Every finding on record at Skaalen Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 52 residents residing in the facility. Surveyor observed a coat of dust on light fixtures and electrical cords above food preparation area while food was being prepared. Surveyor observed food to be in circulation that was expired and observed food in circulation to be opened and undated. Evidenced by: Example - dust On [DATE] at 9:12 AM, during initial tour of the kitchen, Surveyor and DM H (Dietary Manager) observed 3 plastic light covers in the ceiling and electrical cord unit suspended from the ceiling directly over the food preparation area. The light covers and electrical cord had a layer of dust on them. On [DATE] at 9:13 AM, DM H indicated staff in the Maintenance Department are responsible for cleaning the light covers and the electrical cord. DM H indicated there is potential for the dust to dislodge into the open food underneath. Example food dating/expiration Facility policy, entitled Food Brought To Residents From Outside Sources, effective date [DATE], includes, in part: the facility . is responsible for storing food brought in by family or visitors in a way that is either separate or easily distinguishable from facility food . all food or beverages brought into the facility for resident consumption will only be accepted if it is in good condition and not expired . food or beverages brought in . will be labeled with the resident's name . dated with an expiration date/use by date . Facility policy, entitled Labeling and Dating Food, dated [DATE], includes in part: . food is labeled and monitored with an expiration date to clearly state when food is safe to eat . the date marked by the food establishment may not exceed the manufacturers use by date . any unopened food, beverage, condiment that is missing a manufacturer's date or a use by date will be discarded . On [DATE] at 9:13 AM, Surveyor and DM H observed a brown frozen substance in a cup with a plastic dome lid and a straw coming out of the hole on the lid in the facility's freezer. Surveyor and DM H also observed an opened bag of hashbrowns. These items were not labeled or dated. DM H indicated she was unsure who the shake belonged to and indicated items placed in the freezer are to be labeled with a name and dated with a use by date. DM H indicated she was unsure if the shake belonged to a staff member or a resident and stated staff and resident food should not be stored together. On [DATE] at 9:33 AM, Surveyor observed three yogurts with expiration date of [DATE] in the refrigerator and a box of spicy cheese crackers to be opened and on the counter in the facility's kitchenette. CNA I (Certified Nursing Assistant) indicated she was unsure who the crackers belonged to and for how long they were opened. CNA I indicated the yogurt should be thrown out since it is past the expiration date. CNA I indicated food items should be dated with a use by date and labeled with a name. On [DATE] at 10:09 AM, Surveyor observed an opened half-gallon of orange juice with a post-it note attached to it with a resident name and a sticker with a use by date of [DATE]. Surveyor observed a second half-gallon of orange juice with sell by date of [DATE]. Surveyor observed a partially drank bottle of Dr. Pepper labeled with a resident name and dated [DATE]. Surveyor observed a bag of opened food with a handwritten date on it of [DATE]. On [DATE] at 10:30 AM, RN G (Registered Nurse) indicated food should be labeled with a date and a resident name. RN G also indicated food should not be served past the expiration date. RN G indicated the food in the bag was expired and should be thrown in the garbage. On [DATE] at 10:39 AM, DM H indicated all staff are responsible for writing dates and names on food brought in by families. DM H indicated food should not be served past the manufacturer's expiration date.

Based on interview and record review, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation, or mistreatment by failure to conduct timely and complete background checks for 4 (RN D, CNA E, MT C and HK F) of 8 facility staff. RN D (Registered Nurse), CNA E (Certified Nursing Assistant), and MT C (Medication Technician) did not have a background check completed every four years. HK F (Housekeeper) indicated on HK F's Background Information Disclosure (BID) form that HK F had been convicted of disorderly conduct in January 2024. The facility did not request a copy of HK F's criminal complaint, judgement of conviction, or any other relevant court or police documents as instructed by the BID form. This is evidenced by: The DHS memo P-00274 titled Wisconsin Caregiver Program: Offenses Affecting Caregiver Eligibility for Chapter 50 Programs, dated 4/2020, states: This document lists Wisconsin crimes and other offenses that the Wisconsin State Legislature, under the Caregiver Law, Wis. Stat. S 50.065, has determined require rehabilitation review approval before a person may receive regulatory approval, work as a caregiver, reside as a non-client resident at, or contract with an entity.Additional information must be obtained when: -The Background Information Disclosure (BID) or DOJ (Department of Justice) response indicates a conviction of any of the following, where the conviction occurred five years or less from the date on which the information was obtained . 6. Disorderly conduct .These convictions do not prohibit employment but do require the entity to obtain the criminal complaint and judgment of conviction from the Clerk of Courts office in the county where the person was convicted. The facility's Policy and Procedure entitled, Abuse Prevention Resident Rights Program, dated 1/2/2023, states in part: . The facility will take all necessary measures to identify and prevent resident abuse, neglect, exploitation, and misappropriation of property . The facility will conduct a pre-employment screening of applicants for all departments, which will include employment reference checks, criminal background checks, drug testing and relevant state licensing checks . The facility's Policy and Procedure entitled, Background Information Disclosure, dated 6/25/2020, states in part: Policy: All staff members must disclose (self-report) in writing by the next business day any changes to the information included on the BID (Background Information Disclosure) form . Purpose: With this in place, [Facility Name] does not have to require staff to complete a BID form every four years. (Of note: While the facility does not have to require a BID form to be completed every four years, according to regulation, the facility does still need to complete a background check every four years which consists of a Department of Justice (DOJ) and Department of Health Services/Department of Safety and Professional Services (DHS/DSPS) information at the time of hire and every four years thereafter.) Example 1 RN D was hired 1/17/2018. RN D did not have a background check completed every four years. Surveyor requested the caregiver background check information on 9/5/2024 and the caregiver background check provided by the facility was conducted on 9/6/2024. Example 2 CNA E was hired 3/18/2008. CNA E did not have a background check completed every four years. Surveyor requested the caregiver background check information on 9/5/2024 and the caregiver background check provided by the facility was conducted on 9/6/2024. Example 3 MT C was hired 1/14/1991. MT C did not have a background check completed every four years and the previous background check provided to Surveyor was conducted 2/19/2015. Surveyor requested the caregiver background check information on 9/5/2024 and the most recent caregiver background check provided by the facility was conducted on 9/6/2024. On 9/9/2024 at 3:33 PM, Surveyor interviewed NHA A (Nursing Home Administrator). NHA A explained the facility background check process that includes a pre-hire checklist, a background check, drug screening, and human resources will interview an applicant if anything is flagged in the background check process. NHA A also stated that the facility completes background checks upon hire and when staff self-report violations or pending charges. NHA A stated that background checks are not completed every four years. Surveyor asked NHA A if background checks should be completed every four years. NHA A stated that she does not know, and that she believed they were performed according to policy. Example 4 HK F began employment at the facility on 7/24/2024 and completed a BID form on 7/22/2024. In Section A - Disclosures, HK F stated that HK F was convicted of disorderly conduct in January 2024. A review of HK F's Department of Justice letter (DOJ) shows that HK F was charged with disorderly conduct in April 2020, May 2020, June 2020, July 2020, March 2022, and twice in April 2024. The DOJ letter also shows that HK F was convicted of disorderly conduct in June 2020, March 2022, and April 2024. There is no evidence of this at the facility. On 9/10/2024 at 1:32 PM, Surveyor interviewed the NHA again, following a request for further documentation regarding the previously mentioned background checks. NHA confirms at this time that the background checks of RN D, CNA E, and MT C were run on 9/6/2024, and that there are no other background checks run in the past four years. NHA reports that there was some confusion regarding the policy with staff who interpreted their policy to include both the BID and background check, when the policy and statute does require the background check be run every 4 years. NHA A confirmed that background checks should be run every four years. NHA A also confirmed, after speaking with human resources, that there is no additional documentation regarding HK F's background check. According to the Wisconsin Caregiver Program Manual Wisconsin, Statute 50.065 (2) bb states in part; Additional Required Information must be obtained when: 3. The BID or DOJ response indicates a conviction of . o Disorderly conduct Wis. Stat. S 947.01(1) . where the conviction occurred five years or less from the date on which the information was obtained; .

Based on observation, interview, and record review, the facility did not ensure the preparation of food in a clean and sanitary environment with the potential to affect all 47 residents residing in the facility. Surveyor observed Cook G's personal handbag sitting amongst stored clean cookware in the food preparation area. While temping food coming out of the ovens, Cook K used a visibly soiled alcohol wipe to clean thermometer and did not allow thermometer to air dry between foods. Surveyor observed a plastic scoop to be stored in contact with flour inside of a storage bin. Evidenced by: Example 1 On 5/21/23 at 9:14 AM Surveyor observed Cook G preparing food in the food preparation are. Cook G had her personal handbag on a storage shelf amongst clean bakeware. Cook G indicated she should not have her personal items in the food preparation or storage area. On 5/22/23 at 10:51 AM Dietary Manger F (DM) indicated Cook G should not have her personal handbag in the food preparation area on the storage shelf with the clean bakeware. Example 2 Facility policy, entitled Taking Accurate Temperatures, dated 2021, includes, in part: . to take temperatures, a clean, rinsed, sanitized, and air-dried thermometer . is needed . On 5/22/23 at 11:15 AM Cook was temping his food as it came out of the ovens. Surveyor Cook K use one alcohol wipe to wipe the thermometer between 11 different food items. The wipe was visibly soiled, and Cook K continued to use it. Surveyor also observed Cook K lay down the thermometer on the alcohol wipe when not in use and did not allow the thermometer to air dry. DM F indicated Cook K should not use soiled alcohol wipe and should allow thermometer to air dry in between uses. Example 3 On 5/21/23 at 9:14 AM Surveyor observed a plastic scoop lying with its handle in direct contact with flour inside of a rolling bin. Cook G indicated the scoop should not be left inside of the flour bin. On 5/22/23 at 10:51 AM DM F indicated scoops are to be stored in the bin's scoop holder and the handle should not be in direct contact with food.

Based on observation, interview, and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 47 residents (R) in the facility. The facility did not identify a COVID-19 outbreak when they received a positive COVID-19 test from a staff member and the facility did not ensure that their COVID-19 staff line list was filled out completely. R21 was observed with their catheter bag on the floor. Facility staff was observed not performing hand hygiene during a topical treatment. Evidenced by: The facility policy titled Outbreak Prevention and Control last revised on 8/25/22 states in part: .4. A suspect COVID-19 respiratory disease outbreak in a long-term care facility is defined by DPH as one or more residents and/or staff (who worked during their infectious period) within a facility who have a case of COVID-19 .C. Management of ill staff .7. The Staff Case Log for Outbreaks should be maintained to record ill staff symptoms, date when they became ill, when they were symptom free and when they returned to work. The Infection Preventionist, House Charge RN (Registered Nurse) and Nursing Scheduler will maintain the log . Example 1 January COVID-19 Employee line list: RN tested positive for COVID-19 on 1/24/23. The line list does not include symptoms or last day worked. Nursing staff member tested positive for COVID-19 on 1/30/23. Administration staff member tested positive for COVID-19 on 1/30/23. The line list does not include date of onset or date last worked. The facility did not go into outbreak status in January despite having 3 positive cases of COVID-19. February COVID-19 Employee line list: Pastoral Services staff member tested positive for COVID-19 on 2/24/23. Does not include last date in facility. RN tested positive for COVID-19 on 2/5/23 due to having a close contact. The line list does not include last day worked. The facility did not go into outbreak status in February despite having 2 positive cases of COVID-19. March COVID-19 Employee line list: Business Office staff member tested positive for COVID-19 on 3/22/23. The facility did not go into outbreak status despite having 1 positive case of COVID-19. April COVID-19 Employee line list: Business Office staff member tested positive for COVID-19 on 4/5/23. Housekeeping staff member tested positive for COVID-19 on 4/10/23. COVID-19 Resident line list: R31 had a positive rapid COVID-19 test on 4/27/23 and a positive PCR (Polymerase Chain Reaction) test on 4/28/23. The facility declared themselves in an outbreak on 4/29/23. At the time of the survey, the facility had documentation of an additional 9 COVID-19 positive residents and 11 COVID-19 positive staff members after declaring the outbreak. It is important to note that there is no evidence that the facility completed contract tracing for the COVID-19 positive staff members. On 5/23/23 at 9:31 AM, Surveyor interviewed IP C (Infection Preventionist). Surveyor asked IP C how she determines if the facility is in outbreak, IP C stated that she looks at who is testing positive and if it is an administrative staff, she does not put them into outbreak status. IP C stated that she contacts PH (Public Health) and updates them on the plan. IP C stated that if she has 3 or more positives, then she would go into outbreak status, but if there is only 1 positive case, she would put that resident in isolation and would start surveillance testing and tell PH that she would not be going into outbreak at this time. Surveyor asked IP C what the facility's policy states about outbreaks, IP C stated that it says 3 or more cases would be an outbreak. Surveyor reviewed the facility policy with IP C; IP C stated, it says 1 or more. Surveyor asked IP C if she was aware of what the guidance from the CDC (Centers for Disease Control) and CMS (Centers for Medicare and Medicaid Services) identifies a COVID-19 outbreak as, IP C stated 1 case is an outbreak. Surveyor asked IP C if they should have gone into outbreak after receiving their first positive staff member, IP C stated that according to the CDC, they should have. Surveyor reviewed the line lists from January through April with IP C. Surveyor asked IP C if the line list should contain last day worked, date of onset, return to work dates and symptoms of all staff and residents, IP C stated yes. 39849 Example 2 The facility policy, titled, APIC (Association for Professionals in Infection Control) Guideline for Handwashing and Hand Antisepsis in Healthcare Settings, with a handwritten date of 8/17/03, indicates, in part: .2. Bacteria on hands must be removed by hand washing with soap and water or by hand antisepsis with alcohol-based hand-rubs (if hands are not visibly soiled): .b. Before and after caring for each resident .f. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated). g. Every time a person puts on or takes off gloves .7. Glove use .b. Gloves should be used for hand-contaminating activities. Gloves should be removed, and hands washed when such an activity is completed and before there is a risk of contaminating the environment with the material that is on the gloves, when the integrity of the gloves is in doubt, and between patients/residents . On 5/22/23 at 8:15AM Surveyor observed RN D (Registered Nurse) perform a treatment for R5. RN D put on a gown and gloves from the isolation cart outside of R5's room and did not perform hand hygiene prior to putting on gloves. Prior to starting the treatment, R5 indicated to RN D that he felt his colostomy bag was full. RN D indicated that she felt there was gas in the colostomy and proceeded to burp the bag to relieve some of the gas. RN D then took a clean washcloth and placed it into a basin of soap and water and began to wash R5's perineum and scrotal area without performing a glove change or hand hygiene. After washing the area RN D changed gloves without performing hand hygiene and then applied a topical cream to the area she had washed. RN D changed gloves and did not perform hand hygiene and began to gather supplies to change R5's colostomy appliance. After changing the colostomy appliance, RN D removed her gloves and gown, took the gown out of the room directly across the hall to a dirty utility room, and did not perform hand hygiene. Of note, R5 is currently in enhanced barrier isolation precautions. Surveyor interviewed RN D after the treatment and asked when hand hygiene should be performed. RN D indicated, after glove changes. Surveyor reviewed the observation with RN D and RN D indicated she should have performed hand hygiene with the glove changes. Surveyor asked RN D if she should have changed gloves and performed hand hygiene after burping the colostomy and prior to washing the treatment area. RN D indicated she should have. On 5/22/23 at 10:06AM Surveyor interviewed IP C (Infection Preventionist). Surveyor asked IP C when staff are expected to perform hand hygiene. IP C indicated, before and after resident contact, after removing gloves, after touching an item in the resident's environment and before a clean technique like giving medications. Surveyor reviewed the observation for R5's treatment with IP C. IP C agreed that hand hygiene should have been performed between all glove changes. Surveyor asked IP C if she would expect the nurse to change gloves and perform hand hygiene after burping the colostomy bag and prior to washing the treatment area. IP C indicated, yes. 44552 Example 3 Facility policy, entitled, Use of an indwelling urethral catheter, dated 8/24/15, indicates, in part; .Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor. R21 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, kidney disease, overactive bladder, depression, anxiety, and neuromuscular dysfunction of bladder. R21's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/5/23, indicates R21 has a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating moderately impaired cognition. R21 has an Activated Health Care Power of Attorney. R21's current order indicates, TREATMENT: URINARY: indwelling foley catheter REASON FOR INDWELLING CATHETER every shift AM PM NOC First Date: 12/14/22 Administration Instructions: Provide routine foley catheter care per standards of practice and facility protocol. On 5/21/23 at 10:13AM, Surveyor observed R21 sitting in the dining room area. R21 had drinks and a newspaper near R21. Surveyor observed R21's catheter bag hanging on R21's Broda chair directly touching the floor. On 5/23/23 at 12:15PM, CNA E (Certified Nursing Assistant) indicated a resident catheter bag should not be touching the floor. On 5/23/23 at 12:34PM, DON B (Director of Nursing) indicated catheter bags should not be resting/touching the floor.

Based on observation, interview, and record review, the facility did not ensure drinks were prepared in a form to meet the individual needs for 1 of 1 resident (R6) with alterations to fluid for oral intake out of a total of 16 residents sampled. Facility staff served regular thin liquids to R6, who has a dietary order for nectar-thickened liquids. Findings include: R6 was admitted to this facility on 3/31/23 for physical and occupation therapy with primary diagnoses of altered mental status, recurrent falls, poor mobility, weakness, and dementia. R6's most comprehensive recent Minimum Data Set (MDS) assessment dated [DATE] shows R6 has a Brief Interview of Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. Section K. Oral/Nutritional Status indicates that R6 has signs and symptoms of possible swallowing disorder including coughing or chocking during meals or when swallowing medications. R6 has a current dietary order for nectar thickened liquids. Nurse's note in resident's electronic chart from 4/10/23 5:21PM states Order received from SLP [Speech Language Pathologist] for change in liquid consistency to Nectar thick. (A speech language pathologist is an expert who assesses and treats people who have problems with speech and/or swallowing.) 5/22/23 at 3:10 PM Surveyor observed R6 in dining room drinking coffee from a mug. There is also regular-thin ice water in front of her. Surveyor asked R6 if she is having coffee, R6 reported yes, and that she is really enjoying it. Surveyor asked if it was thick, R6 reported no, that it was regular. 5/22/23 at 3:12 PM Surveyor interviewed Registered Nurse I (RN), the unit manager, regarding risk and benefits of R6 consuming thin liquids. RN I reports R6 does not have a risks and benefits form completed. 5/22/23 at 3:22 PM The unit floor nurse, RN J, assisted Surveyor to find resident's meal ticket for supper on 5/22/23, it stated, Fluid Alteration: Nectar liquids. Surveyor asked RN J if resident is currently having thickened liquids. RN J inspected liquids R6 is drinking, talked with R6, and reported that R6 is having thin liquids. 5/22/23 at 4:12 PM R6 has thin coffee, thickened water, and thickened juice currently. RN I states that CNAs, nurses, dietary assistants, or activity professionals cannot just give a resident thin liquids when resident refuses thickened liquids that have been ordered. Surveyor observed staff taking the thin coffee away from R6. 5/22/23 at 4:13 PM RN J reports that resident does not have an order for thin liquids. 5/22/23 at 4:22 PM Surveyor interviewed Certified Nursing Assistant L (CNA). CNA L reports that CNAs get liquids ready for residents before supper. When asked how they know what residents need for thickness of liquids, CNA L showed Surveyor the pile of meal tickets and picked up R6's meal ticket out of the pile of other residents' meal tickets and said for example, for her, I would see nectar thickened liquids on her meal card. We look at the meal ticket or ask the nurse. Today I did not know how thick R6's liquids should be, so I had to ask the nurse. 5/22/23 at 4:46 PM. Surveyor interviewed Dietary Manager F (DM). Who can decide what kind of liquids a resident can have? DM F replied that if a resident wants something like thin liquids when they do not have an order for it, the resident or an APOA-HC needs to sign a risk agreement. DM F states that that was not done for R6 before this incident. 5/22/23 at 4:57 PM Interview with Speech Language Pathologist M (SLP). SLP M reports that she did a simple swallow evaluation with R6, during which R6 was coughing heavily with thin liquids. R6 did well with nectar thickened liquids and had no coughing, so SLP-M then ordered nectar thickened liquids for R6 on 4/10/23. Surveyor asked if it is safe for resident to have thin liquids. SLP M stated that if the resident and Activated Healthcare Power of Attorney (APOA-HC) understand the risks and benefits and want resident to have thin liquids, they can sign a risk agreement. 5/23/23 at 10:01 AM Surveyor interviewed R6's Family Member N (FM), who is R6's APOA-HC. FM N reports that R6 has not had any pneumonia that she can remember, R6 has not had any rehospitalization s since admission to this facility, and R6 has not had any instances of aspirating or inhaling fluids since admission to this facility. The facility reviewed an Informed Choice Form describing the risks and benefits of choosing to drink items of preference other than the ordered diet consistency with FM N on 5/22/23 after this Surveyor asked for a risks and benefits agreement for R6. The facility failed to follow R6's fluid consistency order and did not have a risk vs. benefit completed prior to serving R6 thin liquids.

Based on record review and interview, the facility administered the influenza immunization without receiving consent from the resident's Activated Power of Attorney (APOA) for 1 of 5 residents (R31) reviewed for immunizations. R31 received the influenza immunization without consent and prior to receiving the APOA's declination. Findings include: The facility policy titled Influenza Vaccination Guidelines last reviewed 7/13/21 states in part: .3. Before offering/ administering the vaccine, the resident or the resident's legal representative will receive written education regarding the benefits and potential risks of the vaccination. The resident or legal representative will sign a form attesting to the education and will give written consent to receiving the vaccination or decline the vaccination . R31 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Generalized Anxiety Disorder, and depression. R31's most recent Brief Interview of Mental Status (BIMS) assessment dated [DATE], indicates that R31 is rarely/ never understood. R31 has an APOA that makes medical decisions for her. Documentation in R31's Electronic Health Record (EHR) dated 10/5/22 at 2:50 PM states, in part: Vaccine Administered: Influenza Vaccine Influenza Trade Name: Flu zone Lot Number: ut7680ja. Surveyor also reviewed R31's Influenza consent/declination form signed by R31's APOA dated 10/8/22 that states in part: I do not wish to receive the influenza vaccination. On 5/23/23 at 9:31 AM, Surveyor interviewed IP C (Infection Preventionist). Surveyor asked IP C what the process was for the influenza vaccine, IP C stated that HIS (Health Information Services) sends out a letter for consent or declination, and when the vaccine comes in, the nurses schedule a day to administer the immunization. Surveyor discussed R31's vaccination and her APOA's declination. Surveyor asked IP C if she would have expected staff to not administer the vaccine, IP C stated that she would have expected that R31 not get the vaccine until they got the letter back from the POA giving them consent to administer the vaccine.

Based on observation, interview, and record review the facility did not ensure pressure injury preventive measures were implemented. This was observed with 1 (R44) of 4 residents reviewed for pressure injuries out of a total sample of 16 residents. R44 was observed to not be repositioned at least every 2 hours while in bed. R44 was observed to have heels directly on mattress. Evidenced by: Facility policy, entitled Wound Care Protocol, revised date 7/17/21, includes, in part: .OPERATIONAL DETAILS .2. As part of the above assessment, risk factors must have a corresponding intervention to alleviate or reduce the risk. Preventive interventions may include but are not limited to pressure redistributing seating surfaces, beds, mattresses, extremity offloading, supportive devices, protective dressings, skin observations and repositioning plans . R44 was admitted to the facility on [DATE] with diagnoses including fracture, hypertension, age-related osteoporosis, retention of urine, hearing loss, age-related macular degeneration, glaucomatous, muscle weakness, history of falling, and unspecified severe protein-calorie malnutrition. R44 has a history of femur fracture, history of falls, chronic fractures, and is legally blind. R44's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/30/23, indicates R44 was unable to complete interview. R44 is on hospice and has an Activated Power of Attorney. R44's Comprehensive Care Plan, dated 4/25/23, indicates, .have the potential to have a skin injury am at risk for developing a pressure injury or other skin impairment. Can't move around well on my own, L2 compression fx, have severe osteoporosis, protein/calorie malnutrition reduce pressure and friction between myself and my bed or chair, ensure heels are elevated when I am lying in bed monitor my nutrition or hydration intake-check my skin with cares, monitor lab values, supplement as ordered. Notify hospice as needed. Help me with hygiene and general skin care; avoid using hot water for washing and use moisturizer on my skin, help me reposition at least every 1-2 hours while I'm in bed, help me reposition at least every 2 hour when I'm in a chair, keep good padding around my bony areas, offer me fluids when I change positions, elevate my heels in bed reduce pressure and friction between myself and my bed or chair, help me stay clean and dry. ROHO cushion in w/c, ROHO cushion in recliner or another chair, heelz-up device, or pillow, APP on mattress On 5/21/23 at 12:39PM, R44's daughter indicated R44 is not repositioned at least every two hours. R44's daughter indicated she knows this for a fact and that hospice has shared with the family that R44 should be repositioned at least every two hours. R44's daughter indicated R44 is at risk for skin break down. On 5/21/23 Surveyor observed R44 constantly from 1:00 PM-3:30 PM. R44's care plan indicated R44 should be repositioned every 1-2 hours while in bed. R44 was not repositioned. On 5/22/23 at 9:23 AM, CNA E (Certified Nursing Assistant) indicated R44 should be repositioned at least every two hours. CNA E and Surveyor observed R44's heels to be directly on mattress and heelz-up device noted to be leaning up against dresser. CNA E indicated R44's heels should not be directly on mattress, but that she does decline interventions. CNA E indicated if R44 declines heel protector interventions, CNA's are to tell Nursing and they document the refusal. Surveyor reviewed Care Plan and Progress Notes - Surveyor did not see any documentation that R44 refuses heel protector interventions. On 5/22/23 at 4:00PM, Surveyor observed R44's heels elevated with a pillow and R44 to be sleeping. On 5/23/23 at 12:34PM, DON B (Director of Nursing) indicated if a resident is care planned to be repositioned every 1-2 hours the resident should be repositioned at least by the 2-hour mark. DON B indicated if resident is care planned to have heel protection interventions the resident's heels should be elevated and if there are refusals, that should be documented. DON B indicated R44 should be repositioned at least every two hours and heels elevated.

Based on observation, interview, and record review, the facility did not ensure that every resident was treated with dignity and respect when providing activities of daily living (ADLs) for 2 of 16 residents reviewed and 1 of 1 supplemental resident reviewed (R21, R44, and R305). Surveyor observed R21 in dining room area. R21's catheter bag was not covered with a dignity bag. Surveyor observed staff entering R44's room without knocking or introducing themself. Surveyor heard staff sharing personal information about R305 outside of R305's room. Staff were standing outside of R305's room and Surveyor could hear the conversation while standing at the end of the hall. Example 1 R21 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, kidney disease, overactive bladder, depression, anxiety, and neuromuscular dysfunction of bladder. R21's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/5/23, indicates R21 has a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating moderately impaired cognition. R21 has an Activated Health Care Power of Attorney. R21's current order indicates, TREATMENT: URINARY: indwelling foley catheter REASON FOR INDWELLING CATHETER every shift AM PM NOC First Date: 12/14/22 Administration Instructions: Provide routine foley catheter care per standards of practice and facility protocol. On 5/21/23 at 10:13AM, Surveyor observed R21 sitting in the dining room area. R21 had drinks and a newspaper near R21. Surveyor observed R21's catheter bag hanging on R21's Broda chair. Surveyor observed R21's catheter bag without a dignity bag. On 5/23/23 at 12:15PM, CNA E (Certified Nursing Assistant) indicated if a resident has a catheter bag, there should be a dignity bag over the catheter bag. CNA E indicated the facility is low on dignity bags and there are times that staff use a pillowcase. CNA E indicated CNA E has brought this up to management in the past. On 5/23/23 at 12:34PM, DON B (Director of Nursing) indicated catheter bags should not be resting/touching the floor and that they should have a dignity bag over the catheter bag. Example 2 R44 was admitted to the facility on [DATE] with diagnoses including hypertension, age-related osteoporosis, retention of urine, nonexudative age-related macular degeneration, muscle weakness, hearing loss, history of falling, and unspecified severe protein-calorie malnutrition. R44 is legally blind. R44's most recent BIMS with ARD of 4/30/23, indicates R44 was unable to complete interview. R44 is on hospice and has an Activated Power of Attorney. On 5/22/23 at 9:23AM, Surveyor observed CNA E (Certified Nursing Assistant) enter R44's bedroom without knocking or introducing self. Surveyor observed on R44's bedroom door to have a sign saying introduce self before entering. On 5/23/23 at 12:15PM, CNA E indicated staff should knock and introduce self before entering a resident bedroom. On 5/23/23 at 12:34PM, DON B indicated staff should knock and introduce self before entering a resident bedroom. Example 3 R305 was admitted to the facility on [DATE]. On 5/22/23 at 9:23AM, Surveyor was at the end of hallway. Surveyor heard CNA E talking to another staff in the hallway about R305's level of care needed and lack of compliance with using call light. CNA E was standing outside of R305's bedroom talking about him, and Surveyor was able to hear conversation while Surveyor was four rooms down from R305's room. On 5/23/23 at 12:15PM, CNA E indicated when discussing resident medical information, the conversation should be in a private area. CNA E indicated you should never discuss resident medical information in a public setting, and it always must be in a private area. On 5/23/23 at 12:34PM, DON B indicated resident medical information should not be discussed in an area where it can be overheard by other people. DON B indicated staff should speak quietly when discussing medical information and the best location would be in a private area, like an empty bedroom or a med room.

Based on interview and record review the Facility did not ensure that 1 of 12 Residents (Resident 103) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with their comprehensive assessment and plan of care. Staff did not address the psychosocial wellbeing of R103's missing right upper partial. Staff continued to provide same diet, did not support resident's feelings of embarrassment and humiliation of her appearance secondary to her situational depression. R103 making food choices based upon her inability to chew food, weight loss, and concerns of anger and frustration of the lack of supportive care of the missing partial. Findings include: R103 is a long-term resident of the facility with an admitted [DATE]. R103's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS) dated [DATE]- BIMS (brief interview of mental status) 15, indicates that R103 is cognitively intact. R103 requires extensive assistance of one staff member for bed mobility, transfer, dressing, and toileting. Requires supervision of one staff member for eating and hygiene. Always continent of bowel and bladder. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Care Plan reviewed from 3/1/22-3/30/22. No care plan observed for nutrition. On 3/2/22-3/4/22 Nursing Order: Check weight daily PM. Order DC'd on 3/4/22. Nursing Order on 3/2/22: weekly weight 1x wk. Friday PM. Documentation of the weights: 3/02/22 156.9 pounds 30/3/22 156.9 pounds 3/04/22 154.6 pounds 3/11/22 150.2 pounds 3/18/22 None charted 3/25/22 147.9 pounds TOTAL= 5.74% Weight Loss from 3/2/22-3/25/22 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/2/22 Antidepressant Monitor for [MEDICATION(S)], Mood Symptoms: Appears depressed/hopeless: frustration over loss of independence with need for assistance, NOC (night), AM (morning), PM (evening). No signatures or documentation observed. Weight Change and Nutritional Risk Policy and Procedure Manual Reviewed, Effective date 8/28/10, supersedes: #41-07-B. Procedure #4 states The following criteria will be used to identify residents at nutritional risk: a) pressure ulcers .f) recent change in dental status .k) Any other condition that my interfere with maintaining optimal nutritional status (may not include but not limited to . chronic illness/disease). Procedure #8 states Clinical conditions that demonstrate that maintaining acceptable nutritional status may not be possible include, but are not limited to .c. Increased nutritional needs associated with pressure sores and wound healing (decubitus, fractures, surgery, [CONDITION(S)]) . e. Chronic kidney disease, alcohol/drug abuse, chronic blood loss, .f. Chronic gastrointestinal illness or surgery. Procedure #9 states Interventions may include but are not limited to: a. Supplemental nourishment between meals .d. more frequent weights .h. Menu adjustment, preference updates. Initial Nutritional Screening Note Dated 3/10/22, signed by DM J (Dietary Manager), states late entry from 3/3 reports weight is stable at 150#, reports height 60 reports decreased appetite r/t (related to) lack of exercise, better intake when she is active . difficult chewing r/t missing teeth, does not interfering with intake. Reports she likes to keep her kcal intake light to avoid gaining weight, does like to drink cola. Assist with set up for meals. Feeds self independently. Offered this resident to assist in creating a nutrition care plan, resident gave input. On 03/28/22 at 02:24 PM, Surveyor interviewed R103. Surveyor asked how things were going for R103. She stated she liked it very much, lost partial and say they are not going to stand behind her. I was in bed and had only been here for about 2 days. There were 3 staff, asked the staff to put partial away because it was 9pm and wrapped in tissue. Nobody could find them the next day. The staff they interviewed that took the partial says she doesn't remember, and I am upset that they feel they don't have any grounds to stand on. On 3/29/22 at 3:51 PM, Surveyor interviewed R103's with daughter FM G (family member). Writer asked R103 how she is coping with her missing partial. She states, It bothers me, I can only eat certain foods that I can handle. She further reports being on a regular diet. Usually there is a choice of an entrée, and she will generally choose the one she knows that she can handle. R103 then proceeded to provide an example. There was a choice of pork or meatballs for lunch. She decided on the meatballs because she feels she would be handling it. I have to be careful. I know I can't chew it anyway, so why bother. She then shook her head and looked down with her hand on her forehead. She further reported that she is embarrassed. She lifted her lip and showed surveyor her missing her partial. She stated, That's not pretty, it's terrible, it's disgraceful. She reports that she is very self-conscious in the way she looks. Writer asked FM G if she has received any information of any follow up. She stated she has never gotten a call from anyone here at the facility. On 3/30/22 at 7:50 AM, Surveyor interviewed RN I (Registered Nurse) and asked what the process is for obtaining weights. She reports the CNAs (Certified Nursing Assistants) get them first think when the get up and document in the Treatment Authorization Request (TAR). CNAs have the sheets for everyone that needs weights. Writer asked what would happen if the weight was off. She reports they do a reweigh, many times it's a wheelchair and then reweigh. If there is a true 5-pound loss in a week or a significant change, they call the doctor. If the weights are monthly or weekly, they will get weighed the next day. She reports that dietary is also notified and will review. They may add a protein shake. On 3/30/22 at 8:01 AM, Surveyor interviewed CNA C and asked the process for weighing. She reports that she had R103 yesterday, noticed it yesterday and reported to the nurse that started with the name of J. She described the process of taking the wheelchair for the weight first, then has the exact same weight. She checks the white board in the room for what to weigh. If the equipment weight is different, will reweigh and tell the nurse. It is up to the nurse's discretion to do a reweigh of the patient. She then gives the weight to the nurse on a piece of paper. On 3/30/22 at 2:56 PM, Surveyor interviewed R103 daughter, FM H. She reports the communication has been poor. On 3/22 at the care visit, it was strictly verbal of the event and investigation. No details were given, no negligence. FM H reports not saying anything at the care conference because it had an unexpected outcome. She says they could say that they are both are at fault. On Wednesday morning, she called for a follow up meeting to discuss and asked for additional information. Another meeting is scheduled on Friday April 1, 2022. On 3/31/22 at 9:17 AM, Surveyor interviewed DM J. Surveyor asked if she was made aware of the food choices R103 is making. She states R103 was doing that prior on admission to avoid harder to chew foods. On 3/31/22 at 9:21 AM, Surveyor interviewed SW F (Social Worker). Surveyor asked if she was made aware of the food choices R103 is making based on her ability to eat certain foods without her partial. She stated no. Surveyor asked if she aware of how this made R103 feel. She stated that she really wants to figure out what to do, to keep her updated. On 3/31/22 at 9:38 AM - Surveyor interviewed DON B (Director of Nursing). Surveyor asked if she was made aware of the food choices R103 is making based on her ability to eat certain foods without her partial. She stated no. Surveyor asked if she aware of how this made R103 feel. She stated, I'm sure she's not happy about that, I would expect that. On 3/31/22 at 9:44 AM - Surveyor interviewed ANHA E (Assistant Nursing Home Administrator). Surveyor asked if she was made aware of the food choices R103 is making based on her ability to eat certain foods without her partial. She stated I haven't heard anything different from her. I have told her that it has not appeared. When I checked in on the 18th and asked if it would be okay to follow up at the care conference, the resident said yes. Surveyor asked if she aware of how this made R103 feel. She replied, She seems pretty neutral about it, nothing specifically.

Based on observation, interview and record review, the facility did not promptly secure dental services or provide documentation to secure dental services for the extenuating circumstances that led to the delay in replacing a missing right upper partial for 1 of 12 sampled Residents (R103). R103's right upper partial was reported missing to facility staff on 3/5/22. As of 3/24/22, The facility has been unable to locate R103's missing upper partial or made any effort in replacing them. This is evidenced by: The facility was unable to provide Surveyor with a policy specifically related to missing dentures or partials. R103 was admitted to the facility on [DATE], with the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS) dated [DATE]- BIMS (brief interview of mental status) of 15, indicates that R103 is cognitively intact. R103 requires extensive assistance of one staff member for bed mobility, transfer, dressing, and toileting. Requires supervision of one staff member for eating and hygiene. Always continent of bowel and bladder. R103 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R103 was observed on 3/28/22 at 2:24 PM without right upper partial. R103 was observed on 3/29/22 at 3:51 PM without right upper partial. R103 was observed on 3/30/22 at 2:56 PM without right upper partial. R103's Personal Belongings Worksheet, dated 3/2/22, documentation states, Dentures: partial on top. R103's Nursing Notes reviewed from 3/4/22 at 1:03AM to 3/10/22 at 11:19 PM, had no documentation of a missing right upper partial. R103's Nutritional Coordinator Note from 3/17/22 states, missed entry from 3/3/22, initial visit. Reports height 60, weight stable 150 or so. No Known Food Allergies (NKFA). Missing some teeth, trouble chewing harder foods. Taking meds for constipation though believes she is having trouble give appetite was poor x3 days, appetite improved. No dislikes, likes raisin toast with pb (peanut butter) and honey. She prefers to make her own meal selections and plans to keep kcal (calories) light to prevent weight gain while here. No special meals plan (religious, cultural, etc.) provided menus, discussed snack/beverages available, refrigerator policy/use and accepting foods from the outside. R103 Facility Resident Missing Item Report reviewed, and no documentation found of an appointment for a dental referral being made. States searches were completed on 3/7/22 and 3/8/22. Form is not signed and dated. On 3/28/22 at 2:24 PM, Surveyor interviewed R103. Surveyor asked how things were going for R103. She stated she liked it very much, lost partial and say they are not going to stand behind her. I was in bed and had only been here for about 2 days. There were 3 staff, asked the staff to put partial away because it was 9pm and wrapped in tissue. Nobody could find them the next day. The staff they interviewed, that took the partial says she doesn't remember, and I am upset that they feel they don't have any grounds to stand on. On 3/29/22 at 1:29 PM, Surveyor interviewed ANHA E (Assistant Nursing Home Administrator) and SW F (Social Worker). SW F indicated that facility has completed a missing item log but not a grievance. They are meeting with the resident and family on Friday to discuss the missing partial. States the facility is leaning towards not paying for the missing partial as they have interviewed several staff who indicated they did not get the partial from the resident. Resident though continues to claim she gave it to a CNA (agency). Surveyor requested a copy of the missing item report and the missing item policy. ANHA E indicates that at this time nothing is set in stone. On 3/29/22 at 2:02PM, Surveyor interviewed DON B (Director of Nursing) indicated that the facility does not have a specific denture policy. On 3/29/22 at 2:25PM, Surveyor interviewed ANHA E, who indicates that the facility has a missing items policy but nothing specific that addresses dentures. On 3/29/22 at 3:51 PM, Surveyor interviewed R103's daughter, FM G (Family Member). She states that she reported it to the CNA that came into her mother's room on Sunday 3/6. She did not hear a response except that they are checking on it. On Monday she called the SW and received a message that she was out until Thursday and left a message. In the meantime, she called again and was put through, to who she thought was the CEO, she believes the name was NHA A. She reported leaving a long message. She further reports bringing in 3 (three) other partials from home to possibly use in the meantime. On 3/30/22 at 2:56 PM, Surveyor interviewed R103's daughter, FM H. Surveyor asked if she could recap the missing partial to her knowledge. She stated Communication with the facility has been poor. This happened on 3/5, on 3/6 she texted to say her partial was missing. She states they had her mostly ready for bed, but her partial was still in, so she handed it to the CNA. I would expect them to take partial responsibility in this at least. ANHA E talked to us and discussed it in the meeting but did not identify herself. I later found out it was ANHA E. I have requested an incident report and timeline of events. I was told they would not provide an incident report. I have reached out to the Ombudsman for the Friday meeting, and she will be included. On 3/31/22 at 9:21 AM, Surveyor interviewed SW F. Surveyor asked if she made an appointment to see the dentist for partial replacement. She replied, No. On 3/31/22 at 9:38 AM, Surveyor interviewed DON B. Surveyor asked if she made an appointment to see the dentist for a partial replacement. She replied, no, ANHA E is handling that, and I think SW F. On 3/31/22 at 9:44 AM, Surveyor interviewed ANHA E. Surveyor asked if an appointment was made to see a dentist for the partial replacement. She replied No, we had a care conference last week and it never came up. Surveyor asked if there was a policy that addresses missing or lost dentures or partials and that is their responsibility to ensure the resident gets in to see the dentist or has an appointment within 3 days of learning they have gone missing. She replied she was not aware. Surveyor referenced State Operations Manual F790. She stated she would call NHA A. On 3/31/22 at 10:40 AM, ANHA E came to surveyor and indicating that she wanted to make sure that she followed up and spoke with NHA A. She states that NHA A was not aware of a policy either.

Based on observation, interview and record review, the facility did not ensure that staff followed standards of practice for infection prevention and hand hygiene for 2 of 2 treatment observations (R21 and R48) out of a total sample of 15 Residents. R21 was placed on Enhanced Barrier Precautions due to placement of a foley catheter (a flexible tube that is put through the urinary opening (urethra) and into your bladder). Staff did not complete hand hygiene according to standards of practice while emptying R21's catheter bag. R48 was placed on Enhanced Barrier Precautions due to placement of a foley catheter. Staff did not complete R48's treatment or foley catheter care in a manner to prevent cross contamination. Staff did not complete hand hygiene according to standards of practice when providing care for R48. Evidenced by: The facilities guideline APIC Guideline for Handwashing and Hand Antisepsis In Healthcare Settings, reviewed on 8/17/03, includes, in part: . 1. Hands must be washed thoroughly with soap and water when visibly soiled. 2. Bacteria on hands must be removed by hand washing with soap and water or by hand antisepsis with alcohol-based hand-rubs (if hands are not visibly soiled): b. Before and after caring for each resident. d. Before and after using the toilet. f. After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated. g. Every time a person puts on or takes off gloves. Other aspects of hand care and protection: 7. Glove use: a. Gloves should be used as an adjunct to, not a substitute for, handwashing. b. Gloves should be used for hand-contaminating activities. Gloves should be removed, and hands washed when such an activity is completed and before there is a risk of contaminating the environment with the material that is on the gloves, when the integrity of the gloves is in doubt, and between patients/residents. Gloves may need to be changed during the care of a single patient/resident, for example when moving from one procedure to another . The facility policy titled, Prevention and Control of Antibiotic Resistant Organisms, reviewed on 7/14/21, includes, in part: . Enhanced barrier precautions should be used when: B. Resident has draining wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, [CONDITION(S)]/ventilator) regardless of [CONDITION(S)] (multidrug resistant organism) colonization status residing in an at-risk area. The facilities Enhanced Barrier Precautions, sign states in part: . Everyone Must: Clean hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Wound Care, and Device Care or use: central lines, urinary catheter, feeding tube, [CONDITION(S)]. Example 1 R48 was admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/30/22 at 9:37 AM Surveyor observed peri care (cleaning of the front & back pelvic region) and catheter care on R48. CNA C (Certified Nursing Assistant) took R48 to the bathroom. The catheter leg bag was attached to the LLE. Gloves were put on by CNA C without prior hand hygiene. CNA C washed, rinsed and dried the peri area, both front and back without changing gloves or washing her hands. CNA C pulled up the R48's brief and pants without changing her gloves or performing hand hygiene. Surveyor observed CNA C complete catheter care on R48. CNA C did not wear a gown during procedure. Facility policy is to use enhanced barrier precautions with any resident with a catheter. On 3/30/22 at 1:48 PM, Surveyor observed R48's wound care by RN WCC D (Registered Nurse, Wound Care Certified). Observed barrier placed between recliner foot stool and lower extremities. Hands washed, old dressing was cut off and removed along with non-adherent pads, wound areas cleansed. Gloves were not removed. Areas on RLE cleansed and [MEDICATION(S)] (a cream that works by stopping the growth of bacteria that may infect an open wound.) reapplied with a cotton swab. Lotion was put on R48's feet and lower leg. This task was observed being completed without removing gloves or washing hands. Gloves were not changed; hands were not washed or sanitized by RN WCC D. RN WCC D, applied [MEDICATION(S)] to the area on the inner aspect of the RLE OA (open area). Honey applied on R48's heel, though it's not open, treatment is for maintenance per RN WCC D. Areas were covered with non-stick pads and wrapped with gauze. The scissors used to cut clean gauze, were not sanitized between usage. RN WCC D stated that the resident should have zero gravity boots on when in the bed and in the recliner. RN WCC D removed her gloves, hands cleansed, and new gloves applied. LLE (left lower extremity) treatment; Surveyor observed the same scissors being used again to cut off the old dressing, that was removed and discarded. The LLE area was cleansed, and RN WCC D touched the entire LLE with the same gloves, that were used to remove the old dressing. Continuing to use the same gloves, the LLE area was cleansed, lotion applied and non-adherent (non-stick) pads with Medi honey (medical grade honey) were applied to the lateral aspect of the left heel followed by abd (abdominal pad) for cushion, then wrapped with gauze. Clean gauze was then cut with the same scissors that have not been sanitized by RN WCC D. The remaining open areas on the RLE, per RN WCC D are wrapped more for comfort and padding for the heel. Boots reapplied bilaterally On 3/30/22 at 10:02 AM, Surveyor interviewed CNA C. Surveyor asked about enhanced barrier precautions. She replied they only have to wear a gown, when they are emptying the catheter. Surveyor asked about wearing a gown when completing catheter cares. CNA C replied, only when emptying a catheter. Surveyor asked when to perform hand hygiene. CNA C replied she should have completed hand hygiene prior assisting R48 into the wheelchair. Surveyor asked if she should have completed hand hygiene at any other time. She stated she will have to review the policy. Surveyor asked CNA C if she has ever been observed completing hand hygiene. She stated she does not remember. Surveyor asked if hand hygiene should have been completed when going from dirty to clean. She stated she was not sure. Example 2 R21 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R21 has a foley catheter in place and was placed on Enhanced Barrier Precautions. On 3/30/22 at 9:47 AM, Surveyor observed CNA C (Certified Nursing Assistant) emptying R21's catheter. CNA C put on a gown prior to entering the room, gloves put on, without performing hand hygiene. Barrier placed on the floor, to set the urinal on. Catheter tubing tip wiped with an alcohol pad before and after emptying the catheter into the urinal. R21's urine was dumped into the toilet. CNA C's Hands were washed prior to leaving the R21's room. On 3/30/22 at 10:02 AM, Surveyor interviewed CNA C. Surveyor asked about enhanced barrier precautions. She replied they only have to wear a gown, when they are emptying the catheter. Surveyor asked about wearing a gown when completing catheter cares. CNA C replied, only when emptying a catheter. Surveyor asked when to perform hand hygiene. CNA C replied she should have completed hand hygiene prior to pulling up the brief and pants. Surveyor asked if she should have completed hand hygiene at any other time. She stated she will have to review the policy. Surveyor asked CNA C if she has ever been observed completing hand hygiene. She stated she does not remember. Surveyor asked if hand hygiene should have been completed when going from dirty to clean. She stated she was not sure. On 3/30/22 at 2:12 PM, Surveyor interviewed RN WCC D. Surveyor asked the protocol for the use of scissors. She replied that each resident has their own treatment scissors, and they are cleaned after being done with treatment and at the end of the day by RN WCC D. Surveyor asked when hands should be washed. RN WCC D replied when She washes her hands and changing gloves and when going from dirty to clean. On 3/30/22 at 2:41 PM, Surveyor interviewed DON B (Director of Nursing) and asked if hands should be washed and gloves changed, when going from dirty to clean. She replied Yes, of course. She further reports that Hand hygiene audits are done as part of the Performance Improvement Plan (PIP).

Based on observation, interview, and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (R1, R4, and R5) whose call lights were not within reach. R1 experienced a laceration to his right arm requiring 22 sutures when he was unable to reach his call light and attempted to leave his room without staff assistance. This is evidenced by: R1, who is alert and oriented, has an initial admitted [DATE]. [DIAGNOSES REDACTED]. On 9/9/20, Surveyor reviewed R1's care plan, dated 8/10/20, which notes the following: Need/Preference: I NEED: to have someone help me with transfers. I: am at risk for injuring myself. BECAUSE I: Have [MEDICAL CONDITION] with triplegia, generalized muscle weakness I SHOW THIS BY: not being able to transfer and move around in bed on my own. Approach: .I need everyone to .Call light in reach. Encourage to ask for assist . Goal: MY GOAL IS TO: stay safe while I'm moving about avoid injury. R1's most recent Minimum Data Set (MDS), dated [DATE], has a documented score of 15 for the Brief Interview for Mental Status (BIMS), which indicates cognitively intact. Section G- Functional Status indicates that R1 requires extensive assistance with bed mobility and personal hygiene and is totally dependent on staff for transfers and toileting. On 8/30/20, R1 sustained a laceration to his right arm. Per the facility self-report, dated 8/31/20: .R1 reported to DOSS (Director of Social Services) that his wife had arrived on 8/30/20 and brought him Arby's. He reported she had been ringing the doorbell, but did not receive an answer from staff. His wife called him, and R1 stated his call light was not within reach and he yelled for help, but did not receive any assistance. He then opened the door and went out of his room to go to the nurse's station, but caught his arm on his door causing a skin tear . A staff interview with CNA E, dated 9/4/20, states she reported she knows that she forgot to move his call light from the trapeze to his bed. (Of note, no documentation of the incident was found in the facility nursing notes and this was confirmed by RN F and ADON C.) R1 was seen in the emergency roiagnom on [DATE], as a result of the laceration, and returned to the facility the same day. Per the emergency room report, R1 presented with .a right arm laceration after he was trying to go through his door in his scooter and he got caught that the (sic) hinge .He is on Eliquis currently . (Of note, Eliquis is a blood thinning medication) Report section labeled, Physical Exam, Skin, notes: .7cm x 3cm x 7cm tear not well approximated due to tension. No FB (Foreign Body). No [DIAGNOSES REDACTED]. Bleeding is controlled with dressing nursing home applied . Report section labeled, Procedures, Laceration Repair, notes: .Number of Sutures: 22 . On 9/9/20 at 9:46 AM, Surveyor spoke with R1 and asked how he gets staff assistance when needed. R1 stated he has two call lights in his room. One is kept on his trapeze at night and is supposed to be moved down to his bed once he is up in his chair (motorized wheelchair) and the other one is on the arm of his recliner. Surveyor asked R1 to share how he hurt his right arm. R1 stated that he was in his scooter (motorized wheelchair) and his call light was hooked onto his trapeze over the bed and so he couldn't reach it. His second call light (pointing to recliner) had blankets over it and it had slipped down between the arm and seat cushion and so it was too low for him to reach. His wife had called his cell phone and told him she had some supplies for him and no one was answering the front door. He didn't want her to leave and so when he realized he couldn't reach his call light he decided to go open his door and call out for help and that is when he caught his arm on the door and cut it. On 9/9/20 at 10:27 AM, Surveyor interviewed RN F and verified she was the nurse working the day R1 cut his arm. Surveyor asked RN F how she found out that R1's arm was bleeding. RN F stated that R1 came out into the hallway and that she was at the desk and heard him. Surveyor asked what RN F did when she realized R1 was bleeding. RN F stated she took him into his room, cleansed the area and realized it was deeper than what they could handle here. RN F stated that the Wound Care Nurse was also present and they both felt he needed to be seen in the emergency room . A dressing was applied to control the bleeding and he was sent to the ER. Surveyor asked if R1 reported to her that he couldn't reach his call light. RN F stated, yes, when it happened. On 9/9/20 at 2:40 PM, Surveyor interviewed RN F and asked if she recalled where R1's call lights were on the day he sustained the laceration to his right arm. RN F stated the one light was on the trapeze and not sure where the other call light was. She also stated an incident report was completed, however, they are having difficulty locating it. On 9/9/20 at 10:50 AM, Surveyor interviewed ADON C, who is also the wound care nurse. Surveyor asked ADON C what she recalled about the day R1 sustained the cut to his right arm. ADON C stated that RN F was the nurse on the unit and had notified her that R1 had a skin tear that would possibly need sutures. ADON C stated she assessed R1 with RN F and they felt he needed to be seen for sutures, applied a pressure dressing, and sent him to the emergency room . Surveyor asked ADON C if she was aware that R1 was not able to reach his call light. ADON C stated, yes, that RN F had told her. R1 was unable to reach his call light to ask for assistance. R1 tried to open door and call for help. R1, who has a [DIAGNOSES REDACTED]. This incident could have been prevented if R1 had his call light in reach and was able to receive assistance. Example 2 R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R4's most recent MDS (Minimum Data Set) dated 7/7/20 indicates the following: Section C- BIMS (Brief Interview of Mental Status) is 8 of 15 indicating that R4 has moderate impairment of cognition. Section G- Functional Status indicates that R4 requires extensive assistance with bed mobility and is totally dependent on staff for transfers and toileting. On 9/9/20 at 9:45 AM, Surveyor observed R4 lying in bed, call light noted to be on the floor between the bed and wall. On 9/9/20 at 1:43 PM, Surveyor interviewed CNA D (Certified Nursing Assistant). Surveyor asked CNA D if R4 was able to use her call light, CNA D stated that R4 is able to use her call light. Surveyor asked CNA D if R4 knows what she wants when she turns her call light on and is able to make her needs known, CNA D stated that R4 is usually able to tell staff if she wants something to drink, if she's ready to get up, or what she wants to eat. Example 3 R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R5's most recent MDS dated [DATE] indicates the following: Section C- BIMS 11 of 15 indicating that R5 has moderate impairment of cognition. Section G indicates that R5 requires extensive assistance with bed mobility and transfers. On 9/9/20 at 9:53 AM, Surveyor observed R5 sitting in his wheelchair, call light noted to be on the floor in between the bed and the wall. On 9/9/20 at 9:54 AM, Surveyor interviewed R5. Surveyor asked R5 how he calls for staff if he needs them, R5 stated that he pushes the call light. Surveyor asked R5 if he is able to reach his call light, R5 stated that he was unable to reach his call light because it was on the other side of the bed and laying on the floor. R5 told this Surveyor that he has told staff that when he is in the wheelchair the call light needs to be on the bed. On 9/1/20, the facility had provided education to staff titled Call lights & Calling for help, staff were to read the education and then sign the form to receive credit. The sign in sheet shows that as of 9/9/20 only 6 out of 16 staff working day shift had read the education provided and signed the sheet. On 9/9/20 at 10:44 AM, Surveyor interviewed CNA E. Surveyor asked CNA E if she had received any education recently about call lights, CNA E stated that she had not received any education recently but that she knows to answer them and to let maintenance know if they need to be fixed. When Surveyor asked CNA E what she knows about call light placement, CNA E stated that the call light should always be within reach. Surveyor asked CNA E when the last time she received education about call lights, CNA E stated that the last education she received was earlier this year when they had to go into a room that was all tore up and had to figure out what was wrong.

Based on observation, interview and record review the facility did not ensure residents do not develop pressure ulcers/injuries (PU/PI's) unless clinically unavoidable and the facility provides care and services consistent with professional standards of practice for 1 of 3 Residents (R34) reviewed for Pressure Injuries out of a total sample of 22 Residents. R34 developed an open area (meatal erosion) to his penis related to the use of a medical device (an indwelling Foley catheter). The facility did not assess this area as a medical device PI, and did not update R34's care plan to implement new interventions to relieve pressure of the Foley catheter from this site. R34's POA (Power of Attorney) was not updated on progression and no indication of Physician notification when area progressed. This is evidenced by: Facility Policy entitled 'Wound Care Protocol,' revision date of 10/25/17, states in part: It is the policy of (Facility name) that a resident who enters the facility without a pressure injury does not develop a pressure injury unless the individual's clinical condition demonstrates that it was unavoidable.To ensure residents have a comprehensive skin assessment that identifies risk factors for skin breakdown and appropriate interventions are put into place to prevent pressure injury development. To ensure residents having pressure injuries receive the necessary treatment and services to promote healing, prevent infection and prevent new injury from developing.7. Any pressure injury, stasis ulcer, skin tear, or other type of wound must be reported to the Unit Manager. In the absence of the Unit Manager, report area of concern to a supervisor, ADON (Assistant Director of Nursing), or house charge RN. 8. The nurse who identifies the skin alteration is to update the physician or nurse practitioner as soon as practicable so an appropriate treatment can be initiated. The physician or nurse practitioner must be notified of all open areas, skin tears, skin breakdown, or any other change in skin condition (i.e.: soft heels, blisters, abrasions, etc.). 9. All new pressure injury (SIC) will be comprehensively assessed and documented by a unit manager or other RN. A cause(s) should be identified while critically evaluating why the current preventive interventions failed. Revise preventative interventions as needed to alleviate pressure to the affected area. Initiate the wound treatment as ordered. 10. The pressure injury must be addressed in the care plan along with the treatment plan and appropriate interventions/approaches to promote healing and prevent further open areas from developing. 11. Existing pressure injuries will be measured weekly by the RN-WCC (Registered Nurse Wound Care Certified), unit nurse and/or other RN. Document in the Weekly Wound Charting folder. If signs of infection and/or lack of healing are identified inform the physician/NP . 18. The resident and/or responsible party must be made aware of any changes in condition and treatment orders. Per Wound Care Advisor, A medical device-related pressure ulcer (MDRPU) is defined as a localized injury to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace; splint; cast; respiratory mask or tubing; [MEDICAL CONDITION], collar, or strap; feeding tube; or a negative-pressure wound therapy device. Per the National Pressure Injury Advisory Panel (NPIAP) 'Best Practices for Prevention of Medical Device-related Pressure Injuries in Long Term Care,' poster states, in part: Choose the correct size of medical device(s) to fit the individual. Cushion and protect the skin with dressings in high risk areas . Inspect the skin under and around the devices at least daily (if not medically contraindicated).Reposition devices (if feasible). Avoid placement of device(s) over sites of prior or existing pressure injury or directly under an individual. Educate staff on correct use of devices and prevention of skin breakdown. Be aware of [MEDICAL CONDITION] under device(s) and potential for skin breakdown. Per Drugs.com, [MEDICATION NAME] has the following warnings, external use only.Do not apply to deep or puncture wounds. If condition worsens, or does not improve within 7 days, consult a doctor . R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R34's significant change MDS (Minimum Data Set) assessment, dated 10/7/19, indicated that R34 is moderately cognitively impaired and is able to make himself understood. R34 usually understands others. R34 requires extensive two person physical assistance with bed mobility and transfers. R34 requires one person extensive physical assist with toileting. Section H indicates R34 has an indwelling Foley catheter. Section M indicates R34 is at risk for developing PI's and currently is without pressure injuries. R34's quarterly MDS dated [DATE] indicates R34 has a BIMS (Brief Interview of Mental Status) of an 8 out 15 indicating moderate cognitive impairment. Section G indicates R34 needs two person physical extensive assist with bed mobility and toileting. R34 needs one person physical extensive assist with transfers. Section M indicates R34 is at risk for PIs and currently is indicated as not having any. R34's CNA (Certified Nursing Assistant) Care Plan indicates R34 is a mechanical stand up lift for transfers. R34 is a one assist for bed mobility and going to and from lying position and being repositioned side to side. R34 has a Foley catheter. Care Plan indicates CNAs are to observe skin with cares and toileting and to report changes to the nurse. R34's CNA Care Plan does not identify that R34 has any alteration in his skin related to his catheter. R34's Care Plan dated 1/2/20, states, in part: I: have a catheter because I have: [MEDICAL CONDITION]. I show this by: needing assistance to manage my catheter. I need my nurses to --- care for my catheter as ordered. I need my aides to --- keep track of my urine output, perform Cath care every shift .My goal is to: be free from urinary tract infections . R34's Care Plan dated 1/6/20, states, in part: I: have the potential to have a skin injury because I: can't move around well on my own, I need my nurses to--- reduce pressure and friction between myself and my bed or chair, elevate my heels when I'm laying (SIC) in bed, provide me with wound care, monitor my nutrition or hydration intake, monitor lab values. I need my aides to--- help me with hygiene and general skin care; avoid using hot water for washing and using moisturizer on my skin, elevate my heels in bed, reduce pressure and friction between myself and my bed or chair, assist with regular repositioning. Use pressure redistributing devices: ROHO cushion (pressure relieving cushion) in w/c (wheelchair), elevate heels when in bed, APP (alternating pressure pad) mattress. I need Nutrition staff to--- discuss my nutrition needs with me, monitor my lab values, provide me with enough nutrition and fluids to help me heal. My goal is to: keep my skin healthy and intact. R34's Care Plans, do not identify him having a penile erosion, being at risk for penile erosions or further interventions to keep this area from further deterioration. R34's Physicians Orders signed on 2/3/20, states, in part: 07/23/19 Treatment: Urinary: Other: indwelling Foley catheter care every shift AM (days) PM (evening) NOC (night) .Reason for indwelling catheter retention. 07/23/2019 Treatment: Urinary: Change indwelling Foley catheter . every shift as needed. Reason: malfunction. 07/23/2019 Treatment: Skin: Apply [MEDICATION NAME] Cream (facility stock) Location: penis every shift AM PM NOC Reason: irritation. Administration Instructions: cleanse penis with gentle cleanser and dry, then apply [MEDICATION NAME] to small area on shaft. Update NP (nurse practitioner) if sx (symptoms) worsen or do not improve. R34's Daily Skin/Wound Note's from 7/23/19 to 9/13/19 do not mention any skin areas of concern. Notes indicate [MEDICATION NAME] being applied per orders. On 9/13/19 at 2:46 PM, R34's 'Daily Skin/Wound Note,' states, in part: Increased [MEDICAL CONDITION] in penis, scrotum. Unable to retract foreskin. Cleansed area, [MEDICATION NAME] applied to irritation on foreskin on end of penis . On 9/30/19 at 3:05 PM, R34's 'Daily Skin/Wound Note,' states, in part: .irritation on foreskin improved but still present. Penile/scrotal [MEDICAL CONDITION] reduced . On 10/1/19 at 5:51 AM, R34's 'Urinary Findings,' note states, in part: Resident penis and scrotum more [MEDICAL CONDITION] this shift than the previous shift. The penis is very firm to the touch, but not erect . Called (Hospice Agency) and requested a nurse visit as well as updated (Nurse Practitioners Name). On 10/1/19 R34's Nursing Facility Acute Visit Note, states, in part: .Nursing call to voicemail to report worsening scrotal [MEDICAL CONDITION] . On 10/4/19 at 12:10 PM, R34's Daily Skin/Wound Note, states, in part: .irritation on foreskin improved but still present. Penile/scrotal [MEDICAL CONDITION] reduced . On 10/9/19 at 11:35 AM, R34's 'Daily Skin/Wound Note,' states, in part: .irritation on foreskin improved. Slight redness noted, no open areas. No penile/scrotal [MEDICAL CONDITION] noted . On 10/21/19 at 4:20 PM, R34's Nurses Note, indicates that the Nurse Practitioner came to assess R34's left knee and [MEDICAL CONDITION] in R34's leg. There is no indication that R34's penile erosion was assessed or penis was assessed at this time by the Nurse Practitioner. On 10/25/19 at 4:22 PM, R34's Skin Observation Note states, in part: .increased risk (SIC) for skin impairment and injury r/t (related to) excessive [MEDICAL CONDITION], infection, variable cognition as well as safety awareness. There is no further indication of [MEDICAL CONDITION] or irritation documented to R34's penis or scrotum in R34's skin/wound notes and there is no mention of an open area to R34's penis at this time. On 11/25/19 (no time), R34's Hospice note states, in part: RN visit for Foley catheter issues, catheter is beginning to split meatus of penis. Pt (patient) denies pain at penile area or anywhere else. Laceration noted to bottom of penis; educate staff to rotate catheter leg strap and bag daily from left to right side and ensure there is slack in the line for both comfort and to decrease trauma at insertion site . On 11/25/19 at 10:22 PM, R34's Nurses note states, in part: Monitor urinary meatus to see that the catheter has not migrated too far into the side of the penile head. Switch legs every day when placing the Foley and strap on said leg to reduce erosion on one side of penile head. Left leg every other day AM PM (The day you sign the box should also be the day the strap and Foley are on the left leg- unsigned days should be when the Foley is on the right leg .). There is no indication that R34's POA was updated on the area on his penis at this time or that a Physician was updated regarding this area at this time by the facility staff. There is no further indication of R34 having an open area or any type of deviation to his penis/meatal area after 11/25/19 to present (2/25/20) in R34's Facility Skin/Wound notes. On 11/25/19 R34's Hospice Visit Note states, in part: .Wound type: .Laceration/skin breakdown from Foley cath.Wound length (cm) (centimeters) 1 cm. Wound Width (cm) 0.3 cm. Wound Assessment Clean; Dry; Pink.Primary Dressing open to air.RN visit for Foley catheter issue, staff at facility report that catheter is beginning to split meatus of penis.Upon assessment, writer noticed laceration to insertion site. Staff state Pt Foley catheter strap and catheter bag are usually placed on Pt left side and not rotated. Pt did not c/o (complain of) on pain in penile area during assessment and denied pain overall. Writer switched catheter leg strap and bag to Pt right side. Writer educated both facility RN and facility CNA to rotate leg strap and leg bag daily from left to right side to further (SIC) any more breakdown of skin. Also educated the importance of making sure there is slack in Foley line for both comfort and decrease trauma to insertion site and meatus. Educated staff to contact (Hospice Agency) with questions, concerns, or changes in condition. POAHC (Power Of Attorney for Healthcare) was updated via e-mail . R34's Hospice Note dated either 12/4/19 or 12/7/19, unable to read handwritten date, indicates open area to patient's tip of penis 0.5 cm by 0.5 cm cleansed and applied barrier cream. On 12/11/19 R34's Hospice Note indicates patient continues to have a 0.5 by 0.5 cm open area on tip of penis, wound base red with granulation tissue. Area cleansed and barrier cream applied and left open to air. There is no further mention of R34 having any open areas or penile erosion from the catheter indicated in facility notes or hospice notes. There is no indication that staff are monitoring this area as there are no documented assessments of the area in R34's record and there are no measurements to ensure that the area is not progressing. On 12/13/19 R34's Nursing Facility Acute Visit Note, indicates no urinary concerns continues to have Foley. There is no mention of R34's penile erosion during this visit. On 1/8/20 R34's Physician Nursing Facility Routine Visit indicates, patient is currently using Foley catheter due to [MEDICAL CONDITION]. There is no mention of R34's penile erosion during this visit. On 1/29/20 at 2:46 PM, R34's 'Urinary Finding's,' note, states: Foley Catheter spontaneously dislodged during shower this afternoon, patient denies pain, no bleeding at site noted. Foley balloon was not inflated upon inspection, Foley catheter remains intact, moderate amount of sediment noted in tubing of catheter. Procedure Done: Foley catheter inserted, #14 french with 30 ml (milliliter) balloon inflated with 10 ml as patient c/o discomfort with > (greater than) 10 ml inflation. Patient tolerated well, no further c/o (complaints of) of discomfort. R34's catheter was replaced with a 14 French, 30 ml balloon that was only inflated to 10 ml, without a Physician or hospice order indicating to place a 14 french 30 ml balloon with 10 ml of fluid. When Surveyor asked for Catheter orders, no orders were provided from R34's Physician, Nurse Practitioner or Hospice Agency. Per R34's Nurses Notes, [MEDICATION NAME] continues to be applied daily per orders. R34's orders indicated to apply to penis, does not indicate which portion of R34's penis the [MEDICATION NAME] is to be placed. On 2/17/20 R34's Nursing Facility Acute Visit Note indicates R34 just completed a seven day course [MEDICATION NAME] Urinary Tract Infection and to continue to monitor urine. There is no mention of R34's penile erosion during this visit. On 2/25/20 at 9:45 AM, Surveyor and CNA F observed R34's peri area and catheter at this time. Surveyor observed R34's peri area. R34's catheter strap was observed to be on his left leg. CNA F was observed pulling R34's foreskin back in order for Surveyor to observe R34's penile head. R34's penile head is flayed from the meatus to bottom of penile head in to the frenulum (a small fold or ridge of tissue that supports or checks the motion of the part to which it is attached). R34's catheter sits in the flayed area when R34's penis is lifted to observe the underside of his penis. Penile periwound area appears healthy and pink. No evidence of infection or bleeding observed at this time. On 2/25/20 at 9:55 AM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R34's penile wound (meatal erosion). LPN D indicated she is unable to say how long R34's penile wound caused by his catheter has been present. LPN D indicated she has only worked the unit approximately a month. On 2/25/20 at 10:06 AM, Surveyor interviewed DON B (Director of Nursing) regarding R34's penile wound. DON B is unable to identify when penile wound began. DON B referred Surveyor to RN C (Registered Nurse). On 2/25/29 at 10:26 AM, Surveyor interviewed RN C regarding R34. RN C indicated R34's penile wound is a chronic condition. RN C indicates she will get back to Surveyor with when penile wound first occurred, interventions put in place, who is responsible for monitoring area, and whether the area should be measured. RN C indicated R34's penile wound is not a pressure injury and believes it is a chronic condition. RN C indicated that there was not an open area but an irritation at times to R34's penile head/meatus. RN C indicated R34's penile wound has had treatments on and off for irritation. RN C indicates she evaluates pressure injuries weekly. On 2/25/20 at 10:58 AM, Surveyor interviewed NP H (Nurse Practitioner) regarding R34 and NP H indicates she is unable to answer questions regarding R34's penile wound. NP H indicated she would defer all questions regarding R34's penile wound to DON B and RN C at this time. NP H indicated she is unable to say if she was aware of an actual meatal erosion/split. On 2/25/20 at 11:15 AM Surveyor placed a call to R34's Hospice agency. A message was left to have R34's case worker call Surveyor back, as she is out of the office at this time. On 2/25/20 at 11:27 AM, Surveyor spoke with NP H. NP H indicated she briefly looked at R34's record. NP H indicated that the penile wound is first mentioned on 10/1/19 as a small meatal split and blister. NP H indicates nothing has been reported to her since. NP H indicated R34's penile wound is followed by staff and hospice. NP H indicated she is unable to say if R34's penile wound is a medical device associated pressure injury as it is a symptom of having a chronic Foley catheter. NP H indicated R34's goal is for comfort and would treat any complication of R34's chronic Foley catheter symptomatically. NP H indicated she is not familiar with the NPIAP (National Pressure Injury Advisory Panel) Standard of Practice at this time. On 2/25/20 at 2:12 PM, Surveyor interviewed R34's POA G (Power of Attorney) regarding R34. POA G indicated he was not aware R34 had a penile wound. On 2/25/20 at 2:52 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and he indicated the facility does not have a policy on medical device associated wounds. On 2/25/20 at 12:56 PM, Surveyor interviewed RN C regarding R34's penile wound. RN C indicated it was an irritation that became an erosion from the catheter. RN C indicated that friction is not considered pressure and there is currently nothing in place to ensure penile wound does not deteriorate further. RN C indicated she would not expect it to be measured routinely if eroded. RN C indicated R34's penile wound was not being monitored regularly. On 2/25/20 at 1:40 PM, Surveyor and RN C observed R34's penile wound at this time. RN C indicated she was unaware that R34's catheter had eroded/split through R34's meatus into the penile head down into the frenulum. R34's penile wound appears to be approximately 2 centimeters in length and at least one centimeter wide at the widest part as the wound is in a shape of a V. R34's Foley catheter sits perfectly in the bottom of the V shaped penile deviation when R34's penis is lifted up to see under the penile head. On 2/25/20 at 3:06 PM, Surveyor interviewed LPN D and LPN E regarding R34's catheter. LPN D and LPN E indicated hospice sends R34's catheters over to facility. LPN D showed Surveyor a 16 French silicone catheter with a 10 milliliter balloon. LPN D indicated R34 currently has in a 16 French silicone catheter with 10 milliliter balloon in. LPN E indicated there is no physician order specifying what size or type of catheter to be used. The facility does not have an actual order for placement of a 16 French catheter with a 10 milliliter balloon. Therefore staff cannot be certain that this is the correct size catheter to be used on R34. Staff are not assessing R34's catheter size as being a contributing factor to his penile erosion/wound. On 3/2/20 at 9:30 AM, Surveyor received and reviewed additional information from NHA A (Nursing Home Administrator) regarding R34. Additional typed information provided by NHA A states, in part: Factors to consider: Level of alertness and activity fluctuated from somnolence to [MEDICAL CONDITIONS], hallucinations and attempts to self-transfer, would sometimes sit on the edge of the bed, 3 falls in November, related to self-transfers likely resulting in tugging or pulling on catheter whether it was secured or not.Muscosal tissue of the penis was compromised by the significant [MEDICAL CONDITION], any movement of the catheter tubing was likely to cause some irritation or trauma, regardless of interventions or position of the tubing. The incidences of skin impairment noted on 10/1/19 and 11/25/19 healed quickly with interventions and as [MEDICAL CONDITION] was brought under control (which was primary causative factor).11/4, 11/16 and 11/21/19, dates of falls by scooting out of his recliner. No matter how the catheter would have been secured, it likely sustained some pulling or tugging with him scooting off the end of recliner and footrest. Measurements of the split initially would have been inconsistent and would not have been an accurate (SIC) to determine healing or worsening because of the [MEDICAL CONDITION] and the distortion effect on the tissue. Once the area was healed, measurements would not be necessary-the mucosal tissue heals without scarring. The urethral opening now an irregular shape, but the tissue is able to regenerate. Hospice standing orders for catheters is 16-22 fr/5 ml (french/5 ml). (Name) from Hospice states that they start with a 16 and only go to the larger sizes if there is a problem. He has a size 16 fr. in place. (answer to no MD order for size - we had one, it just wasn't listed in the order to change the catheter PRN.) . Surveyor did not receive any type of catheter orders from Hospice or Hospice standing orders when Surveyor asked for R34's catheter orders. There is no evidence of the Hospice Standing Orders in the additional information that was provided, other than what was typed up by the NHA A.

Based on observation, interview and record review, the facility did not ensure that its medication error rate was 5 percent or less for 26 medication pass opportunities and 3 of 6 residents observed (R60, R271, and R27). The facility's medication error was 15.38 percent with 4 errors observed for R271, R60, and R27. R271 received 2 different insulins and the nurse did not prime the insulin pens before injections, if insulin pens are not primed the resident may not be receiving the correct dose of insulin. R60 received insulin when it should have been held and the nurse did not prime the insulin pens before injections. R27's [MEDICATION NAME] was left on greater than 12 hours and a new one was placed after removing the old patch. This is evidenced by: The facility's Medication Administration Policy revised on 4/27/18 states in part Medications will be administered in a safe and effective manner and according to the practioner's orders . The nurse . verifies the medication to be given: a) The medication name, dosage and interval are read from the Medication Administration Record [REDACTED]. b) The label on each medication card is read at all three of these designated times: before removing the medication from the card, when pouring or punching the medication and when putting the medication back in the drawer. The nurse . ensures the 5 rights. Right resident, right medication, right dose, right time and right administration route . Manufacturer's recommendations for administration of [MEDICATION NAME] Pen notes in part: Step 3 perform a Safety test, Dial a test dose of 2 units . Press the injection button all the way in and check to see that insulin come out of the needle. The dial will automatically go back to zero after you perform the test . Always perform the safety test before each injection . Manufacturer's recommendations for administration of Basaglar Kwik Pen notes in part: Priming your Pen, Prime before each injection . If you do not prime before each injection, you may get too much to too little insulin . To prime your Pen, turn the Dose knob to select 2 units . Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles in the top . Continue holding your Pen with the needle pointing up. Push the Dose Knob in until it stops and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the needle . Example 1: R271 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R271 Physician orders [REDACTED]. On 2/17/20 [MEDICATION NAME] 40 units sub-Q (subcutaneously) daily AM for Diabetes Mellitus On 2/17/20 [MEDICATION NAME] Insulin sub-Q per sliding scale Blood Glucose 151-200=2 units, 201-250=4 units . three times a day at 07:30 AM, 11:30 AM, 4:00 PM for Type 2 Diabetes Mellitus On 2/20/20 at 7:32 AM Surveyor observed LPN N (Licensed Practical Nurse) obtain R271's Blood Glucose reading of 211. Surveyor observed LPN N draw up 40 units of [MEDICATION NAME] from the insulin pen without priming the pen before drawing up the administered dose. Surveyor interviewed LPN N asking when she primes the insulin pen, LPN N stated that she primes the pen one time when they first open the pen. Surveyor observed LPN N draw up 4 units of [MEDICATION NAME] Insulin from the insulin pen without priming the pen. Surveyor observed LPN N administer both insulins into two different injection sites. Example 2: R60 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R60's Physician order [REDACTED]. On 10/30/19 (Basaglar Kwik Pen) Insulin [MEDICATION NAME] 100 unit/ ML Solution Pen-injector sub Q dose order (106 units) daily 800 AM for Type 2 Diabetes Mellitus On 2/18/20 Hold [MEDICATION NAME] (Basaglar) if Blood Glucose is less than 110 On 2/20/20 at 8:04 AM Surveyor observed LPN N obtain R60's Blood Glucose reading of 108. Surveyor observed LPN N take two Basaglar insulin pens and draw up 53 units in each pen without priming the pen. Surveyor observed LPN N administer the Basaglar insulin into two different injection sites to R60's abdomen. On 2/20/20 at 8:13 AM Surveyor was reviewing R60's record when LPN N came to Surveyor and stated that she should not have given R60 his Basaglar insulin as his order stated to hold the insulin if R60's Blood Glucose was below 110 and R60's Blood Glucose was 108. LPN N stated that she made an error giving the insulin when she should have held it, LPN N said she reported it right away to the Nurse Practitioner and was ensuring that R60 ate his breakfast. LPN N continued to monitor R60 and at about 10:30 AM LPN N reported to Surveyor that R60's Blood Glucose was 168 and had no negative effects from receiving the insulin. On 2/20/20 at 2:17 PM Surveyor requested the manufacturer's recommendations for use of insulins pens. Survey interviewed LPN N about administration of R271's insulin and R60's insulin. LPN N stated that she thought it was correct to prime the insulin pens when it was first opened, but agreed that it was not the correct procedure. On 2/20/20 at 2:45 PM Surveyor interviewed DON B (Director of Nursing) about insulin administration using insulin pens. DON B stated that the insulin pens should be primed before each dose to assure the correct dose is given and this was not done and should have been. Example 3: On 2/20/20 at 7:34 AM, Surveyor conducted medication administration observation with RN J for R27. R27 was observed to still have his Aspercreme [MEDICATION NAME] on from 2/19/20. RN J removed R27's patch at this time from his right hip and placed the new patch just slightly below where the old patch had been removed. RN J indicated the patch should have been taken off at bedtime on 2/19/20 as they're only good for 12 (twelve) hours. RN J indicated he made an error by not removing last night. R27's Physician Orders, signed on 2/6/20, indicates [MEDICATION NAME] 4% patch topical, 1 patch daily on AM off PM, apply to right hip. Manufacturer box for R27's Aspercreme [MEDICATION NAME] Patch, states Use 1 patch for up to 12 hours.

Based on interview and record review, the facility did not ensure residents who use [MEDICAL CONDITION] drugs have supporting documentation for use and provide non-pharmacological interventions for 4 of 6 residents reviewed for unnecessary medications (R33, R28, R34, & R60). R33 received [MEDICATION NAME] daily. The facility did not ensure it was for the correct [DIAGNOSES REDACTED]. R28 is receiving an antipsychotic medication without a proper [DIAGNOSES REDACTED]. R34 is receiving PRN (as needed) [MEDICATION NAME], which has not been renewed every 14 days and does not have a designated duration or time frame for usage. R60 was prescribed an as needed order for an antiolytic, which was in place longer than 14 days, without an end date and then again was ordered an as needed antiolytic without a stop date. This is evidenced by: The facility policy #3.8 [MEDICAL CONDITION] Medication Use includes the following: Facility should comply with the Psychopharmacologic Dosage Guidelines creased by the Centers for Medicare and Medicaid Services, the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacologic medications . The should not use [MEDICAL CONDITION] medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. Facility should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person-centered non-drug and pharmaceutical interventions . [MEDICAL CONDITION] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms . PRN (as needed) orders for [MEDICAL CONDITION] drugs should be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order . Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving [MEDICAL CONDITION] medication for organic mental syndrome with agitated or psychotic behavior(s) . Facility should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions . Facility staff should inform the resident and/or resident representative of the initiation, reason for use and the risks associated with the use of [MEDICAL CONDITION] medications, per facility policy or applicable state regulations. Example 1: R33 was admitted to the facility with on [DATE] with [DIAGNOSES REDACTED]. Her admission Minimum Data Set completed on [DATE] indicated she has moderately impaired cognition. R33's Care Plan includes, [DATE] the need to take [MEDICAL CONDITION] medications to treat Dementia with behavioral disturbance and depression; let nurses know if R33's mood or behavior seems worse or out of the ordinary . Keep track of the mood or behavior R33's taking the medication for and evaluate its effectiveness . R33's Care Plan did not include specific mood or behaviors she was taking the [MEDICATION NAME] for. Her care plan did not include to attempt non-drug interventions or list any that might work for R33. R33 was admitted with an order for [REDACTED]. On [DATE] the pharmacy review of her medication made the recommendation to [MEDICATION NAME] as augmentation for depression not her Dementia. If that is the case, please be sure POC (plan of care), target behaviors and Consents reflect that . Please remind staff to document these items as required by the regulatory guidance. On [DATE] at 8:36 AM Surveyor interviewed RN I (Registered Nurse) who was the nurse for R33's unit during the survey. RN I explained if a resident is on a [MEDICAL CONDITION] medication, they monitor specific target behaviors on the Medication Administration Record [REDACTED]. Surveyor asked if R33 had specific target behaviors to be monitored. RN I stated she would have to check the MAR. On [DATE] at 9:41 AM Surveyor interviewed RN C, who viewed R33's MAR indicated [REDACTED]. She stated the pharmacy recommendation of the [DIAGNOSES REDACTED]. Example 2: R28 was admitted on [DATE] and has [DIAGNOSES REDACTED]. R28's Quarterly MDS (Minimum Data Set) dated [DATE], indicates R28 is moderately cognitively impaired. Section B indicates that R28 is able to make herself understood and sometimes understands others. Section E indicates R28 does not have delusions or hallucinations and is not exhibiting any type of behavioral symptoms. Section N indicates that R28 received antipsychotic medications for 7 of the 7 days during the look back period. R28's Physician Orders, signed on [DATE], state in part: [DATE] [MEDICATION NAME] 0.25mg (milligram) tablet dose ordered: (2 tablet/0.5mg) by mouth twice a day AM (days) HS (bedtime) First date: [DATE]. For: Dementia with [MEDICAL CONDITION]/agitation/behaviors. [DATE] [MEDICATION NAME] 2.5mg P.O (by mouth) daily am x (times) 7 days then 5mg P.O. daily (at) h.s. [MEDICATION NAME] 0.5mg P.O daily at h.s [DATE] - [DATE]. Update NP (Nurse Practitioner) on [DATE]. R28's Telephone Order dated [DATE], states, in part: Stop AM dose of [MEDICATION NAME] [DATE]. Start [MEDICATION NAME] 2.5mg po Q (every) am starting [DATE] x 7 days then [MEDICATION NAME] 5mg po Q hs from [DATE] and stop [MEDICATION NAME]. R28's Telephone Order, dated [DATE], states, in part: Clarification: Stop [MEDICATION NAME] [DATE] (night dose) start [MEDICATION NAME] 5mg q HS [DATE]. Call (NP's name) or (Physician's name) response (SIC) in 2 wks (weeks). R28's CNA Care Plan provided to Surveyor, states, in part: Behaviors, resistive - potential, explain cares. Document behaviors. Please note there are no further behavioral interventions indicated on the CNA Care Plan for R28. R28's Care Plan provided to Surveyor, states, in part: I need: to take [MEDICAL CONDITION] medications to treat my condition(s) [MEDICAL CONDITION] with agitated [MEDICAL CONDITION], dementia. I need my nurses to --- Check if I am having medication side effects, keep track of the mood or behavior I'm taking the medication for and evaluate its effectiveness consider non-pharmacological approaches to support my prescription, talk with me about what I need. I need my nurses to --- Provide and encourage use of song lyrics as a way of distraction (folder kept at nurses station.) I need my aides to --- Let my nurse know if my mood or behavior seems worse or out of the ordinary, help me attend activities in a way that is comfortable for me, keep my routine consistent, let me make decisions about my care and day. I need social services to --- Keep track of the mood or behavior I'm taking the medication for and evaluate its effectiveness. My goal is to: benefit from taking the medication without negative side effects . [DATE] at 10:30 AM, R28's Behavior Note, states, in part: . repetitive behavior calls out frequently whenever staff in view. [DATE] at 10:30 AM, R28's Behavior Note, states, in part: .was less combative with shower this AM. Was yelling out but did not attempt to scratch or hit aide. [DATE] at 11:25 AM, R28's Behavior Note, states, in part: .Did briefly call out for husband . when informed he was not here she stated oh, okay. Maybe I'll see him later. Moved on to reading from book of song lyrics without further incident. Also watched tv with other residents in main solarium. No crying, yelling out, or inappropriate interactions with staff or peers. [DATE] at 7:35 AM, R28's Behavior Note, states, in part: .During shower resident still called out throughout the shower but was more cooperative . writer is changing her shower from Mon PM (Monday PM) to Friday AM since morning seems to work better for resident at this time . [DATE] at 10:30 PM, R28's Behavior Note, states, in part: . Calling out for staff attention while at the dinner table but enjoyed reading for staff. No other behaviors noted. [DATE] at 11:01 AM, R28's Behavior Note, states, in part: Calling out for attention from staff while sitting in the dining area. Resident reading song lyrics most of the morning. Pleasant. No concerns noted. [DATE] at 1:36 AM, R28's Behavior Note, states, in part: late entry for [DATE] behavior: resident had very minimal calling out this shift. Was easily consoled and resident went back to sleep with no issues. [DATE] at 12:41 PM, R28's Behavior Note, indicates: late entry for [DATE] during shower resident still called out throughout the shower but was more cooperative. [DATE] at 1:25 AM, R28's Behavior Note, states, in part: late entry for [DATE] . During shower resident still called out throughout the shower but was more cooperative . [DATE] at 1:59 PM, R28's Behavior Note, states, in part: Irritable with staff while getting out of bed, has been smiling and cooperative rest of the shift . [DATE] at 10:52 PM, R28's Behavior Note, states, in part: Resident is up when author arrives, already calling out to staff and passers-by. It seems that if she is not given attention, she becomes more insistent, more agitated. Staff attempt to address her concerns and talk to her about whatever may have agitated her. She is more energized tonight calling out random names to everyone . [DATE] at 10:44 PM, R28's Behavior Note, states, in part: called out only to get staffs attention to ask staff questions or attempts to tell us something. Pleasant and cooperative. [DATE] at 1:14 PM, R28's Behavior Note, states, in part: Called out several times from her seat at the table in the solarium to speak to staff or residents, but no inappropriate behaviors, yelling, or crying . [DATE] at 9:47 PM, R28's Behavior Note, states, in part: Frequent calling out after supper but only wanted to talk to someone or try to ask a question. [DATE] at 10:11 PM, R28's Behavior Note, states, in part: Calling our (SIC) during and after supper but only wanted staff attention to try to tell us something or attempt to ask a question. [DATE] at 10:10 AM, R28's Mood Note, states, in part: Anxious, agitation, frequent calling out to staff with repetitive statements such as change duty a lot sir, change duty a lot, she gave me that, she gave me that, I can't stand up on my feet, I can't stand up, I can't stand while sitting at the dining room table. Interventions: 1:1 (one to one) interactions and conversation offered, appears agitated that staff is unable to understand her. Activity, attempts to read lyric books and color, back rub, massage/touch, no calling out with massage however resumes shortly thereafter. Offered snack, which was declined, toileted, reassured that lunch would be arriving soon and that staff is here to help with needs, left alone and reapproached. Outcome: unchanged [DATE] at 9:42 PM, R28's Behavior Note, states, in part: Frequent calling out for staff while awake but only wanted to try to ask a question or have staff near her. [DATE] at 9:25 PM, R28's Behavior Note, states, in part: Calling out to staff when up but only wanted to tell staff something or attempt to try to ask a question. [DATE] at 10:30 PM, R28's Behavior Note, states, in part: Calling out at the dinner table after supper but only wanted to get staff attention to try to tell staff something. [DATE] at 2:47 PM, R28's Behavior Note, states, in part: Did call out asking for (deceased husband)(name) Have you seen him? writer replied I had not seen him. Resident accepted that and was easily redirected to other topics. [DATE] at 10:37 PM, R28's Behavior Note, states, in part: Occasional calling out to try to ask a question or get staffs attention. Quiet and sleeping when in bed. [DATE] at 10:02 AM, R28's Behavior Note, states, in part: Calling out to staff. Talking to self at dining room table. There are no further indications of behaviors. There are no indications that R28's behaviors are harmful to herself or others based on the facility's charting for the last 3 months. On [DATE] 11:32 AM Surveyor spoke with FM M (Family Member) who indicated that R28 had a recent medication change. FM M is unsure if changing R28's [MEDICATION NAME] may be making her sleep more. On [DATE] at 12:34 PM, Surveyor observed R28 in the dining room. R28 was observed sleeping at dining room table in her wheel chair since 11:30 AM, when Surveyor interviewed FM M regarding R28. R28 was observed at this time to be not arousable by FM M in order to eat her meal. R28's [DATE], Physician Nursing Facility Routine Visit Note, indicates the following: Met with daughter who informs me that trial of tapering [MEDICATION NAME] failed. Her behaviors escalated and is much better with restoration of previous dose. Plan indicates stiffness more than likely from use of [MEDICATION NAME]. Will phase out [MEDICATION NAME] and phase in [MEDICATION NAME]; will try this for the next couple of weeks. Can back track if this strategy doesn't work. Physician met with the daughter and explained plan of management will continue to emphasize comfort cares. On [DATE] 01:51 PM Surveyor interviewed LPN L (Licensed Practical Nurse) regarding R28. LPN N indicated she did not see a consent for [MEDICATION NAME] in R28's chart. LPN L indicated that staff use diversional activities like pictures and a song book. LPN L indicated that R28 does yell out quite a bit but not in a negative way. LPN L indicated as an example that R28 yells come over here, come over here, is this my water. LPN L indicated she hasn't seen anything negative but R28's behavior is frequent and her volume is loud. LPN L indicated that R28 is easily redirected with a song book and picture book, and by sitting down and talking to her. LPN L indicated that R28's behaviors are not harmful to herself or others, just abrupt because of her loud voice. On [DATE] at 3:30 PM, Surveyor received a note from DON B indicating that the NP reviewed R28's [MEDICATION NAME] ([MEDICATION NAME]) use with R28's Power of Attorney, but a consent has bot been signed yet. R28 has been receiving [MEDICATION NAME] since [DATE] without a signed consent or a consent indicating a verbal consent was contained, which would be valid for 10 days. On [DATE] at 8:29 AM, Surveyor interviewed LPN D regarding R28. LPN D indicated that R28's behaviors are anxiety related outbursts and that R28 has a lot of calling out and shouting mixed anxious or overwhelmed characteristics. LPN D indicated that R28 has a lot of shouting help me, help me, help me and yells names out, rarely knows the staff by their names. LPN D indicated again that R28 repetitively calls out and has verbal out bursts with cares. LPN D indicated that R28 will say don't touch me and is able to be redirected by giving her time and by explaining the cares to her. LPN D indicated R28's behaviors are persistent, but they have gotten better or improved but has periods of increased behaviors. LPN D indicated at times she seems in distress during increased anxiety periods and can affect the atmosphere of her peers, but is not harmful to her peers as she can be redirected. On [DATE] at 9:57 AM, Surveyor interviewed DON B regarding R28's behaviors. DON B indicated that R28 was on [MEDICATION NAME] and now [MEDICATION NAME] due to dementia, for behavioral issues and has been on the medication long term. DON B indicated that R28's behaviors have improved with interventions while on the unit. DON B indicated that when she first came she had more agitation and yelling out. DON B indicated that most of R28's agitation and yelling out now occurs around bathing and ADL (Activities of Daily Living) and that has improved as well. DON B indicated it happens every time staff bathe R28. DON B indicated that R28's behaviors are not harmful to her self or others at this time but if she was striking out at staff and not allowing cares to be done they could be harmful. DON B indicated that calling out behaviors are not harmful and that agitation behaviors are not harmful. DON B indicated that calling out could be emotionally harmful, but staff respond and comfort her therefore it's not harmful to her. DON B indicated that R28's medication was changed from [MEDICATION NAME] to [MEDICATION NAME] due to stiffness. Example 3: R34 was admitted on [DATE] with [DIAGNOSES REDACTED]. R34's Physician Orders, singed on [DATE], states, in part: [DATE] [MEDICATION NAME] 0.5mg (milligram) tablet. Dose ordered: (1 tablet/0.5mg) by mouth every 4 hours as needed. First Date: [DATE]. For: Anxiety, restlessness, nausea. There is no duration of time indicated for R34's [MEDICATION NAME], to indicate extended use beyond 14 days. There is no evidence in R34's record that R34's [MEDICATION NAME] order has been reordered or re-evaluated every 14 days for continued use. On [DATE] at 9:48 AM, Surveyor interviewed DON B regarding PRN [MEDICATION NAME] orders. DON B indicated that Residents can be on PRN [MEDICATION NAME] for as long as they need to be. DON B indicated that they have the initial order then they would receive a 14 day review and would review on visits going forward. DON B indicated that R34's PRN [MEDICATION NAME] order should have a designated length of duration/use indicated and that you're unable to tell based on the order. DON B indicated that R34 has been receiving it as needed. Example 4: R60 was admitted to the facility on [DATE] with diagnoses, including: major [MEDICAL CONDITION] and encounter for palliative care. R60's Physician orders [REDACTED]. R60's Pharmacy review, dated [DATE], includes, in part: (R60) has as needed order for an anxiolytic, which has been in place for greater than 14 days without a stop date: [MEDICATION NAME] 0.5mg every 6 hours as needed for anxiety, restlessness started [DATE] around the time she was suspected of having an Urinary tract infection. Recommendation: Please discontinue as needed [MEDICATION NAME]. If medication cannont be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy, and rationale for the extended time period. Rationale for recommendation: Center for Medicare and Medicaid Services (CMS) requires that as needed order for non-antipsychotic [MEDICAL CONDITION] drugs be limited to 14 days unless prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the as needed order . I decline recommendation above and do not wish to implement any changes due to the reasons below. Rationale: Patient on hospice with goal of care for comfort continue as needed [MEDICATION NAME] as benefit outweighs risk. signed [DATE] . R60's hospice note, [DATE], includes, in part: . Notes: Writer called patient's son (named) and left a voice message to call writer back. Writer faxed new order for [MEDICATION NAME] to the facility and informed (named RN) that medication had been called into the pharmacy. Writer was on another visit when (named son) called. Writer explained assessment and what medication was ordered. (Named son) is okay with the patient having [MEDICATION NAME] and thanked writer for calling him. R60's telephone orders, include: [DATE] . continue as needed [MEDICATION NAME] 0.5mg every 6 hours as needed for anxiety and restlessness/comfort . R60's Medication Administration Record, [REDACTED]. given: ,[DATE] and ,[DATE] There is no noted duration on this as needed order for [MEDICATION NAME].

Based on interview and record review, the facility did not conduct care conferences that included the participation of the IDT (Interdisciplinary Team), resident or resident's representative for 1 of 8 sampled residents (R26). Per interview with family, facility staff, the IDT does not meet quarterly to comprehensively review the resident's care plan or hold a care conference. The State Agency received an anonymous complaint on 12/11/19 stating the facility does not have Care Conferences and that resident representatives are not invited. This is evidenced by: Surveyor requested a copy of the facility's policy and procedure related to care conferences. No information was received. R26 was admitted to the facility on [DATE]. Review of R26's MDS's (Minimum Data Set) Assessments note that R26 had assessments as follows: Quarterly on 3/14/18, Quarterly on 6/10/18, Quarterly on 8/14/18, Annual on 1/27/19, Quarterly on 4/16/19, Quarterly on 7/11/19, Quarterly on 10/6/19 and Annual on 12/29/19. Review of R26's record notes the facility held a Care Conference with the IDT and R26's family on 1/3/18, 6/22/18, 8/9/19. Upon request there was no other information provided regarding R26's Care Conferences since 8/9/19. On 2/19/20 at 3:38 PM Surveyor interviewed R26's wife and is also R26's (APOA-HC) Activated Power of Attorney who stated that she could only recall having one Care Conference in 2 years and thought it was supposed occur more often than that. On 2/25/20 at 9:55 AM Surveyor interviewed SW S (Social Worker) about resident Care Conferences. SW S said that Social Services was in charge of the process, that they invite the resident and resident representatives. SW S stated that the facility is trying to call and get Care Conference Meetings scheduled consistently. SW S stated that this is not documented. SW S stated that Care Conferences should be held quarterly and with each comprehensive assessment and should document if the resident or representative attends or declines to attend. On 2/25/20 at 12:49 PM Surveyor interviewed NHA A (Nursing Home Administrator) who stated the facility had identified that Care Conferences were not be completed and documented on 8/28/19 and the facility was working on a PIP (Performance Improvement Plan) for this, but had not completed it yet. Plan includes in part: to develop a method of inviting the Resident and/or Resident Representative to Care Plan Conferences . Complete Care Plan Conference Charting Audits . Surveyor reviewed the plan noting that there was no evidence action items had been completed to assure Care Conferences were now being completed and documented for residents. NHA A stated that the facility has not received any concerns or grievances regarding resident Care Conferences. No further information was provided.

Based on observation, record review, and resident and staff interviews, the facility did not develop and implement a Comprehensive Resident-Centered Care Plan for 2 residents (R59, and R1) receiving anticoagulation therapy, out of 22 sampled residents reviewed. The facility did not develop a Care Plan for precautions or monitoring related to use of anticoagulation medication for R59, R59 was observed with bruises to her abdomen . This is evidenced by: Example 1: R59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R59's Physician order [REDACTED].>~1/18/20 [MEDICATION NAME] 40 MG /0.4 ML (Milligrams/Milliliters), sub-Q (subcutaneous) injection daily AM ~1/18/20 ASA (Aspirin) 81 MG, 1 tablet by mouth twice a day AM/ PM [MEDICATION NAME] Review of R59's Comprehensive Care Plan and CNA (Certified Nursing Assistant) Care Plan do not include any reference or interventions related to the use of anticoagulants ([MEDICATION NAME]) and Aspirin, such as special precautions and monitoring for/or reporting unusual bruising or bleeding. Review of R59's MAR (Medication Administration Record) for 2/20 notes administration of [MEDICATION NAME] 40 MG/0.4 ML sub-Q, but no there is indication of site rotation for the injections. On 2/24/20 at 10:50 AM Surveyor observed CNA P (Certified Nursing Assistant) transfer R59 from her chair to her bed. Surveyor observed multiple bruises to R59's abdomen, one bruise was purple measuring about 2 inches by 6 inches, and 2 fading yellow/green bruises measuring about 1.5 inches by 1.5 inches on the right abdomen, and 3 purple to yellow bruises on the left abdomen each measuring 1.5 inches by 1.5 inches. Surveyor interviewed CNA P asking how long R59 has had those bruises, CNA P stated she did not know. Review of R59's Nurses Notes note: On 2/24/20 11:58 AM NP updated on bruises to abdomen concurrent with [MEDICATION NAME] injections ([MEDICATION NAME]). It is important to note that documentation of bruising did not occur until after Surveyor asked about R59's bruises. On 2/24/20 at 3:36 PM Surveyor interviewed RN O (Registered Nurse) asking if there should be a care plan for R59 for monitoring for bruising and bleeding related to long term use of anticoagulants and Aspirin use. Surveyor reviewed R59's Care Plan and CNA Care Plan with RN O. RN O stated the nurses should notice the bruises when they give the injection to R59. RN O stated that [MEDICATION NAME] and Aspirin use would increase R59's risk for bleeding and bruising and there should be a care plan for that and there was not. On 2/24/20 at 3:50 PM Surveyor interviewed DON B (Director of Nursing) about R59's use of anticoagulants and her observed bruises to her abdomen, DON B stated that monitoring for bruising and bleeding should be under the skin care plan and we should have injection sites marked on the MAR for R59 and this was not done. Example 2: R1 was admitted to the facility, on 5/13/17, with diagnoses, including: multiple schlerosis, [MEDICAL CONDITION], chronic [MEDICAL CONDITIONS], aneurysm of lower extremity (11/4/19) and [MEDICAL CONDITION]. R1's Physician orders, 1/2020, include, in part: Apixiban 5 MG tablet by mouth twice daily, start date 1/30/2020 for [MEDICAL CONDITION] Fibrillation. R1's CNA Care Card does not indicate R1 is on an anticoagulant medication or that he is a high risk for bleeding and bruising due to his anticoagulant medication use. R1's Comprehensive Care Plan does not indicate R1 is on a high risk medication (Apixiban) and does not include goals and interventions related to R1's use of anticoagulant medications. On 2/25/20 at 3:45 PM during an interview, DON B indicated R1's comprehensive care plan and CNA care plan should identify R1 as being a higher risk to bleeding and bruising due to his use of anticoagulant medication. DON B also indicated R1's comprehensive care plan and CNA care plan should include interventions and goals related to R1's anticoagulant use.

Based on observation, interview and record review the facility did not ensure 1 of 18 sampled residents (R26) was assisted with meals, which is associated with activities of daily living (ADLs). R26 was observed at mealtime not receiving assistance and R26 was unable to feed himself. This is evidenced by: R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R26's quarterly MDS (Minimum Data Set) assessment on 12/29/19 notes that R26 requires supervision and set up assist with eating. R26's CNA (Certified Nursing Assistant) Care Plan, dated 2/19/20, under Dietary notes Regular diet, scoop plate, built up handle utensils. It is important to note there is no indication how much assistance R26 requires with meals. R26's Comprehensive Care Plan dated 12/31/19, notes in part: R26 can't complete cares on my own because of muscle weakness, get confused, have dementia . having trouble making decisions, not being able to tell you what I want or need . I need my nurses to assess my functional level . I eat with supervision with scoop plate and built up handle utensils . Goal: Maintain my ability to feed self . Review of R26's Rehab Recommendations to Nursing document dated 10/23/19 notes in part: Feeding . Limited Assist, Problem: Scoop plate and built up handle utensils . It is important to note this document notes choices of Independent, Supervision, Limited Assist, Extensive Assist and Dependent for assist. On 2/19/20 at 12:00 Noon, Surveyor observed at lunch R26 sitting with his food in front of him, not feeding himself for 25 minutes before staff provided assist (scoop plate and built up utensil handles were in place). After 25 minutes, staff did provide R26 with a fresh plate of hot food which R26 declined but R26 did eat 100 percent of his desert. On 2/20/20 at 9:10 AM Surveyor spoke with CNA R about when R26 might being going to breakfast, CNA R stated that he would be going to get R26 into his wheelchair and would be sitting with R26 for breakfast. On 2/20/20 at 9:50 AM Surveyor observed R26 being given his breakfast (sausage and oatmeal) and CNA R handed R26 his juice glass with a straw then CNA R left R26. R26 drank 1/2 of the orange juice then appeared to fall asleep resting his juice glass on the edge of the table. At 10:05 AM Surveyor observed a CNA stop and cue R26 to eat, R26 fed himself one bite of sausage and finished drinking his orange juice and set the glass on the table and sat in the same position watching television. At 10:36 AM Surveyor observed a dietary staff greet R26. Surveyor observed a nurse walk by the dining area, no other staff offered to help R26 or check on R26. R26 did not feed himself any more food. At 10:49 CNA R came to R26 and offered to heat up his food and got R26 a glass of orange juice for R26 then sat down to help R26 finish eating. On 2/25/20 at 7:30 AM Surveyor observed R26 sitting in the dining area with his breakfast in front of him, R26 was holding a piece of toast partially cut in half, but R26 was unable to get it to his mouth, R26 was sitting in the same position for about 4 minutes. Dietary staff were present and dishing up food. Surveyor did not observe other staff in the dining area. Surveyor went to get RN O (Registered Nurse) to check on R26. RN O stated that R26 needs help and sat down to help R26 with his breakfast. On 2/25/20 at 7:50 AM Surveyor interviewed RN O about how staff know how much assistance to provide to R26 at meal times. RN O stated it is on R26's Care Plan. Surveyor asked RN O what is the expectation if the R26 Care Plan says supervision? RN O stated that there should be someone in the area to monitor and if R26 is not taking the initiative to feed himself, someone needs to help him. Surveyor reviewed R26's CNA Care Plan with RN O. RN O stated the CNA Care Plan doesn't really say how much assistance R26 needs, but that nursing staff are frequently in the dining area and observe and cue R26 as needed. Surveyor reviewed R26's Rehab Recommendations to Nursing document dated 10/23/19, which indicates that R26 needs limited assist with dining, RN O stated she had reviewed this on 10/24/19 and did not include any specific instructions as to how much assist R26 required into his plan of care but should have. On 2/25/20 at 3:00 PM Surveyor interviewed SLP (Speech Language Pathologist) Q about what Limited Assist means on the Rehab Recommendations to Nursing for R26, SLP Q stated it means for staff to set up R26 and let him get started. If R26 doesn't continue to feed himself then staff should provide hands on assistance.

Based on observation, interview and record review, the facility did not ensure drugs and biologicals used were labeled in accordance with currently accepted professional principles and were not discarded after the expiration date for 1 of 3 medication carts observed affecting 1 supplemental resident of approximately 14 residents (R49) served from these medication carts. R49 had 8 vials of Duo Neb (albertol-[MEDICATION NAME]) in circulation that have a manufacturer expiration date of ,[DATE]. This is evidenced by: Facility Policy entitled '5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles,' revised on [DATE] states, in part: 5 .5.4 When Ophthalmic Solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle.7. Facility should store all medications and biologicals requiring special containers for stability in accordance with manufacturer/supplied specifications . Per Drugs.com, a [MEDICATION NAME] is a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. [MEDICATION NAME] and [MEDICATION NAME] are [MEDICATION NAME][MEDICATION NAME] that relax muscles in the airways and increase air flow to the lungs. R49's Physician Orders, signed on [DATE], state, in part: . ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] 0.5MG (milligrams)/3ML (milliliter)-2.5 (3) MG/3ML Solution dose ordered: (1ml) inhalation four times a day as needed . For: [MEDICAL CONDITION]. On [DATE] at 1:22 PM, Surveyor conducted a Medication Cart observation with RN K (Registered Nurse) on the(NAME)View unit. During this observation, Surveyor observed R49 to have a Duo Neb carton with 8 vials of solution. R49's carton had a manufacturer expiration date of ,[DATE]. RN K indicated that R49's vials are expired and should not be in the cart.

Based on interview and record review, the facility did not notify the physician or the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 3 residents (R1) reviewed. R1's APOAHC (Activated Power of Attorney for Health Care) representative was not notified of all of R1's falls or of changes in R1's fall care plan interventions. R1's physician was not notified when R1's bed and chair alarms were discontinued, on 2/6/19, and when R1's pulse was found to be below ordered parameters. This is evidenced by: The facility's Fall Risk Management policy, dated 1/15/17, states, in part: . The resident's POA (Power of Attorney) . will be informed of all falls regardless of whether there was an injury. Discretion can be used in deciding when to notify the family if the fall did not result in injury. Notification of fall occurring between 9:00 PM and 7:00 AM can take place as soon as possible on the next day . The facility's Acute Change in Resident Condition policy, dated 1/14/11, states, in part: The facility will promptly identify acute changes in resident condition and will notify the resident, his or her attending physician and POA/Guardian of the change . 4. In addition to acute changes, the nurse will immediately notify the physician/NP (Nurse Practitioner), the resident POA/guardian when . a significant change in the resident's physical, mental or psychosocial status (i.e., a deterioration in health .); Deemed necessary or appropriate in the best interest of the resident. A need to alter treatment significantly . Findings: R1 was reviewed as a closed record. R1 was admitted to the facility, on 12/20/18, with [DIAGNOSES REDACTED]. R1 had an APOAHC in place. R1's quarterly MDS (Minimum Data Set) assessment, on 3/14/19, noted a BIMS (brief interview for mental status) score of 3 of 15, indicating severe cognitive impairment. R1's CNA (Certified Nursing Assistant) Care Plan, dated 3/18/19, indicates that R1 was at risk for falls and was 1 assist with a gait belt for transfers. R1's Physician Orders, signed 12/20/19, include notification to physician if pulse is less than 50 or greater than 100. On 12/28/18 R1's NP wrote an order for [REDACTED].>Example 1 R1's Nurses Notes note the following: On 2/6/19 at 2:35 PM : Supportive Devices Assessment: Pad alarms have been used on the bed and chair for (R1) since time of admit, as (R1) has been and is at risk for falling. (R1) is impulsive and forgetful and continuously attempts self-transfers . The alarms are ineffective, because by the time staff respond to them, (R1) has already completed transfer or other task. Alarms discontinued as of 2/6/19, and the following interventions have been added to help mitigate risk for falls: Autolock brakes added to wheelchair; pouch attached to both walker and wheelchair for (R1) to safely transport items with (R1); walker kept in reach at all times; gripper socks on at all times; bathroom light on at night; check on when walking past room and remind (R1) to use the call light for help. (It is important to note that R1's NP or physician was not notified of the discontinuation of R1's bed and chair alarms when there was a specific order written for these devices on 12/28/18.) On 2/20/19 at 12:22 AM: Note states R1 had an unwitnessed fall without injury on 2/19/19 at 11:30 PM, found sitting on the floor in room, had slid off bed, wearing regular socks . family has not been notified yet. On 3/2/19 at 12:00 AM, R1 had an unwitnessed fall without injury, found sitting on the floor in room, transferred self without staff assist. (It is important to note there is no documentation regarding family notification for this fall.) On 3/18/19 at 6:50 AM, R1 has an unwitnessed fall without injury; found sitting of floor in room next to bed, may have slid self down onto the floor . Unit Nurse to update POA . There is no documentation the above 3 fall occurrences were reported to R1's APOAHC. On 4/22/19 at 1:07 PM, Surveyor interviewed RN C (Registered Nurse) about R1's falls and care plan. Surveyor asked if RN C completed R1's Supportive Devices Assessment and updated R1's care plan with new interventions on 2/6/19, RN C stated yes. Surveyor asked RN C if R1's APOAHC should have been notified of these changes, RN C confirmed they probably should have updated the APOAHC and did not. Surveyor asked RN C if R1's APOAHC was notified of R1's falls on 2/20/19, 3/2/19, and 3/18/19, RN C did not find any documentation that this was done. RN C stated R1's APOAHC should be notified of all R1's falls. Example 2 R1's Nurses Notes also include, in part: 1/23/19 at 12:58 PM: Pulse: 43 1/27/19 at 1:35 PM: Pulse: 48 3/2/19 at 10:59 AM: Pulse: 44 (Of note, R1's pulse was below the parameter of less than 50 and the facility did not notify the physician as ordered.) On 4/22/19 at 2:30 PM, Surveyor interviewed DON B (Director of Nursing) reviewing R1's falls, care plan and vital sign monitoring. Surveyor asked DON B if she would expect the staff to notify R1's APOAHC of falls, DON B stated that staff can notify the family the next morning if there was no injury from the fall. DON B indicated that R1's APOAHC should have been notified of R1's falls on 2/20/19, 3/2/19 and 3/18/19 and was not. Surveyor asked if she would expect the POA to be notified with changes to R1's care plan, DON B stated that she would. Surveyor asked DON B if she would expect the staff to notify R1's physician when R1's bed and chair alarm were discontinued (on 2/6/19) and when R1's pulse was below the parameter of 50. DON B stated yes, she would expect the nurse to consult with the NP or physician and staff did not.

Based on interview and record review, the facility did not ensure that each resident was free from physical, verbal and mental abuse for 1 of 17 sampled residents (R11). R11 suffered emotional and physical abuse when CNA O (Certified Nursing Assistant) left R11 in her room, did not assure her call light was within reach, and shut the door. R11 could not open the room door on her own. CNA O was observed by CNA R arguing with R11 and R11 told CNA R that CNA O was nasty to her. CNA O was observed by CNA T being rough with R11 when assisting with cares, arguing with R11 about completing cares, yanking R11's shirt up. R11 talked with CNA T about how rough CNA O had been and R11 had informed CNA T about CNA O leaving her in her room for 1 hour and 45 minutes without a way to call for assistance. CNA O informed CNA T that R11 had to wait. R11 stated she was afraid that CNA O would do something harmful to her, R11 did ask CNA O to leave the next time CNA O came into R11's room to help care for her. Evidenced by: R11's [DIAGNOSES REDACTED]. R11 is her own decision maker. R11's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/9/17, indicates R11 is cognitively intact, is totally dependent with transfers, does not ambulate, and needs extensive assistance with dressing and toileting. R11's care plan, dated 9/27/17, includes, in part, the following: Problem: Self Care Deficit, dated 5/11/17; Approach: Call button in reach, dated 8/10/17. On 9/26/17, at 2:10 PM, Surveyor interviewed R11. R11 stated, on 9/22/17 during the PM (evening) shift, CNA O came into her room and wanted R11 to undress in her wheelchair. R11 stated it is too painful to undress in the wheelchair. R11 stated CNA O told R11 she would have to sit there, shut the door and left. R11 stated she waited 1 hour and 45 minutes and did not have a call light in reach. R11 stated due to her [MEDICAL CONDITION] arthritis she had a difficult time opening her room door, it took her 10 - 15 minutes to manipulate the door knob and open the door a few inches and then she hollered for assistance. R11 stated CNA O and CNA R came into the room to assist her. R11 stated she did not say anything about CNA O as she was afraid that CNA O might do something harmful to her. R11 stated that she spoke with CNA T and CNA P, on 9/23/17, on the AM (morning) shift, about what had occurred on the PM shift, on 9/22/17. R11 stated CNA T and CNA O told R11 to talk to her daughter about the incident and R11's daughter would know what to do. R11 stated CNA O did come in to assist her on 9/24/17 during the AM shift. R11 stated she felt CNA O had it in for her, she did not know if CNA O would hurt her so she did not talk to her that morning and CNA O left. On 9/26/17, at 4:35 PM, Surveyor interviewed RN G (Registered Nurse). It is important to know RN G is the Unit Manager. RN G stated R11 asked to speak with her on 9/26/17. RN G stated she went into R11's room around 2:00 PM and R11 informed her that CNA O wanted to undress R11 in her wheelchair. When R11 said she did not want to get undressed in the wheelchair, CNA O told R11 she would have to wait and left. RN G stated this was the first time R11 had told her this. Surveyor discussed the allegations R11 had told her with RN G. RN G stated she would have expected CNA T and CNA P to report the allegation when they learned of it on AM Shift 9/23/17. RN G stated she had not informed either DON B (Director of Nursing) or NHA A (Nursing Home Administrator). On 9/26/17, at 4:50 PM, Surveyor interviewed CNA T. CNA T stated, on 9/22/17 PM shift, she assisted CNA O with getting R11 off the bedpan. CNA T stated she assisted R11 to roll over and CNA O was cleaning R11 between her legs. R11 stated CNA O was not washing far enough between her legs and CNA O got rough and put too much pressure on R11 and R11 stated that it hurt. CNA O stated she was just cleaning R11 up. R11 stated CNA O did not know what she was doing. CNA O stated, I am a CNA and I know what I am doing and CNA O shoved R11 and R11 let out a grunt, as if it hurt. CNA T stated at this time CNA O and R11 were arguing about the cares. CNA O grabbed R11's gown to put it on her and R11 stated you didn't clean under my armpits. CNA O stated one night won't hurt you to not wash up, as you get cleaned up every morning, we are short. CNA T stated at this point CNA O yanked R11's shirt up. CNA O was not gentle and R11 has sore shoulders and is unable to lift her arms above her head. R11 yelled that she hurt and was going to report CNA O. CNA O stated go ahead, report me in the morning. R11 got quiet. CNA T stated she asked CNA O if she needed anymore assistance, CNA O stated, No and CNA T left R11's room. CNA T stated, on 9/23/17, she was caring for R11 along with CNA P. R11 was talking about how rough CNA O was with her, on 9/22/17 PM shift. CNA T stated she informed R11 that she should talk it over with her daughter and her daughter would know who to talk with. CNA T stated she also suggested R11 talk with RN G. CNA T stated she and CNA P, on 9/23/17, after caring for R11, went to speak with RN Q about R11's concerns with CNA O. CNA T stated RN Q told CNA T to write up her concerns. CNA T stated she did not write anything up because she didn't know who to tell or give her write up to. CNA T stated, on 9/24/17 AM shift, CNA O was assigned to the group with R11 on it. CNA O went to answer R11's light and came out of R11's room and stated R11 wanted a different caregiver. CNA O was assigned to a different group for the rest of the shift. CNA T stated, on 9/22/17, while she was in the room caring for R11 with CNA O, R11 did state she waited for 1 hour and 45 minutes before being laid down. CNA T stated CNA O said she told R11 she would have to wait. Surveyor asked CNA T if she thought the interactions could be allegations of abuse. CNA T stated, I see it as being abuse. On 9/27/17, at 2:30 PM, Surveyor interviewed CNA R. CNA R stated, on 9/22/17, CNA O asked if she could assist her with laying R11 down in her bed. CNA R stated when she and CNA O got into R11's room; R11 stated it had taken CNA O a long time to get back. CNA O argued about time with R11. CNA O stated she was sorry that R11 could not tell time anymore. CNA R stated CNA O was very sarcastic. CNA R stated she looked at CNA O and shook her head to stop talking. CNA O became quiet as they transferred R11 to her bed. CNA O went to roll R11 over and pushed R11, making R11 mad. R11 asked CNA R if she was going to be in the room, CNA R stated, Yes. R11 stated, Good, because CNA O was nasty to her. CNA R stated she and CNA O assisted R11 onto the bedpan, gave R11 her call light, and they left. Surveyor asked CNA R if she saw anything wrong with the interaction. CNA R stated CNA O should not talk to R11 that way. CNA R stated she should have reported the interaction to the nurse on 9/22/17. The facility failed to protect, investigate, or report the allegation made by R11 and observed by CNA R and CNA T. CNA O was allowed to work with R11 after observations were made by CNA R and CNA T. R11 stated she was afraid that CNA O would harm her in some way. Staff did not stop CNA O from continuing with cares when R11 stated CNA O was hurting her and CNA O was nasty to her. RN G did not immediately report the allegation to NHA A upon learning of the allegation.

Based on observation, interview and record review, the facility did not ensure that residents who enter the facility without a pressure injury (PI) do not develop a PI for 2 of 10 residents (R5 and R2) reviewed for PI's and PI prevention. R5 was admitted to the facility without a PI and was identified to be at risk for PI development. R5 developed an avoidable, unstageable PI which progressed to a Stage IV PI while in the facility. The facility failed to ensure that dressings were in place and PI deteriorated. R2 has a Stage 3 Pressure Injury (PI) on her coccyx. It is documented on 4 occasions. R2 was found with the wound dressing not intact and the Surveyor observed the dressing not intact during wound care. This is evidenced by the following: The facility's Wound Care Protocol, dated 3/1/05 and revised 2/15/16, includes in part: 9. Existing pressure ulcers are to be measured weekly by the unit nurse and unit manager or other RN. Document in the Weekly Wound Charting folder (on the tool bar). Each button should be used. If signs of infection and/or lack of healing are identified, inform the physician/NP (Nurse Practitioner). A clean pressure sore with adequate blood supply and nerve supply should show evidence of stabilization and/or healing within 2-4 weeks. 10. A resident with a pressure ulcer must have daily documentation completed. Document in the Daily Skin/Wound Note folder which will pop up when you sign off the treatment in the TAR (Treatment Administration Record). Dressing status, peri-wound status, signs and symptoms of infection, presence/absence of pain and interventions used, are to be addressed at least daily in the documentation. Wound Care Education Institute's guidance on wound care is: As wound tissues lose moisture, a cooling effect occurs in the wound. Because cells and enzymes function optimally at normal body temperature, a drop of just 2° C is sufficient enough to negatively affect the biological healing process. In fact, when a wound dressing is changed, it can take a wound base temperature up to four hours before it returns to normal. This is an important factor to consider when anticipating healing times, as well as when prepping your patient for a dressing change. Additionally, when tissue cooling occurs, it can lead to a higher risk of infection due to [MEDICATION NAME], and hemoglobin's increased need for oxygen. This, in turn, decreases the amount of oxygen available for [DIAGNOSES REDACTED]s, which fight infection. Example 1 R5 was admitted to the facility, on 4/26/97, with a re-admission date of [DATE]. R5's [DIAGNOSES REDACTED]. R5 is cognitively intact and her own decision maker. R5's most recent MDS, with an ARD of 7/06/17; Section G0110: bed mobility requires extensive assistance with 2 person physical assist; Transfer requires total dependence with two person physical assist. Section M0150: R5 is at risk for PI development. Section M0210: R5 has a PI. Section M0300: F. R5 has 1 unstageable PI due to coverage of the wound bed with slough and / or eschar. Section M0610: A. Pressure ulcer length 3.5cm (centimeter); B. Pressure ulcer width 3.5 cm and pressure ulcer depth 0cm. Section M0700: R5's most severe tissue type for any pressure ulcer is eschar. R5's Norton score, which is a skin risk assessment, dated 6/12/17, was 10, which indicates R5 is at high risk for skin breakdown. Nursing Comprehensive Care Plan: Impaired skin integrity, dated 7/07/17, which is manifested by (on 6-9-17): chronic skin breakdown, history of ulcers, PI to right ischium 6/6/17, includes in part: Approach, dated 6/9/17, Nurses-Administer tx (treatment) to right ischium as ordered. Weekly measurements. NP's (Nurse Practitioner) note, from 6/06/17, indicated, in part: Temp (Temperature) of 101 yesterday and generally not feeling well. Skin: Wound to left buttock (it is important to know that wound is actually on the right buttocks) is not making much progress in healing .Patient's incontinence is frequent and large making it difficult to keep dressings in place to buttock .Round ulcered area to left buttock pale in color, with some induration/firmness to periwound that is dark in color Slight odor .Assessment: Unstageable pressure ulcer of left buttock .Plan: Get culture of left buttock wound. Continue present wound cares . NP's note from 6/16/17, indicated in part: .Seen today for follow up for unstageable pressure ulcer of left buttock (it is important to know that wound is actually on the right buttocks) as reported by patient and nurse .Nursing home staff and or family express the following concerns regarding patient: Nursing describing hard eschar cap to wound surface that she wants me to take a look at .Skin: Wound to left buttock examined is-round in shape with soft slough surface to 95% of wound bed with edge having a bit of eschar noted; less induration to periwound today; slight odor .Culture: Heavy Escherichia Coli (Abnormal), Moderate [MEDICATION NAME] faecalis (abnormal), Moderate Gram Negative Rods (abnormal), Moderate Bacteria resembling skin flora; Assessment: Unstageable pressure ulcer of left buttock .Comment: Tx with Keflex to try and cover above bacteria to site . Physician order [REDACTED].>5/25/17 at 1245PM: Right buttock wound: Cleanse (with) wound cleanser. Skin prep to periwound skin, ILEX paste (zinc oxide based paste) to wound bed, allow to dry for at least 1 minute then cover (with) [MEDICATION NAME] dressing and [MEDICATION NAME] if needed. Change Q (every) 5 days and PRN (as needed) until resolved. 6/9/17 at 2:40PM: 1. D/C (Discharge) tx to right ischium 2. Right ischium: Cleanse wound with wound cleanser, pat dry. Apply thin layer of [MEDICATION NAME] wound dressing (Hydrogel) to wound bed, no sting barrier spray to periwound. Cover (with) foam dressing, (change) Qday and PRN until healed. 6/16/17: 1. D/C current treatment order for right ischial tuberosity deep tissue injury. 2. Tx for right ischial tuberosity deep tissue injury: Cleanse wound (with) wound cleanser, pat dry. Apply Venelex ointment to wound bed, skin prep to periwound, cover with foam dressing, secure with [MEDICATION NAME]. Change daily and as needed. 6/26/17 at 08:00AM: 1. D/C right ischium tx 2. Right ischium PI: Cleanse wound with wound cleanser, skin prep to periwound skin. Apply [MEDICATION NAME] active dressing, secure (with) foam and [MEDICATION NAME], (change) daily and PRN until slough removed. 7/07/17 at 2:30PM: If [MEDICATION NAME] active dressing is not available, follow this tx for right ischium: Cleanse wound with wound cleanser. Apply Santyl ointment to slough on wound bed. Fill wound cavity with fluffed non-woven sponge, cover with piece of ABD pad and secure with [MEDICATION NAME] and [MEDICATION NAME], Qday and PRN until slough gone. 7/10/17 at 1:00PM - General Surgery Instructions: Cleanse wound, (and 2 inches around wound) with soap and water, or wound cleanser, pat dry. Apply Santyl to the wound bed of the deep open wound only. Cover with bordered foam dressing. Cover clean coccyx with a bordered foam dressing as well to protect. Change dressings daily to open wound. Change protective coccyx dressing every 3 days and as needed if soiled. Date each dressing. Reduce pressure to area as much as possible. Up in chair for meals and activities. Patient has an air mattress. Reposition every 2 hours. 7/11/17 at 08:30 AM: Clarification: Right ischium tx: Cleanse wound (with) wound cleanser. Apply skin prep to periwound skin. Apply Santyl ointment to wound bed slough. Pack wound cavity (with) fluffed (open all the way up) non-woven sponge gauze, cover with foam dressing and [MEDICATION NAME] daily and PRN until slough gone. 8/4/17 at 11:20AM: Right ischium wound: Cleanse wound with wound cleanser. Wick excess moisture out. Apply skin prep to periwound skin. Apply Santyl ointment to wound cavity, fluff (with) gauze, cover wound opening with calcium alginate, followed by foam, then [MEDICATION NAME]. Daily and PRN till slough gone then re-eval. 8/11/17 at 12:30PM: 1. D/C current tx right ischium. 2. Right ischium PI: Cleanse wound (with) wound cleanser. Apply Santyl ointment to slough in wound bed. Skin prep periwound skin. Pack (with) calcium Alginate AG. Cover (with) foam and [MEDICATION NAME] Qday and PRN till slough gone. 8/18/17 - UW Plastic Surgery Wound Care Treatment Recommendations: Stop current wound treatments (when new treatments have been ordered and are available for application) and start treatment of [REDACTED].A.C. Therapy) dressings in the manner noted below; change dressings every Monday, Wednesday, Friday (or if a seal is lost with the VAC dressing, and you are unable to fix this within 2 hours); VAC settings to be 150 mm HG, Continuous suction 8/25/17 at 10:30AM: Right ischium wound: if wound vac is not functional or unable to replace dressing for wound vac, then follow this tx: Cleanse wound with NS (normal saline), Apply skin prep to periwound skin. Apply [MEDICATION NAME] wound dressing (ointment) to wound cavity. Pack (with) Calcium Alginate, cover (with) foam dressing PRN. R5's Wound Notes include, in part, the following entries: 6/08/17 at 4:30PM - Weekly Wound Assessment: Assessment type: Initial assessment 6/08/2017; Pressure injury: Unstageable - deep tissue injury in evolution; Area 1: Right ischial tuberosity; Onset/Discovery date: 6/06/2017; Wound tissue: dark red; Surrounding tissue: red and purple discoloration extending around the entire edge, induration present, tender with palpation. No increased warmth or odor. Area: length (cm) 2.0; width (cm) 2.5; depth 0. Comments: Wound was assessed on 6/06/17 by R5's NP. Wound culture obtained .Has an appropriate tx in place, difficulty maintaining integrity of the dressing due to incontinence. At high risk for unavoidable PI. 6/11/17 at 10:03 AM - Daily skin/wound note: Dressing was not in place at time of treatment . 6/12/17 at 06:55 AM - Daily skin/wound note: Dressing was not in place at time of treatment . 6/13/17 at 2:28 PM - Daily skin/wound note: Dressing was not in place at time of treatment . 6/14/17 at 11:03 AM - Daily skin/wound note: Dressing was not in place at time of treatment. Wound bed covered with eschar cap which is black on one side and light yellow on the other. Periwound slightly indurated, scant amount of drainage noted . 6/15/17 at 11:45 AM - Weekly Wound Assessment: Assessment type: Follow-up assessment; Wound tissue: Wound bed covered with slough/eschar cap, yellow in color with areas of black; Surrounding tissue: Red and purple discoloration surrounding entire wound; induration present as well; resident reports tenderness on palpation .moderate amount of purulent drainage noted on old dressing; Description: becoming larger; Area: length (cm) 3.3cm; width: 3.5; depth: 0; Comments: .There is currently difficulty in maintaining integrity of the dressing due to incontinence. At high risk for unavoidable PI. 6/18/17 at 11:20 AM - Daily skin/wound note: Previous dressing was not in place at time of treatment . 6/18/17 at 9:34 PM - Daily skin/wound note: Dressing was not in place at time of treatment . 6/19/17 at 10:31 AM - Daily skin/wound note: Dressing was not in place at time of treatment . 6/22/17 at 3:16 PM - Weekly Wound Assessment: Area: length (cm): 3.2cm; Width (cm) 3.4cm; depth: 0; Comments: .Very little changes noted in this wound, wound bed still covered with slough cap . 6/27/17 at 4:22 PM - Weekly Wound Assessment: Wound tissue: 100% yellow green slough, firmly adherent, but starting to break apart. Area: length (cm): 3.0; width (cm): 3.0; depth: unknown r/t slough; Comments: Debridement is needed . 7/07/17 at 6:09 PM - Weekly Wound Assessment: Wound tissue: Base is 100% firmly adherent gray slough .Area: length (cm): 3.5; width (cm): 3.5; depth: unknown r/t slough . 7/20/17 at 4:27 PM - Weekly Wound Assessment: Wound tissue: 90% firmly adherent gray slough. 10% granulation tissue; Area: length (cm):4.0; width (cm): 3.5; depth: Depth is unknown at present due to slough . (Of note, there is no Weekly Wound Assessment from 7-8-17 to 7-19-17.) 7/28/17 at 1:26 PM - Weekly Wound Assessment: Area (cm): 4.0; width (cm): 3.5; depth: Not known yet r/t slough 8/4/17 at 1:47PM - Weekly Wound Assessment: Pressure injury: Has full thickness of skin and subcutaneous (sic) tissue lost, exposing muscle and/or bone (Pressure Stg. 4); Area (cm): 4.0; width (cm): 3.5; depth: base of wound bed still covered with slough . 8/11/17 at 7:14 PM - Weekly Wound Assessment: Area (cm): 3.5; width (cm) 3.0; depth: 3.2 . 8/12/17 at 8:59 AM - Daily Skin/wound note: .Old dressing was in off at time of tx . 8/13/17 at 11:31 AM, Daily Skin/wound note: .Old dressing was not in place at time of tx . 8/16/17 at 5:18 PM - Weekly Wound Assessment: Area: length (cm): 3.5; width (cm): 3.0; depth: 3.0 . 8/19/17 at 11:25AM - Daily skin/wound note: . Old dressing was not in place at time of tx . 8/20/17 at 11:27AM - Daily skin/wound note: .Previous dressing not in place at time of tx . 8/21/17 at 5:18PM - Weekly Wound Assessment: Area: length (cm): 3.0; width (cm): 4.0; depth: 2.4 at 9:00, 3.8 at 3:00. Comments: .Initiating wound vac today (Important to note, R5 declined to have surveyor observe wound or wound vac dressing change procedure.) On 9/26/17, at 11:50AM, Surveyor spoke to ADON M (Assistant Director of Nursing) about dressing changes not in place at time of treatment. ADON M would expect that dressing wound be in place and if dressing is not in place at time of treatment, that nurse doing treatment would try something else. On 9/26/27, at 12:06PM, Surveyor spoke to RN N about finding the wound with previous dressing not in place at time of treatment. RN N stated that she would proceed with treatment if it was found that way. Surveyor asked if MD (Medical Doctor) was updated. RN N stated no, but that she talked with ADON M, who is the Wound Care Nurse as well. RN N stated that this was not charted. On 9/26/17, at 12:14 PM, Surveyor spoke to LPN C about finding the wound with previous dressing not in place at time of treatment. LPN C stated that she had let ADON M know of this, but did not document this in the chart. She did not update MD. On 9/26/17, at 2:05PM, Surveyor spoke with ADON M to see if she was updated by RN N or LPN C about dressing not being in place at the time of tx. ADON M couldn't recall if either talked with her about missing dressings and it wasn't documented that RN N or LPN C had updated her. On 9/27/17, at 1:00PM, Surveyor spoke with DON B about dressing not being in place at time of treatment. Surveyor asked DON B if dressing should be in place when going to do treatment and she stated, Yes. Also, if there were issues with dressings staying in place, that the MD should be updated. The facility failed to ensure that dressings were appropriately in place. This ended up creating a negative wound healing environment. MD wasn't updated timely about dressing not being in place, which resulted in deterioration of wound as evidenced by eschar to the wound bed. Example 2 R2's [DIAGNOSES REDACTED]. R2 is cognitively intact and her own decision maker. R2's Wound Care Notes include, in part, the following entries: 8/13/17, 10:02 PM, Daily Skin/Wound Note: Dressing was not intact at time of treatment, however, Purocol Plus Ag and [MEDICATION NAME] Blue still in wound and removed. 8/20/17, 9:48 PM, Dressing was not intact at time of treatment due to dressing falling off from pericare. 9/9/17, 9:51 PM, Dressing completed per treatment order. Old dressing not intact at time of treatment. 9/10/17, 9:59 PM, Dressing completed per treatment order. Old dressing intact at time of treatment. On 9/26/17, at 9:05 AM, Surveyor observed CNA K toilet R2. Surveyor observed R2 did not have a dressing on her coccyx. Surveyor asked CNA K if she removed the dressing. CNA K indicated that R2 has been sitting in her wheelchair since the night shift got her up and dressed. On 9/26/17, at 12:20 PM, Surveyor interviewed LPN C regarding R2's dressing not in place at the time of the toileting observation. LPN C indicated that R2 is up and dressed in her wheelchair when she arrives on the floor at 6:25 AM. LPN C indicated that the night shift CNA will get R2 up and dressed after the night nurse changes R2's dressing. LPN C indicated that the night CNA should have reported the dressing was not in place to the night nurse before getting her up in the wheelchair.

Based on observation, interview and record review the facility did not ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident 23). Resident 23 was able to exit the unit and enter a stairwell without staff knowledge because the alert system was not functioning. The failure to ensure adequate supervision when the alarm system was not functioning created a finding of immediate jeopardy that began on 10/5/16. Director of Nursing B was notified of the immediate jeopardy on 10/12/16 at 9:37 AM. The immediate jeopardy was removed on 10/9/16. However the deficient practice continues at a severity/scope of D (isolated/no actual harm) until all the components of training are completed. This is evidenced by the following: The facility has multiple floors. On the second floor there are at least five doors with Wanderguard alarms. The Wanderguard alarm is supposed to sound when anyone wearing a Wanderguard bracelet exits through the alarmed door. One of the alarmed doors is a set of double doors at the end of the hallway. On the other side of the doors is a small corridor. In the corridor to the left is an unalarmed door that leads to a stairwell with stairs ascending and descending. Straight ahead is another set of double doors that lead into the Assisted Living area. On 10/11/16, at 11:02 AM, Surveyor interviewed Maintenance J who stated that on 9/22/16 he was informed the Wanderguard alert system on the second floor door was not functioning properly. Maintenance J replaced the sensors at the exit on 9/22/16. On 9/26/16 Maintenance M again informed Maintenance J that when Maintenance M did his weekly checks of the Wanderguard system the second floor door was acting strange. Maintenance J looked at the system and noted that the antenna needed to be reset and that was completed. On 9/29/16 it was once again brought to Maintenance J's attention the system was not working right. Maintenance J determined the alarm was giving the pre-alert, soft chirp if near the doors, but was not annunciating if someone with a Wanderguard bracelet went through the doors. Maintenance J worked on the system until 10/5/16. Maintenance J stated he contacted the service company on 10/5/16 to come and look at the system because he could not get it to work consistently. Despite knowledge that the alarm on this set of doors was not working, the facility did not implement alternate measures to alert them if/when a resident with a Wanderguard bracelet went through the doors. On 10/10/16, at 3:15 PM, Surveyor interviewed DON B. DON B stated she was aware the sensor had been replaced recently but had thought the sensor had been fixed. On 10/11/16, at 3:24 PM, Surveyor again interviewed DON B. DON B stated she was told the Wanderguard sensor was replaced a couple weeks ago when Maintenance M noted it was not working on his weekly checks. DON B stated she was not aware that the Wanderguard sensor was not working after it was replaced. At 3:31 PM, Maintenance M joined the interview. Maintenance M stated he reported it to Maintenance J and Maintenance Director L when he noted it was not working. Surveyor then interviewed Maintenance Director L. Maintenance Director L stated he was informed the system was not working last week as it was not picking up the signal and that Maintenance J tweaked it. He was under the impression it was working. Resident 23, who resides on the second floor, has dementia. Resident 23's care plan identified the problem area of Identified Wanderer on 4/24/15. Resident 23's Minimum Data Set, dated dated [DATE] indicates Resident 23 has short term memory problems and requires two-person physical assistance for transfers. Resident 23 has had a Wanderguard bracelet since 4/24/15 to alert staff if she attempts to elope off the unit. Resident 23's progress notes indicate that on 10/9/16, at 6:45 AM, staff found Resident 23 in the stairwell on the other side of the double doors sitting on the third step going up. Resident 23's wheelchair was on the landing directly in front of her. Resident 23 was confused and agitated per normal. According to this progress note, Resident 23 had been restless, confused and intermittently agitated. She had been wandering into other's rooms. Resident 23's chair pad alarm was activated and alarming. Resident 23's Wanderguard was working but the stairwell Wanderguard was not working. Resident 23 did not have any injuries, although she could have been seriously hurt had she fallen down the stairs. There is no indication when the last time staff saw Resident 23 to determine how long she was off the unit and in the stairwell. New interventions included adding a personal alarm to the exit doors to alert staff if Resident 23's tried to go through the doors again and increase interactions when wandering. On 10/10/16, at 11:20 AM, Surveyor noted a personal alarm attached to the exit door on the second floor. On 10/10/16, at 11:23 AM, Surveyor interviewed Licensed Practical Nurse (LPN) K about the alarm on the door. LPN K stated the alarm was put on the door yesterday (10/9/16). Resident 23 is a frequent wanderer and she got through the doors again yesterday. LPN K stated she was told someone was coming today to fix the Wanderguard alarm on the door. On 10/11/16, at 11:02 AM, Surveyor interviewed Maintenance J. Maintenance J stated after Resident 23 got into the stairwell nursing put a personal alarm on the door. Maintenance J stated he thought they were doing that sooner but they had not. Maintenance J e-mailed DON B on 10/9/16 that they needed to get the Wanderguard sensor fixed immediately. The failure to ensure the environment was free of hazards and that Resident 23 received supervision while wandering the facility created a finding of immediate jeopardy. The facility removed the immediacy on 10/9/16 when it attached a personal alarm on the door until it could be fixed by the service company and provided additional interventions for Resident 23's wandering.

Based on observation, interview and record review the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 15 residents from a sample of 19 (Resident 5, 4, 14 and 16). The facility did not ensure that staff consistently followed care-planned approaches for preventing falls. Resident 5's fall interventions were not in place per care plan. Resident 5 fell and fractured her hip on 1/6/16 and fractured her wrist on 2/7/16 when staff failed to follow the care plan. Resident 5 fell an additional time without fall interventions in place. During the survey, Resident 5 was observed without alarms in place as care planned to prevent falls. Resident 4 sustained a fall and her fall interventions - alarm and non-skid pad - were not in place at the time of the fall. Resident 14 sustained a fall when he was left unattended on the toilet. Resident 16 was left sitting on the edge of her bed and her Personal Alarm (PA) was not attached to her after she was assisted into the wheelchair. The failure to ensure that staff consistently followed care-planned approaches to prevent accidents created a finding of immediate jeopardy. The immediate jeopardy began on 1/5/16. Nursing Home Administrator A was notified of the immediate jeopardy on 9/16/16 at 2:22 PM. The facility removed the immediate jeopardy on 9/16/16 but the deficient practice continues at a scope/severity level E (potential for more than minimal harm that is not immediate jeopardy/pattern) as all of the facility corrective actions have not been fully implemented. This is evidenced by the following: The facility's Fall Risk Management policy, revised 8/21/14, includes the following: An accident risk assessment will be performed on each resident and a fall prevention care plan developed and revised to meet each resident's unique safety needs. Procedure: 2. A risk for falls care plan will be developed based on the accident risk assessment and individual resident safety needs. 3. Fall prevention is a facility wide project and must involve all staff. Care Plans: The IDT (Interdisciplinary Team) care plan lists Facility Safety/Standard Protocols. These are our facility standards of practice and will not be repeated in the CNA care plans. They include: . A resident should not be left alone on the toilet/commode unless the care plan states otherwise. On 9/7/16, at 4:07 PM, Surveyor interviewed DON (Director of Nursing) B. DON B stated following a fall the nurse will complete an assessment of the resident. The nurse manager of the unit will review the documentation and review care plan interventions and update the care plan if needed. If it is determined that a CNA (Certified Nursing Assistant) did not follow the care plan they should receive formal counseling and it would be documented in their file. DON B stated all falls are reviewed by the team. Example 1 Resident 5's [DIAGNOSES REDACTED]. Resident 5's progress notes indicate on 8/23/15 Resident 5 fell while independently ambulating without her walker. Resident 5 sustained a right wrist fracture and right femur fracture with gamma nail repair. Resident 5's care plan was updated on 8/28/15 to include: Anticipate needs, pressure alarm at all times, have in common areas unless in bed. Resident 5's progress note indicates on 9/10/15 Resident 5 fell at 6:53 PM. Resident 5 stated she was trying to go to bed but appears to be transferring self to chair. Pressure alarm and gripper pad in place. Resident 5 was encouraged to ask for assistance. Resident 5's care plan was updated on 9/10/15 to include offer to help to bed at 6:30 PM and every half hour until in bed. Resident 5's Minimum Data Set (MDS), reference date 1/5/16 indicates Resident 5 has short term and long term memory impairments. Resident 5's progress notes: -1/5/16 at 7:02 PM, Resident 5's alarm was sounding and Resident 5 was found lying on the floor. Resident 5 was unable to move right leg and grimaces if it is touched. Resident 5 was transferred to the emergency room . CNA (CNA N) did not offer to put Resident 5 to bed at 6:30 PM per care plan and was last toileted before supper. -1/5/16 Resident 5 was sent back to the facility. X-ray of pelvic, hips and shoulders were all negative. -1/6/16 11:03 AM, for fall on 1/5/16. Root cause of fall: Resident 5 is unable to verbalize her intent but likely she wanted to either use the bathroom and/or go to bed. Staff typically offer bedtime assist at 6:30 PM and every half hour. Current care plan interventions are appropriate. New intervention is Resident 5 is not to be left in the dining room after meals have been completed. -1/6/16 12:34 PM, NP (Nurse Practitioner) contacted due to continuous complaint of pain post fall. -1/6/16 Resident 5 is transferred to hospital at 8:19 PM. On 1/6/16 Resident 5's hospital history and physical indicates Resident 5 was diagnosed with [REDACTED]. While in the hospital Resident 5 underwent left hip gamma nailing. On 1/8/16 the facility issued a Written Warning to CNA N for not following Resident 5's care plan. CNA N stated she did not offer to assist Resident 5 to bed at 6:30 PM but was on the way to do so at the time of the fall. Resident 5 returned to the facility from the hospital on [DATE]. Resident 5's care plan was updated on 1/6/16 with the approaches of pressure alarm at all times, body pillow along open side of bed, have in common areas unless in bed. Do not leave in dining room unsupervised after meals. Resident 5's progress notes indicate on 2/7/16 Resident 5 fell . At 9:50 AM Resident 5 was observed falling to the floor and landing on her left side by CNA O. CNA O stated she could not get to her in time. Resident 5 was sitting at the dining room table by the nursing station as she just completed breakfast. Resident 5 walked on her own from that table and fell in front of another resident's room door. Resident 5 was last toileted at 8:30 AM. The current care plan for Resident 5 indicated a pressure/pad alarm in Resident 5's bed and chair meaning reclining chair but no alarm was present in the wheelchair during the time Resident 5 independently ambulated. The CNA care plan was to have a personal/tab alarm in the wheelchair and this was not in place. Additionally, the care plan indicated Resident 5 was not to be left alone in the dining room after meals and this was not followed. When nurse arrived to assess, Resident 5 would not cooperate with neurological assessment. 1/2 inch cut was located distal upper left eye brow. Resident 5 also began to complain of pain in her left wrist and eventually began to grab her right hip stating it hurt. Resident 5 was transported to the emergency room . Resident 5's hospital notes dated 2/7/16 indicate Resident 5 had a left wrist fracture. On 2/10/16 Resident 5 underwent surgery to repair the left distal radius fracture. Resident 5 was readmitted to the facility on [DATE]. On 2/11/16 Resident 5's care plan was updated to include personal alarm and pressure alarm at all times. Offer bed at 6:30 PM and every 1/2 hour until in bed. Resident 5 not to be out of sight of staff and if none available that assigned staff are to have resident outside of room the staff person is in. On 2/15/16 CNA O received an Oral Warning regarding not having Resident 5's pressure alarm in place on 2/10/16 at the time of the fall. Note: They did not address being unsupervised in the dining room after meal was completed. Resident 5's care plan related to fall risk was updated on 4/11/16. Resident 5's care plan indicates: Anticipate needs. Pressure alarm at all times, personal alarm at all times. Offer bedtime at 6:30 PM and every 1/2 hour after until in bed. Have in view of staff when out of room. On 6/13/16, at 6:42 PM, Resident 5 was found on the floor by a visitor in the dining room. Resident 5's incident report indicates the pressure alarm was activated. CNA (CNA P) acknowledges that she did not offer bed before time of fall. Resident 5 did not receive any injuries from the fall. Note: There is no indication Resident 5 was in view of staff as per care plan. On 6/13/16 the facility issued an Oral Warning to CNA P for failure to follow procedure. Care plan directs that Resident 5 be offered toileting at 6:30 PM. Resident 5 was found on the floor at 6:42 PM. CNA P stated she did not offer Resident 5 toileting at or preceding 6:30 PM. Note: The disciplinary action does not address that Resident 5 was not in view of staff at the time of the fall. Resident 5's care plan related to fall risk was updated on 7/6/16 and includes: Anticipate needs. Pressure alarm at all times, personal alarm at all times, offer bedtime at 6:30 PM and every 1/2 hour after that until in bed. On 9/7/16, at 8:00 AM, Surveyor observed Resident 5 in her wheelchair in the dining room. Resident 5 had a pressure alarm in place; however, there was no personal alarm in place. At 9:19 AM, Surveyor noted Resident 5's personal alarm was added to her wheelchair. Surveyor interviewed CNA O who indicated she assisted Resident 5 up prior to breakfast. CNA O stated that she missed the personal alarm when she got Resident 5 up and put it in place after breakfast. On 9/7/16, at 4:07 PM, Surveyor interviewed DON (Director of Nursing) B. DON B stated staff did receive counseling for not following the care plan. DON B stated the CNA and nursing care plan should match and if it indicates an alarm in the chair that would indicate any chair unless specified. On 9/8/16, at 7:45 AM, Surveyor and DON B observed Resident 5 in bed sleeping. Resident 5's pressure pad was not plugged into the alarm box, thus not functioning. DON B plugged the alarm pad in and confirmed it should have been plugged in. Example 2 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's Minimum Data Set (MDS), reference date 1/14/16, indicates Resident 4 has a short term memory impairment. Resident 4's nursing notes indicate on 1/18/16 at 2:00 PM Resident 4 fell while attempting to transfer herself to the bathroom. Resident 4's CNA (Certified Nursing Assistant) care plan was updated on 1/21/16 to include pad alarm in bed, personal alarm in the recliner and wheelchair and do not leave alone in the bathroom. Resident 4's nursing notes indicate Resident 4 dislocated her hip when crossing her legs. Resident 4's CNA care plan indicates full hip precautions. Resident 4's CNA care plan was updated on 1/25/16 indicating the use of a Roho cushion in the chair with a non-skid cover. Resident 4's nursing notes indicate on 3/4/16 at 2:50 PM, Resident 4 was found lying on the floor in front of her wheelchair. Resident 4 was attempting to go to the bathroom. Personal alarm did not activate and the gripper pad was not in place on the wheelchair. Resident 4's care plan was updated to toilet between 2 and 2:30 PM. On 3/4/16 the facility issued an Oral Warning to CNA Q for not following Resident 4's care plan by not putting the personal alarm and gripper pad in place prior to Resident 4's fall. Example 3 Resident 14 was admitted to the facility on [DATE]. Resident 14's CNA (Certified Nursing Assistant) Care Plan, dated 7/15/16, indicates Resident 14 is at risk for falls and is to have a pad alarm in his bed and chair. Resident 14 requires 2 staff to assist with transfers. Resident 14's Minimum Data Set was completed on 7/27/16. Resident 14 scored a 3 in his Brief Interview for Mental Status indicating severe cognitive impairment. Resident 14's incident report indicates on 8/1/16 at 7:00 PM, Resident 14 fell when attempting to transfer himself off the toilet. CNAs involved were coached. On 8/1/16 Resident 14's care plan was updated to include do not leave on toilet unattended. On 9/8/16, at 10:48 AM, Surveyor interviewed Director of Nursing (DON) B who stated it is facility policy that if a resident has an alarm they should not be left unattended on the toilet unless the care plan specifies it is okay. DON B was not able to provide documentation regarding CNAs being coached following the 8/1/16 incident. Example 4 Resident 16's [DIAGNOSES REDACTED]. Resident 16's quarterly Minimum Data Set completed 7/31/16 indicates that she has severe cognitive impairment. Section G0110 indicates that Resident 16 requires extensive assistance with two person physical assist. Resident 16's Nursing Care Plan dated 5/17/16 includes in part, Risk for falls- Pad alarm on bed, check for position and function, pad alarm in chair, body pillow open side of bed, personal alarm on when out of bed, auto locks brakes on wheelchair. Resident 16's CNA Care Plan dated 6/29/16 indicates that Resident 16 is at risk for falls. Interventions include in part, Pad alarm in chair and bed, body pillow, low bed, mat on floor, auto lock brakes. Resident 16's nursing notes dated 8/23/16 at 7:34 PM, includes in part, staff heard a thump and Resident 16 was observed sitting on the floor between the back dining and a cupboard facing the nursing station. Safety: PA did not activate as it was not attached. Pad alarm did not activate as it was not turned on. Staff reported that the alarms were placed appropriately, but, contrary to the care plan, did not check for function at that time. On 9/8/16 at 7:50 AM, Surveyor observed CNA D place a gait belt on Resident 16 who was sitting on the edge of the bed. CNA D reviewed the care plan and indicated that Resident 16 is a two person transfer. CNA D placed the wheelchair directly in front of Resident 16, locked the brakes and left the room with Resident 16 sitting on the edge of the bed. On 9/8/16 at 7:52 AM, Surveyor observed CNA D return to Resident 16's room with CNA L who assisted with the two person pivot transfer to the wheelchair. Surveyor observed the pad alarm in the wheelchair. CNA D did not attach the PA alarm. CNA D wheeled Resident 16 to the dining room and placed her at a table. Surveyor asked CNA D why she put the wheelchair in front of Resident 16 before she left the room. CNA D indicated that she did not want her to move as she is a 2 person transfer. On 9/8/16 at 8:40AM, Surveyor asked RN E to observe Resident 16. Surveyor asked RN E if Resident 16 had the PA attached to her. RN E indicated that Resident 16 did not have the PA attached. Surveyor asked RN E if Resident 16 should have the PA attached and verified the function. RN E indicated yes, the PA should be attached, checked for function and education would be provided. Surveyor asked RN E if Resident 16 should be left sitting on the edge of her bed. RN E indicated that Resident 16 should not have been left sitting on the edge of the bed, and education would be provided on this as well. Intervention added to the CNA care plan and the nursing care plan on 8/23/16 includes in part, check alarms for function/placement when toileting/checking incontinence product. Although the facility revised the care plans after a fall, the facility failed to ensure that staff consistently followed care-planned approaches to prevent falls, providing evidence that the facility had ineffective measures for preventing falls. This created a finding of immediate jeopardy. The facility removed the jeopardy on 9/19/16 by which time it had begun implementing the following: Fall care plans were reviewed for residents identified and those with falls in the last three months, education of nursing staff was initiated on the importance of following the fall care plan, administration to be notified if fall care plan was not followed during a fall and random audits were initiated for fall interventions.

Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure injury does not develop a pressure injury unless the resident's condition demonstrates that they were unavoidable and a resident with a pressure injury receives necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing for 2 of 15 residents reviewed with pressure injuries or at risk for pressure injuries (Resident 4 and 13). Resident 4 was admitted to the facility without a Pressure Injury and was identified to be at risk for Pressure Injury development. Interventions were not put into place to prevent Resident 4 from developing a Pressure Injury or prevent the worsening of the Pressure Injury. Resident 4 developed an avoidable; Stage 3 Pressure Injury to sacrum area. Resident 4's example rises to a level of actual harm and the following example is at a level of no actual harm. Resident 13 is at risk for pressure injuries. Resident 13 was observed without their pressure injury prevention devices in place. This is evidence by: The National Pressure Ulcer Advisory Panel (NPUAP) now refers to pressure ulcers (PU) as pressure injuries (PI). The National Pressure Ulcer Advisory Panel (NPUAP): Prevention and treatment of [REDACTED]. As a result of pressure or pressure in combination with shear a number of contributing or confounding factors are associated with pressure ulcers. Pressure ulcer classification should be used to document tissue loss in ulcers resulting from pressure or pressure in combination of shear. Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition. Expect some sign of pressure ulcer healing within 2 weeks. Adjust expectations for healing in the presence of multiple factors that impair wound healing. If progress toward healing is not seen within two weeks, the individual, the pressure ulcer and the plan of care should be re-evaluated with each dressing change, observe the pressure ulcer for signs that indicate a change in treatment is required. Address signs of deterioration immediately. Signs of deterioration (example: increase wound dimensions, change issue quality, increased exudate or other signs of infection) should be addressed immediately. [DIAGNOSES REDACTED] indicates that the body has not recovered from the previous loading and requires further respite from repeated loading. Repositioning techniques: 1. Reposition the individual in such a way that the pressure is relieved or redistributed. 2. Avoid positioning the individual on bony prominences with existing non blanchable [DIAGNOSES REDACTED]. Non-blanchable [DIAGNOSES REDACTED] is an early sign of pressure ulcer damage. If an individual is positioned directly onto bony prominences with pre-existing non-blanchable [DIAGNOSES REDACTED], the pressure and/or shearing force sustained will further occlude blood supply to the skin, there by worsening the damage and resulting in more severe pressure ulceration. 3. Avoid subjecting the skin to pressure or shear force. Additional recommendation for individuals with existing pressure ulcers: 1. Do not position an individual directly on a pressure ulcer. Repositioning to prevent and treat heel pressure ulcers: 1. Ensure that the heels are free of the surface of the bed. Use heel suspensions devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Apply heel devices according to the manufacturing instructions. The facility policy titled Wound care protocol, dated 2/15/16 (revised), in part, Policy: A resident who enters the facility without a pressure ulcer (Pressure Injury) does not develop a pressure ulcer unless the individual's condition demonstrates that it was unavoidable. Purpose: To ensure residents have a comprehensive skin assessment that identifies risk factors for skin breakdown and appropriate interventions are put into place to prevent pressure ulcer development. To ensure residents having pressure ulcers receive the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Policy: A comprehensive assessment will be done. As part of the assessment, risk factors must have corresponding intervention to alleviate or reduce risk. Any pressure ulcer or other type of wound must be reported to Unit Manager. The nurse who identifies the skin alteration is to update the physician or nurse practitioner (NP) must be notified of all open areas, skin breakdown or any other change in skin condition. All new pressure ulcers will be comprehensively assessed and documented by a unit manager or Register Nurse (RN). A cause should be identified while critically evaluating why the current preventive interventions failed. Revise preventive interventions as needed to alleviate pressure to the affected area. Pressure ulcer must be addressed in the care plan along with treatment plan and appropriate interventions/approaches to promote healing and prevent further open areas from developing. Existing pressure ulcers are to be measure and documented in the weekly wound charting. If signs of infection and/or lack of healing are identified inform the Physician/NP. A clean pressure sore (injury) with adequate blood and nerve supply should show evidence of stabilization and/or healing within 2 - 4 weeks . Example 1 Resident 4 was admitted to the facility on [DATE] with the following diagnoses; Fracture of left femur, Right foot drop, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED] of skin of rift lower limb including hip, [MEDICAL CONDITION], and [MEDICAL CONDITION] Arthritis. Resident 4's Minimum Data Set (MDS) reference date 1/14/16 indicates Resident 4 is at risk for pressure ulcer and there are no current pressure ulcers. Resident 4's care plan titled impaired skin integrity, dated 1/25/16, Problem: Pressure ulcer on the sacrum, reddish discoloration on the tips and dorsal surfaces of the toes. Goal: Skin integrity. Approach: Identify and minimize exposure to mechanical and chemical skin irritants. Educate resident/family/staff regarding treatment and preventative measures. Treatment to sacral area as ordered until healed, weekly measurements. Minimize pressure to bony prominences. Use pillow for support. Roho cushion in wheel chair (w/c), static overlay mattress. Foot cradle on bed. Gripper socks. Resident 4's Certified Nursing Assistant (CNA) care plan, dated rewritten on 2/4/15, indicates the following. Static overlay applied to bed on 1/25/16. Roho cushion with non-skid cover applied on 1/25/16. Heel protector: Heels up dated 5/5/16. Place pillow under Residents feet to float them especially when in recliner dated 6/17/16. Zero gravity boots to feet to prevent breakdown dated 5/24/16. Resident 4's care plan titled Risk for falls, dated 1/18/16, Approaches dated 7/11/16, Resident 4 does not desire the heelz-up cushion to reduce pressure to her feet. Resident will now use a pillow to float her heels especially when in the recliner. Admission nursing note dated 1/7/16 at 1:32 PM, admitted with terminal Diagnosis: [REDACTED]. At 4:16 PM, General skin condition: Skin intact, but very flaky and pale with odd coloring, bruising, and small scabs. Skin Observation: Pale dry, very flaky, warm, fragile, decreased skin turgor. Nursing note, dated 1/16/16 at 2:23 AM, Skin problem: New area, Center of left cheek a dime size reddened area. Reddened area turns white when pressure applied. Repositioned and placed pillows to keep off the area. Action: Referral to wound care nurse. (Note: Wound care nurse initial wound evaluation occurred on 1/25/16.) Nursing Note dated, 1/23/16 at 8:40 PM, Skin Problem: Has open lesion other than foot: right buttocks open area size of dime. Resident denies pain. A and D (ointment) applied and resident encouraged to reposition side to side. Actions: (Nurse Practitioner (NP) name) left a message. General condition of the skin: Skin is fragile. Nursing note 1/24/16 at 2:32 PM, Skin problem: Has open area on right (R) buttock. A&D (ointment) applied. Nursing note on 1/25/16 at 12:58 PM, Weekly wound assessment: Initial assessment, Unstageable - wound bed covered by slough and/or eschar. Area: Sacrum. Wound tissue: 100% thick firmly adherent pale yellow slough. Surrounding tissue: Has little subcutaneous (sub Q) tissue over sacral area, skin loose and sagging related to (r/t) loss of sub Q, increasing risk for shearing with movement. Increased moisture and friction where skin folds fall together at the gluteal cleft. Pain: states she feels it burning every once in a while. Measurement: 1.5 centimeter (cm) length, 2.0 cm width. Push score 8. Gel cushion changed to Roho cushion, static air overlay mattress put into place. (NP name) updated, orders for treatment obtained and implemented this am. Care plan updated with interventions. Norton Plus pressure ulcer scale. On 2/4/16 Resident 4's total Norton plus score was 10 indicating Resident 4 was at high risk for skin breakdown. On 2/18/16 Resident 4's score was 12 indicating Resident 4 was at moderate risk for skin breakdown. On 2/15/16, 3/3/16 and 3/10/16 Resident 4's total score was 14 indicating Resident 4 was at moderate risk for skin breakdown. Resident 4's stage 3 pressure injury weekly wound measurements and Physician orders [REDACTED]. -1/25/16, Initial assessment: Unstageable - wound bed covered by slough and/or eschar. Measurement 1.5 cm by 2.0. -1/25/16 Physician order, Sacral wound tx: Cleanse with wound cleanser spray or normal saline (ns). Apply skin prep to peri wound skin. Apply Curasalt gauze to wound bed, cover with [MEDICATION NAME]. Change every 3 days and as needed (PRN) until slough is gone, and then re-evaluate tx. May use foam cover dressing if [MEDICATION NAME] does not stay in place. -1/28/16 Physician order, Discontinue (DC) current tx to sacrum. Sacral ulcer: Cleanse with Normal Saline. Apply skin prep to peri wound. Apply Curasalt gauze to slough on wound bed, cover with 2 by 2 non-woven sponge secure with [MEDICATION NAME]. Change very (Q) day and PRN until slough gone. -2/4/16, Unstageable. 100 % thick form adherent white slough. Skin loose and slides over sacral area adding friction and shearing forces. Roho cushion was not in place. Resident 4 stated that is was uncomfortable. Evaluated Roho and deflated some air to make less firm, and placed beneath her. Mobility limited related to (r/t) left [MEDICAL CONDITION]. Area measure 1.5 cm by 2.0 cm. [MEDICATION NAME] process in place, treatment daily, using Curasalt gauze with non-woven sponge and secured with a [MEDICATION NAME]. Dressing is at risk for coming off r/t location and deep recessed sacral area and loose sagging buttock skin. Goal is to complete debridement. Impaired cognitive with short term memory impact intervention effectiveness as well. -2/25/16, has full thickness of skin loss, exposing the Sub Q tissue - presents as a deep crater (Pressure stage 3) sacrum. 100% granulation. Measurements 1.8 cm by 1.0 cm by 0 depth (it is important to note the description indicates the wound is a deep crater, however the depth is written as 0.) Slough is completely debrided; wound bed is clean, pink. Edges defined no depth. Update to NP with recommendation for treatment change order. Cleanse wound bed, applied [MEDICATION NAME] cream covered with folded non-woven sponge, secured with [MEDICATION NAME]. Able to shift weight independently, however noted above this increasing shearing ad friction to sacral area. -2/25/16 Physician order, DC current tx to sacral wound. New order: Sacral wound tx: Cleanse with normal saline. Apply skin prep to peri wound. Apply small amount, [MEDICATION NAME] cream, cover with folded 2 by 2 non-woven sponge, secure with [MEDICATION NAME] every day and PRN til healed. -2/25/16 Physician order, Juven 1 packet orally (po) twice a day (bid) for wound healing. -3/3/16 Physician order: DC Sacral ulcer tx. New order: Sacral Ulcer tx: Cleanse wound with NS. Apply skin prep to peri wound. Apply small amount [MEDICATION NAME] cream to wound bed, loosely pack with packing string gauze cover with non-woven sponge, secure with [MEDICATION NAME] every day and PRN til healed. -3/4/16, Has full thickness loss, presents as a deep crater sacrum. Measuring 1.2 cm by 1.0 cm by 0.2 cm. Slight depth noted this week. Location difficult to apply a dressing. Order received adding a small amount of packing strip gauze along with [MEDICATION NAME], covered with non-woven, secured with [MEDICATION NAME]. -3/15/16, Has full thickness loss, presents as a deep crater sacrum. 100% thin firmly adherent yellow slough. Measuring 1.0 cm by 0.8 cm unknown r/t slough. Wound bed re-accumulated slough. Change treatment to Curasalt packing strip gauze to promote debridement of slough. -3/22/16 - Has full thickness loss, presents as a deep crater sacrum. Admits to some discomfort when sitting r/t dressing placement. Measurements: 1.2 cm by 0.8 cm by 0.2 cm Daily treatment using packing strip gauze, covered with non-woven sponge, secured with [MEDICATION NAME]. Location is very difficult to maintain integrity of dressing. -5/31/16 -Difficulty keeping dressing intact with location which is likely contributing to the delay in healing. -6/8/16, Wound is slowly improving. Packing tends to fall out of small wound opening. Wound has a little depth yet, so still needs a filler of some sort. -6/9/16 Physician order: DC current sacral wound TX. New Order: Cleanse with warm water and soap, rinse pat dry. Apply skin proper to peri wound. Apply small amount packing strip gauze, secure with steri strips. Cover with non-woven sponge, secure with [MEDICATION NAME] every day and PRN til healed. -6/13/16, Wound is nearly closed. Measures: 0.3 cm by 0.3 cm by 0.1 cm. Discontinue collagen. Continue packing strip gauze, secure with steri strips, covered with non-adherent dressing. Continue tx until healed. -6/16/16, Description: Edges have epibole (epibole: Edges of top layers of epidermis have rolled down to cover the lower edge of epidermis so that the [MEDICATION NAME] cells cannot migrate from wound edges. Making the wound unable to heal.) Base of wound bed is shiny and smooth, wound healing has been very slow/stalled. Chronic nature of this wound suggested a biofilm may be present. Tx change to Iodorsorb gel and calcium alginate, cover with foam dressing. (treatment for [REDACTED]. Use sharp debridement to the epibole areas.) -6/16/16 Physician order: DC current tx to sacral wound. New order: Cleanse with hydrating foam cleanser. Apply skin prep to peri wound. Apply small amount Iodorsorb gel to wound bed. Cover with calcium alginate. Secure with foam or other non-adherent dressing every day and PRN til healed. -7/1/16, (No change in wound) -7/8/16, Edges have epibole. No change. Wound healing stalled. -7/15/16, Wound is unchanged this week despite change in treatment. Complete closure will be difficult r/t epibole of the edges. Hold TX on 7/16 and 7/17/16 to allow long acting Iodorsorb to work better. Writer to re-evaluate on 7/18/16. (Note: Wound assessment was not documented for 7/18/16.) -7/22/16, Small amount of bleeding from wound. Complete wound healing may not be possible due to epibole. -7/29/16, Wound remains open in small amount, with epibole edges. Making it very difficult to complete closure. Tx will be Monday - Wednesday- Friday. -7/29/16 Physician order, Discontinue (DC) tx to Sacrum wound. Sacral wound tx: Do not cleanse unless area is soiled with incontinence or other debris. Apply skin prep to peri wound. Apply puracel plus AG (Silver) to wound cavity, cover with foam type dressing. Change Monday - Wednesday - Friday and PRN til healed. -8/5/16, No change in wound after 1 week, will allow for another week and reassess. -8/12/16, Wound is stalled. Treatment has been in place 2 weeks. Will continue with treatment another week then re-evaluate. Appetite and weight are stable. -8/19/16 Physician order, Sacral wound tx: change cover dressing to Elastogel plus. Change 3 times week and as needed (PRN). -8/20/16, new cover initiated yesterday, noted to be bunched up between buttocks. Cover dressing elastogel is not effective. Current tx utilizes collagen in attempt to promote cellular growth r/t length of time wound has been stalled. Change cover dressing back to foam dressing. -8/20/16 Physician order, Change Sacral cover dressing to foam 3 times week and PRN. -8/31/16, Chronic wound with epibole edges. Recommending leaving cover dressing off and just apply [MEDICATION NAME] every (Q) shift, NP updated, order received and implemented. (It is important to note Resident 4 remains with a Stage 3 pressure injury and the dressing to promote a warm moist climate to heal has been removed and a dry skin lotion is now applied into the stage 3 pressure injury.) -8/31/16 Physician order, Discontinue (D/C) current tx to sacrum. Apply [MEDICATION NAME] to sacrum every (Q) shift. -9/1/16 Physician order, D/C juven. Mattress Overlay static air manufacturer recommendation, dated 2005 - 2016; Features Does not require pump to maintain inflation, Straps to existing Mattress. On 9/7/16, at 7:49 AM, Surveyor observed Resident 4 in bed lying on her back. Resident 4's feet were not floated off the mattress and there was not a foot cradle on then end of her bed. Resident 4's sheets and blankets were directly on her feet. On 9/8/16, at 7:50 AM, Surveyor interviewed Resident 4. Resident 4 stated last night they brought in the heelz up device and she used it. The foot cradle was brought in this morning and has not been used yet. -At 10:45 AM, Surveyor observed Resident 4 sitting in her recliner. Resident 4 was sitting on a Roho cushion however her heels were not floated. On 9/8/16 at 10:53 AM Surveyor observed Registered Nurse (RN) C complete Resident 4's sacral wound treatment. RN C is the facility wound certified Nurse. Resident 4 was sitting on her recliner with her heels lying directly on the recliner foot board. Resident 4 did not have a pillow under her calves or legs. RN C assisted Resident 4 into a standing position. RN C removed Resident 4's pants and incontinent brief. Resident 4's stage 3 pressure ulcer was observed not to have dressing covering her pressure injury. RN C observed Resident 4's wound and stated she was going to measure Resident 4's stage 3 pressure injury. RN C bent over behind Resident 4 and stretched Resident 4's stage 3 pressure injury and placed a plastic measuring device against Resident 4's buttocks. RN C indicated the area measure 0.4 centimeters (cm). Surveyor observed the same plastic measuring device and note the wound to measure 0.8 cm in length. RN C stated she needed help to measure the wound to get an accurate measurement. Surveyor asked RN C if she always measured Resident 4 standing and the way she is currently measuring her. RN C stated yes this is the way she always measure Resident 4's pressure areas. RN C with assistance of another Certified Nursing Assistant (CNA) re-measured Resident 4's stage 3 pressure injury to measure 0.6 cm by 0.6 cm. RN C then fold the same plastic measuring device that touched Resident 4's un-cleansed buttock and inserted the plastic folded measuring device into Resident 4's pressure injury. RN C stated Resident 4's pressure injury depth measured 0.1 cm. Surveyor asked RN C if that is the way she always measures Resident 4's depth to her wound. RN C stated yes that is the way I measure all depth to pressure injuries. (It is important to note assessing for undermining and tunneling of the pressure injury was not completed by RN C.) National alliance of wound care, July 2012, when measuring depth: Pressure Ulcer: Place a cotton-tip applicator into the deepest part of the wound bed. Grasp the applicator by the wound margin and place it against the ruler. We also need to measure undermining and tunneling. Measure undermining using the face of a clock as well, and measure depth and direction. Tunneling will measure depth and direction. The National Pressure Ulcer Advisory Panel (NPUAP): Prevention and treatment of [REDACTED]. Position the individual in a consistent neutral position for wound measurement. It is possible to distort soft tissue with variations in positioning yielding a larger or smaller measurement depending on position of the individual. Select a uniform, consistent method for measuring depth. Care should be taken to avoid causing injury when probing the depth of a wound bed in determining the extent of undermining or tunneling. Consider further diagnostic investigation of wound bed tissue when healing does not progress. On 9/8/16 at 10: 56 AM Surveyor and RN C observed Resident 4's stage 3 pressure injury. Resident 4's stage 3 pressure injury wound bed was pale pink to white and dry in appearance. Resident 4's visual depth was approximately 0.2 to 0.3 cm deep, (although measured to be 0.1 with a folded inserted plastic measuring device.) The area directly surrounding the wound base was white in appearance (such as in maceration.) Surveyor asked RN C was the white substance was surrounding the base of the pressure ulcer. RN C stated that is scar tissue. The wound edges have scar tissue, so now I do not expect the wound to heal. The skin surrounding the pressure injury was light gray in appearance. RN C then squeezed [MEDICATION NAME] ointment onto her right index gloved finger. RN C then placed the [MEDICATION NAME] with her gloved had into Resident 4's pressure injury. RN C continued to spread the [MEDICATION NAME] over Resident 4's sacral area and back across Resident 4's pressure injury 3 times. RN C replaced Resident 4's incontinent brief and pulled up Resident 4's pants. (RN C did not apply a dressing to Resident 4's stage 3 pressure injury.) Resident 4 sat back in her recliner and raised the foot of her recliner. RN C placed a pillow directly under Resident 4's bilateral heels. Resident 4's heels were not float freely from the pillow. RN C washed her hands and exited the room with Surveyor . [MEDICATION NAME] moisturize dry skin therapy: [MEDICATION NAME] dry skin therapy helps moisturize severely dry skin. It is specially formulated for daily use to help prevent and treat minor skin irritations. [MEDICATION NAME] closely mimics the human skin lipids functions to maintain skin integrity and reduce skin breakdown. Ideal for: Dry, cracked heels, reddened, unclear prone skin, and Incontinence associated [MEDICAL CONDITION]. Uses: Helps protect ulcer prone skin, treatment of [REDACTED]. On 9/8/16 at 1:10 PM Surveyor interviewed Director of Nursing (DON) B regarding the standard of practice related to pressure injury treatment. Surveyor asked DON B what standard of practice the facility uses for wound prevention and treatment. DON B stated they use National Pressure Ulcer Advisory Panel. Surveyor asked DON B the current standard of practice for measuring depth of a wound. DON B stated RN C should use a stick type measuring device usually a wooden Q-tip type device should be used. Surveyor asked DON B if a plastic square sheet measuring device should be folded and placed inside the pressure injury to measure depth. DON B stated no that would not give an accurate measurement of the wound. DON B was notified of RN C technique of measuring the depth of Resident 4's stage 3 pressure injury. DON B stated she would expect RN C to use a Q-tip type device hold her finger to where the end comes out of the wound and place that on the plastic sheet to get an accurate measurement. On 9/8/16, at 2:30 PM, Surveyor interviewed RN C regarding Resident 4's skin. RN C stated prior to 1/25/16 Resident 4 had a gel cushion in her wheelchair and her heels were elevated. On 1/25/16 RN C completed a skin assessment and the only open area/pressure injury Resident 4 had was on her sacrum. At that time an air overlay was placed on Resident 4's bed and a Roho cushion was added to her wheelchair and recliner. RN C stated she was not aware of an area on Resident 4's buttock and there was nothing on the buttock when she assessed Resident 4 on 1/25/16. RN C stated the NP has also been involved with Resident 4's wound healing and noted on 3/29/16 in her note that the pressure injury was improving. RN C stated the pressure injury healing had stalled and they encouraged Resident 4 to eat more proteins. The pressure injury has been the same for some time now as the edges have grown over and the wound bed is not granulating, scar tissue is what will form in the area. RN C stated they went to the [MEDICATION NAME] because she felt the packing was disrupting the skin growth and RN C wanted to maintain the moisture so scar tissue will grow. RN C again stated the edges have epibole (rolled under) so it won't heal over. Surveyor asked if RN C considered other treatment to open the edges up for healing. RN C stated the edges can be opened surgically or with silver [MEDICATION NAME] which she has done in the past but there is a chance it can go into the wound and damage the wound bed. RN C stated she did not go the surgical route as she did not think Resident 4 would want to go through that. RN C stated she could not recall if she ever asked Resident 4 if she would like the surgical or other interventions done to promote the healing process. RN C confirmed Resident 4 has not been seen at a wound clinic or plastic surgeon for a consultation. RN C also stated she has not consulted with a Physician for Resident 4's alternative procedure for the rolled wound edges. RN C stated she has applied skin lotion to a Resident in the past, so she thought she would try this treatment for [REDACTED]. Surveyor asked RN C about Resident 4's mattress. RN C stated they do not use an air loss mattress due to Resident 4 trying to get out of bed and her history of dislocating her hip. RN C stated the team felt the static overlay was the safest option for Resident 4. RN C stated they have not tried a different mattress since Resident 4's hip has healed and is no longer on hip precautions. Example 2 Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 13's Norton skin assessment, conducted on 7/18/16, resulted in a score of 15, which indicates moderate risk for pressure injury. Resident 13's latest care plan states, Problem: impaired skin integrity. Goal: skin integrity will remain intact unless unavoidable. Approach: Float heels at all times using Zerogravity Boots. The CNA Care Plan for Resident 13 states, Float heels while in bed and in wheelchair with Zerogravity Boots at all times. On 9/8/16 at 8:18 am, Surveyor observed Resident 13 in bed with his heels resting on the bed. Resident 13's zero gravity boots were observed in the chair in the corner. This was observed again by Surveyor at 9:50 am. On 9/8/16 at 10:00 am, Surveyor interviewed Registered Nurse (RN) I. RN I stated Resident 13 should have Zerogravity Boots on while in bed. RN I then went to Resident 13's room and attempted to put the Zerogravity Boots on. Resident 13 refused. On 9/8/16 at 10:20 am, Surveyor interviewed Certified Nursing Assistant (CNA) J. CNA J stated Resident 13 wears Zerogravity Boots but often refuses. CNA J stated if Resident 13 refuses, she will place a pillow under his heels. CNA J also stated she does not report when Resident 13 refuses the Zerogravity boots. On 9/8/16 at 10:50 am, Surveyor interviewed RN C. RN C stated she had just heard about Resident 13 refusing to wear Zerogravity Boots. RN C also stated there was no documentation regarding Resident 13's refusals to wear the boots. RN C stated Resident 13 had not been given risks/benefits of skin breakdown prevention measures and refusal to follow plan of care.

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 4 residents (Residents 17, 2, 1, and 3) of 10 residents reviewed for fall risk. Resident 17 was admitted to the facility with a cervical fracture from a fall at home and was assessed to be at high risk for falls. Resident 17 had interventions on his care plan that were effective to prevent falls. Those interventions were discontinued without an adequate safety assessment and new interventions were not added to the care plan. Resident 17 fell and sustained a hip fracture after his fall interventions were discontinued. Resident 2 sustained six falls at the facility from December 2011 to March 2012. The facility did not investigate all falls to determine if interventions were in place to prevent falls. The facility did not update Resident 2's plan of care with interventions to prevent future falls. Resident 1 had a fall on 5/8/11 where she fell out of her PVC (pipe) walker. The facility did not add interventions to Resident 1's plan of care until 5/26/11. Resident 1 had an additional incident involving the PVC walker on 5/16/11. Resident 3's care plan states that Resident 3 is to have an alarm in the wheel chair when up. On 3/12/12 Surveyor observed Resident 3 up in the wheelchair with the alarm not turned on/ plugged into the unit. This is evidenced by: Facility Policy entitled "Fall Risk Management" Number 41-11-C dated 1/15/07 states: "A fall risk assessment will be performed on each resident and a fall prevention care plan developed and revised to meet each resident's unique safety needs. Procedure: 1. Each resident will receive a fall profile risk assessment upon admission, quarterly, or with a significant change of condition. 2. A risk for falls care plan will be developed based on the fall profile risk assessment and individual resident safety needs. 3. Fall prevention is a facility wide project and must involve all staff...5. If a resident falls the RN (Registered Nurse) will assess for injury...7. The RN will thoroughly investigate the circumstances of the fall and the possible cause. Using the Incident charting folder the RN will document in detail the results of the investigation. 8. As a result of the investigation the RN will develop at least one new fall prevention intervention. This will be documented in the nurse care plan, CNA care plan when indicated and the unit's 24 hour report form...Communication of this new intervention is of the utmost importance...10. On their next working day following a fall, the Unit Manager or other RN will perform a fall review, documenting their brief assessment and any care plan changes in the Fall Follow-up charting folder...12. The DON (Director of Nursing) and/or the Falls team will audit documentation for proper fall assessment, documentation, interventions and physician and family notification." Example 1 Resident 17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 17 had been admitted to the Hospital from home on 1/21/11. The hospital admission summary dated 1/21/11 states: "(Resident 17) was having increased falls and was deemed unsafe on his own...(Resident 17) presented to the ER (emergency room ) and was found to have a C2 fracture and a bony cyst at the fracture site...He had a right superficial laceration and contusion that was sutured on site. He was placed in a Cervical collar...We anticipate that this fracture may take 3-6 months to heal." The hospital Discharge Orders dated 1/25/11 state: "Patient at High Risk for Falls." Resident 17's Care Area Assessment (CAA) for Fall Risk on the admission Minimum Data Set (MDS) assessment dated [DATE] states: "Internal Risk Factors: Hypertension, Dementia, Brain Contusion, Memory Loss and Peripheral Neuropathy." The CAA summary states: "[AGE] year old with history of falls due to poor cognition, is not aware of safety needs or physical limitations-will develop Care Plan." Resident 17's Care Plan for Falls dated 2/8/11 note the following approaches to minimize fall risk: "...Observe for unsafe situations and correct as able or notify appropriate personnel; Bed in low locked position; Non-skid footwear; Pad alarm in chair/bed at all times. The entry for Pad Alarm in chair/bed at all times was dc'd (discontinued) on 3/15/11. Resident 17's CNA (Certified Nurse Assistant) Care Plan dated 2/4/11 states: "Transfers-One assist/gait belt; Falls/Safety-At risk for falls-Pad alarm in chair, in bed." The alarms in chair and in bed were dc'd 3/15/11. The section for Mobility/Ambulation states: "One assist with ww (wheeled walker)." The section for Elimination/Toileting shows Resident 17 needs "One Assist." A Physician Telephone Order dated 2/4/11 states: "Please d/c PT (Physical Therapy) orders due to reaching max functional potential." A Physician Telephone Order dated 2/11/11 states: "Please d/c OT (Occupational Therapy) orders due to reaching max level of functioning at this time." Rehabilitation Daily Progress Note for OT dated 2/11/11 states: "D/C Summary...Transfers: Able to complete safely with verbal cues and supervision. Forgets to use walker when not given cues. Goals partially met." Nurse's Notes in January and February indicate that Resident 17 required assistance for transfers and ambulation and had poor safety awareness: 1/26/11 - "Writer reviewed use of call light with him (Resident 17) and, while he was able to state that he required assistance to meet transfer/ambulation needs, it is unlikely he will remember to ask for assistance due to the dementia. Writer discussed use of pad alarm in wheelchair/bed with (family member) who is in agreement to their use. Writer explained that the alarms may not prevent falls, but would allow staff to attempt to intervene faster..." 1/29/11 - "Transfers: staff lifting involved, requires one assist. Res noted to transfer self at times." 2/2/11 - "Observed ambulating in room with alarms sounding. Easily redirected..." 2/8/11 - "PT wrapped on 2/4/11. (Resident 17) requires SBA (stand by assist) for safety..." 2/14/11 - "Needs one assist with transfers for safety but often transfers self." On 2/15/11 at 9:30 AM, Resident 17 fell . Nurse's Notes state: "(Resident 17) is noted to be seated on the floor, back to his hutch, wheelchair is across from him...When asked what happened staff indicated that CNA had found (Resident 17) sitting on the floor and the pad alarm had not activated. (Resident 17) indicates that he was trying to get from his wheelchair to his room chair when he fell . He states he tripped over his own feet. Surrounding area is clutter free, floor is dry, and shoes are in good condition...Writer checked alarm and it was turned on, attached appropriately and pad positioned appropriately in the wheelchair. When writer pushed down on the pad and let up, it did sound. Wheelchair was not locked, and given his dementia writer feels he is unlikely to remember to lock wheelchair. Will request auto-lock brakes." A later note on 2/15/11 at 11:40 AM indicates: "(Resident 17) remains at high risk for unavoidable falls related to poor safety awareness, poor awareness of physical limitations combined with attempts at independent transfers/ambulation." Notes further indicate: "cervical collar worn at all times." The Care Plan has a handwritten update dated 2/15/11 stating: "auto lock brakes on wc." Notes indicate the batteries were changed in the pad alarm to improve function. Nurse's Notes continue to indicate poor safety awareness for Resident 17: 2/16/11 - "Safety awareness poor-continues to get up despite instructions to wait for assistance." 2/19/11 - "requires one assist. Does make frequent attempts to transfer self despite reminders to ask for assistance." 2/20/11 - "Ambulates with one assist but frequently found ambulating unassisted." 2/28/11 - "Decreased safety awareness and uses a pressure alarm at all times." 3/2/11 - "Ambulation with one assist and gait belt...many attempts to self transfer and ambulate without assist. alarms alert and staff immediate assist d/t (due to) memory loss." 3/6/11 - "Requires SBA for safety but often transfers self setting off pressure alarm." 3/10/11 - "Unable to anticipate safety needs, bed alarm and chair alarm at all times...Ambulation: walks in room with 1 assist and gait belt, attempts to ambulate independently alarms alert staff then assist x 1 is provided." 3/14/11 - Ambulation: CGA (care giver assist) of one for ambulation. Frequently ambulates per self despite reminders to ask for assistance." Nurse's Notes on 3/15/11 state: "Attempted to remove pad alarm today, as (Resident 17) frequently sets it off with independent transfers and ambulation. Alarm does not remind or encourage him to sit down or request assistance...1st attempt was this morning, alarm removed...two minutes later he was out of his room, looking for the alarm and for the person who took it..." The pad was replaced with a similar non-alarming pad but the resident continued to be angry that the pad was missing. Nurse's notes state: "he appeared happier when the pad/alarm box were put back where they belong. Will keep pad alarm at this time, as it appears to be resident's preference. Writer surmises that he feels the alarm and the box are personal property and by removing them he feels something has been taken from him. Daughter updated of above, states that she will try to talk to him about giving up the alarms. Writer did let daughter know it is okay if (Resident 17) prefers to keep the alarm." This is the last note related to alarms. However, the pad alarm in bed and chair were dc'd on the Care Plan and the CNA care plan effective this date. There is a Care Planning Conference note dated 3/16/11 which states it is a late entry for a care conference held on 2/15/11. This notes states that the IDT (interdisciplinary team), family and resident were present for the care conference. The note states: "Therapies indicate that (Resident 17) is doing well, requiring SBA (stand by assist) with ADL for safety, and feels that he will continue to require supervision for safety." This is the only therapy assessment noted prior to the alarms being discontinued on 3/15/11. Nurse's Notes beginning on 3/17/11 state that Resident 17 is independent with transfers and that Resident 17 walks in his room and is independent for ambulation. There is no Accident Risk Assessment completed prior to this change of status (per facility policy, this assessment should be completed for a significant change in condition). There is no therapy assessment noted prior to this change of status. The Care Plan and the CNA Care Plan were not updated to show that Resident 17 could transfer or ambulate independently. The Care Plan continued to indicate an assist of one needed for transfers, ambulation and toileting. Resident 17 is still noted to be wearing a cervical (Aspen) collar for the C2 fracture he had on admission. On 4/3/11 at 3:15 AM, Resident 17 fell while ambulating independently in his room. Nurse's notes state: "Resident stated he was walking back from bathroom, did not call for assistance, and slipped and fell on to the floor." The Cause of fall is noted as: "without staff assist, resident was found on floor of room did not use call light for assistance." Injury is noted as: "laceration to the right upper arm approx 5-6 mm long, laceration to right elbow approx 2 mm long." Actions taken state: "non-skid footwear applied to feet, continue to observe...Related Care Plan: Risk for Falls. New interventions resident will wear shoes or non-skid footwear while ambulating." This intervention is already on the care plan dated 2/8/11. No new updates to the care plan were made on 4/3/11. Nurse's Notes from 4/3/11 at 9:02 AM state: "Updated by CNA of complaints of pain and does not wish to get out of bed for breakfast. This is unusual for (Resident 17) as he is usually up for breakfast. Pain is likely secondary to fall which occurred last evening...Writer assessed at 8:20 AM...he is unable to rate his pain when asked on a scale of 1-10. When asked if his pain is bad, very bad or very, very bad, he indicates very bad. He indicates mid to lower back pain..." Nurse's Notes from 4/7/11 state: "...this writer did observe (Resident 17) prior to lunch laying supine in bed with tears from both eyes running down his cheeks. (Resident 17) was not able to point to the painful area but did shake his head yes to pain..." Probable cause is noted as "fall from 4/3/11." A new order was received for Aleve x 2 weeks and bio-freeze to apply topically. On 4/4/11 there is a Physician Office Visit Summary on file. The encounter notes states: "(Resident 17)....fall 2 months ago sustaining cervical spine fracture, is seen today in follow-up for nursing home. He has had a recent fall with abrasions and contusions on his arm. This occurred at night when he got up on his own and did not ask for assistance...He continues to wear cervical collar as per neurosurgery...Plan: We'll continue medications and treatment plan. I recommend he be cautious in getting up, and ask for assistance whenever needed..." On 4/15/11 there is a Fall/Incident Follow-up noted in the record. This is 12 days after the date of the fall. Facility policy indicates that the Follow-up should be completed within 1 business day after the fall. This follow-up states: "...Other risk factors include: no safety awareness, poor balance, and frequent attempts at independent transfers and ambulation." The new intervention noted is: "gripper socks on at HS (bedtime)." This new intervention was not added to the care plan or the CNA care plan. The new intervention does not address the cause of the fall which is noted several times to be related to poor safety awareness and not calling for assistance with transfers. The Care Plan and the "Resident Fall Report" indicate that Resident 17 needs one assist for ambulation and one assist and a gait belt for transfers. Yet Resident 17 was ambulating independently in his room at the time of the fall. No alarms sounded during the 4/3/11 fall since the alarms had been discontinued on 3/15/11. The need for alarms/supervised transfers was not re-assessed after the 4/3/11 fall. Resident 17 is still noted to be wearing a cervical (Aspen) collar for the C2 fracture he had on admission. Nurse's Notes dated 4/29/11 under the heading "Transfer Assessment" state: "No changes in transfers, since last review. Continues to transfer with: independent." The Care Plan and CNA Care Plan continue to reflect Transfers with "one assist and a gait belt." A Physician Telephone Order dated 5/11/11 states: "Keep collar Velcro set to current markings." Resident 17 is still wearing the cervical (Aspen) collar for the C2 fracture he had on admission. On 5/14/11 at 12:30 AM, Resident 17 fell and fractured his hip. Nurse's Notes indicate that Resident 17 fell in the hallway. The section entitled "Staff involved" states: "none." The Nurse's Notes go on to say: "(Resident 17) lost his balance falling onto his left side. He has a skin tear on his left elbow area that is near 1 inch in length and .5 inches wide with all skin removed. Has abrasion (not bleeding) on his left leg by the knee...when we stood him up he was unable to bear weight on his left leg and the foot abducted severely. He then complained of thigh pain and was lowered to the floor. Received call from (name of Doctor) to send to (name of Hospital) ER..." Resident 17 was admitted to the hospital where he underwent surgery to repair a fractured hip. There is no Fall/Incident Follow-up Report for the 5/14/11 fall as per the facility policy. There is no hard copy "Resident Fall Report." There is no evidence in the Medical Record that this fall was investigated or analyzed to determine the circumstances or cause of the fall. The Nurse's Notes do not indicate if Resident 17 was wearing gripper socks as had been noted to be the intervention in the 4/3/11 fall. The notes also do not indicate if Resident 17 received any assistance for transfer or ambulation prior to or during the fall as per his care plan. A "Discharge Summary" Nurse's Note dated 5/15/11 (discharge to hospital due to hip fracture) states: "(Resident 17) worked with physical and occupational therapy on gait and transfers, progressing to a SBA (stand by assist) level..." On 5/17/11, Resident 17 was readmitted to the facility following his hospitalization . A hand-written note on the Fall Risk Care Plan dated 5/17/11 states: "re-admit following left hip fracture" and "pad alarm chair and bed." The new CNA Care Plan (undated) has a hand-written note stating: "*fall risk* check on frequently and encourage to be out of room as able in view of staff." The CNA care plan notes: "Transfer-One assist/gait belt" and "Falls/Safety-At risk for falls, Personal alarm at all times, Pad alarm in chair, in bed, and Electric low bed." On 8/18/11, Resident 17 leaned over in his wheelchair reaching for an object and the chair tipped. Resident 17 sustained a laceration to the left ear and finger. An Accident Risk Assessment was completed. The new intervention added was a weight on the back of the wheelchair. This intervention was added to the Care Plan on 8/18/11. On 9/4/11 at 2:50 PM, Resident 12 was found sitting on the floor at the foot of his bed. Per the Nursing Notes, the wheelchair was across from the resident with the wheels locked. The pad alarm was in place but did not alarm. There is no Fall/Incident Follow-up noted in the record. There are no new interventions added to the Care Plan after this fall. There is no investigation report indicating the reason for the non-functioning alarm. Action taken was to replace the pad alarm. On 3/14/12 at 11:20 AM and at 1:15 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated that the Unit Manager for each unit does the Fall Follow-up Assessments. The manager does an analysis of the fall and looks at risk factors and patterns. They then choose from a list of possible fall interventions. DON B stated that it is her expectation that this analysis will be done within 1-2 business days after the fall occurs. DON B stated that at least one new intervention should be put in place immediately by the nurse on duty at the time of the fall. DON B stated that the decision as to how a resident should transfer or ambulate (independent, supervised, with assist, etc.) is generally a joint decision with therapy involvement if the Resident is still being seen in therapy. DON B stated that there was no assessment from the therapy department after Resident 17 was discharged from therapy on 2/4/11 (PT) and 2/11/11 (OT). DON B reviewed Resident 17's Care Plan and stated that Resident 17 should have had "one assist with a gait belt" for transfers at the time of the 5/14/11 fall per his Care Plan. DON B stated that, if Resident 17 was supposed to transfer and ambulate independently after 3/17/11, his care plan did not reflect this. DON B stated that the decision to remove alarms should be based on individual factors. DON B stated that the alarms are sometimes removed if the alarm is making a resident agitated or if it is doing more harm than good (has negative impact). Resident 17 did not react negatively to alarms and in fact was upset and wanted the alarm back when it was removed on 3/15/11. The alarms had been effective in preventing injury prior to 3/15/11. Resident 17 fell two times and sustained serious injuries in the period between 3/15/11 and 5/14/11 when the alarms were not in place. DON B agrees that there was not an Accident Risk Assessment completed in March prior to the alarms being removed and the transfer status changed. DON B agrees that non-skid footwear had already been on Resident 17's care plan prior to the 4/3/11 fall and that gripper socks (a type of non-skid footwear) was not added to the care plan on 4/3/11. Thus, there was no new intervention added to the care plan per the facility policy after the 4/3/11 fall with injury. On 3/14/12 at 10:15 AM, Surveyor interviewed the Unit Manager RN (Registered Nurse) D. RN D stated that the decision to change a transfer status from needing assistance to independent is generally a joint decision between therapy and nursing. RN D stated that Resident 17 was doing well enough in March, 2011 to walk independently from his room to the central lounge. RN D stated that they were supervising Resident 17 by keeping an eye on him in the common areas. RN D stated that supervision is a different thing than needing an assist to ambulate. RN D stated that even now the resident is quite independent in trying to get up in his room. RN D stated that the problem is safety and cognition and that Resident 17 is impulsive and does not recognize his limitations. RN D stated that this is how Resident 17 has always been--his cognition has not changed since admission. RN D stated that the pad alarm does not bother Resident 17--he just ignores it but it "gives staff a heads up" about what he is doing. On 3/14/12 at 2:00 PM, Surveyor spoke with RN D. RN D reviewed the medical record regarding the fall of 4/3/12. RN D stated that the RN on duty at the time of the fall is responsible to choose the intervention. Another RN had decided that the fall might have been related to wearing regular socks (rather than non-skid socks) when getting up at night. RN D stated that she had reviewed this fall and it seemed like an isolated incident and that gripper socks would help in getting from the bed to the bathroom. RN D agreed that Resident 17 already had non-skid footwear on his Care Plan dated 2/8/11. RN D did not do an analysis of Resident 17's ability to be unsupervised in his room because he had been doing well with independent ambulation. RN D stated she completes the fall reviews on her unit herself and there is not a team that reviews falls. Example 2 Resident 2 has [DIAGNOSES REDACTED]. Resident 2's Care Area Assessments (CAAs) dated 12/29/11 state the following: "(Resident 2) remains at risk for falls related to dementia with limited safety awareness, use of meds with risk for side effects, history of falls in past, excessive ambulation with risk for fatigue and weakness, impaired hearing, impaired vision. Care plan: will develop Care Plan Revise current plan." Resident 2's Care Plan, dated 12/23/11 states the following: "Problem: Risk for falls/risk for trauma/risk for injury ...Approach: 12/23/11: bed in low position, call light in reach, offer to assist with toileting, ADLs (activities of daily living), ect; ...12/23/11: Pad alarm when in bed at night. Keep light on in bathroom; 12/23/11: Report restlessness to LN, keep room free of clutter, offer to lay down if she appears fatigued; 2/29/12: do no use bedroom slippers s (without) heels. Use slipper-gripper socks or shoes that fit ..." According to Nurse's Notes, dated 12/23/11, Resident 2 sustained a fall from bed at the facility. The facility intervened by placing a bed alarm on Resident 2's bed. According to Nurse's Notes, dated 1/4/12 Resident 2 sustained a fall out of bed at 8:37 PM. Nursing Notes state, "Last seen lying in bed where she had been settled because she wanted to rest, but not sleep ...Cause: 'knees gave out' although scene suggests she tripped over blanket she dropped ...no evidence of injury ...Related to care plan: Risk for falls, will offer toileting every hour while awake ..." It is important to note that this intervention was not added to Resident 2's plan of care. Nurse's Notes, dated 1/19/12 state the following: "Fall she stated a black girl was giving her a bath states "I fell backward and hit my head" "it hurts" she sates she is alert when the little larger than 1 inch slightly red area is touched. She is able to put her finger exactly on the spot ...no new interventions at this time. Event is being investigated and interventions will be made as needed. The facility completed follow up related to this incident, as documented in the Nurse's Notes as follows: "1/18/12 per PM staff report she did slip in the shower room and fell back against the wall requiring staff to lower her to the floor, this would be consistent with the 2 cm hematoma noted on the mid back of her head. No redness or bruising noted at the time of assessment ...staff member indicated that she had turned her back towards (Resident 2), when placing the walker out of the way, when she turned back (Resident 2) was leaning back against the wall, sliding down. This would be consistent with slipping on the tiled floor in the shower room ...New Intervention: Keep (Resident 2) in line of vision while in shower room ..." It is important to note that this intervention was not placed on Resident 2's plan of care. Resident 2, according to Nurse's Notes, sustained a fall at the facility on 2/16/12 at 5:35 AM. "Incident Type: Fall, Resident states "I slid down." Found sitting on buttocks resting against wall by bathroom. Very anxious to get up and go to the bathroom ...Injury: Abrasion to left shoulder a small red area and reports hitting head. No bump or redness noted at this time. Class of injury: 2-abrasion cared for in building ..." The facility did not investigate whether Resident 2's alarm was sounding or if Resident 2 was offered assistance with toileting every hour. Surveyor spoke with Director of Nursing (DON) B on 3/14/12 at 10:00 AM. DON B stated that the facility assesses residents for fall risk upon admission, quarterly and based on those results will put interventions in place. DON B stated that if a resident has a fall, interventions to prevent future falls will be placed on the residents care plans. Surveyor asked DON B if Resident 2's alarm was sounding at the time of the fall on 1/4/12. DON B stated that it would be part of the investigation. Surveyor asked DON B if interventions were added to Resident 2's plan of care after falls on 1/19/12 and 2/16/12. DON B stated that these interventions should be placed on the resident's care plan. DON B and Surveyor reviewed Resident 2's plan of care. DON B agreed that the interventions to prevent falls were not placed on Resident 2's plan of care. Example 3 Resident 1 has [DIAGNOSES REDACTED]. Resident 1's "Skaalen CNA Care Plan" dated 3/9/10 states the following intervention "5/26/11: Limit time in PVC walker to 30-60 when restless/agitated. Staff assist with amb (ambulation). Seat in center solarium recliner ..." This same intervention was added to Resident 1's plan of care (computer-based) on 11/30/11. According to Nurse's Notes, dated 5/9/12, Resident 1 sustained a fall at the facility on 5/8/12. "Resident had not wanted to go to sleep and was walking about the front solarium. She was back in the area by the TV and in front of the couch with its back toward A wing. She was found down on the floor in front of her PVC walker. She was laying on her right side with her legs back in the PVC walker, the middle seat strap was still in between her legs. The PVC front bar was in place. CNA noted she needed to loosen the strap and then undo the seat belt to help assist her out of the position with the strap there between her legs ...Cause: Resident was in PVC walker. She walks stooped forward and in attempting to get out of walker placed her head and shoulders between the strap, which was slightly loosened, and the top bar and right side bar of the walker and fell forward on to her right side ...Injury: none apparent ...Fall/Incident Follow UP: VS (vital signs): 132/60, 60, 20, 98.2. No noted pain or discomfort for fall noted on PM shift 5/8/11. Res. (resident) in bed all this shift with no noted difficulties. Res. Sleeping at this time ...No injury from fall. Resident is stable after fall from PVC walker last evening ..." It is important to note that the facility did not put immediate preventative measures in place to prevent future falls or injury from the use of the PVC walker. Nurse's Notes dated 5/16/11 state the following: "Incident type: other, reported to this writer this am upon arrival to the unit at approx 0615 (6:15 AM) ...Equipment Involved: (Resident 1) was up in her PVC walker. CNA noted (Resident 1) to be sitting on the grey strap of the walker and had bumped her cheek on the front bar of the walker on the left side of her cheek. (staff name) states that there was a little redness present when she observed. CNA then walked to get (Resident 1) her glasses and states that when she returned with them, there was a small scratch present to the bridge of her nose that had not been present when she looked moments earlier ...Cause: Concluded that (Resident 1) went to sit down on PVC seat, sat too far forward on the seat and when seated on grey she bumped her left cheek on the front bar of the walker ..." Nurse's Notes dated 5/26/11 state, "RN Fall Review No change from accident risk assessment 4/22/11. Resident did have a fall on 5/8/11 when she attempted to get out of PVC walker by getting under PVC strap. She was up ambulating in the PVC walker during a period of restlessness. Resident with no safety awareness and poor judgment ability. New intervention added to nursing and CNA care plans to limit time in PVC walker to 30-60 minutes when resident is restless/agitated. Instead staff to offer to walk with her or attempt to seat her in a recliner in the center solarium." This intervention was added to Resident 1's plan of care on 5/26/11, 16 days after the first incident with the PVC walker. Surveyor spoke with Director of Nursing (DON) B on 3/14/12 at 10:00 AM about Resident 1's falls and incidents with use of the PVC walker. Surveyor informed DON B that a new intervention was not added to Resident 1's plan of care after her fall on 5/8/11 and Resident 1 sustained an additional injury while using the PVC walker. DON B stated that staff should be immediately putting new interventions on the care plans. Example 4 Resident 3 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Resident 3's Plan of Care for Self Care Deficit related Dementia, Manifested by Potential for Falls, with no goal date, states the following: "Apply all adaptive equipment per FRP and CNA care plan." Resident 3's CNA Care plan dated 3/7/12 under FALLS/SAFETY states that Resident 3 is at risk for falls, and a Pad Alarm is to be used in Resident 3's bed and chair. Review of Resident 3's nurses notes incidents that on 3/8/12 at 18:30 PM, Resident 3 was in her room in her wheelchair. Resident 3 stood from her wheelchair to gather nightgowns, lost her balance and fell forward onto her hands and knees and did not hit her head. On 3/12/12 from 8:30 AM-to 9:00 AM, Surveyor observed Resident 3 up in her wheelchair at the table waiting for breakfast with the alarm unit on the back of her wheelchair. Surveyor observed the alarm not plugged into the unit. On 3/12/12 at 9:00 AM, Surveyor interviewed RN/UM D (Registered Nurse/Unit Manager) if Resident 3's alarm was turned on. RN/UM D stated, "No," and plugged the alarm in. The alarm sounded when RN/UM D plugged the cord into the unit.. RN/UM D stated, "I will follow up with the appropriate CNA, this should have been turned on." On 3/13/12 at 1:15 PM, Surveyor interviewed RN/UM D regarding the alarm for Resident 3, RN/UM D stated, "The alarm should have been plugged in, I talked with the CNA about it."

Based on interview and record review the facility failed to ensure that they immediately consulted with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status, and the need to alter treatment for 2 residents out of 7 reviewed (Residents 1 and 4). On 10/20/11 it was noted that Resident 1 had a change of condition; [MEDICAL CONDITION], somnolence, fever and lethargy. The physician was called and the facility did not report the [MEDICAL CONDITION], somnolence, fever or lethargy, but only asked for an oxygen order. On 10/20/11 the family of Resident 1 alerted the facility that Resident 1 had previous episodes of not reacting well with medications especially narcotics. The PM nurse did review the hospital records and noted that the evening before admission Resident 1 received [MEDICATION NAME] due to [MEDICAL CONDITION] and lethargy and his condition improved. The facility did not call Resident 1's MD to report this concern and his current condition and continued to give narcotics without consultation regarding Resident 1's symptoms. The facility stated that they did call the MD on 10/21/11 to ask to have the [MEDICATION NAME] discontinued, even though this medication was ordered on an as needed basis. However, there is no evidence that this call occurred and no evidence that the MD called the facility back. Resident 1 received [MEDICATION NAME] one time and [MEDICATION NAME] CR 15 mg, a narcotic, 3 more times in the facility even though the family expressed concern about [MEDICATION NAME] use. The family called the MD on 10/22/11 updated the physician who called the facility and discontinued the [MEDICATION NAME]. Resident 1's fluid and food intake was noted to be poor and the physician was not called and/or consulted. Resident 4 had multiple episodes of low blood sugar requiring intervention. A physician was not notified timely of these low blood sugar episodes. Findings as follows: AMDA (American Medical Directors Association) guidelines for physician notification indicates to report immediately to the physician any of the following symptoms: a medical complaint by a family member or patient, an altered level of consciousness if a sudden change in level of consciousness or responsiveness, and for diarrhea to report immediately with over 3 loose stools with change in level of consciousness, Temp of over 101.1F or altered vital signs. The facility policy for Hydration includes the following for intake and output: 1. new admissions will have intake and output (documented) for 3 days to establish a baseline pattern...2. a The PM Nurse will total intake and output daily and document on the MAR. b. The unit manager or other RN will evaluate daily intake and output totals to determine if the intake is less than the estimated fluid needs...c. interventions will be put in place if it is determined that fluid needs are not being met. Example 1 Resident 1 was admitted to the facility for rehabilitation after surgery on his knee. Additional [DIAGNOSES REDACTED]. Resident 1 was his own legal decision maker. Resident 1's Hospital Progress notes dated 10/20/11 indicates that on 10/19/11 on the PM shift Resident 1 had been given [MEDICATION NAME], an opioid (narcotic) antagonist, that is used for the complete or partial reversal of opioid depression, including respiratory depression. It is also used for [DIAGNOSES REDACTED]. Resident 1 was noted to respond well and woke up and his oxygen levels increased. A review of Resident 1's "Pre-Admission Worksheet" dated 10/20/11 indicates that he is alert and oriented x3, has a low appetite, and is a "little dopey." A review of Resident 1's Dehydration Risk Assessment Worksheet, dated 10/20/11, indicates that Resident 1 has risk factors of lethargy/weakness, diuretic use, laxative use and [MEDICAL CONDITION] drug use. The form does not indicate what interventions were put in place to prevent complications and the document is not signed by a staff member. Resident 1's admission physician orders [REDACTED]. Tylenol 650 mg every 4 hours, and [MEDICATION NAME] 7.5-325 mg 1 to 2 tabs every 6 hours as needed. In addition, the facility was to notify Resident 1's physician if his pulse was over 110 or less than 50 or for blood pressure readings higher than 180 or below 90 systolic and over 100 and below 50 diastolic, and if Resident 1's temp is above 100.5 degrees. A nursing note on 10/20/11 at 5:40 PM, states that Tylenol 650 mg was given for a fever. At 6:30 PM Resident 1's temp was 101.4. At 7:35 PM no improvement was noted yet (in reducing the fever) Ice pack applied and cold wash cloth put on his head, will continue to monitor. There was no call to the physician with this change in condition, despite direct physician orders. A nursing note on 10/20/11 at 8:46 PM states, "Condition stability: at 6:35 PM, author notified of (Resident 1's name) fever (and other VS) (vital signs), somnolence, and SpO2 in the 70's. Author directed administration of oxygen 2 L/M (liters per minute), check SpO2 (Saturation of Peripheral Oxygen) after 15 minutes, then consult the physician. On subsequent examination, he was wearing a nasal cannula with oxygen running at 2 l/m. His SpO2 was 90% but he falls asleep easily and it drops to 88%. Awakens easily again; speech was clear but nonsensical. Family arrived at 6:45 PM. Daughter (daughter's name) reports that he had trouble with an unknown medication, thought to be a narcotic, during hospital stay before this one. At that time she states he hallucinated states that he was clear last night in the hospital. When he was admitted today he was 'bright...., friendly...., cooperative..., oriented x3' Author made a cursory review of his chart initially that reveals he has been receiving [MEDICATION NAME] since at least 10/18/11. Following conversation with daughter (daughter's name) notes from (hospital name) examined more closely. According to those notes, (Resident 1's name) had been somnolent since late morning yesterday, with SpO2 drops during sleep sometime between 7:20 PM and 11:23 PM yesterday. (Physician's assistant name) was consulted by the RN and [MEDICATION NAME] was ordered and given. (Resident 1) woke up immediately, coughed and SpO2 improved. (Physician's assistant name) noted CXR (Chest x-ray) showed atelectasis vs pneumonia, and she wrote several orders including decreasing the [MEDICATION NAME] from every 4 to every 6 hrs. Resident 1 was given [MEDICATION NAME] CR 15 mg at 8:00 AM on 10/20/11. Comments: (Resident 1's name) presentation consistent with opioid sedation. Author's first instinct was to hold MS Contin. However in light of (PA's name) note will hold [MEDICATION NAME] (Please note that [MEDICATION NAME] was ordered on an as needed basis and was not scheduled and Resident 1 had not had any [MEDICATION NAME] since his admission to the facility). He has not been having pain so we may be able to convert him MS IR and wean soon." This entry was written by PM Charge Nurse D. There is no evidence that Charge Nurse RN D consulted with an MD with the information that he acquired from the hospital paperwork and the family information. It should be noted that RN D had suspected Resident 1 was having opioid sedation, this conclusion would require a call to Resident 1's physician. RN D's directions to hold the [MEDICATION NAME] and wanting to "wean him" from the [MEDICATION NAME]"soon" are not within RN D's license to practice. Additionally, in light of his concern that Resident 1's presentation was consistent with "opioid sedation" his direction to "convert" Resident 1 to MS IR ([MEDICATION NAME]), another opioid medication, is inconsistent with his assessed observations and again beyond his scope of practice. On 10/20/11 at 9:01 PM a nursing note, documented by RN D, states, "Cond (condition) Stability: Remains somnolent author directed (nurse F's name) to hold the [MEDICATION NAME]." A nursing note on 10/21/11, a late entry for 10/20/11 PM shift states that Resident 1 was very confused and had [MEDICAL CONDITION] when assessed. Oxygen was put on as ordered by the on call MD and his saturations improved. Resident 1 was only alert to his name and did not know the correct day or where he was when assessed, Resident 1 was very lethargic and slept most of the shift. He did have a fever of 101.4 and was given Tylenol. At about 9:45 his fever did go down to 100.8 however he continued to have a fever throughout the shift. [MEDICATION NAME] and [MEDICATION NAME] were held because of his altered level of consciousness. Will continue to monitor his condition and call the MD if necessary. Vitals: b/p 138/64, T-104.4F, Pulse 110, respirations 24 SpO2 74% after oxygen applied 95% on 2 liters of oxygen. On 10/21/11 at 2:35 AM a nursing note states, "[MEDICATION NAME]/APAP ([MEDICATION NAME]) location of pain left knee leg pains scale 9 with movements a 2 when still." At 4:34 AM a nursing note states relief from pain after [MEDICATION NAME]. (It is important to note that the plan of care was not to give Resident 1 the [MEDICATION NAME] as it was felt that it was causing his change of condition.) A nursing note on 10/21/11 at 11:53 AM states that wife and daughter confirm that resident is showing remarkable improvement in comparison to the previous day. A nursing note written on 10/21/11, at 12:51 PM states, "Assessed at 8:50 AM related to reports of sedation and fever over the PM and night shift. (Resident 1) is noted to be in center lounge, he is A and O x3 affect is bright and he reports that he is feeling well...He is currently receiving [MEDICATION NAME] mg at 8:00 AM and 8:00 PM scheduled, and staff is currently holding [MEDICATION NAME] due to possible sedation...Will update MD and request that [MEDICATION NAME] be discontinued and that [MEDICATION NAME] be considered for breakthrough pain." There is no evidence that Resident 1's MD was called and consulted and it is important to note that Resident 1 was given [MEDICATION NAME] during the night. Resident 1's CNA flow sheet revealed that no intake for food was recorded for breakfast or lunch and Resident 1 refused dinner on 10/21/11. The only recorded fluid intake on 10/21/11 was 240 cc for PM shift. A nursing note on 10/22/11 at 6:30 AM states that Resident 1 complained of loose stools. A nursing note on 10/22/11 (Saturday) at 2:15 PM states, "Comments: Writer approached by res wife, this shift. Writer told per wife that resident had difficulties taking [MEDICATION NAME] and that the doctor had been told prior to resident coming to the facility. Wife told writer that resident gets very lethargic and won't eat when given this medication. Res. and wife are requesting not to use medication until MD can be updated on Monday and obtain different meds. Will alert PM shift nurse. RN house charge advised." It should be noted that this is a second verbal warning to the staff that Resident 1's family is concerned about Resident 1's potential adverse drug reaction history to a narcotic medication and this information was again not conveyed to Resident 1's physician by facility staff and staff indicate that they would wait up to over 40 hours to call the physician on Monday. A nursing note on 10/22/11 at 2:51 PM states that Resident 1 had large loose stools and only bites for breakfast and 50 % of meal at lunch. A note at 8:46 PM states the [MEDICATION NAME] was held. A nursing note on 10/22/11 at 11:39 PM states, MD called during the shift and discontinued Resident 1's [MEDICATION NAME]. Surveyor reviewed a phone message from Resident 1's physician's clinic dated 10/22/11 at 4:24 PM which indicated a message was left for the physician from the daughter of Resident 1 indicating that she was concerned that Resident 1 was receiving [MEDICATION NAME] and she felt this was causing his lethargy. The physician then called the nursing home and the [MEDICATION NAME] was discontinued. Resident 1's CNA Flow sheet for 10/22/11 indicates that Resident 1 had bites of breakfast, 50% for lunch and bites for dinner with only 720 cc total fluid intake recorded. A nursing note on 10/23/11 at 8:50 PM states that Resident 1 had a large loose stool. Resident 1's CNA Flow sheet for 10/22/11 indicates that Resident 1 had 25% of breakfast and lunch and only bites for dinner with a total of 960 cc of recorded fluid for the day. A nursing note on 10/23/11 at 11:30 PM states that Resident 1 was having heartburn towards the end of the shift around 10:45 PM. He was given antacid and repositioned to sit up at the end of the bed. A nursing note on 10/24/11 at 12:28 AM states, "Resident presents with having an emesis, black, liquid. Sitting in day room, writer noted resident cough, burp then excoriate into tissues a dark green black gritty substance. Abdomen is round rotund and winced to writers touch..." The MD was called and Resident 1 was sent to ER for evaluation. A review of Resident 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident 1 was given his scheduled [MEDICATION NAME] CR 15 mg on 10/21/11 morning and evening and in the morning on 10/22/11, a total of 3 doses at the facility. A review of Resident 1's Hospital Encounter dated 10/24/11 indicates that Resident 1's BUN was 152 (Normal 9-20) and Creatinine was 4.5. (Normal 0.8-1.5). Final diagnostic impressions is upper GI bleed, [MEDICAL CONDITION] and Acute [MEDICAL CONDITION]. (On 10/19/11, the day before admission to the facility Resident 1's BUN was 24 and his Creatinine was 1.4) On 12/8/11 at 1:00 PM Surveyor interviewed Unit Manager G regarding Resident 1. Unit Manager G stated that on 10/21/11 Resident 1 was kind of tired, but that is not unusual for any resident on the day of admission. I came back the next day (10/21/11) and there were concerns with over sedation the night before. I talked to the family and they were concerned with the sedation also. I told them that I would call the doctor and see if we can discontinue the [MEDICATION NAME] and try [MEDICATION NAME], the family was happy with that and I called the MD. The MD did not call back to the unit manager and Unit manager G stated that she should have made sure that he called back and he did not. Unit Manager G was not aware that Resident 1 received [MEDICATION NAME] during the Noc shift prior. Surveyor asked Unit Manager G what the procedure for monitoring intake and ouput is. Unit Manager G stated that new admissions are monitored every shift for 3 days to get a baseline. The PM shift totals them up for the 24 hour total. If the total is less than 1000 cc an assessment should be done, put a hydration protocol in place (extra fluids 90 or 120 cc with each med pass), and the MD should be called. On 12/8/11 at 1:35 PM Surveyor interviewed LPN E who worked on 10/22/11 PM shift. LPN E stated that she remembered that the family had been very worried about his lethargy and that Resident 1 was still receiving [MEDICATION NAME]. LPN E told the family that the [MEDICATION NAME] could be held until Monday when the nurse can talk to his primary MD. The family was adamant that he not get any more [MEDICATION NAME]. LPN E indicated "He (Resident 1) was in and out of it (lethargic) that day." LPN E did not indicate why the MD could not be contacted by the facility until Monday. On 12/8/11 at 2:25 PM Surveyor interviewed LPN F regarding Resident 1's condition on 10/20/11. LPN F stated that she remembered that when she went to give him his medications and assessments he was desating into the 70's. "I called the MD and told him he was a little low (oxygen) and asked for an oxygen order." LPN F stated that she "didn't report any thing else" to the physician except the low oxygen level and the request for an oxygen order. Surveyor asked LPN F who monitors the intake and output that are recorded. LPN F stated that if the amount is below 1000 cc then to push fluids and report it to the unit manager so they can do an assessment. The MD should be called to report low intake and output. On 12/8/11 at 3:00 PM Surveyor interviewed PM Charge Nurse D regarding Resident 1's change in condition on 10/20/11 PM shift. Charge Nurse D stated that he was called to Resident 1's room and was told he had a fever and his sats were low. Charge Nurse RN D stated that when he saw Resident 1 he was sleeping and when awoke his sats would go up but fell back asleep again, he looked like "opiate sedation." Charge Nurse D indicated he told LPN D to call the MD and get an oxygen order and report his condition. Charge Nurse D stated that he would expect that LPN F reported Resident 1's condition to the MD including vital signs, somnolence and mental status, and that Resident 1 looked like he had opiate sedation. Surveyor asked Charge Nurse D if he knew what LPN D actually said to the MD as the only order received was for oxygen, and no orders were noted for any changes in his narcotic medications. Charge Nurse D stated that he did not ask LPN F what she spoke to the MD about. Surveyor asked Charge Nurse RN D who monitors the intake and output results. Charge Nurse RN D stated that he would make sure the unit manager knows about it. On 12/8/11 at 3:25 PM Surveyor clarified with LPN F her phone conversation with Resident 1's MD on 10/20/11. LPN F stated, "I only was able to ask him for an oxygen order before he ended the conversation. I did not get time to report his fever, lethargy, and his change in mentation. He (the physician) got off the phone before I was able to report any information." On 12/8/11 at 4:00 PM Surveyor interviewed DON B regarding Resident 1's medical record. DON B stated that she was not aware that anything was wrong with his stay. DON B did not receive any concerns about Resident 1. DON B stated that the facility should have given Resident 1's MD a complete picture of his condition and that if the family had concerns about his narcotics the MD should have been updated. DON B stated that they use the AMDA guidelines for changes of condition. The facility did not report to Resident 1's physician his symptoms of a fever, somnolence, change in mentation, and lethargy. In addition after the charge nurse was made aware by the family and by reviewing prior hospital records that resident 1 had this occur the evening before the charge nurse did not contact the MD to report this condition. Resident 1's intake and outputs were low and this was not reported to the MD in addition to his other changes. Example 2 The facility's Policy and Procedure on Diabetes Management, dated 10/3/2011, states: "When to call the Practitioner: Whenever the resident's blood sugar is outside the established individual parameters..... Treating [DIAGNOSES REDACTED] - [DIAGNOSES REDACTED] is defined as blood glucose less than 70 mg/dL. However, some residents develop [DIAGNOSES REDACTED] symptoms at higher blood glucose levels. while others may not develop symptoms even at considerable lower levels... " Resident 4's [DIAGNOSES REDACTED]. Resident 4's current physician orders [REDACTED]. Resident 4's current physician orders [REDACTED]. Resident 4 has no "Diabetic Standing Orders". Resident 4's Nurses Notes document the following: *11/29/11- 11:50 PM: "Blood sugar: 49 diaphoretic, alert, at 2335 (11:23 PM), [MEDICATION NAME] (sic) given at 2345 (11:45 PM), had eaten pc (piece) toast with peanut butter on it. Remains alert and verbally responsive. Will recheck at 0000 (12:00 am)." (There is no evidence a physician was notified of this episode of [DIAGNOSES REDACTED]. It is unclear why [MEDICATION NAME] IM (intramuscularly) was administered when Resident 4 was alert and taking oral sustenance.) *12/3/11 - 4:48 am: "Resident called to have blood sugar checked because "I could feel this happening". Blood sugar checked by RN (Registered Nurse) was 39. IM [MEDICATION NAME] given. Resident noted to be pale, but not experiencing any other symptoms other than "the feeling". Write will recheck blood sugar." (There is no evidence a physician was notified of this episode of [DIAGNOSES REDACTED]. It is unclear why [MEDICATION NAME] IM was administered when Resident 4 was having no other symptoms other than being "pale" and having "the feeling".) On 12/8/11 at 4:30 pm Surveyor spoke with ADON (Assistant Director of Nursing) C regarding Resident 4 and Resident 4's [DIAGNOSES REDACTED] episodes. ADON C stated that in the absence of parameters set by the physician, facility should notified a physician each time a resident's blood sugar goes below 70.

Based on interview and record review the facility did not ensure the medical justification for continued use of an indwelling catheter for 1 of 4 residents (Resident 14) sampled. Resident 14 was admitted with an indwelling catheter. Resident 14 was to keep indwelling catheter until weight bearing status improved. When the weight status improved, catheter was not discontinued. Resident 14 had five urinary tract infections over the seven months that she had the catheter. This is evidenced by: American Family Physician Publication dated January 15, 2000 article: Urinary Catheter Management, written by: David D. Cravens M.D. and Steven Zweig, M. D. states the following: "Urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Studies have shown that universal bacteriuria occurs within four days when open catheters are used versus approximately 30 days with closed systems. Complications of long-term catheterization include ... symptomatic urinary tract infection with [MEDICAL CONDITION], bacteremia,[MEDICAL CONDITION] and death. ... While catheters are frequently used in older patients, chronic indwelling catheterization is not a substitute for good nursing care in the management of incontinence ..." Resident 14's [DIAGNOSES REDACTED]. Resident 14's Minimum Data Set (MDS), reference date 5/29/10 indicates Resident 14 has long and short term memory impairment, needs extensive assist when using the toilet and uses an indwelling catheter. Resident 14's MDS, reference date 2/19/11 indicates Resident 14 has long and short term memory impairment, needs extensive assist when using the toilet and is occasionally incontinent of bladder. Resident 14 was originally admitted [DATE], admission nursing note indicated Resident 14 was continent of urine. Resident 14 was discharged to an assisted living on 3/10/10. Resident 14 was readmitted on [DATE] after a fall with fracture to right hip. Resident 14 was admitted with an indwelling catheter per physician order. Nursing admission note indicated the indwelling catheter increased the risk for potential impaired skin and UTI (urinary tract infection). Resident 14 was discharged to the hospital on [DATE] after sustaining a fall and re-fracturing her right hip. Resident 14 was readmitted on [DATE] with an indwelling catheter per physician order. On 4/21/10 the indwelling catheter was discontinued. Per nursing note 4/30/10 Resident 14 was continent. Resident 14 was discharged to the hospital 5/15/10 after sustaining a fall with a right femur fracture. Resident 14 was readmitted on [DATE] with an indwelling catheter per physician order. Resident 14's order stated may have indwelling Foley catheter d/t (due to) resident's non-weight bearing status and difficulty with transfers. 1. 7/4/10, 3:55 PM, the following order was written: obtain urine specimen for UA and C&S (urinalysis and culture and sensitivity) Dx (diagnosis) possible UTI. Nursing note dated 7/4/10, 7:05 PM Irrigated Foley with 30 ml (milliliters) normal saline due to cloudy urine with large blood clot. Tolerated procedure well. Temp (temperature) 99.6. Call placed to on call M.D. (medical doctor) and received orders. Tylenol given for temp. 7/4/10, 9:30 PM, the following order was written: [MEDICATION NAME] DS (double strength) (antibiotic) po (orally) 1 tablet BID (twice a day) x (times) 10 days for UTI. Nursing note dated 7/6/10, 3:27 PM, Writer changed Resident's (Resident 14) indwelling catheter this afternoon d/t (due to) output of hematuria and blood clots, which were clogging Foley tubing. Hematuria is r/t (related to) current DX of UTI, which is being Tx (treated) [MEDICATION NAME](antibiotic) per NP (nurse practitioner) O; refer to MAR/TAR (medication administration record/treatment administration record) for further information .... 7/8/10, (no time indicated) the following order was written: order for stat I.V. (intravenous) D 5 ? NS (normal saline) 75 cc / hr (Saline lock with 1 gram of [MEDICATION NAME] (antibiotic) 1 dose) Nursing note dated 7/9/10, 12:07 PM, Hematuria noted, red/brown in color, has c/o (complaints of) feeling need to void, foley is patent. NP O here to see resident, assessed. 7/9/10, 6:00 PM, the following order was written: 1. (triangle shaped symbol meaning change) Foley cath (catheter) today, use one w/ 5 cc balloon (hematuria) 2. Referral to urology (hematuria) 3. (arrow pointing down meaning decrease) Bactrim DS to 1 tab (tablet) po daily x 14 days [MEDICAL CONDITION] Nursing note dated 7/21/10, 9:40 PM Foley catheter changed by writer per TAR. Change was done at appx (approximately) 1910 (7:10 PM). ... As of 2140 (9:40 PM) no urine noted in bag. ...staff retrieved the bladder scanner with the instructions when turned on stating "battery is low, will shut off". ... At 2230 (10:30 PM) writer scanned bladder of resident with 108 ml of urine in bladder. Writer removed Foley and replaced it with a different one with success (urine return). 9/1/10, 3:00 PM, the following order was written: WBAT (weight bearing as tolerated) R (right) leg if no pain. (It is important to know that the Foley catheter order stated: Foley catheter d/t (due to) resident's non-weight bearing status and difficulty with transfers.) Nursing note dated 9/2/10 2:29 PM ... Foley catheter in place therefore is bladder continent; she is alert to toileting needs usually and will alert staff for assistance appropriately; able to make needs known; and she is cooperative with cares. ... Nursing note dated 9/3/10, 11:37 PM, Resident making frequent c/o (complaints of) tonight of Foley Catheter bothering her and feeling like she needs to void all the time. Catheter patency checked and is flowing easily clear dark gold UO (urinary output) in good amounts. Daughter in to visit and approached writer to note that her c/o needing to go frequently concern her as she had had similar complaints when she last had a UTI. .... Her only c/o is feeling like she needs to go and it feels uncomfortable .... 2. Nursing note dated 9/16/10, 1:33 PM, This writer was called to (Resident 14's) bedside for reports of cloudy urine and bypassing. (Resident 14) did not have a Foley output today so far but (Resident 14's) Foley has been passing foul smelling cloudy with small amount of bloody sediment urine and she has been incont. (incontinent) x 2. This writer did easily irrigate (Resident 14's) Foley with a cloudy urine return. (Resident 14) is unable to vocalize any flank pain, urgency, chills at this time per her usual mentation but slight hematuria was noted. (Resident 14's) temp is 99.5 tymp (tympanically, taken in the ear) and is being encouraged and assisted to increase her fluid intake. This writer did leave a message on NP O voice mail requesting an UA (urinalysis). This writer did leave a message with APOA cell phone voice mail for an update, will await her return. 9/16/10, 2:00 PM, the following order was written: UA / C&S if indicated dysuria (painful urination) Nursing note dated 9/16/10, 2:35 PM, This writer did change (Resident 14's) 18F (catheter size) Foley without any pain or discomfort and without any difficulty. Once this writer introduced (Resident 14's) current 18F Foley, a cloudy, off white, foul odor urine return was received and a sample was obtained and sent to Stoughton Hospital Lab. Will await for UA results. 9/16/10, (no time indicated), the following order was written: PT (Physical Therapy) clar (clarification) order to eval (evaluate) & tx (treat) 2 - 4 x / wk (week) for 8 wks... 9/16/10, 4:05 PM, the following order was written: [MEDICATION NAME] Mono (antibiotic) po BID 100 mg x 7 days, UTI. Resident's condition appeared to improve over the next three days, but then a nursing note dated 9/20/10, 1:09 AM, notes [MEDICATION NAME] given for elevated temp 101, currently on antibiotic therapy for UTI. Nursing note dated 9/20/10, 2:59 PM, Lime green urine noted. 50 cc out. Resident is currently on [MEDICATION NAME] for UTI. T (temperature) - 99.4. 9/20/10, 4:45 PM, the following order was written: CBC, BMP, for UTI and poor urine output. Start IV fluids: D 5 ? NS at 75 ml / hr x 1 liter. Leave saline lock after fluids are complete, flush per house protocol for UTI and poor urine output. D/C (discontinue) [MEDICATION NAME], start Bactrim DS 1 tab po BID x 10 days, UTI. 9/20/10, 6:45 PM, the following order was written: Change IV fluid to [MEDICATION NAME] Ringers at 75 ml / hr x 1 liter Nursing note dated 9/20/10, 10:41 PM, UTI, resident continues to have very little urine output this evening. Her current temp is 97.7. She denies any pain or frequency. She did have a scant amount of urine in the commode. Bladder scan results of 0 ml urine residual. ... Nursing note dated 9/21/10, 1:43 AM, [MEDICATION NAME] given for temp 100. 9/21/10, (no time indicated), the following order was written... D/C saline lock after IV is finished. 9/22/10, (no time indicated), the following order was written: Bactrim DS po x 10 days for UTI. Nursing note dated 9/26/10, 6:24 PM, Temp 99.2. Resident is being treated for [REDACTED]. Resident encouraged to frequently push fluids, and offered often. Resident denies any pain or urgency, foley cath in place. Will continue to monitor. Nursing note dated 9/30/10, 12:54 AM, Temp 99 fluids encouraged but accepts poorly. Bactrim DS was discontinued today as noted on the MAR. Nursing note dated 10/4/10, 1:45 AM, Urine has completed antibiotic therapy, temp 99.4, fluids encouraged but accepts poorly thru night, indwelling Foley cath patent. Nursing note dated 10/4/10, 2:30 PM, Temp 98.8, no s/sxs (signs and symptoms) of infection at this time, will continue to monitor. Nursing note dated 10/6/10, 4:53 PM ...This is a new CNA (Certified Nursing Assistant) program for both Transfer and Ambulation.... Resident should attempt to ambulate 100 feet x 1 day, 7 days/week as tolerated. (It is important to note that the resident is now full weight bearing.) 3. Nursing note dated 10/20/10, 12:23 AM ... Temp 100.3. Follow-up nursing notes, 1:32 AM, [MEDICATION NAME] given for temp 100.3, 3:02 AM, Moderate effect temp 99.3, fluids encouraged. Nursing note dated 10/20/10, 5:57 PM, Temp 99.1 at this time, denies pain urine clear, fluids encouraged but will only take a couple sips at a time. NP updated via voice mail of elevated temp, urine is clear, no congestion noted. 10/20/10, (no time indicated), the following order was written: CBC w/ diff (Complete Blood Count with differential, this is a blood test), BMP, UA, Dx fever. Nurse Practitioner (NP) O wrote the following note 10/20/10: ... UTI - to start on [MEDICATION NAME] 100 mg po bid to be on continually to tx current mild inf (infection) as well as to be providing [MEDICATION NAME]. I do want to keep in Foley as in last year pt (patient) has had 3 falls resulting in fx that were felt to be r/t pt attempting to transfer self to bathroom. Pt has done well w/ (with) Foley in, no further falls have occurred and patient has remained safe, 10/20/10, (no time indicated), the following order was written: 1. [MEDICATION NAME] 100 mg, po bid x 7 days, then (arrow pointing down indicating decrease) to 50 mg po qd (every day) (UTI, UTI [MEDICATION NAME]) 2. CXR (chest x-ray) (fever, resp (respiratory) congestion) 3. [MEDICATION NAME] 5 mg po qd (dementia). 10/20/10, (no time indicated), the following order was written: [MEDICATION NAME] (antibiotic) 400 mg 1 po daily x 7 days for RLL (right lower lobe) pneumonia. Nursing note dated 10/21/10, 11:36 PM, Bladder tx done, reinserted 10 cc balloon normal saline sol (solution), indwelling cath. Inserted Foley changed routine cath. care. ... temp 98.6 ... 10/26/10, 11:00 PM, the following order was written: Bactrim DS 1 BID x 5 days for UTI. 10/27/10, (no time indicated), the following order was written: Discontinue [MEDICATION NAME] 50 mg po daily, start on [MEDICATION NAME] (antifungal medication) 100 mg x 3 days, then d/c. 10/27/10, (no time indicated), the following order was written: When Bactrim DS course complete, start on Bactrim SS 80/400 mg 1 po daily (UTI [MEDICATION NAME]). Nursing note dated 10/30/10, 6:31 AM, Res. (Resident) continues use of Bactrim DS BID for UTAI. Temp 98.0. No noted adverse effects noted from antibiotic therapy at this time. 11/1/10, 9:00 AM, the following order was written: D/C Bactrim SS,[MEDICATION NAME]([MEDICATION NAME], antibiotic) PO BID x 7 days. Nursing note dated 11/21/10, 11:06 PM, Catheter changed this shift, per MD monthly order. Urine return noted upon insertion of new 18F cath. 10cc balloon inflated. Res. denies pain during procedure. Nursing note dated 11/22/10, 2:09 PM, [MEDICATION NAME] given for Temp 100.3. Follow up notes: 1440 (2:20 PM) temp 100.0. Nursing note dated 11/26/10, 6:28 AM, Temperature 100.1, Bedroom hot and had several heavy quilts on, quilts removed and felt cooler shortly after that ... Nursing note dated 12/1/10, 12:35 AM, Temp 99.2... NP O wrote the following note 12/2/10: ... 8. Indwelling Foley Catheter. Patient has a Foley catheter in place currently as past falls appeared to be as a result of patient attempting to transfer self to the bathroom. Plan is to keep in place at this time, as patient has remained free of falls. ... Nursing note dated 12/8/10, 3:58 PM, [MEDICATION NAME] given for fever of 99.5. Nursing note dated 12/8/10, 10:53 PM, Resident had a temperature of 99.5 this evening. Upon re-checking temp at 2047 (8:47 PM), it was 99.1 ...Writer auscultated lungs and crackles were heard in all fields. Urine was clear ... Nursing note dated 12/13/10, 1:02 PM, ... Resident has extensive HX (history) of UTIs. She currently has a indwelling Foley catheter in place d/t severe unawareness of her safety environment r/t advancing Dementia. The Foley catheter remains in place d/t (Resident 14's) extensive fall Hx with noted multiple traumas d/t self inflicted actions. In this specific case the benefits of catheter in place outweigh the risks, most importantly to maintain resident's safety. ... 12/13/10, 10:10 AM, the following order was written: Uty stat (cranberry supplement) 1 oz (ounce) po daily Dx UTI prevention. 12/13/10, 3:35 PM, Bowel and Bladder Assessment: No changes in bowel and bladder status since last review. She remains continent of bladder d/t Foley catheter in place, and continent of bowel most of the time with incontinent episodes occurring once per week or less. Resident currently has indwelling Foley catheter in place d/t severe short term memory deficit and severe decline in cognition making her unaware of her safety environment, both of which are d/t advancing Dementia process. Foley catheter remains in place per MD/NP order d/t (Resident 14's) extensive fall Hx with noted multiple traumas. Upon review of resident's previous incidents documentation has shown (Resident 14's) falls have all resulted d/t independent attempts to transfer self OOB (out of bed), W/C, etc. to use the bathroom. ... , and she also receives Uty Stat (as of today) daily [MEDICATION NAME] for UTI preventions. Will continue with current interventions in place, and document findings/results as appropriate. Plan: Should current interventions prove not to be effective in preventing, or at least minimizing UTI occurrences will then proceed to perform a trial discontinuation of Foley catheter per MD/NP order. Please note: Current interventions are proven effective in maintaining Resident's safety as evidenced by she has had no falls since re admission noted on 5/15/10 .... Nursing note 12/21/10, 10:23 PM, Monthly Foley catheter change ... resident with no complaints and tolerated well ... 4. 1/7/11, 10:20 AM, the following order was written: ... obtain UA d/t cloudy, foul smelling urine. 1/8/11, (no time indicated), the following order was written: Bactrim DS PO BID x 7 days, for UTI. Nursing note 1/8/11, 10:49 PM, At 1800 (6:00 PM), resident's temperature was 99.3. Writer gave 2 PRN (as needed) Tylenol and at 2030 (8:30 PM), the resident's temperature was 98.8 and sleeping. 1/12/11, 4:00 PM, the following order was written: Continue Bactrim DS for 10 days (from 7). [MEDICATION NAME] mg PO BID x 10 days [MEDICAL CONDITION]. Repeat urine culture in 2 weeks [MEDICAL CONDITION] Nursing note 1/15/11, 7:22 PM, Urine continues [MEDICATION NAME] Bactrim DS for UTI. T: 99.3, tympanic. (Resident does have a thick sweater on and a lap blanket though) ... Nursing note 1/16/11, 7:05 PM, Urine continues [MEDICATION NAME] Bactrim DS for UTI. No adverse reactions. T: 99.7 (tympanic) at 1730 (5:30 PM), 98.2 at 1850 (6:50 PM). ... 5. 1/26/11, (no time indicated), the following order was written: Keflex 500 mg po QID (4 times a day) x 14 days for UTI. 1/26/11, 3:10 PM, the following order was written: d/c foley, push fluids, monitor for urine output, bladderscan before bed - if > (greater than) 250 ml urine administer new indwelling foley catheter. 1/26/11, 4:00 PM, the following order was written: d/c Keflex 500 mg for UTI - will wait to see what urine culture grows. (It is important to note there is no documentation indicating what time the Foley catheter was discontinued found in the resident's medical record) 1/29/11, 12:20 PM, the following order was written: [MEDICATION NAME] 100 mg po bid x 7 days, UTI. 1/31/11, 8:45 AM, the following order was written: Discontinue [MEDICATION NAME], Obtain St (straight) cath UA with C&S - Dx: fever, s/p (status [REDACTED]. 1/31/11, 10:00 AM, the following order was written: [MEDICATION NAME] 150 mg PO x 1 on 1/31/11. Dx yeast in urine. It is important to note that Resident 14 was treated with multiple antibiotics for a total of 5 urinary tract infections in 7 months while she had the indwelling catheter. Resident 14's weight bearing status was upgraded to weight bearing as tolerated on 9/1/10. Resident 14's physician order [REDACTED]. On 2/22/11 at 2:00 PM, Surveyor interviewed RN N. RN N stated that the catheter was in place due to Resident 14's weight bearing status to begin with and was kept for safety as ordered per the nurse practitioner. RN N stated she thought that NP O should have talked with the family and informed the APOA of the risks and benefits of an indwelling Foley catheter. RN N stated there was no education/discussion documented in the medical record. On 2/23/11 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated that she would expect RN N to be more proactive to educate the nurse practitioner and family about the risks and benefits of an indwelling Foley catheter. DON B also stated she would expect all orders for indwelling catheters to be medically justified.