPAP should be listed on the care plan. She stated, Yes. 8. On 08/11/23 at 9:37 AM, the Surveyor asked the MDS Coordinator to look at Resident #130's Care Plan. and asked if having an indwelling catheter should be listed on the care plan. She stated, Yes, every time.

Based on observation, interview and record review, the facility failed to ensure residents nails were cleaned and trimmed and residents received a shower, a clean change of clothes and clean bed linen to maintain dignity and good personal hygiene for 2 (Residents #8 and #71) of 37 (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #15, #16, #18, #19, #23, #25, #27, #29, #32, #36, #39, #40, #43, #46, #47, #49, #51, #55, #57, #58, #59, #65, #69, #71, #75 and #130) sampled residents who required assistance with nail care, bathing and maintaining clean bed linen. The findings are: 1. A review of Resident #8's Physician's Orders, noted a diagnosis of candidiasis of skin and nail. a. On 08/07/23 at 2:07 PM, observed Resident #8 lying in bed. Her fingernails protruded past the end of the fingers approximately 1/8 inch. The Surveyor asked Resident #8 if she had requested her nails be cut. She stated, That goes back to them having enough staff. I hate to ask them. b. On 08/09/23 at 8:15 AM, Resident #8 stated that she was given a bath on Monday (08/07/23) afternoon, however her fingernails were not cut or trimmed. c. Resident #8's Care Plan did not address nail care. d. On 8/10/23 at 1:57 PM, the Surveyor asked Licensed Practical Nurse (LPN) #5 when nail care should be provided. LPN #5 stated, Per the schedule and as needed. The Surveyor asked if nail care should be addressed on the resident's Care Plan. LPN #5 stated, I would think so. 46723 2. Review of Resident #71's Care Plan for activities of daily living (ADL), last revised on 04/06/23 noted Resident #71 required limited to extensive assistance of 1 or 2 staff with personal hygiene and oral care. a. On 08/07/23 at 8:39 AM, Resident #71 was sitting up in bed. Resident #71's shirt, sheets and pillowcase were dirty. Resident #71 stated, I am supposed to have a shower and a shave today. b. On 08/08/23 at 8:19 AM, Resident #71 was sitting up in bed. Resident #71 stated he had not had a shower yet. He was still wearing the same dirty shirt stained with food, the sheet and pillowcase were still dirty. c. On 08/08/23 at 8:39 AM, the Surveyor asked LPN #1 when Resident #71 had his last shower. LPN #1 said, I'm not sure. The resident gets his baths, he just forgets. The Surveyor informed LPN #1 that yesterday, Resident #71's t-shirt was stained with food his pillowcase and sheet were dirty and this morning, Resident #71 was still in the same stained t-shirt and his pillowcase and sheet remained dirty. The Surveyor asked LPN #1 if she was aware of that. LPN #1 said, No. d. On 08/08/23 at 8:46 AM, the Surveyor asked CNA #4 if the CNAs change the resident's clothes when they get a shower. CNA #4 said, Yes, they're supposed to. The Surveyor asked if Resident #71 was showered yesterday. CNA #4 looked in the electronic chart and said, Yes, [Resident #71] had a shower yesterday. The Surveyor asked who charted it. CNA #4 said, [CNA #3]. I am giving him a shower this AM, because he didn't get a shower yesterday. e. On 08/08/23 at 2:56 PM, the Surveyor returned to Resident #71's room, he had been showered, the pillowcase and sheets were still dirty. Resident #71 acknowledged he had a shower. The Surveyor asked if his pillowcase and sheets were still dirty, did they not change them? Resident #71 said, No, [CNA #4] is supposed to come back to change them. [CNA #4] is busy right now. f. On 08/09/23 at 9:20 AM, the Surveyor asked Resident #71 if they changed his sheets last night. Resident #71 stated no, they're busy making up schedules and other things. The Surveyor spoke to the LPN #1 and asked why Resident #71's sheets had not been changed. Do they change sheets when they shower the residents. LPN #1, said, Yes, they're supposed to. LPN #1 asked, CNA #2 about Resident #71's sheets. CNA #2 said, I told the resident I would change them after breakfast. I will change them now. g. On 08/09/23 at 10:21 AM, the Surveyor asked Resident #71 if his sheets were changed. The resident said, Yes.

Based on observation, interview, and record review, the facility failed to ensure indwelling catheter drainage bags were maintained and kept off the floor for 2 (Residents #2 and #130) of 2 sampled residents; catheter bags were in a privacy bag for 1 (Resident #2) of 2 (Residents #2 and #130) sampled residents and residents were promptly toileted in a timely manner to prevent accidental incontinence for 1 (Resident #15) of 1 sampled resident. The findings are: 1. Review of a Physicians Order with a start date of 06/27/23 documented Resident #2 had a suprapubic indwelling catheter. a. On 08/07/23 at 10:32 AM, Resident #2 was sitting in a wheelchair in his room. An indwelling catheter bag was attached under the wheelchair frame. The catheter drainage bag spout was on the floor and not in a privacy bag. b. On 08/07/23 at 1:10 PM, Resident #2 was in his wheelchair in the Dining Room. An indwelling catheter bag was attached under the wheelchair frame. The catheter bag drainage spout was on the floor and not in a privacy bag. 2. Review of a Physicians Order dated 08/08/23 documented Resident #130 had an indwelling catheter. a. On 08/09/23 at 9:35 AM, Resident #130 was lying in bed. A catheter bag was lying on the floor. b. On 08/09/23 at 9:39 AM, the Surveyor asked Certified Nursing Assistant (CNA) #7 if Resident #130's catheter bag was supposed to be on the floor. CNA #7 replied, No. The Surveyor asked who was responsible for ensuring catheter bags were not on the floor. CNA #7 replied, The CNAs. The Surveyor asked why catheter bags should not be in the floor. CNA #7 replied, For infection. The Surveyor asked why catheter bags should be in a privacy bag. CNA #7 replied, For safety. The Surveyor asked who was responsible for ensuring resident catheter bags were covered or in a privacy bag. CNA #7 replied, The CNAs. c. On 08/10/23 at 6:34 AM, the Surveyor asked Licensed Practical Nurse (LPN) #5 why catheter bags should not be in the floor. LPN #5 replied, Bacteria and germs, and it could get stepped on. The Surveyor asked why catheter bags should be in a privacy bag. LPN #5 replied, It's a dignity issue. The Surveyor asked who was responsible for ensuring resident catheter bags are not on the floor and are covered or in a privacy bag. LPN #5 replied, We all are. d. On 08/10/23 at 1:56 PM, the Surveyor asked Registered Nurse (RN) #1 if catheter bags were supposed to be on the floor. RN #1 replied, No. The Surveyor asked why catheter bags should not be on the floor. RN #1 replied, Because of bacteria. The Surveyor asked who was responsible for ensuring catheter bags were not on the floor. RN #1 replied, Everybody. The Surveyor asked why catheter bags should be in a privacy bag. RN #1 replied, For privacy and dignity. The Surveyor asked who was responsible for ensuring resident catheter bags were covered or in a privacy bags. RN #1 replied, Nursing staff. 3. Review of the Care Plan with a revision date of 05/10/21 documented Resident #15 had occasional bowel and bladder incontinence and required one person extensive staff assistance to check and change every 2 hours and as needed and to take Resident #15 to the toilet at same time each day for bowel movements. a. On 08/08/23 at 8:40 AM, Resident #15 was sitting in a recliner in his room and had his call light on. Resident #15 stated, I turned my light on eight minutes ago. I need help to go to the bathroom, they don't realize I need help. If I could do it myself, I would. b. On 08/08/23 at 8:57 AM, Resident #15 stated, I'm getting close to having a bowel movement. I'm passing gas now and when it stops my bowels start and it's getting very close. The Surveyor asked Resident #15 if he had to have help to go to the bathroom. Resident #15 stated, Yes, because I might fall. c. On 08/08/23 at 9:13 AM, the Surveyor asked Resident #15 how it makes him feel when he needed help and it takes them so long to come. Resident #15 stated, I feel helpless. I can't help myself and they won't help me. d. On 08/08/23 at 9:31 AM, Licensed Practical Nurse (LPN) #2 entered Resident #15 ' s room to administer medications. LPN #2 asked Resident #15, Are you hurting this morning? Resident #15 stated, No. I'm hurting to go to the bathroom, my call light has been on over an hour. LPN #2 stated, I'll get someone to help me get you to the bathroom. Resident # 15 stated, It will take two people. e. On 08/08/23 at 9:34 AM, CNA #6 and CNA #8 assisted Resident #15's roommate with adjusting the resident in bed and changing the resident's brief. f. On 08/08/23 at 9:41 AM, the Surveyor asked Resident #15 if he was doing ok. Resident #15 stated, No. I need to go to the bathroom. I needed to go for over an hour. CNA #6 and CNA #8 both stated, We'll be right there and get you to the bathroom. g. On 08/08/23 at 9:47 AM, CNA #6 applied a gait belt around Resident #15 and assisted Resident #15 to the bathroom. h. On 08/08/23 at 9:58 AM, the Surveyor asked CNA #6 who was assigned to Resident #15. CNA#6 replied, Myself, and two others. The Surveyor asked CNA #6 why was over an hour too long to answer a call light. CNA #6 replied, That's a very long time period. Residents shouldn't have to sit for an hour, it's unacceptable. i. On 08/08/23 at 10:02 AM, the Surveyor asked CNA #8 who was assigned to Resident #15. CNA #8 replied, Three of us on the hall. j. On 08/08/23 at 1:36 PM, the Surveyor asked LPN #2, At 9:33 AM, you told [CNA #6] that [Resident #15] needed to go to the bathroom. When should the CNAs have assisted [Resident #15]? LPN #2 replied, [CNA #6] should have asked [Resident #15] right then. The Surveyor asked when a call light should be answered. LPN #2 replied, When available. Fifteen minutes would be way too long.

Based on record review and interview, the facility failed to ensure the annual comprehensive resident assessments were completed and transmitted within 14 calendar days to facilitate appropriate care planning and maintain current and accurate assessment records for 8 (Residents #5, #11, #18, #23, #27, #47, #51 and #65) of 8 sampled residents whose comprehensive assessments were reviewed. The findings are: During resident record review the following annual resident assessments were not completed within the regulatory time frame: 1. Resident #5's Annual Assessment with an Assessment Reference Date (ARD) of 06/23/23 was still in progress. 2. Resident #11's Annual Assessment with an ARD of 06/16/23 was still in progress. 3. Resident #18's Annual Assessment with an ARD of 06/05/23 was still in progress. 4. Resident #23's Annual Assessment with an ARD of 05/18/23 was still in progress. 5. Resident #27's Annual Assessment with an ARD of 06/14/23 was still in progress. 6. Resident #47's Annual Assessment with an ARD of 06/06/23 was still in progress. 7. Resident #51's Annual Assessment with an ARD of 05/09/22 was still in progress. 8. Resident #65's Annual Assessment with an ARD of 05/11/23 was still in progress. 9. On 08/11/23 at 9:35 AM, the Surveyor asked the MDS Coordinator who was responsible for completing the MDS. She stated, Myself and [Rehab MDS Coordinator]. The Surveyor asked when the MDS should be completed. She stated, Upon entry, when resident had a significant change, quarterly and annually. The care areas should be completed within 14 days. 10. On 08/11/23 at 9:58 AM, the Surveyor asked the MDS Coordinator if there was a facility policy on completing the MDS. She stated, No, we use the RAI [Resident Assessment Instrument] Manual. 11. The RAI Manual documents the Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis. The MDS completion date must be no later than 14 days after the ARD.

Based on observation, interview and record review, the facility failed to store tobacco products in a manner to ensure resident safety for 2 (Residents #1 and #47) of 2 sampled residents who smoked or used smokeless tobacco products. The findings are: 1. Review of Resident #1's Care Plan with a revision date of 05/18/22 documented Resident #1 was a smoker and smoking materials were to be stored by the facility and will be provided when in the appropriate smoking area and being supervised. a. On 08/07/23 at 10:45 AM, Resident #1 was lying in bed. Two packs of cigarettes were on Resident #1's nightstand and not contained. b. On 08/07/23 at 1:20 PM, Resident #1 was lying in bed. Two packs of cigarettes were on Resident #1's nightstand and not contained. 2. Review of Resident #47's Care Plan with a revision date of 05/18/22 documented Resident #47 was a smoker and had been oriented to the smoking procedures and areas and voiced understanding. a. On 08/07/23 at 11:08 AM, eight cans of smokeless tobacco were on Resident #47's nightstand and a pack of cigarettes was on the bedside table. b. On 08/07/23 at 1:33 PM, Resident #47 was lying in bed. Eight cans of smokeless tobacco were on the nightstand. The Surveyor asked if he was supposed to keep cigarettes in his room. Resident #47 stated, No, they keep them up front with the nurse. 3. On 08/09/23 at 11:34 AM, the Surveyor asked Certified Nursing Assistant (CNA) #5 where the resident ' s cigarettes and smokeless tobacco products were stored when not in use. CNA #5 replied, The locked smoke box. The Surveyor asked who was responsible for ensuring the resident smoking materials/smokeless tobacco products were not left in the resident rooms. CNA #5 replied, Nursing staff. 4. On 08/10/23 at 6:34 AM, the Surveyor asked Licensed Practical Nurse (LPN) #5 where are resident cigarettes and smokeless tobacco products stored when not in use. LPN #5 replied, On the nurses cart. The Surveyor asked who was responsible for ensuring the resident smoking materials/smokeless tobacco products were not left in the resident rooms. LPN #5 replied, The nurses. 5. A policy titled, Smoking Policy and Procedure, provided by the Administrator on 08/09/23 at 8:42 AM documented, It is the facility's intention to maximize its ability to provide a safe environment to all residents admitted to the facility, including residents who smoke or use electronic cigarettes . 8. No smoking materials will be in any resident's possession at any time, including electronic cigarettes . Any materials found in a resident's possession or in a resident's room will be removed from the resident's possession . All smoking materials will be labeled, kept in a secure, designated area and furnished to the resident during the smoking times designated by the facility's smoking schedule .

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to promote the resident's rights and failed to incorporate the resident's right to choice in treatment, care and services as evidenced by the facility's failure to provide ice and/or sips of water as requested for 1 (Resident #23) of 2 case mix residents (Residents #3 and #23) who were to receive nothing by mouth (NPO) and were receiving end of life care. The failed practice resulted in a pattern of harm for Resident #23 who was dying and requested ice as part of comfort measure for him during his end of life experience and had the potential to affect 4 residents who were NPO according to a list provided by the Medical Records Registered Nurse (RN) on 7/24/15 and 5 residents who were on Hospice according to a list provided by the Administrator on 7/13/15. The findings are: 1. Resident #23 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 6/9/15 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status; required supervision/set-up help only for eating; received as needed (PRN) pain medication; had a feeding tube; and received Speech-language/audiology services. a. A Speech Therapy Bedside Swallow and Evaluation dated 5/22/15 documented, .Pt. (patient) tolerated several trials of tsp. (teaspoon) pureed without s/s (signs and symptoms) aspiration; however this is a short look into pt's capabilities during swallowing tasks. Pt. reports everytime he tries to eat by mouth he gets pneumonia. Best course of action is to remain NPO for safety .If pt. is adament about having something by mouth .2 - 4 oz's (ounces) of pureed with strict precautions would be the safest consistency .Diet - NPO PEG tube. Comment. Pleasure feeds if needed: pureed/pudding thick . The document was faxed to the facility on [DATE], the day after the resident left the facility. b. A physician order [REDACTED].@ (at) 50cc/hr (cubic centimeters per hour) via pump continuous (DX (diagnosis): Malnutrition, severe protein) .All meds (medications) P.T. (per tube) (DX: PEG tube with dysphagia). c. A [MEDICAL CONDITION] Progress note dated 6/15/15 documented, .Pt desires no further w/u (work up) & (and) wants to be kept comfortable & wants H2O (water). Will consult Hospice & make his comfort our (first) goal. Please call if I can be of further assistance. d. A physician order [REDACTED]. e. A Nurse Note dated 6/19/15 (no time) documented, .I asked (Resident #23) what his desire for hospice was & his response was 'water'. I informed pt (patient) & family that even on hospice, while in our facility he would remain NPO. I told pt & family that we would do everything we could to keep his mouth moist & clean. Oral care Q (every) 2 (hours), offered chapstick, etc. Res (resident) refused @ this time . f. A Daily Note signed by the Speech-Language Pathologist dated 6/19/15 documented, treatment of [REDACTED].Ice Chips - tolerated 5/5 (5 of 5) (with) (no) s/s of asp (aspiration)/penetration . g. A physician order [REDACTED].O. (new order) Admit to Hospice and [MEDICATION NAME] 20 mg/ml (milligrams per milliliter) 0.5 ml SL (sublingual) q (every) 2 hrs prn (as needed). The June 2015 Medication Administration Record [REDACTED]. The medication was administered on the 11:00 p.m. to 7:00 a.m. shift on 6/22/15 per the nurse initials. There was no documentation that the resident had s/s of choking/aspiration with the sublingual medication. h. A Hospice Physician's Plan of Care dated 6/20/15 documented, Medical Treatment Orders: Nutrition/Diet: NPO peg feedings only, however pt is begging for ice. States he knows he could aspirate if he eats or drinks anything. Notified (hospice doctor) who states as long as pt understands the risks, he can have what he wants. Notified pts primary nurse, (name) LPN (Licensed Practical Nurse), who states she does not feel comfortable giving pt anything. Notified weekend charge (name) who called DON (Director of Nursing), and she said no that pt could not have anything by mouth at this time. States she will discuss with Administrator on Monday) . The note was not in the facility clinical record and was faxed upon surveyor request from the Hospice agency on 7/23/15. i. A Hospice Nurses note dated 6/20/15 at 1:30 p.m. documented, Spoke to team members this a.m. regarding pts admission and the fact that he had a peg tube and is NPO. All the pts wants is to have some Ice and the facility is not allowing him to have any ice even with a Waiver signed by the pt and the pts brother. The pt is well aware that by attempting to eat ice he could aspirate or even choke, he states he would rather take that chance to have a better quality of life even if it means he may die because of it. The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. j. A Hospice nurse note dated 6/21/15 at 10:39 a.m. documented, Nutrition/Diet: NPO. Comment: peg feedings only, however pt is begging for ice. States he knows he could aspirate if he eats or drinks anything. Notified (hospice physician) who states as long as pt understands the risks, he can have what he wants . The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. k. The Care Plan dated 6/22/15 documented, .Potential for alteration in nutrition, aspiration, and GI (gastrointestinal) discomfort R/T (related to) dysphagia, severe protein malnutrition and iron def (deficiency) [MEDICAL CONDITION] .If aspiration is suspected, monitor lung sounds and temp. (temperature) for 48 hrs (hours); notify MD (medical doctor) and family .Hospice to TX (treat) resident as indicated R/T severe protein malnutrition .Resident and Family to have wishes carried out this quarter. 1. Notify MD, Family, and Hospice with changes 2. Comfort measures to be given .6/22/15 Hospice called requesting a waiver to be signed to allow PO (oral) intake. IDT (Interdisciplinary Team) reviewed info (information) and agreed that risk of PO intake out weighed the benefit. l. A Hospice nurse note dated 6/22/15 at 3:33 p.m. documented, Intervention: Discussed pts request for ice, pts/family understands verses benefit and options for pt./family since (nursing facility) refusing to honor pts wishes. At 3:35 p.m. documented, Call was placed to (facility) spoke to (name) LPN, nurse for pt today. Ask her if the waiver that was discussed on Friday when legals were signed on pt and Saturday when pt was admitted to hospice had been signed so pt could have some ice. pt is npo and all he wants is ice. She transferred me to (name), RN, DON. I ask (DON) she stated no that she would have to consult with the Administrator and call me back .(DON) returned my call stating the Administrator was not going to allow pt or his brother to sign waiver to (allow) pt to have ice even though the pt and brother knew the risk verses the benefits. She stated that their options were to place pt in In Patient hospice or they could change facilities. I placed a call to the pts brother and he stated he would like to see if pt could transfer to (another nursing facility). I called and spoke with (social worker) and she was going to discuss it with (DON of the other nursing facility) and Administrator. (name) RN from (other nursing facility) called back and states they would be willing to accept him and allow him to sign waiver. I called the brother back and papers were faxed to (other nursing facility) so they could evaluate the pt today. The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. m. A typed Note dated 6/25/15 (no time) and signed by the Administrator documented, (Resident #23) had an order for [REDACTED]. (doctor's) order and determined that the risk of the patient having ice chips out weighed the benefit. The hospice nurse (name) was told that this could not happen here but perhaps another location or in patient hospice could honor the request. n. A Nurses Note dated 6/25/15 documented, (at) 1845 (6:45 p.m.) transported to (hospital) via (ambulance) via stretcher. (Hospice) aware. Family aware. o. A Hospice Nurse note dated 6/26/15 documented, Reason for visit?: pt transferring .Most important to patient now: Ice. Pt is begging for a piece of ice. What are the patient's immediate needs? Better pain control and a piece of ice. Most important to family: (name) the pts brother wants pt to be comfortable and to have ice or anything else he wants to eat .pt very excited about being given a few ice chips he is almost crying .pt did not like the nursing facility he was in because they would not give him any ice even though he was willing to sign a waiver .nutrition/diet: puree .pt can have anything he wants but he prefers soft or full liquid. Swallowing/eating: WNL (within normal limits) for patient, Aspiration precautions, chokes easily, Diminished chewing skills, Dysphagia, Total feed .Comment: pt has been tube fed if he would accept it. He has been NPO at nursing facility but he is begging for ice and was given ice chips on arrival to hospital and he's not choked . p. On 7/23/15 at 3:06 p.m., the Administrator and DON were asked for the facility criteria for when a resident that was NPO could have a waiver for fluids/ice. The Administrator stated, Based on the IDT and risk versus benefits. When asked if (Resident #23) had been offered any ice/puree/pudding thick fluids by facility staff, the Administrator stated, He could choke to death and die. Not choking here. Gave him nothing by mouth while at facility. There was no order from Hospice doctor for other than NPO. No doctor ordered ice. Remained NPO. I felt he could choke. When asked how did they know the resident would choke if he had received nothing by mouth while at the facility, the Administrator stated, From the brother . When asked why (Resident #3), who had declined Hospice but was on the facility log for comfort care and NPO, could have a signed waiver for fluids and Resident #23 could not, the DON stated, (Resident #3)'s waiver was okay. He was not choking. He had silent aspiration. The DON was shown the speech therapy note for the resident (Resident #23) from 6/19/15 that documented the resident tolerated 5 of 5 ice chips was reviewed. The DON stated, I didn't read that. q. On 7/23/15 at 3:40 p.m., the Administrator of the Hospice agency was informed of the lack of Nurse and Aide notes in the facility hospice record and was asked if Nurses and Aides should leave a copy with the facility. The Hospice Administrator stated, Absolutely must leave a copy of nurse/aide notes. The Hospice agency faxed a Medication Profile, Physician's Plan of Care dated 6/21/15, a Modified Order sheet dated 6/23/15 and 6/24/15, Hospice Aide notes dated 6/19/15 through 6/25/15 and Nurse Notes from 6/20/15 through 6/25/15 for this facility and notes following the discharge of the resident from the facility through 7/6/15. r. On 7/23/15 at 4:10 p.m., the Administrator was asked if she had called the doctor and asked if the resident could have ice chips. The Administrator stated, No. We had the order and he was NPO. The Administrator was asked, when he was begging for ice chips, did you call the doctor and ask him if he could have ice chips, the Administrator stated, No. We're on the same page and the order for him was NPO. s. On 7/24/15 at 8:05 a.m., the Speech-Language Pathologist who had written the note dated 6/19/15 was asked about her documentation on the note. She stated, Trying ice chips, small - the size of the end of a fingertip. His mouth was so dry, so very dry. When dry, can create oral dysphagia. Gave ice chips, very small/small amounts .Used very small ice chips in the mouth and let melt .He tolerated with no signs or symptoms of aspiration. t. On 7/24/15 at 9:05 a.m., the resident's attending physician was asked if anyone talked to him about letting the resident sign a waiver to have ice and/or water. The physician stated, Not that I recall. He was on hospice. A dying man can have whatever he wants. If he wants to choke, he can. I would have said okay to a waiver if I had been asked. 2. A staff in-service training was conducted on 6/22/15 and documented the following: Resident Rights .The Right to Participate in Their Own Care, including the right to: Direct whether to receive nutrition or hydration .Participate in their assessment, care-planning, treatment, and discharge; Refuse medication and treatment; Be advised by physician or appropriate professional staff of alternative courses of care and treatments and their consequences .

Complaint # was substantiated (all or in part) with these findings. Based on record review and interview, the facility failed to ensure necessary care and services were provided to ensure comfort during end of life care for Resident #23. The facility failed to ensure the coordination of Hospice care and failed to provide ice chips and/or sips of water to Resident #23 per the resident's informed request for 1 (Resident #23) of 2 (Residents #3 and #23) case mix residents who had orders for nothing by mouth (NPO) and were receiving end of life care. The failed practice resulted in a pattern of harm for Resident #23 who was dying and requested/begged for ice as part of comfort measure for him during his end of life experience and had the potential to affect 4 residents who were NPO according to a list provided by the Medical Records Registered Nurse on 7/24/15 and 5 residents who were on Hospice according to a list provided by the Administrator on 7/13/15. The findings are: 1. A Nursing Facility Services Agreement dated 1/13/14 documented the following: .Hospice and Facility will jointly develop and agree upon a written coordinated Plan of Care which is consistent with the hospice philosophy and is responsive to the unique needs of the Hospice Patient and his or her expressed desire for hospice care . Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communication in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day . Hospice retains primary responsibility for development of the Plan of Care . Facility shall prepare and maintain complete and detailed records concerning each Hospice Patient receiving Facility Services under this agreement in accordance with prudent record-keeping procedures .Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning each Hospice Patient, including evaluations, treatments, progress notes, authorizations to admission to Hospice and/or Facility, physician orders [REDACTED]. Each record shall document that the specified services are furnished in accordance with this Agreement and shall be readily accessible and systemically organized to facilitate retrieval by either party . 2. Resident #23 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 6/9/15 documented the resident scored 14 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status; required supervision/set-up help only for eating; received as needed (PRN) pain medication; had a feeding tube; and received Speech-language/audiology services. a. A Speech Therapy Bedside Swallow and Evaluation dated 5/22/15 documented, .Pt. (patient) tolerated several trials of tsp. (teaspoon) pureed without s/s (signs and symptoms) aspiration; however this is a short look into pt's capabilities during swallowing tasks. Pt. reports everytime he tries to eat by mouth he gets pneumonia. Best course of action is to remain NPO for safety .If pt. is adament about having something by mouth .2 - 4 oz's (ounces) of pureed with strict precautions would be the safest consistency .Diet - NPO PEG tube. Comment. Pleasure feeds if needed: pureed/pudding thick . The document was faxed to the facility on [DATE], the day after the resident left the facility. b. A physician order [REDACTED].@ (at) 50cc/hr (cubic centimeters per hour) via pump continuous (DX (diagnosis): Malnutrition, severe protein) .All meds (medications) P.T. (per tube) (DX: PEG tube with dysphagia). c. A [MEDICAL CONDITION] Progress note dated 6/15/15 documented, .Pt desires no further w/u (work up) & (and) wants to be kept comfortable & wants H2O (water). Will consult Hospice & make his comfort our (first) goal. Please call if I can be of further assistance. d. A physician order [REDACTED]. e. A Nurse Note dated 6/19/15 (no time) documented, .I asked (Resident #23) what his desire for hospice was & his response was 'water'. I informed pt (patient) & family that even on hospice, while in our facility he would remain NPO. I told pt & family that we would do everything we could to keep his mouth moist & clean. Oral care Q (every) 2 (hours), offered chapstick, etc. Res (resident) refused @ this time . f. A Daily Note signed by the Speech-Language Pathologist dated 6/19/15 documented, treatment of [REDACTED].Ice Chips - tolerated 5/5 (5 of 5) (with) (no) s/s of asp (aspiration)/penetration . g. A physician order [REDACTED].O. (new order) Admit to Hospice and [MEDICATION NAME] 20 mg/ml (milligrams per milliliter) 0.5 ml SL (sublinqual) q (every) 2 hrs prn (as needed). The June 2015 Medication Administration Record [REDACTED]. The medication was administered on the 11:00 p.m. to 7:00 a.m. shift on 6/22/15 per the nurse initials. There was no documentation that the resident had s/s of choking/aspiration with the sublingual medication. h. A Hospice Physician's Plan of Care dated 6/20/15 documented, Medical Treatment Orders: Nutrition/Diet: NPO peg feedings only, however pt is begging for ice. States he knows he could aspirate if he eats or drinks anything. Notified (hospice doctor) who states as long as pt understands the risks, he can have what he wants. Notified pts primary nurse, (name) LPN (Licensed Practical Nurse), who states she does not feel comfortable giving pt anything. Notified weekend charge (name) who called DON (Director of Nursing), and she said no that pt could not have anything by mouth at this time. States she will discuss with Administrator on Monday) . The note was not in the facility clinical record and was faxed upon surveyor request from the Hospice agency on 7/23/15. i. A Hospice Nurses note dated 6/20/15 at 1:30 p.m. documented, Spoke to team members this a.m. regarding pts admission and the fact that he had a peg tube and is NPO. All the pts wants is to have some Ice and the facility is not allowing him to have any ice even with a Waiver signed by the pt and the pts brother. The pt is well aware that by attempting to eat ice he could aspirate or even choke, he states he would rather take that chance to have a better quality of life even if it means he may die because of it. The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. j. A Hospice nurse note dated 6/21/15 at 10:39 a.m. documented, Nutrition/Diet: NPO. Comment: peg feedings only, however pt is begging for ice. States he knows he could aspirate if he eats or drinks anything. Notified (hospice physician) who states as long as pt understands the risks, he can have what he wants . The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. k. The Care Plan dated 6/22/15 documented, .Potential for alteration in nutrition, aspiration, and GI (gastrointestinal) discomfort R/T (related to) dysphagia, severe protein malnutrition and iron def (deficiency) [MEDICAL CONDITION] .If aspiration is suspected, monitor lung sounds and temp. (temperature) for 48 hrs (hours); notify MD (medical doctor) and family .Hospice to TX (treat) resident as indicated R/T severe protein malnutrition .Resident and Family to have wishes carried out this quarter. 1. Notify MD, Family, and Hospice with changes 2. Comfort measures to be given .6/22/15 Hospice called requesting a waiver to be signed to allow PO (oral) intake. IDT (Interdisciplinary Team) reviewed info (information) and agreed that risk of PO intake out weighed the benefit. l. A Hospice nurse note dated 6/22/15 at 3:33 p.m. documented, Intervention: Discussed pts request for ice, pts/family understands verses benefit and options for pt./family since (nursing facility) refusing to honor pts wishes. At 3:35 p.m. documented, Call was placed to (facility) spoke to (name) LPN, nurse for pt today. Ask her if the waiver that was discussed on Friday when legals were signed on pt and Saturday when pt was admitted to hospice had been signed so pt could have some ice. pt is npo and all he wants is ice. She transferred me to (name), RN, DON. I ask (DON) she stated no that she would have to consult with the Administrator and call me back .(DON) returned my call stating the Administrator was not going to allow pt or his brother to sign waiver to (allow) pt to have ice even though the pt and brother knew the risk verses the benefits. She stated that their options were to place pt in In Patient hospice or they could change facilities. I placed a call to the pts brother and he stated he would like to see if pt could transfer to (another nursing facility). I called and spoke with (social worker) and she was going to discuss it with (DON of the other nursing facility) and Administrator. (name) RN from (other nursing facility) called back and states they would be willing to accept him and allow him to sign waiver. I called the brother back and papers were faxed to (other nursing facility) so they could evaluate the pt today. The Hospice note was not in the facility clinical record and was obtained via fax upon surveyor request from the Hospice agency on 7/23/15. m. A typed Note dated 6/25/15 (no time) and signed by the Administrator documented, (Resident #23) had an order for [REDACTED]. (doctor's) order and determined that the risk of the patient having ice chips out weighed the benefit. The hospice nurse (name) was told that this could not happen here but perhaps another location or in patient hospice could honor the request. n. A Nurses Note dated 6/25/15 documented, (at) 1845 (6:45 p.m.) transported to (hospital) via (ambulance) via stretcher. (Hospice) aware. Family aware. o. A Hospice Nurse note dated 6/26/15 documented, Reason for visit?: pt transferring .Most important to patient now: Ice. Pt is begging for a piece of ice. What are the patient's immediate needs? Better pain control and a piece of ice. Most important to family: (name) the pts brother wants pt to be comfortable and to have ice or anything else he wants to eat .pt very excited about being given a few ice chips he is almost crying .pt did not like the nursing facility he was in because they would not give him any ice even though he was willing to sign a waiver .nutrition/diet: puree .pt can have anything he wants but he prefers soft or full liquid. Swallowing/eating: WNL (within normal limits) for patient, Aspiration precautions, chokes easily, Diminished chewing skills, Dysphagia, Total feed .Comment: pt has been tube fed if he would accept it. He has been NPO at nursing facility but he is begging for ice and was given ice chips on arrival to hospital and he's not choked . p. On 7/23/15 at 3:06 p.m., the Administrator and DON were asked for the facility criteria for when a resident that was NPO could have a waiver for fluids/ice. The Administrator stated, Based on the IDT and risk versus benefits. When asked if (Resident #23) had been offered any ice/puree/pudding thick fluids by facility staff, the Administrator stated, He could choke to death and die. Not choking here. Gave him nothing by mouth while at facility. There was no order from Hospice doctor for other than NPO. No doctor ordered ice. Remained NPO. I felt he could choke. When asked how did they know the resident would choke if he had received nothing by mouth while at the facility, the Administrator stated, From the brother . When asked why (Resident #3), who had declined Hospice but was on the facility log for comfort care and NPO, could have a signed waiver for fluids and Resident #23 could not, the DON stated, (Resident #3)'s waiver was okay. He was not choking. He had silent aspiration. The DON was shown the speech therapy note for the resident (Resident #23) from 6/19/15 that documented the resident tolerated 5 of 5 ice chips was reviewed. The DON stated, I didn't read that. q. On 7/23/15 at 3:40 p.m., the Administrator of the Hospice agency was informed of the lack of Nurse and Aide notes in the facility hospice record and was asked if Nurses and Aides should leave a copy with the facility. The Hospice Administrator stated, Absolutely must leave a copy of nurse/aide notes. The Hospice agency faxed a Medication Profile, Physician's Plan of Care dated 6/21/15, a Modified Order sheet dated 6/23/15 and 6/24/15, Hospice Aide notes dated 6/19/15 through 6/25/15 and Nurse Notes from 6/20/15 through 6/25/15 for this facility and notes following the discharge of the resident from the facility through 7/6/15. r. On 7/23/15 at 4:10 p.m., the Administrator was asked if she had called the doctor and asked if the resident could have ice chips. The Administrator stated, No. We had the order and he was NPO. The Administrator was asked, when he was begging for ice chips, did you call the doctor and ask him if he could have ice chips, the Administrator stated, No. We're on the same page and the order for him was NPO. s. On 7/24/15 at 8:05 a.m., the Speech-Language Pathologist who had written the note dated 6/19/15 was asked about her documentation on the note. She stated, Trying ice chips, small - the size of the end of a fingertip. His mouth was so dry, so very dry. When dry, can create oral dysphagia. Gave ice chips, very small/small amounts .Used very small ice chips in the mouth and let melt .He tolerated with no signs or symptoms of aspiration. t. On 7/24/15 at 9:05 a.m., the resident's attending physician was asked if anyone talked to him about letting the resident sign a waiver to have ice and/or water. The physician stated, Not that I recall. He was on hospice. A dying man can have whatever he wants. If he wants to choke, he can. I would have said okay to a waiver if I had been asked.

Complaint # was substantiated (all or in part) with these findings: Based on interview and record review, the facility failed to ensure wound assessment were consistently performed and documented to include size of wound, color and shape of wound, condition of the surrounding tissue, presence or absence of odor and drainage to enable staff to promptly identify deterioration or lack of improvement; to ensure prompt physician consultation regarding worsening or lack of improvement; to ensure interventions were developed/implemented and their effectiveness evaluated for 1 (Resident #1) of 4 (Residents # 1, #4, #5 and #6) case mix residents who had non-pressure related wounds. The failed practice caused a pattern of actual harm for Resident #1, whose wounds further deteriorated requiring hospitalization , and had the potential to cause more than minimal harm for 11 Residents who had non- pressure related wounds according to the list provided by the Administrator on 12/10/10. The findings are: 1. Resident #1 had the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with the assessment reference date of 9/21/10 documented the resident had independent cognitive skills for daily decision making, had no pressure sores and had skin tears. a. The Plan of Care dated 9/21/10 documented, "10. Pt. (patient) potential for alteration in skin integrity R/T (related to) Pt. requires asst. (assistance) with bed (chair) mobility, Pt. has dx. (diagnosis) of Diabetes Mellitus, Type 2, and Pt. is incontinent at times. Approaches: 1. Keep pt. clean and dry after incontinent episodes. 2. Skin audits weekly by LPN (Licensed Practical Nurse) and q (every) shift by CNA's (Certified Nursing Assistants) with skin care. 3. Shower / WP (whirlpool) 3 X's (times) weekly and PRN (as needed). 4. Notify MD (physician) and family as needed. 5. Asst. Pt. to reposition q 2 hrs. (hours) and PRN. 6. Tx (treatments) as ordered by MD. 7. Keep all dermatologist appts. (appointments)." The care plan did not address actual wounds with interventions to promote healing. b. The October 2010 Weekly / Monthly Wound Log received from the Administrator on 12/8/10 at 9:00 a.m. documented, " ... Type: S/T (Skin Tear) , Date First Observed: 8/12/10, Location: (R) (Right) (Lower) Leg, Week 1(measurements were): ... Size: 0.5 X 0.25; Week 2 (measurements were) 0.25 x 0.25; Week 3 (measurements were) 0.25 x 0.25 and Week 4 (measurements were) 0.25 x 0.2. treatment plan: [REDACTED]. The form documented the Treatment Plan remained the same for all four week. There was no documentation of any other skin tear to the lower extremity. c. The Nurse's Note dated 10/8/10 documented, "1500 (3:00 p.m.) ...Res (resident) obtained S/T (skin tear) to RLE while transported to [MEDICAL TREATMENT] ... Res had a S/T approx (approximately) 1 cm (centimeter) x 1/2 cm. Applied TAO (Triple Antibiotic Ointment) (with) [MEDICATION NAME]" There were no further wound sizes for this skin tear documented for the month of October 2010 in the Nurses Notes. 1) The physician's orders [REDACTED]." 2) The Treatment Administration Record (TAR) dated from 10/1/10 through 10/31/10 documented the treatment was administered on 10/8/10, 10/11/10, and 10/15/10. A line was drawn across the entry section after the last entry with the hand written note, "D/C (discontinue) healed." There were no other leg wound treatments documented on the TAR for October 2010. 3) On 12/10/10 at 9:40 a.m., a review of the Skin Audits reports performed on 10/7/10, 10/14/10 and 10/21/10 had no documentation that that there were skin tears/[MEDICAL CONDITION] on the lower extremities. d. The November 2010 Weekly / Monthly Wound log, received from the Administrator on 12/8/10 at 9:00 a.m., documented the skin tear to the right lower leg measured 0.25 x 0.75 (cm) on week 1, 0.25 x 0.5 on Week 2, and 0.25 x 0.25 on week 3. The Treatment Plan continued in November 2010 with [MEDICATION NAME] every 3 days. There was no wound characteristics documented in the Nurses Notes. e. The Skin Audit sheet dated 11/4/10 documented, "Notes: ... ulcers on L (left) + R (right) back side + R (right) ankle." There was no documentation of the size or character of the wound to the right ankle. f. The Nurse's Note dated 11/4/10 documented, "1130 (11:30 a.m.) When (resident) lifted up abdominal fold for this nurse to assess for presence of rash, (resident) was scratching and (resident) has large ring on 4th finger of L (left) hand and scratched, producing skin tear approximately 5 cm long and 3 cm wide. N/O (new order) received to cleanse (with) Saf Clens, apply TAO (Triple Antibiotic Ointment) and [MEDICATION NAME] q (every) day and prn (as needed) until healed." There was no assessment of this wound documented on the wound log for November 2010 or in the Nurses Notes after 11/4/10. There was no documentation to indicate a complete assessment was done to include, color, odor, drainage, and surrounding tissue for this wound in the Nurses Notes. g. The Nurse's Noted dated 11/4/10 documented, "... Bandage applied to R (right) ankle." There was no documentation on the wound log or clinical record as to the size or condition of the wound covered by the bandage. There was no documentation to indicate a complete assessment was done to include, color, odor, drainage, and surrounding tissue for this wound in the Nurses Notes. h. The Nurse's Notes dated 11/11/10 documented, "0030 (12:30 a.m.) ... Exchanged 'dressing' "consisted of paper towel " on res (resident's) right leg, shin weeping heavily. Applied abdominal binders (pads) and held in place with tubifast. Left leg only a small amount of weeping. Dressed with abdominal binders (pads) and tubifast as well. 0345 (3:45 a.m.) Had to change abdominal binders (pads) on res right leg again. Soaked through completely. Several abdominal binders applied again and secured with tubifast. Left dressing still dry." There was no documentation to indicate a complete assessment was done to include, color, odor, drainage, and surrounding tissue for this wound in the Nurses Notes. The Skin Audit sheet dated 11/11/0 did not document any [MEDICAL CONDITION] or concerns related to the lower extremities. As of 12/9/10 at 11:10 a.m., there was no assessment of the legs documented on the wound log, no documentation in the record that the physician was consulted regarding the weeping, and no documentation of the presence or absence of weeping in the legs after 11/11/10. i. The Nurse's Notes dated 11/18/10 documented, "3-11 Summary: ... Bilateral ankles have sores which are wrapped (with) clean & (and) dry dressing." There was no documentation of the size, characteristic or type of sores on the ankles. 1). As of 12/8/10 at 2:45 p.m., there was no documentation in the Nurse Notes or Physician orders [REDACTED]. 2). The Skin Audit sheet dated 11/18/10 documented, "Notes: ... Dressing on bilateral ankles." There was no documentation to indicate a complete assessment was done to include, the size, color, odor, drainage, and surrounding tissue for wounds to the bilateral ankles on the Skin Audit sheets for November, 2010. j. Nurses Note dated 11/21/10 (no time) documented, " (Resident) ...V/S (vital signs) 120/70 (blood pressure), 98.2 (temperature), 50 (heart rate) and 36 (respiration), SpO2 (Saturation of Peripheral Oxygen) is 77% on 2 L/M (liters per minute) of O2 (oxygen). MEMS (Metropolitan Emergency Medical Services) called to transport (resident) to (hospital) ER (emergency room ) ... (at) 0455 (4:55 a.m.) ...Hospital called ... (resident) was admitted ... " k. The Hospital emergency room record documented, "06:32 Sunday (11/21/2010) ... Note: Drsg (dressing) to BLE (bilateral lower extremities) removed. Foul odor. Green / yellow saturated ABD (abdominal) pads removed from skin surface. Skin peeling from areas to backs of lower legs. ... MD (physician) assessed wounds." The Emergency Department Physician documented on 11/21/10, " Bones, Joints, Extremities: 2+ [MEDICAL CONDITION]. She has stasis ulcers in both legs, particularly on the right. I do not see any large, ulcerated areas. It is mostly just weeping. There is pseudomonas smell and green color to the dressing that they had on when we took these off. She did not look to be actively drainage. I do not see an overt fluctuance or necrosis..." The Physical Therapy Progress Note dated 11/22/10 documented, "... Removed dressings on bilateral lower legs and noted trophic changes to skin with scales present and irony discolorations of skin with small open area on L (left) anterior shin and large wound with moderate drainage on posterior left calf with mildly foul odor... Removed dressing from small wound in mid-lower abdomen and noted minimal purulent drainage with mildy foul odor... Debrided some loose necrotic tissue using forceps and scissors. Wound measured approximately 2.5 cm diameter..." l. On 12/8/10 at 8:30 a.m., the Treatment Nurse and the Director of Nursing (DON) were interviewed. The Treatment Nurse was asked, "Who does the body audits?" The Treatment Nurse stated, "Each nurse does their own." The Treatment Nurse was asked, "Where are they documented?" The Treatment Nurse stated, "In front of the MARS (Medication Administration Record)." The Treatment Nurse was asked, "How often are body audits done?" The Treatment Nurse stated, "Weekly." The Treatment Nurse was asked, "Who measures the wounds?" The Treatment Nurse stated, "I do." The Treatment Nurse was asked, "Where is this documented?" The Treatment Nurse stated, "In the wound book." On 12/8/10 at 3:10 p.m., the Treatment Nurse was asked, "Is there any other documentation on wounds?" The Treatment Nurse showed the wound log documentation and stated, "This is where I document wound measurements." The DON was asked, "The Wound Log documented assessments were performed on 'week 1 and week 2, how do you know what date the wound was assessed?" The DON stated, "You don't." The Treatment Nurse was asked, "Where do you document if a wound has any drainage, slough or odor?" The Treatment Nurse stated, "I write it on the nurse's notes." n. On 12/9/10 at 10:58 a.m., the DON was asked, "If a wound is identified, what happens?" The DON stated, "The nurse will immediately notify (Treatment Nurse's name). The physician is then notified and treatment orders obtained." The Treatment Nurse was asked, "Do you assess the wound?" The Treatment Nurse stated, "Yes. I measure it and use the treatment orders prescribed." The Treatment Nurse was asked, "Do you document drainage, condition of the wound?" The Treatment Nurse stated, "Yes. In the nurse's notes." The DON was asked, "Was the physician notified that the legs were draining and treatment orders obtained?" The DON stated, "I had talked with the physician, but I've shredded all my notes."

Complaint # was substantiated (all or in part) with these findings: A. Based on observation, record review and interview, the facility failed to ensure wound assessments were completed to include the current status of the wound, Stage, surrounding tissue, presence of granulation, eschar or slough, presence of exudates, odor and wound measurements to ensure an accurate assessment of a pressure ulcer and to accurately evaluate the effectiveness of the current treatment; the Physician was promptly consulted for a new area of skin breakdown to ensure prompt treatment; wound care was not provided without physician orders; wound care was provided consistently as ordered and staff was knowledgable in the assessment of and Staging of a healing or non healing decubitus wound for 2 (Resident #1 and 2) of 4 (Residents # ,[DATE] ) case mix residents who had pressure sores. The failed practice caused a pattern of actual harm for Resident #1 who was diagnosed with [REDACTED]. The findings are: 1. Resident #1 had the [DIAGNOSES REDACTED]. The quarterly Minimum Data Set Assessment with an assessment reference date of [DATE] documented the resident had independent cognitive skills for daily decision making, required extensive assistance with bed mobility and transfers and had no pressure sores and had skin tears. a. The Plan of Care dated [DATE] documented, "10. Pt. (patient) potential for alteration in skin integrity R/T (related to) Pt. requires asst. (assistance) with bed (chair) mobility, Pt. has dx. (diagnosis) of Diabetes Mellitus, Type 2, and Pt. is incontinent at times. Approaches: 1. Keep pt. clean and dry after incontinent episodes. 2. Skin audits weekly by LPN (Licensed Practical Nurse) and q (every) shift by CNA's (Certified Nursing Assistants) with skin care. 3. Shower / WP (whirlpool) 3 X's (times) weekly and PRN (as needed). 4. Notify MD (physician) and family as needed. 5. Asst. Pt. to reposition q 2 hrs. (hours) and PRN. 6. Tx (treatments) as ordered by MD. 7. Keep all dermatologist appts. (appointments)." As of [DATE] at 2:45 p.m., the care plan did not document any actual pressure sores or interventions to promote healing. b. A Physician's Telephone Order dated [DATE] documented, "T.O. (Telephone Order) Apply [MEDICATION NAME] to DTI (Deep Tissue Injury) bilateral hips BID (twice a day) / PRN (as needed) until healed." A Physician's Telephone Order dated [DATE] documented, "T.O. Clean R (Right) hip open area (with) Saf Clens, apply [MEDICATION NAME] (and) cover (with) Tielle Plus Q 3 D (every 3 days) until healed." c. The [DATE] Treatment Administration Record (TAR) documented, " Clean Rt (right) hip open area with saf clens, apply [MEDICATION NAME] and cover with tielle plus Q 3 D until healed. [MEDICATION NAME] B apply to DTI bilateral hips BID (and) PRN until healed." The TAR documented the treatments were initiated on [DATE] as indicated by an initial on the date the treatment was provided. The BID treatment for [REDACTED]. 1). The TAR documented the treatment for [REDACTED]. The TAR documented no initials to indicate treatment was completed on the ,[DATE] shift for [DATE], 8, 10, 12, 14, 25 thru the 27 and the 31st. The TAR documented no initials to indicate treatment was completed on the ,[DATE] shift on [DATE], 10 - 16 and 26 thru 31st. There were thirty two times on the TAR that treatments were not documented as performed. 2). The TAR documented the treatment to clean the Rt (right) hip open area with saf clens and apply [MEDICATION NAME] and cover with tielle plus Q 3 D was initiated on [DATE] on the ,[DATE] shift as indicated by an initial. The ,[DATE] shift was the only shift identified that treatment was to be done. Treatment was completed on [DATE], 9, 13, 15, 16, 19, 21, 22, 24 and the 28th. There were three days instead of 2 (ordered every 3 days) between the treatments provided on the 9th and 13th and the 24th and 28th. d. The [DATE] Nurses Notes was reviewed with these findings: 1). As of [DATE] at 10:40 a.m., the Nurses Notes dated [DATE] thru [DATE] had no documentation to indicate wounds were being managed and wound care was being provided. There was no documentation in the Nurses Notes dated [DATE]. 2). Nurse's Note dated [DATE] documented, "Weekly Summary: ... Ulcer to right hip dressing dry & (and) intact, Red bottom, [MEDICATION NAME] B BID & skin protectant..." The Nurses Notes contained no documentation to reflect the current status of the wound such as the characteristics of the wound, surrounding tissue, presence of granulation, eschar or slough, presence of exudates and wound measurements. There were no documented wound measurements of the ulcer to the right hip, no documentation of the character or condition of the wound, and no documentation of the size of the red area to the resident's bottom. e. The [DATE] TAR at the bottom of the record a graduated wound measuring paper guide dated [DATE] documented, "R (right) hip ulcer 5.5 x 2.0." There was no documentation regarding the condition or character of the wound, the presence, or absence of drainage or odor, the color of the wound tissue or the presence of granulation, eschar, or slough. f. The [DATE] Weekly / Monthly Wound Log documented a weekly wound measurement and treatment for [REDACTED]. The form had no other wound documentation for this resident. g. Physician's Progress Note dated [DATE] documented, "Subjective: Patient has developed ulcers over both hips. Her chair seems to be irritating the lateral aspect of the greater trochanters and she now has Stage 2 ulcers. Several different treatments have been tried. We will have to get her a wider chair to decrease the pressure over her hips. She also has some increased swelling in her legs. ... Impression: ... 9. Decubitus ulcers over both hips. We will obtain a wider chair to try to keep the pressure off of her hips. ..." 1). Nurses's Notes dated [DATE] documented, "M.D. (physician) visit with N.O. (new order) ... 8. Needs wider chair to keep pressure off of hips ASAP (as soon as possible). Do not allow to sit in chair more than 2 hours at a time..." 2). Nurses Notes dated [DATE] documented, "0700 (7:00 a.m.) S/W (spoke with) R (resident) re (regarding) (Physician's name) orders to only be in chair only 2 (hours) @ (at) a X (time). R states 'Don't start. I'm not getting up.' Stressed importance to maintain skin integrity. R states ' I don't (I'm) not going to get in bed'..." There no documentation in the Nurse Notes that the physician was regarding the resident's refusal to only be in chair for 2 hours. As of [DATE] at 2:45 p.m., the care plan did not address the resident's refusal to comply with the physician's order and there was no documentation of interventions to minimize the pressure from the continued use of the recliner. 3). The DON was asked, "Is there any reason none of the wounds or the resident refusals were care planned?" The DON stated, "Her MDS assessment was in September. The ADON (Assistant Director of Nursing) should have updated it." h. Physician's Order dated [DATE] documented, "Clean Bil (bilateral) hip wounds (with) Saf Clens, cover (with) [MEDICATION NAME] Q 3 days & (and) PRN (as needed) until healed." i. The [DATE] TAR documented, " Clean Bil (Bilateral) hip wounds (with) Saf Clens, cover (with) [MEDICATION NAME] Q 3 days (and) prn (as needed) until healed. " The TAR documented the treatment was initiated on [DATE] as indicated by an initial on the date the treatment was provided. The treatment was scheduled to be provided on the ,[DATE] shift. The [DATE] TAR documented, " Clean the Rt (right) hip open area with saf clens and apply [MEDICATION NAME] and cover with tielle plus Q 3 D until healed. As of [DATE] at 10:45 a.m., there was no documentation on the TAR that the Physician order dated [DATE] was being provided to the bilateral hip. j. The [DATE] TAR documented, " [MEDICATION NAME] B apply to DTI bilateral hips BID (and) prn until healed. " Treatment was provided on the ,[DATE] shift on [DATE] and the ,[DATE] shift on [DATE] and on the ,[DATE] shift on [DATE] and[DATE] as indicated by an initial on the date the treatment was provided. As of [DATE] at 10:40 a.m., there was no other order in the clinical record, Nurses Notes, Physician Orders for wound treatment to the left hip or to indicate the wound had healed. k. Nurse's Notes dated [DATE] documented, ",[DATE] Summary: ...Ulcers decubitus noted on R (right) + (and) L (left) sides of lower back. Treatment provided to areas today + R (resident) c/o (complains of) severe pain + burning @ (at) sites. ... Dark red area noted medial to spine on center lower back. ... R (resident) also has bandage wrap applied to R (right) ankle. ..." As of [DATE] at 10:40 a.m., the Nurses Notes contained no documentation to reflect the current status of the wounds such as the characteristics of the wound, surrounding tissue, presence of granulation, eschar or slough or the presence of exudates. There was no documentation that the physician was consulted and no documentation of treatment orders in the Physician Orders. l. The Nurse's Notes dated [DATE] documented, ",[DATE] Summary: ... Sores on bilateral hips lateral to spine, on either side. Bandage intact + clean + dry. ... Bilateral ankles have sores which are wrapped (with) clean and dry dressing..." As of [DATE] at 10:40 a.m., the Nurses Notes contained no documentation to reflect the current status of the wounds such as the characteristics of the wound, surrounding tissue, presence of granulation, eschar or slough or the presence of exudates. There was no documentation that the physician was consulted and no documentation of treatment orders in the Physician Orders. m. The [DATE] Weekly / Monthly Wound Log documented the following information for the Left hip wound: Week 1: (Left) hip: Current Stage: III Size: 2X4 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. Week 2: (Left) hip Current Stage: III Size: 2X3.5 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. Week3: (Left) hip: Current Stage: IV Size: 2.25X4 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. (The form documented that the resident expired [DATE].) As of ,[DATE] at 9:40 a.m., there were no physician orders in the clinical record for the treatment documented on the wound log for the Left hip and no physician orders for wound treatment for [REDACTED]. The [DATE] TAR documented, "Clean (L) (left) hip open area (with) Saf Clens. Apply N/S (Normal Saline) moistened Mesalt and Tielle Plus QD (daily)." The entry was dated [DATE]. The TAR documented this treatment was initiated on [DATE] and was provided on [DATE], [DATE], [DATE] and [DATE] as indicated by nurses initials. The entry on [DATE] was circled, the note on the back of the form documented, "[DATE]: R (Resident) refused tx (treatment) to hip ulcer." n. The [DATE] Weekly / Monthly Wound Log documented the following information for the Right hip wound: Week 1: (Right) hip: Current Stage: II Size: 1.5X3.5 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. Week 2: (Right) hip Current Stage: II Size: 1.5X3 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. Week3: (Right) hip: Current Stage: II Size: 2X3 Treatment plan and frequency of change: [MEDICATION NAME], Tielle Plus QD. (The form documented that the resident expired [DATE].) The [DATE] Physicians Orders sheet documented a physician's order dated [DATE], "Clean R (right) hip open area (with) Saf Clenz, apply [MEDICATION NAME] and cover (with) Tielle Plus Q 3 days until healed. ..XXX[DATE] Clean bil (bilateral) hips (with) Saf Clens, cover (with) [MEDICATION NAME] Q 3 days + PRN until healed. ..." The Novmeber 2010 TAR documented, "Clean RT (right) hip open area with Saf Clens, apply [MEDICATION NAME] and cover with Tielle Plus Q 3 days until healed." The TAR documented the treatment was administered on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. The entries for [DATE], [DATE] and [DATE] were circled and an undated note on the back of the TAR documented, "Resident refused tx to hips." A note on the back of the TAR dated [DATE] documented, "R (Resident) refused tx to hip ulcer. The treatment for [REDACTED]. o. Nurse's Notes dated [DATE] ([DATE]) documented, "R (resident) has (increased) confusion @ (at) 0430 (4:30 a.m.)... (Name of Ambulance) called to transport to (Name of Hospital emergency room ) ..." p. A Hospital Consultation Note dated [DATE] dictated by Physician #1 documented, "With aide of nursing staff, I was able to view both lateral iliac crest regions. On the right side, there is a fairly large decubitus ulcer with full thickness necrosis on the middle of the ulcer. The overall ulcer size measures nearly 8 to 9 cm in length by approximately 4 cm maximum width. In the middle of this ulcer is an area measuring 3 x 1.5 cm. This is soft and obviously full thickness skin necrosis in this area... The left iliac crest ulcer was then examined and again measures approximately a maximum of 4 cm in length x 1 cm in width... Impression: Bilateral iliac crest decubitus ulcers, right worse than left, as described... Plan: ...The patient has had positive blood cultures. She may benefit from debridement of the right lateral decubitus ulcer..." 1) The Hospital Physical Therapy Progress Note dated [DATE] documented, " O: (observation) ... Removed dressings from iliac crests and noted moderate foul purulent drainage and covered with slimy dark eschar and unstageable... A: (Assessment) Iliac wounds need sx. (surgical) debridement..." 2) The Hospital Discharge Summary dated [DATE] documented, "Disposition: (Resident's Name) passed away on [DATE] at 10:05 a.m. Primary Diagnoses: [REDACTED]. 2. Very severe stage 4 sacral decubitus. 3. [MEDICAL CONDITION]. 4. [MEDICAL CONDITION]. 5. End Stage [MEDICAL CONDITION]. 6. [MEDICAL CONDITION] was probably what caused her end of life, but multiorgan failure contributed. 7. Chronic underlying medical conditions that left her frail for a long period of time. History and Hospital Course: ... Blood cultures were done because of an elevated white blood cell count and a low grade fever of 99.6 and all of those blood cultures came back positive for gram-positive cocci, which has since been identified as Staphylococcus epidermis. ... She had a multidrug resistant Staphylococcus epidermis. ... I think probably her ultimate cause of death was Staphylococcus [MEDICAL CONDITION] and this was complicated by [MEDICAL CONDITION] and [MEDICAL CONDITION], although she had baseline [MEDICAL CONDITION]. ...She had the severe sacral decubitus which were over the iliac crest area which were severe and were going to need intervention with debridement. I suspect that is why she had the positive blood cultures. This was a major contributor to her end of life for these wounds which led [MEDICAL CONDITION]." q. On [DATE] at 8:30 a.m., the Treatment Nurse and the Director of Nursing (DON) were interviewed. The Treatment Nurse was asked, " Who does the body audits?" The Treatment Nurse stated, "Each nurse does their own." The Treatment Nurse was asked, "Where are they documented?" The Treatment Nurse stated, "In front of the MARS (Medication Administration Record)." The Treatment Nurse was asked, "How often are body audits done?" The Treatment Nurse stated, "Weekly." The Treatment Nurse was asked, "Who measures the wounds?" The Treatment Nurse stated, "I do." The Treatment Nurse was asked, "Where is this documented?" The Treatment Nurse stated, "In the wound book." On [DATE] at 3:10 p.m., the Treatment Nurse was asked, "Is there any other documentation on wounds?" The Treatment Nurse showed the wound log documentation and stated, "This is where I document wound measurements." The DON was asked, "The Wound Log documented assessments were performed on 'week 1 and week 2, how do you know what date the wound was assessed?" The DON stated, "You don't." The Treatment Nurse was asked, "Where do you document if a wound has any drainage, slough or odor?" The Treatment Nurse stated, "I write it on the nurse's notes." r. On [DATE] at 10:35 a.m., the Treatment Nurse was asked, "(Resident's Name) was documented as having a deep tissue injury on [DATE], but there was no assessment of the size documented on the wound log." The Treatment Nurse stated, "I would document that on the nurse's notes." The Treatment Nurse was informed by the surveyor the nurse's notes in the clinical record had been reviewed and there was no documentation of an assessment for the wound documented?" The Treatment Nurse stated, "It would be on the wound sheet." The Treatment Nurse was asked, "Where are the wound sheets for (Resident's name)?" As of[DATE] at 9:40 a.m., there were no wound sheets on the resident provided by the Treatment Nurse. s. On [DATE] at 10:35 a.m., the Administrator was asked, "Tell me about the order for the bigger chair?" The Administrator stated, " ...We got the biggest wheelchair available. But it wouldn't fit in the van, so we'd have to put her in the narrower one to transport her to [MEDICAL TREATMENT]." The Administrator was asked about the recliner and the documentation in the Nurse Notes indicated that the nephew was trying to get a bigger recliner. The Administrator stated, "Yes. They were having trouble finding a bigger recliner for her." The Administrator was asked, "Did the facility attempt to get a bigger recliner?" The Administrator stated, "No." t. On [DATE] at 10:58 a.m., the DON was asked, "If a wound is identified, what happens?" The DON stated, "The nurse will immediately notify (Treatment Nurse's name). The physician is then notified and treatment orders obtained." The Treatment Nurse was asked, "Do you assess the wound?" The Treatment Nurse stated, "Yes. I measure it and use the treatment orders prescribed." The Treatment Nurse was asked, "Do you document drainage, condition of the wound?" The Treatment Nurse stated, "Yes, in the nurse's notes. ...We know the wounds were getting worse. We discussed it in the stand up meeting." The DON was asked, "Is there any reason none of the wounds or the resident refusals were care planned?" The DON stated, "Her MDS assessment was in September. The ADON (Assistant Director of Nursing) should have updated it." The DON was asked, "Was the physician notified that the wound was getting worse?" The DON stated, "I had talked with the physician, but I've shredded all my notes." 2. Resident #2 had the [DIAGNOSES REDACTED]. a. The [DATE] Weekly / Monthly Wound Log documented the wound on the Resident's left buttock was originally observed on [DATE]. The logs for [DATE] documented the following wound information: Week 1: Stage IV and Wound Measurements were 1.5(cm) x1.5 x 1.5. Week 2: Stage IV and Wound Measurements were 1.5 x 1.5 x 1. Week 3: Stage IV and Wound Measurements were 1.5 x 1.5 x1. Week4: Stage IV and Wound Measurements were 1.5x 1.5 x 1. 1) A Physician Orders sheet dated [DATE] and signed by the Treatment Nurse documented wound measurements as follows: " ...L (Left) Buttocks ...Stage III 5 (cm)x 4 x 3.5 (with) undermin(ing) at 12 o ' (clock) (that measured) 3 cm. " 2) A report titled treatment for [REDACTED]. b. The Novmeber 2010 Weekly / Monthly Wound Log documented the wound on the resident's right buttock was originally observed on [DATE]. The logs for [DATE] documented the following wound information: Week 1: Stage 4 Wound measurements were 0.5 (cm) x 0.5. Week 2: Stage 4 Wound measurements were 0.5 x 0.25. Week 3: Stage 2. Wound measurements were 0.25x 0.25. Week 4: Stage 2. Wound measurements were 0.25 x 0.25. 1) A Physician Orders sheet dated [DATE] and signed by the Treatment Nurse documented wound measurements as follows: " ...R (Right) Buttocks ...Stage II 1.5 (cm)x .5. " 2) A report titled treatment for [REDACTED]. c. The [DATE]Weekly / Monthly Wound Log documented the wound on the resident's right ankle was originally observed on [DATE]. The logs for [DATE] documented the following wound information: Week 1: Stage IV. Wound measurements were 0.75 (cm) x 0.5. Week 2: Stage IV. Wound measurements were 0.5 x 0.5. Week 3: Stage IV. Wound measurements were 0.5x 0.5. Week 4: Stage IV. Wound measurements were 0.5 x 0.5. 1) A Physician Orders sheet dated [DATE] and signed by the Treatment Nurse documented wound measurements as follows: " ...R (right) ankle ...Unstageable 6 (cm) x 5. " A report titled treatment for [REDACTED]. " d. The November Weekly / Monthly Wound Log did not document any findings for the wound on the resident's left foot. 1) A Physician Orders sheet dated [DATE] and signed by the Treatment Nurse documented wound measurements as follows: " ...L (left) ankle ...Stage II 1 (cm) x 1. " 2) A report titled treatment for [REDACTED]. foot. e. As of [DATE] at 3:13 p.m., there was no documentation in the Nurses Notes to reflect the current status of the wounds on the left and right buttock such as the characteristics of the wound, surrounding tissue, presence of granulation, eschar or slough, presence of exudates and wound measurements. f. The Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE] documented the resident had severely impaired cognitive skills for daily decision making, was always incontinent of bowel and had an indwelling urinary catheter, had 3 stage IV pressure sores with the most severe measuring 1.5centimeters (cm) long by 1.5 cm wide by 1.5 cm deep with the most severe tissue type as slough, and was on a scheduled pain medicine regimen. g. The Plan of Care dated [DATE] documented, "... 9. Res (resident) has impaired skin integrity R/T (related to) ulcers to Rt. (right) ankle, Lt. (left) mid foot, and buttocks. Pt. (patient) has impaired physical mobility and poor nutritional intake. Pt. is also incontinent and has dx (diagnosis) of [MEDICAL CONDITIONS]. ...Interventions this quarter: ...2. Keep sheets and bedclothes clean, dry, and free from wrinkles, crumbs and other irritating material. 3. Body audits weekly by LPN (Licensed Practical Nurse) and skin checks q (every) shift by CNA's (Certified Nursing Assistants) with skin care. ... 7. Tx (treatment) as ordered ..XXX[DATE] Pt. (patient) returned from hosp (hospital) stay (with) ulcer to R (right) ankle increased in size & (and) ulcers to hips bilateral of Stage I. Ulcer to R (right) ankle now unstageable." h. The [DATE] Physicians Orders sheet documented, "Clean open area Lt (left) buttocks with Saf Clens, apply moistened Mesalt and Santyl, cover with Tielle Plus QD (daily) until healed. Clean open area on Lt (left) mid foot with Saf Clens apply [MEDICATION NAME], cover with [MEDICATION NAME], Kerlix, tape q2D (every 2 days). Clean open area Rt (right) buttocks with Saf Clens and apply [MEDICATION NAME], cover with Tielle Plus Q2D and PRN (every 2 days and as needed). Clean Rt (right) ankle with Saf Clens - apply [MEDICATION NAME], cover with [MEDICATION NAME], wrap with Kerlix q (every) day." i. On [DATE] at 9:45 p.m., the Treatment Nurse provided wound care for the resident. The left hip had a large circle shaped deep wound with a brown liquid on the incontinent brief. There was no dressing on the wound. The Treatment Nurse was asked, "Is he supposed to have a dressing?" The Treatment Nurse stated, "He had a shower." The Treatment Nurse was asked, "Is that what happened to the dressing, it came off in the shower?" The Treatment Nurse stated, "Yes." The uncovered Stage 4 wound was in contact with the incontinent brief, which was soiled with brown drainage. The resident had a sock and heel protector on the right foot. The Treatment Nurse removed the heel protector. The sock had a large circle of dried drainage over the right ankle area. The Treatment Nurse was asked, "Is that drainage from the wound?" The Treatment Nurse stated, "Yes." The Treatment Nurse removed the sock from the resident's right foot. The sock had adhered to the wound, and tissue pulled from the wound bed when the sock was removed. The wound began to bleed. There was no dressing on the ankle wound. The Treatment Nurse was asked, "Is that supposed to have a dressing on it?" The Treatment Nurse stated, "Yes, it probably came off in the (shower)." The Treatment Nurse was asked, "Are they supposed to put a sock back on (without a dressing)?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "What stage is that?" The Treatment Nurse stated, "It's primarily unstageable due to slough on it. It's either a 4 or unstageable." The Treatment Nurse wiped the wound with 4 x 4 gauzes that had been moistened with Normal Saline. The Resident muttered and moaned and pulled the right foot away from the Treatment Nurse. The Treatment Nurse stated, "Does that hurt? It might be that it's cold." and continued performing the dressing procedure. j. On [DATE] at 4:00 p.m., the Director of Nursing (DON) was shown the wound measurements for the left buttock wound and right ankle on the November Wound log for week 4 and the wound measurements received from the Treatment Nurse on [DATE] that was completed on [DATE]. (see wound measurement documented above in a and c). The DON was asked, "Is this accurate?" The DON stated, "No." B. Based on observation, record review and interview, the facility failed to ensure pressure relieving devices were implemented consistently and correctly for 1 (Resident #4) of 5 (Residents #,[DATE]) case mix residents with preventative skin treatments. The facility failed to ensure aseptic technique was maintained during wound care, gloves were changed when contaminated and items when dropped on the floor were not place back in useable stock for 1 (Resident #3) of 4 (Residents # ,[DATE]) case mix residents with pressure sores. This failed practice had the potential to affect 83 residents in the facility with preventative skin treatments according to the Resident Census and Conditions of Residents report provided by the Administrator on [DATE] and 8 residents in the facility with pressure sores according to the list provided by the Administrator on [DATE]. The findings are: 1. Resident #3 had the [DIAGNOSES REDACTED]. The Significant Change MDS with an Assessment Reference Date of [DATE] documented the resident had independent cognitive skills for daily decision making, was incontinent of bowel and bladder, and had a Stage II pressure sore and a Stage II vascular ulcer. a. The Plan of Care dated [DATE] documented, "11. Pt. (patient) has impaired skin integrity R/T (related to) wounds to heels bil. (bilateral) ... 2. Tx's (treatments) as ordered. 3. Pressure relieving mattress to bed; cushion to w/c (wheelchair). " b. The Wound Log for [DATE] documented that the Resident had a Stage 1 pressure sore on the left heel that was first observed on [DATE]. The log documented the wound measured 0.5 cm x 0.5 cm for week 1, 0.5 cm x 0.75 cm for week 2, 0.75 cm x 0.5 cm for week 3, and 1 cm x .75 cm for week 4. The documented treatment for [REDACTED]. c. A Physician's Order dated [DATE] documented, "Mesalt to L (left) heel daily." d. On [DATE] at 11:50 a.m., the Treatment Nurse stated, "The doctor just got through looking at the resident and I'm ready to do his wound." The Treatment nurse sprayed wound cleanser on gauze 4x4's, then dropped an empty red biohazard bag on the floor next to the resident's chair. The Treatment Nurse then got down in the floor, took the gloved hand and turned the red biohazard bag over, touching the side of the biohazard bag that was in contact with the floor, opened the bag, then with the contaminated glove took the gauze 4x4 wet with wound cleanser and wiped the wound to the back of the left heel. Fresh blood was noted on the gauze after wiping the wound. The Treatment Nurse stated, "It's a Stage 3. I'm going to talk to the (doctor). It looks like it had some slough on it." The Treatment Nurse opened the top drawer of the treatment cart rapidly, and a package popped out of the treatment cart and fell to the floor. The Treatment Nurse picked up the package and placed it back into the treatment cart drawer. The Treatment Nurse was asked, "When opening the treatment cart drawer, a package fell to the floor and was placed back into the cart. Is there a reason why?" The Treatment Nurse stated, "Well, it was still clean. It wasn't open." The Treatment Nurse was asked, "Is the inside of your cart considered clean?" The Treatment Nurse stated, "Yes." e. On [DATE] at 12:50 p.m., the Director of Nursing (DON) was asked, "If someone contaminates gloves during wound care, what are they supposed to do?" The DON stated, "Start over." 2. Resident #4 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set with an assessment reference date of [DATE] documented the resident was severely impaired in cognitive skills for daily decision making, was totally dependent for activities of daily living, was incontinent of bowel and bladder and did not have a pressure ulcers. a. A Braden Scale form dated [DATE] documented, "...Total Score 12...Total Score of 12 or less represents HIGH RISK..." b. The Care Plan dated [DATE] documented, " ...13. Patient at risk for impaired skin integrity related to impaired mobility, incontinence, and inability to verbalize pain or discomfort...Pressure relieving device on bed and in reclining Geri-chair..." c. On [DATE] at 5:27p.m., the resident was in a Geri-chair with no pressure relieving device in the Geri-chair. d. On [DATE] at 9:14 a.m. and 2:24 p.m., the resident was observed in the bed on a GeoMat mattress, the lettering toward the top of the mattress read "Foot End" with an arrow pointing toward the head of the bed. e. On [DATE] at 2:28 p.m., Certified Nursing Assistant (CNA) #1 was asked if there was a pressure relieving device in the Geri-chair and the CNA stated, "Laundry is washing the cushions today ...and we couldn't find any." CNA #1 was then asked do yo