Every finding on record at St Francis Health Services

Based on observation, interview and record review, the Facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R43 & R4) of 3 Residents reviewed for pressure injuries. *R43 is dependent for all cares, requires substantial/maximal assistance with bed mobility and is at risk for developing pressure injuries. On 12/24/2025, the Facility implemented a care plan for R43's risk for pressure injuries with interventions not supportive of R43's needs. On 1/27/2026, R43 developed a Deep Tissue Injury (DTI) (an injury which occurs with prolonged pressure and shear forces) to R43's bilateral heels. On 2/18/2025, R43's right heel DTI almost doubled in size and observations of improper wound treatment were observed in place. *R4 was admitted with pressure injuries to the coccyx and right heel. The pressure injury to the coccyx was not staged appropriately and the pressure injuries were not comprehensively assessed weekly. Findings: 1.) R43 was admitted to the facility on [DATE] after a fall at home resulting in multiple rib fractures. R43 was admitted with diagnoses including multiple fractures (crack or break in a bone) of right side, weakness and dementia (a progressive decline in memory). R43's admission Minimum Data Set (MDS), dated [DATE], indicates R43 has a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, no rejection of care, taking narcotic pain medication, is dependent on staff for toileting hygiene, shower/bathing, upper/lower body dressing, putting on/taking off footwear, sit to lying, lying to sit at side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, requires substantial/maximal assistance rolling left to right, is at risk for developing pressure injuries and has moisture associated skin damage with application of ointments to other than feet. Surveyor reviewed the Facility provided document, titled Physical Therapy, with a date of service of 12/24/2025 through 1/2/2026 and indicates R43 admitted to the facility after 2 falls at home resulting in rib fractures and traumatic pneumothorax (a partial or complete lung collapse caused by air entering the pleural space due to chest injury). Skilled interventions provided include direct, hands on care with R43 focused on increased strength, range of motion bilateral lower extremities along with trunk for improved functional mobility. R43 was readmitted to the hospital on [DATE] for unrelated medical condition. R43 returned to the facility on 1/6/2026. Surveyor reviewed the Facility provided document, titled readmission Evaluation, dated 1/6/2026, which indicates the following: R43 requires extensive assistance of 1 for bed mobility, requires extensive assist of 1 for transfers and total lift dependent. Scored 17 on a Braden scale, indicating R43 is at risk for skin integrity, with no skin impairments present and is taking narcotic pain medication. A progress note, dated 1/28/2026, at 2:03 AM, in R43's medical record, notes that upon answering R43's call light, blood was noted on the bedsheet from R43's right heel, which appears to have a blood blister. A progress note, dated 1/28/2026, at 2:13 PM, indicates during wound rounds, a DTI to left heel was identified. Recommendations for interventions included -Air Mattress -offloading as tolerated -off loading heel shoes to continue therapy to improve strength and mobility -liquid protein -skin prep three times a day -repositioning every 1-2 hours R43's Pressure Injury Weekly Tracker for R43, dated 1/28/26 documents: Pressure injury 1- right heel- suspected DTI- -8.0 centimeters (cm) x 6.0cm x 0.2cm (length x width x depth) -surface area greater than 24cm2 (l x w) -Tissue Type- epithelial tissue -Skin %- 100% -light bloody drainage -Peri-wound- Pink and normal for ethnic group -Wound edges- distinct, outline clearly visible, attached, even with wound base -Summary- improving -Plan/treatment- monitor in treatment administration record, heel protectors, turn and reposition, treatment as ordered and wound nurse to measure weekly. Pressure injury 2- left heel- suspected DTI- -6.0 cm x 4.0 cm x 0 -surface area 12.1 – 24.0 cm2 -Tissue Type- closed -no drainage -Peri-wound- Pink and normal for ethnic group -Wound Edges- blank -Summary- first observation, Plan/treatment- monitor in treatment administration record, assess signs/symptoms of infection, float heels, heel lift boot, specialty mattress, pressure reduction device for bed, maintain correct wheelchair position, treatment as ordered, medications as ordered, and wound nurse to measure weekly. Surveyor noted the above wound assessment did not document a wound bed description, wound edges or skin color of wound. Per the State Operation Manual (SOM), the following is the guidance for staging a Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions The Facility provided document, titled Care Plan Report, indicates R43 has an actual DTI to the right and left heel, with interventions of: -Administer treatment per orders, initiated 1/28/2026 -Air Mattress, initiated 1/28/2026 -Diet and supplements per order, initiated 1/28/2026 -Educate resident/representative on wound care procedure. Observe return demonstration until comfort level achieved, initiated 1/28/2026 -Encourage and assist as needed to turn and reposition; use assistive devices as needed, initiated 1/28/2026 -Enhanced Barrier precautions, initiated 2/6/2026 -Float heels as able, initiated 1/28/2026 -Follow up with doctor as ordered, initiated 1/28/2026 -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc., notify doctor as needed, initiated 1/28/2026 -Reposition every 1-2 hours and as needed, initiated 1/28/2026 -Reposition every 1-2 hours, encourage to stay off back, initiated 2/11/2026 -Therapy to eval at treat as ordered, initiated 1/28/2026 -Toileting program as indicated, initiated 1/28/2026 -Use pillows and/or positioning devices as needed, initiated 1/28/2026 The Facility provided document, titled Care Plan Report, indicates R43 is at risk for alteration to skin integrity, with interventions of: -Barrier cream to peri area/buttocks as needed, initiated 12/24/2025 -Diet and supplements per order, initiated 1/15/2026 -Encourage to reposition as needed; use assistive devices as needed, initiated 12/24/2025 -Float heels as able, initiated 12/24/2025 -Observe skin condition with daily cares, repost abnormalities, initiated 1/15/2026 -Obtain labs as ordered and notify doctor of results, initiated 1/15/2026 -Podiatric care as needed, initiated 1/15/2026 -Pressure redistributing device to bed/chair, initiated 12/24/2025 -Provide preventative skin care daily, initiated 1/15/2026 -Therapy eval and treat as ordered, initiated 1/15/2026 The Facility provided document, titled Order Summary Report for R43, includes: -Soft boots on when in bed. Every shift, start date 1/28/2026 Surveyor noted R43's order for Soft boots on while in bed, is not listed in R43's care plan or the Certified Nursing Assistant (CNA) Kardex. Surveyor noted the following interventions listed on the Pressure Injury Tracker, are not part of R43's care plan or Certified Nursing Assistant (CNA) Kardex: -heel lift boot for R43's left heel -heel protector for R43's right heel -maintain correct wheelchair position R43's Pressure Injury Weekly Tracker for R43, dated 2/4/2026 documents: Pressure injury 1- right heel- suspected DTI- -8.0 cm, x 6.0 cm x 0.2 cm -surface area greater than 24cm2 (l x w) -Tissue Type- granulation tissue -Skin %- 100% -Drainage- bloody -Amount- light -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- Distinct, outline clearly visible, attached, even with wound base -Summary- improving. -Plan/Treatment- monitor in treatment administration record, assess signs/symptoms of infection, complete nutritional risk, heel protectors, specialty mattress, pressure reduction device for bed, nutrition or hydration intervention to manage skin problems, turning/repositioning, treatment as ordered, and wound nurse to measure weekly. Pressure injury 2- left heel- suspected DTI- -6.0 cm x 4.0 cm x 0 cm -Surface area 12.1 – 24.0 cm2 -Tissue Type- closed -Drainage- none -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- blank -Summary- improving -Plan/Treatment- monitor in treatment administration record, assess signs/symptoms of infection, complete nutritional risk, heel lift boot, float heels off bed, specialty mattress, pressure reduction device for bed, maintain correct wheelchair position, treatment as ordered, medications as ordered and wound nurse to measure weekly. Surveyor noted the above wound assessment did not document a wound bed description, wound edges or skin color of wound and that the above interventions were still not listed on R43's skin plan of care. R43 was readmitted to hospital for an unrelated medical condition on 2/7/2026 through 2/11/2026. Surveyor reviewed the Facility provided document, titled readmission Evaluation, dated 2/11/2026 and indicates R43 has impairment to skin which included a right heel unstageable pressure injury and a left heel suspected DTI. R43's Pressure Injury Weekly Tracker for R43, dated 2/11/2026 documents: Pressure injury 1- right heel- unstageable- -5.0 cm x 5.0 cm x depth is blank -Surface area 2.1 – 3.1 cm2 -Tissue Type- necrotic -Drainage- none -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- Distinct, outline clearly visible, attached, even with wound base -Summary- first observation upon readmission to Facility from hospital. -Plan/Treatment- monitor in treatment administration record, assess signs/symptoms of infection, complete nutritional risk, heel protectors, specialty mattress, pressure reduction device for bed, nutrition or hydration intervention to manage skin problems, turning/repositioning, treatment as ordered, medications as ordered and wound nurse to measure weekly. Pressure injury 2- left heel- suspected DTI, 8.0 cm x 5.0 cm x 0 -Surface area- greater than 24.0 cm2 -Tissue Type- closed -Drainage- none -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- blank Summary- improving -Plan/Treatment- monitor in treatment administration record, assess signs/symptoms of infection, complete nutritional risk, heel lift boot, float heels off bed, specialty mattress, pressure reduction device for bed, maintain correct wheelchair position, treatment as ordered, medications as ordered and wound nurse to measure weekly. Surveyor noted the above wound assessment did not document a depth measurement, a wound bed description, wound edges or skin color of wound. Surveyor noted R43's right heel wound had decreased in size but changed in staging from a DTI to an unstageable pressure injury. Surveyor noted that R43's left heel wound had increased in size since returning from the hospital. The Facility provided document, titled Care Plan Report, indicates R43 has an actual DTI to the right and left heel, with interventions of: -Administer treatment per orders, initiated 1/28/2026 -Air Mattress, initiated 1/28/2026 -Diet and supplements per order, initiated 1/28/2026 -Educate resident/representative on wound care procedure. Observe return demonstration until comfort level achieved, initiated 1/28/2026 -Encourage and assist as needed to turn and reposition; use assistive devices as needed, initiated 1/28/2026 -Enhanced Barrier precautions, initiated 2/6/2026 -Float heels as able, initiated 1/28/2026 -Follow up with doctor as ordered, initiated 1/28/2026 -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc., notify doctor as needed, initiated 1/28/2026 -Reposition every 1-2 hours and as needed, initiated 1/28/2026 -Reposition every 1-2 hours, encourage to stay off back, initiated 2/11/2026 -Therapy to eval at treat as ordered, initiated 1/28/2026 -Toileting program as indicated, initiated 1/28/2026 -Use pillows and/or positioning devices as needed, initiated 1/28/2026 The Facility provided document, titled Care Plan Report, indicates R43 is at risk for alteration to skin integrity, with interventions of: -Barrier cream to peri area/buttocks as needed, initiated 12/24/2025 -Diet and supplements per order, initiated 1/15/2026 -Encourage to reposition as needed; use assistive devices as needed, initiated 12/24/2025 -Float heels as able, initiated 12/24/2025 -Observe skin condition with daily cares, repost abnormalities, initiated 1/15/2026 -Obtain labs as ordered and notify doctor of results, initiated 1/15/2026 -Podiatric care as needed, initiated 1/15/2026 -Pressure redistributing device to bed/chair, initiated 12/24/2025 -Provide preventative skin care daily, initiated 1/15/2026 -Therapy eval and treat as ordered, initiated 1/15/2026 The Facility provided document, titled Order Summary Report for R43, includes: -Soft boots on when in bed. Every shift, start date 1/28/2026 Surveyor noted R43's order for Soft boots on while in bed, is not listed in R43's care plan or the Certified Nursing Assistant (CNA) Kardex. Surveyor noted, the following interventions listed on the Pressure Injury Tracker, are not part of R43's care plan or Certified Nursing Assistant (CNA) Kardex: -heel lift boot for R43's left heel -heel protector for R43's right heel -maintain correct wheelchair position On 02/18/2026, at 9:10 AM, Surveyor observed Director of Nursing (DON)-B, Licensed Practical Nurse (LPN)-D and Certified Nursing Assistant (CNA)- J provide wound care for R43. Surveyor observed R43 to have only white tape covering R43's bilateral heels. DON-B checked R43's order and informed Surveyor that R43 does not have the correct dressings in place for R43's heel wounds and indicated foam dressings should be in place. DON-B measured the wounds, stating them out loud. Surveyor noted the following measurements provided by DON-B: -left heel- measured in cm- 5 x 5.5 x 0 -right heel- measured in cm- 5.5 x 5 x 0 and 3.5 x 3 x 0 Surveyor observed DON-B measure 2 wounds for R43's right heel. Surveyor observed R43's right heel wound, which appears to be in a shape similar to an oval, with a smaller diameter near the center. Surveyor noted the wound to be dark in color compared to R43's skin complexion, appearing dark purple/black, non-blanchable. Surveyor clarified with DON-B if there is two right heel wounds or 1. DON-B indicated she would get back to surveyor with that information but is measuring the right heel as 2 wounds for now. Surveyor asked DON-B to provide Surveyor with a copy of the wound assessment once DON-B has completed it. R43's document titled Order Summary Report indicates an active order with a start date of 2/12/2026 for every day shift: Wash right and left heels with soap and water, pat dry. Left posterior heel apply Betadine, cover with foam dressing. Right posterior heel apply Betadine, cover with foam dressing. Surveyor observed R43 with white tape covering R43's left and right heel wounds prior to the start of wound care, which did not match with R43's prescribed pressure injury treatment. R43's Pressure Injury Weekly Tracker for R43, dated 2/18/2026 documents: Pressure injury 1- right heel- unstageable- -5.5 cm x 5.0 x depth is blank -Surface area- greater than 24.0 cm2 -Tissue Type- necrotic -Slough- 100% -Drainage- none -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- Distinct, outline clearly visible, attached, even with wound base Summary- improving. -In the additional interventions/plan section- DON-B indicates the pressure injury contains 2 areas. Actual eschar which is 5.5 cm x 5.0 cm and extended to 3.5 cm x 3.0 cm DTI with a wound clinic appointment on 2/24/2026. Pressure injury 2- left heel- suspected DTI- -5.5 cm x 5.0 cm x 0 -Surface area- greater than 24.0 cm2 -Tissue Type- closed -Drainage- none -Peri-wound tissue- Pink or normal for ethnic group -Wound Edges- Distinct, outline clearly visible, attached, even with wound base -Summary- improving - monitor in treatment administration record, assess signs/symptoms of infection, complete nutritional risk, heel lift boot, float heels off bed, specialty mattress, pressure reduction device for bed, maintain correct wheelchair position, treatment as ordered, medications as ordered and wound nurse to measure weekly. Surveyor noted R43's right heel surface area approximately doubled in size and the depth measurement is blank. Surveyor noted that the wound had progressed from a DTI to unstageable since R43 returned from the hospital. On 02/18/2026, at 1:20 PM, Surveyor interviewed DON-B and VP of Success-C. VP of Success-C indicated R43 appears to have a baseline care plan for skin which was initiated upon admission. DON-B informed Surveyor that DON-B is counting the right heel as 1 wound and will add in the comments an extension of the wound and include the additional measurements. DON-B indicated the treatment will be the same and R43 has a referral for the wound clinic. DON-B informed Surveyor that they discussed therapy, upon discovery of the bilateral heel DTI's, and believed the cause was due to R43 self-propelling in wheelchair excessively using R43's heels. Surveyor noted, no documentation or evidence provided by the Facility to support the Facility addressing R43 using R43's heels to self-propel in R43's wheelchair and/or what interventions the Facility took to prevent R43's wound from deteriorating due to this concern. On 02/18/2026, at 1:51 PM, Surveyor interviewed Occupational Therapy Assistant (OTA)-M who indicated, R43 was a moderate/max assist of 2 using a Sara lift with transfers on unit. R43 has significant posterior center of gravity and did self-propel in wheelchair and were working on it in therapy but only with hands. R43's feet were always up on foot pedals and do not believe R43's heel wounds were caused by propelling in wheelchair. OTA-M described the way R43 would stand up and tend to lean back due to prior use of a lift chair at home. This would cause R43's feet to come forward. OTA-M indicated they could not get shoes on R43's feet for a long time due to swelling and would only get to partial standing and then sit. After evaluations, OTA-M would fill out what therapy would want done for R43 and the DON or nursing would add to care plan, indicating therapy does not have access to add to care plans. Surveyor noted, no documentation or evidence provided by the Facility to support the Facility addressing R43 using R43's heels to self-propel in R43's wheelchair and/or what interventions the Facility took to prevent R43's wound from deteriorating due to this concern. On 02/18/2026, at 2:02 PM, Surveyor interviewed NHA-A. Surveyor asked NHA-A what NHA-A's expectations are as to when a residents care plan should become patient centered following a baseline care plan, NHA-A did not respond. Surveyor asked NHA-A what R43's interventions of float heels as able and encourage repositioning mean. NHA-A indicated R43 should be repositioned every 2-3 hours, or more frequently if needed, and wear boots as R43 can tolerate. NHA-A made aware of the above concerns regarding the care and treatment of R43's Facility acquired pressure injuries. NHA-A administrator encouraged Surveyor to speak with the Rehab Director regarding R43. On 02/18/2026, at 2:41 PM, Surveyor interviewed Rehab Director-N. Rehab Director-N indicated that on occasion she would catch R43 using feet to propel across the dining room floor but no more than that and someone was usually pushing R43 in the wheelchair. R43 has a posterior center of gravity causing R43 to bear weight onto R43's heels when trying to stand. R43 was receiving therapy 5 times per week but switched to 3 times per week when Rehab Director-N found out about wounds and was not getting therapy as often. Surveyor asked Rehab Director-N about who is responsible for R43's interventions, Surveyor was informed that Surveyor would have to ask nursing. No additional information was provided. 2.) R4 was admitted to the facility on [DATE] with diagnoses of acute cystitis (inflammation of the bladder), pressure ulcer to the right heel and right buttock, anxiety, depression, and obesity. R4's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented R4 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12, needed maximum assistance for bed mobility, had a Stage 3 pressure injury on admission, and had an Unstageable pressure injury on admission. R4's Activities of Daily Living (ADL) Care Plan was initiated 12/5/2025 with the intervention of two assist for bed mobility and was revised on 12/26/2025 with assist of two and a sit to stand lift for transfers. R4's At Risk for Alteration in Skin Integrity Care Plan was initiated 12/5/2025 with interventions: -Barrier cream to peri area/buttocks as needed. -Encourage to reposition as needed; use assistive devices as needed. -Float heels as able. -Pressure redistributing device on bed/chair. -Use pillows/positioning devices as needed. R4's Actual Stage 3 Pressure Injury to coccyx; Unstageable Pressure Injury to Right Heel Care Plan was initiated 12/5/2025 with interventions: -Administer treatment per physician orders. -Air mattress/cushion on bed/wheelchair. -Encourage and assist as needed to turn and reposition; use assistive devices as needed. -Float heels as able. -Follow up care with physician as ordered. -Reposition every 1-2 hours; encourage to stay off of back; protective boots on at all times as tolerated. (added to Care Plan 12/6/2025) -Use pillows and/or positioning devices as needed. -Vicair cushion (name brand of cushion used for pressure reducing characteristics). (added to Care Plan 12/6/2025) On 12/5/2025 on the admission Evaluation, Registered Nurse (RN)-L documented R4 had a Stage 2 pressure injury to the right buttock measuring 2 cm x 2 cm with no depth or wound description documented, a Stage 2 pressure injury to the left buttock measuring 0.5 cm x 1 cm with no depth or wound description documented, and an Unstageable pressure injury to the right heel measuring 4 cm x 2 cm with no depth or wound description documented. COCCYX PRESSURE INJURY On 12/5/2025 on the Pressure Injury Weekly Tracker form, RN-L documented R4 had a Stage 3 pressure injury to the coccyx measuring 3.5 cm x 2 cm x 0 cm with 100% necrotic slough and no drainage with exposed muscle. RN-L documented in the narrative section of the form the left buttock had an open area that measured 0.5 cm x 1 cm and the right buttock had an open area that measured 2 cm x 2 cm. Surveyor noted the two wounds were measured as one wound with both exposed muscle and 100% necrotic tissue covering the wound base; the wound would be classified as Unstageable or Stage 4 depending on the characteristics of the wound, not a Stage 3. On 12/6/2025 on the Pressure Injury Weekly Tracker form, Director of Nursing (DON)-B documented R4's coccyx Stage 3 pressure injury measured 4 cm x 3 cm x 0.3 cm with 100% necrotic slough and no drainage. This was DON-B's initial observation of R4's wound. DON-B did not document the wound had two separate open areas. Surveyor noted R4's coccyx pressure injury was inaccurately staged as a Stage 3 pressure injury with 70% to 100% necrotic tissue documented weekly from admission through 1/28/2026. On 2/4/2026, R4's coccyx pressure injury was not comprehensively assessed or documented. RIGHT HEEL PRESSURE INJURY On 12/5/2025 on the Pressure Injury Weekly Tracker form, RN-L documented R4 had an Unstageable pressure injury to the right heel measuring 4 cm x 2 cm x 0 cm with 100% necrotic tissue and no drainage. On 12/6/2025 on the Pressure Injury Weekly Tracker form, DON-B documented R4's right heel Unstageable pressure injury measured 4 cm x 2.5 cm x 0 cm with 100% necrotic tissue, no drainage, and loose eschar. This was DON-B's initial observation of R4's wound. On 2/4/2026, R4's right heel pressure injury was not comprehensively assessed or documented. On 2/16/2026 at 10:31 AM, Surveyor observed R4 sitting in a wheelchair in R4's room. R4 had a heel boot on the right foot. R4 had an air mattress on the bed and six pillows piled on at the head of the bed. Surveyor asked R4 about the pillows on the bed. R4 stated R4 had a sore on the heel of the right foot, and the staff use the pillows to keep the foot up off the bed. R4 stated R4 had a sore on the back, too, that the nursing staff puts a dressing on. In an interview on 2/17/2026 at 1:51 PM, Surveyor asked Licensed Practical Nurse (LPN)-D if R4 is seen by a wound physician for the pressure injuries. LPN-D stated R4 goes to a wound clinic. Surveyor asked how often R4 was seen at the wound clinic. LPN-D stated that it depends on when the wound clinic wants to see R4, not every week but maybe every other week or once a month. Surveyor reviewed the wound clinic consult sheets. R4 was seen at the wound clinic on 12/17/2025, 1/7/2026, and 2/4/2026. The consult sheets did not document an assessment of the wounds. On 2/18/2026 at 7:37 AM, Surveyor accompanied LPN-D and DON-B to provide wound care to R4. R4 had a circular foam ring around the right ankle to keep the heel from touching the bed. R4 rolled to the left independently to provide LPN-D access to the coccyx wound. No dressing was in place to the wound. DON-B did a comprehensive assessment of the wound. The Stage 3 coccyx wound measured 1.5 cm x 1.5 cm x 0.5 cm with 70% granulation tissue and 30% slough. The treatment was applied to the wound. The right heel dressing was dated 2/16/2026 which was accurate because the wound treatment was every Monday, Wednesday, and Friday. DON-B did a comprehensive assessment of the wound. The Unstageable right heel wound measured 3.5 cm x 2.5 cm x 0 cm. The wound was a large open area with eschar in the center. The treatment was applied to the wound. DON-B stated R4 goes to the wound clinic, and the treatments are done as ordered by the wound clinic. In an interview on 2/18/2026 at 9:12 AM, Surveyor shared with DON-B the documentation on 12/5/2025 by RN-L of R4's coccyx pressure injury. RN-L documented R4 had two open areas, one to the right buttock and one to the left buttock and had muscle showing. DON-B stated DON-B did R4's assessment the next day and believed DON-B's measurements were correct. Surveyor showed DON-B the documentation by DON-B of the coccyx wound having 100% slough or necrotic tissue and staging the wound at a Stage 3. DON-B stated DON-B should have documented that as Unstageable. Surveyor asked DON-B who does the comprehensive assessment of wounds when DON-B is not working that day. DON-B stated the RN on the unit will do the measurements and DON-B will look at the wound the next day. Surveyor shared with DON-B the concern R4's coccyx and right heel pressure injuries were not comprehensively assessed on 2/4/2026. DON-B stated R4 may have been at the wound clinic that day and would get more information to Surveyor regarding that date. On 2/18/2026 at 9:29 AM, DON-B told Surveyor R4 went to the wound clinic on 2/4/2026 so DON-B did not do an assessment that day. DON-B stated since R4 went to the wound clinic, they looked at the wound and put a clean dressing on it. Surveyor shared the concern with DON-B that there was nothing in the wound clinic consult notes that documented an assessment with measurements or description of the wound. DON-B agreed the wound should have been assessed by DON-B on 2/4/2026. On 2/18/2026 at 11:06AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concerns R4's coccyx pressure injury was not accurately staged, and the coccyx and right heel pressure injuries were not comprehensively assessed and documented on 2/4/2026. No additional information was provided at that time.

Based on record review and interview, the facility did not ensure that it did not employ individuals who were found guilty of abuse, neglect, exploitation or mistreatment by failing to conduct a background information disclosure every four years for 1 (Social Services (SS)-G) of 8 facility staff reviewed.This deficient practice has the potential to affect residents who may receive care from SS-G. Findings include:The facility policy titled Abuse, Neglect, and Exploitation with implemented date 3/2018 and revised date 7/15/2022 documents:Policy: it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Screening . potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. Background checks, including re-checks, will be completed consistent with applicable state laws and regulation. Responsibility of performance of compliance checks on contracted temporary staff will be established via contractual agreement. screenings may be conducted by the facility itself, third-party agency or academic institution. the facility will maintain documentation of proof that the screening occurred. On 2/16/26, Surveyor requested employee files for 8 randomly selected employees from Nursing Home Administrator (NHA)-A. On 2/17/26 at 8:11 AM, Surveyor reviewed facility employee files to ensure completed background checks, including background information disclosure (BID) with Department of Justice (DOJ) response and Integrated Background Information system (IBIS) letter, which are to be completed every four years by State of Wisconsin regulation. Surveyor reviewed the employee file for SS-G, with hire date documented as 12/1/2016, and located a BID form, DOJ response, and IBIS letter all dated 2/16/26. Surveyor notes this is the date of the start of the survey, and the date Surveyor requested SS-G's BID from NHA-A. In an interview on 2/17/26 at 8:40 AM, NHA-A stated SS-G's previous BID with DOJ response and IBIS letter was completed in 2021, so a new one was completed yesterday 2/16/26. Surveyor requested SS-G's previous BID from 2021. NHA-A provided Surveyor with SS-G's previous BID, DOJ response, and IBIS letter, which all document a completed date of 4/26/2021. On 2/17/26 at 10:18 AM, Surveyor shared concern with NHA-A that SS-G did not have a BID, DOJ response, and IBIS letter completed every four years per state regulation. NHA-A stated NHA-A understood the four-year timeline was missed for SS-G, and no other information was provided.

Based on observation, interview, and record review, the facility did not ensure medications were stored in accordance with facility policy and procedures for 1 of 1medication room reviewed for medication storage.*On 2/17/2026, at 7:29 AM, Surveyor observed the door to the medication room wide open, and the door propped open with a doorstop. Surveyor noted an open plastic bin with medication packages inside and easily accessible.*On 02/17/2026, at 1:52 PM, Surveyor observed the vaccine refrigerator to read 30 degrees Fahrenheit with frost build up on the inside of refrigerator.Findings:The Facility's policy, titled Medication Storage dated 1/2025, indicates the following, . 3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aids) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remained locked when not in use or attended to by persons with authorized access.13. The refrigerator should be kept clean and frost-free. On 02/17/2026, at 7:29 AM, Surveyor observed medication pass with Licensed Practical Nurse (LPN)-K. During medication pass, LPN-K went to the medication room to retrieve the medication. Surveyor followed LPN-K and noted the door to the medication room to already be wide open and was held open with a doorstop. LPN-K closed the door and informed Surveyor that the door should not be left open and she is unsure who left it like that. LPN-K indicated that only the nurses and the Director of Nursing (DON) have keys to the medication room.On 02/17/2026, at 1:52 PM, Surveyor asked LPN-K to tour the medication room with Surveyor. Surveyor noted the door to the medication room was now closed and LPN-K had to unlock the door using her key. Surveyor observed the vaccine fridge with LPN-K. LPN-K and Surveyor noted the refrigerator to be at 30 degrees Fahrenheit with frost build up. LPN-K was unsure what the ranges should be and that DON-B would be a good person to ask. Surveyor encouraged LPN-K to follow up and clarify with administration.On 02/17/2026, at 3:03 PM, during the daily exit conference, Surveyor informed the Nursing Home Administrator (NHA)-A and DON-B of the above concerns.On 02/18/2026, at 7:51 AM, NHA-A informed Surveyor that after they were notified of the concern, they have added ranges to the temperature log sheets and will be reaching out to pharmacy regarding the vaccines that are in the fridge.On 02/18/2026, at 8:05 AM, DON-B and Surveyor went to check the vaccine refrigerator in the medication room. Surveyor noted the medication room door to be closed and locked. DON-B used a key to access the medication room. DON-B and Surveyor noted there to still be frost build up in the vaccine refrigerator and the refrigerator reading at 40 degrees Fahrenheit.On 2/18/2026, at 10:57 AM, VP of Success-C provided Surveyor with the pharmacy consult regarding the vaccine refrigerator and indicated the flu vaccines have now been discarded.Surveyor reviewed the Facility provided email from the pharmacy, dated 2/18/2026 at 10:41 AM. Surveyor noted the email indicates, in part, that the influenza vaccines (Fluad) are likely to be affected by potential freezing and should be discarded.No additional information was provided.

Based on interview and record review, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R30) of 1 resident reviewed for hospice. R30 enrolled in hospice services on 12/26/25. The facility did not complete a Significant Change MDS until 1/26/26. Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.19.1 dated 10/2024 documents:A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program . the Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election. R30 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, anxiety, depression, and congestive heart failure. A progress note in R30's electronic health record (EHR) dated 12/29/25 at 9:15 AM documents: [R30] was evaluated by hospice on 12/26/25 and was re-admitted on to services that day. Surveyor located a SCSA MDS dated [DATE] in R30's EHR. On 2/17/26 at 1:24 PM, Surveyor interviewed MDS Licensed Practical Nurse (LPN)-E who stated team leaders at the facility inform MDS LPN-E of any significant changes in residents daily, and the interdisciplinary team (IDT) would determine if a significant change MDS needs to be completed. MDS LPN-E stated if a resident enrolls in hospice, a significant change MDS would be completed within 7 days, and the ARD on the MDS should capture the day of admission on to hospice services. Surveyor shared concern with MDS LPN-E that R30 enrolled in hospice services on 12/26/25 and did not have a SCSA MDS completed until 1/26/26. MDS LPN-E stated R30's significant change MDS was late because MDS LPN-E was not notified that R30 was enrolled in hospice on 12/26/25, as MDS LPN-E was off during that time and a different MDS coordinator was covering the facility, and it got missed. On 2/17/26 at 3:03 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and [NAME] President of Success-C that R30 admitted on to hospice services on 12/26/25 but did not have a significant change MDS completed until 1/26/26. No additional information was provided.

Based on observation, interviews, and record review, the facility did not ensure residents with hearing impairment received proper treatment and assistive devices to maintain hearing abilities for 1 of 1 (R2) residents reviewed for hearing.* Surveyor observed R2 to be very hard of hearing and not wearing hearing aids. According to R2's most recent audiology consult, and R2's annual Minimum Data Set (MDS), R2 uses hearing aids. The facility failed to ensure R2 received treatment and assistive devices to maintain hearing abilities. Findings include:R2 was admitted to the facility on [DATE] with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) (a progressive lung disease with long term breathing problems).R2's Annual Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R2 is cognitively intact, has adequate hearing and uses a hearing aid.On 02/16/2026, at 9:52 AM, Surveyor interviewed R2. Surveyor noted R2 to be very hard of hearing. R2 indicated that R2 has hearing aids but they disappeared. R2 informed Surveyor that R2 followed up about R2's hearing aids to a staff member and was told they were following up with Veterans Hospital regarding R2's hearing aids.Surveyor reviewed the Facility provided document, titled Consultation/Clinic Referral, dated 6/11/2024 and indicated R2 has bilateral hearing loss with the following recommendations: Microphones on hearing aids should be brushed daily and the wax guard needs to be changed at least once per month in the left hearing aid, or as needed.Surveyor reviewed the Facility provided document, titled Order Summary Report for R2 and noted there are no orders regarding R2's hearing aids.Surveyor reviewed the Facility provided document, titled Care Plan Report for R2 and noted a focus area for R2's independent activities with an intervention of speak into left ear as this is the better ear initiated 2/2/2026.On 02/17/2026, at 11:32 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-H. CNA-H indicated R2 does use hearing aids but they are in the process of getting fixed. CNA-H was not sure where the hearing aids are in the process and encouraged Surveyor to follow up with R2's Hospice Nurse.On 02/17/2026, at 11:35 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D. LPN-D indicated one of R2's hearing aids do not work. R2 is on hospice, and the Hospice Nurse is working on getting R2's hearing aids replaced. LPN-D informed Surveyor that R2's hearing aid has been broken for maybe 6 months but R2 does not complain about it.On 02/17/2026, at 12:31 PM, Surveyor interviewed Director of Nursing (DON)-B and VP of Success-C. DON-B informed Surveyor that a request was called into to VA audiology regarding R2's hearing aids and will get back to surveyor regarding this. Surveyor asked DON-B if R2 should be care planned to have hearing aids. DON-B indicated R2 has a care plan under Activities but should have a care plan indicating R2 has hearing aids and should have a care plan in place, which nursing should implement. VP of success-C indicates the care plan for R2's hearing is appropriate for activities but doesn't clarify, with or without hearing aids and if R2 has hearing aids, that should be in the care plan.On 02/17/2026, at 12:39 PM, Surveyor interviewed MDS Coordinator-E. MDS Coordinator-E indicates that R2's annual MDS, dated [DATE], has hearing aids for R2 but believes the hearing aids broke and thinks family took them home. MDS Coordinator-E informed Surveyor it would trigger under the communication Care Area Assessment (CAA) but R2 does not have current communication care plan. MDS Coordinator-E was out during and someone else was doing the MDS during that time. If something triggers or is missing and it doesn't pull up on care plan the system gives an opportunity to use what pops up and personalize it. The person who did MDS at that time would have been responsible for implementing triggered CAAs for R2. On 02/17/2026, at 1:34 PM, DON-B and Social Services-G informed Surveyor that they found 2 pairs of hearing aids in R2's room. They replaced the batteries and R2 can hear better now and is able to respond better to staff.On 02/17/2026, at 1:49 PM, MDS Coordinator-E informed Surveyor that R2's care plan has now been updated to include R2's communication need.On 02/17/2026, at 3:03 PM, Surveyor informed NHA-A and DON-B of the above findings. No additional information was provided.

Based on record review and staff interviews, the facility did not always ensure that 1 out of 1 residents ( R6) reviewed for urinary incontinence received the necessary care and services to maintain or restore bladder incontinence. R6 experienced a decline from frequently incontinent of urine to always being incontinent of urine and the facility did not implement interventions in place to help restore R6's urinary continence. This is evidenced by: R6 was admitted to the facility on [DATE] with diagnosis that included Nontraumatic intracerebral hemorrhage, epilepsy, dementia, mood disorder, hypertension, hyperlipidemia and unspecified psychosis.R6's most recent annual MDS ( Minimum Data Set) dated 4/19/25 documents that R6 is frequently incontinent of urine and a trial of a toileting program, prompted voiding or bladder training has not been attempted.R6's Urinary Incontinence and Indwelling Catheter CAA ( Care Area Assessment), dated 4/19/25, was triggered r/t (related to) need for assistance with toileting impaired mobility dementia and incontinence. The CAA questions if urinary incontinence will be addressed on care plan. The facility answered yes. The objective was listed to have improvement and avoid complications. R6 requires moderate assistance with toileting and is occasionally incontinent of bladder. Therapy is working with R6 to improve toileting function. Goal is to ensure R6 will be dry, clean odor free and comfortable.A review of R6's quarterly MDS, dated [DATE] documents that R6 is now always incontinent of urine and there is no toileting program in place.R6's most recent quarterly MDS dated [DATE] documents that R6 is always incontinent of urine and in addition, no toileting program for bladder is documented. A review of R6's individual plan of care notes that R6 has incontinence due to: cognitive deficit secondary to neurological deficit, decreased mobility. Interventions include: Will attain/maintain continence, based upon usual voiding pattern . Provide assistance with toileting as needed. Report changes in skin integrity found during daily care Report S&S of UTI such as flank pain, c/o burning/pain, fever, hematuria, change in mental status, etc.R6 experienced a decline in his urinary incontinence from 4/19/25 to 10/20/25 MDS assessments. The plan of care did not include individualized interventions to help R6 attain urinary incontinence, including trial voiding patterns.The Certified Nursing Assistant ( CNA) care card did not document any information/ interventions for R6's bladder incontinence. On 2/17/26, Surveyor asked to review the most recent bowel and bladder assessment for R6. A copy of the Quarterly Clinical Review dated 1/17/26 was provided by Administrator- A on 2/18/26 at 8:00 AM. Section J- Bladder/ Bowel documents that R6 is incontinent of bladder and there is no change in this status since last assessment. The assessment asks how long R6 has been incontinent of bladder- answered unknown. How often is R6 wet? Answer: 1-2 x daily during day and nighttime. The assessment documents that R6 is continent of stool and there is no change in bowel incontinence status since the last assessment. Bowel pattern is normal formed stool. This section was completed by a Licensed Practical Nurse on 1/17/26. 2/18/26 at 12:10 PM, Surveyor conducted an interview with DON ( Director of Nursing) - B regarding R6's decline in urinary incontinence. DON- B was unable to provide any additional information regarding the assessments for bladder for R6. Surveyor shared concerns regarding R6's decline and that the plan of care is not individualized and does not address type of incontinence and interventions to maintain continence. No additional information was provided.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 12 residents observed. During observation of catheter care for R3, certified nursing assistant (CNA)-I did not perform appropriate hand hygiene or wear a gown when enhanced barrier precautions (EBP) were in place for R3.Findings include:The facility's policy titled Enhanced Barrier Precautions with implemented date 3/25/24 and revised date 8/8/24 documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs).All staff receive training on enhanced barrier precautions and the definition of high-contact resident care activities upon hire and at least annually . all licensed nursing staff receive training on high-contact care activities and common organisms that require enhanced barrier precautions . An order for enhanced barrier precautions . will be initiated for residents with any of the following: . indwelling medical devices (e.g., . urinary catheters.) even if the resident is not known to be infected or colonized with a MDRO. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities . High-contact resident care activities include: . device care or use: . urinary catheters . Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until . discontinuation of the indwelling medical device that placed them at higher risk. The facility's policy titled Hand Hygiene with review date 11/2/2022 documents: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.R3 admitted to the facility 1/23/26 with diagnoses including chronic kidney disease with heart failure (long term weakness of the kidneys and heart), retention of urine (inability to fully empty the bladder resulting in urine buildup), and benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate causing blockage of the flow of urine).R3's admission Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition for R3. The MDS documents that R3 is dependent for toileting hygiene and that R3 has an indwelling urinary catheter. R3's Care Area Assessment (CAA) for Urinary Incontinence and Indwelling Catheter dated 1/29/26 documents [R3] has an indwelling foley catheter related to urinary retention. Staff provide routine catheter care and observe for any changes in urine output or appearance . Proceed to care plan. R3's indwelling urinary catheter care plan documents the following interventions with implemented date 1/27/26:-enhanced barrier precautions-change urinary collection bag as neededR3's physician order dated 1/23/26 documents: Catheter care every shift and as needed.R3's physician order dated 1/30/26 documents enhanced barrier precautions due to Foley catheter every shift. On 2/17/26 at 8:43 AM, Surveyor observed an Enhanced Barrier Precautions sign posted on R3's door. The sign documents: Everyone must: Clean their 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. device care or use: . urinary catheter On 2/18/26 at 8:13 AM, Surveyor observed CNA-I complete catheter care for R3. Surveyor observed CNA-I exit R3's room to obtain alcohol wipes, then CNA-I returned to R3's room and donned gloves without performing hand hygiene. Surveyor observed CNA-I complete the process of emptying R3's catheter without donning a gown. On 2/18/26 at 8:25 AM, Surveyor shared concern with CNA-I that Surveyor did not observe CNA-I perform hand hygiene prior to donning gloves, and Surveyor did not observe CNA-I wear a gown while providing catheter cares to R3. CNA-I replied CNA-I was not aware a gown was supposed to be worn. In an interview on 2/18/26 at 9:01 AM with Licensed Practical Nurse (LPN)-D, LPN-D stated a resident who has a catheter should be on enhanced barrier precautions. LPN-D stated staff would be expected to wear a gown and gloves when performing catheter care for a resident. In an interview on 2/18/26 at 9:12 AM with Director of Nursing (DON)-B, DON-B stated a CNA should wear a gown and gloves when doing catheter care and follow enhanced barrier precautions. Surveyor shared concern with DON-B and [NAME] President of Success-C of observations of CNA-I not performing hand hygiene prior to donning gloves and not wearing a gown when performing catheter care for R3. On 2/18/26 at 10:37 AM, Surveyor informed Nursing Home Administrator (NHA)-A of observations of CNA-I not performing hand hygiene prior to donning gloves and not wearing a gown when performing catheter care for R3. No additional information was provided.

Based on interview and record review, the facility did not transmit a discharge assessment within 7 days after completion for 1 (R19) of 1 residents reviewed for late Minimum Data Set (MDS) assessments.*R19 discharged to the hospital on 8/30/2025. The Discharge Return Anticipated (DCRA) MDS assessment dated [DATE] was completed but not submitted.Findings include:1.) R19 was admitted to the facility on [DATE] after hospitalization for acute on chronic neck pain. On 8/30/2025 at 11:10 AM in the progress notes, nursing documented R19 was in bed with complaints of pain to the neck and back. R19's family indicated R19 was not responding as they normally would. R19's vital signs were abnormal, R19 was placed on 3 liters of oxygen and transferred to the hospital.R19's DCRA MDS assessment dated [DATE] was completed. The assessment was not submitted.In an interview on 2/17/2026 at 1:24 PM, Surveyor shared with MDS Licensed Practical Nurse (LPN)-E the concern R19's DCRA assessment dated [DATE] had not been submitted as documented in R19's medical record. MDS LPN-E reviewed R19's medical record and agreed the assessment was coded as completed but not accepted. MDS LPN-E reviewed four batches of assessments that had been submitted in that timeframe and R19's DCRA assessment was not included in any of the batches. MDS LPN-E called the supervisor [NAME] President of Clinical Reimbursement (VP of CR)-F to explain Surveyor's concern with R19's DCRA assessment. MDS LPN-E stated VP of CR-F agreed the assessment had not been submitted and would submit it at that time.On 2/17/2026 at 3:03 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R19's DCRA assessment dated [DATE] had not been submitted after completion. NHA-A stated MDS LPN-E had discussed this with NHA-A and understood that it had been missed.No additional information was provided.

Based on record review, interview, review of the Misconduct Incident Report, and facility policy review, the facility failed to ensure that a thorough investigation was documented regarding a potential visitor-to-resident altercation for one (R1) resident out of a sample of 14 residents reveiwed for abuse. Findings include: Review of facility policy titled Abuse, Neglect and Exploitation, revised 07/15/22, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .V. Investigation of Alleged Abuse, Neglect and Exploitation .B. Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s). Review of the Misconduct Incident Report (final report) provided by the facility dated 05/07/25 revealed On 05/01/25 R1 reported to staff at [name of the facility] that she was not happy with her friend and care giver from the community [name of the friend]. R1 stated she no longer wanted to have any contact with this person. R1 stated she no longer wants [name of the friend] to provide care for her at home when she discharges after rehab, and she does not want [name of the friend] to visit her here in the nursing home. The social worker inquired as to why and asked what had occurred and R1 stated that [name of the friend] came to visit her the previous weekend and was not nice to her. R1 said that [name of the friend] yelled at her and shook her by her arms. She [meaning R1] also made an indication that money may have been taken from her by [name of the friend] previously when living in the community. R1 was very upset with [name of the friend] interaction with her on the previous weekend yelling at her and shaking her. R1 said she is afraid of her and does not want [name of the friend] to be close to her. R1 said that she feels very safe being at the facility and if [name of the friend] is not allowed to visit her, she feels fine with the situation. She has been eating normal meals and socializing in the dining room. She [meaning R1] remains participatory in therapy and activities of her choice. She [meaning R1] continues to have a pleasant demeanor and is not having any ill effects from the incident. R1 does not have a roommate, and there were no witnesses to the incident. Upon initial report of the concern, the facility initiated an investigation. The investigation included interviews with R1, and the [name of the city] police department was also contacted and came out to take her statement. Notification to staff posted telling them not to let [name of the friend] visit R1 if she is to come into the building. There was no evidence of staff being interviewed regarding the abuse allegation. During an interview on 06/30/25 at 1:45 PM with the Administrator, she said that since this incident did not involve the facility staff, the staff at the facility were not interviewed. The Administrator stated that the facility staff were informed not to let the friend visit and the police were contacted. At 3:30 PM, the Administrator stated that R1 was assessed after the incident and did not have any marks on her bilateral arms. During an interview on 07/01/25 at 3:47 PM with the Social Services Director (SSD), she said that an unknown Certificated Nursing Assistant (CNA) came to her and stated that R1 was upset that her friend visited over the weekend. The SSD stated that she and the CNA went and spoke with R1 who said that her friend was upset with her and shook her arms/hands. The SSD said she reported this incident to the Administrator and R1 was interviewed. R1 stated that her friend asked for her bank card and R1 stated no, and R1's friend became upset and shook her. R1 was upset that the police were contacted because she did not want to press any charges. The SSD confirmed that no residents were interviewed during the investigation The SSD stated that the incident occurred in R1's bedroom and that R1 did not have a roommate and there were no witnesses to the alleged incident.

Based on staff interview, and record review, the facility did not maintain an effective infection control program under which it investigates, controls, and prevents infections in the facility. * Total infection rates were not calculated accurately and rates of infection for individual infection types were not calculated. Since infection rates were not calculated it was not possible to analyze the data to determine if there was a rise in the prevalence of infections from month to month with a potential to affect 29 of 29 residents. Findings include: 1.) On 4/9/25, at 1:30 PM., Surveyor interviewed Director of Nursing (DON)-B, who is in charge of the infection control program. DON-B indicated she does not calculate individual rates of infection and will count an infection in more than 1 month if it continues to the next month or is chronic. DON-B indicated she does not separate the facility associated infection from the community based infections. On 4/9/25 the facility's monthly infection rate surveillance summary reports from 10/24 to 3/25 were reviewed and did not include calculations for each individual type of infection only the numbers of infections. The total infection rates included community based infections and facility associated infections included in the total rate of infections. The facility's monthly infection surveillance logs from 10/24 to 3/25 were reviewed and infections included in the rates of infection included infections from previous months and residents that have chronic infections due to multiple drug resistant organisms. On 4/9/25, DON-B was asked for the facility policy for calculating infection rates or a standard of practice for which they are calculating infection rates. None was provided. On 4/9/25, at 3:00 PM, Surveyor notified Nursing Home Administrator (NHA)-A and DON-B of the above findings. Additional information was requested if available, however none was provided as to why the facility did not calculate rates of infection for each type of infection and only use new infections/health-care associated infections in their infection rate calculations.

3.) R5 was admitted to the facility on [DATE]. On 4/9/25, the Surveyor reviewed R5's medical record and it indicated R5 was transferred to the hospital on 3/29/25. R5's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalization. On 4/9/25 at 3:00 PM, the above findings were shared with Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why a transfer notice was not given to R5 and/or their representative for their hospitalization on 3/29/25. 4.) R14 was admitted to the facility on [DATE]. On 4/9/25, the Surveyor reviewed R14's medical record and it indicated R14 was transferred to the hospital on 1/16/25. R14's medical record did not include documentation that a transfer notice had been given to the resident and/or their representative for the hospitalizations. On 4/9/25 at 3:00 PM, the above findings were shared with Administrator-A and Director of Nurses-B. Additional information was requested if available. None was provided as to why a transfer notice was not given to R14 and/or their representative for their hospitalization on 1/16/25. Based on interview and record review, the facility did not ensure 4 (R3, R9, R5 and R14) of 4 residents reviewed for hospitalizations received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. *R3 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R9 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R5 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. *R14 was transferred to the hospital while residing in the Facility and evidence was not provided that they or their representative were given the required transfer notice information. Findings include: The Facility Policy and Procedure titled, Transfer and Discharge . last revised 7/15/2022, states in part: 7. Emergency Transfers/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified) . j. Provide transfer notice as soon as practicable to resident and representative . On 4/09/25, at 9:58 AM, Nursing Home Administrator-A was interviewed and indicated no transfer notices were given to R3 ,R5, R9 and R14 when they were transferred to the hospital. 1.) R3 was admitted to the facility on [DATE]. R3's Significant Change Minimum Data Set (MDS) with an assessment reference date of 2/27/2025 documents R3 had a Brief Interview for Mental Status score of 02 (severe cognitive impairment). R3 has an activated Power of Attorney (POA). R3's discharge summary progress note dated 2/19/25, at 5:30 pm, documents: Resident admitted to [Name of Hospital] with Acute hypoxic RF (respiratory failure) with hypercapnia. Family is in the hospital by the residents bedside. Surveyor requested to view the transfer notice that was provided to R3 and to R3's responsible party at time of R3's hospitalization. The form Bed Hold Notice was provided by the Facility. No information was included that the resident or their representative were provided in writing the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. On 04/09/25, at 03:01 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator (NHA)-A, Surveyor informed the facility of the concern a transfer notice was not provided to R3 or R3's representative at the time sent to hospital. NHA-A stated the form the facility used got lost in the shuffle when switched to a new computer system, the form has been reinstated. 2.) R9 was admitted to the facility on [DATE]. R9's 5 day Minimum Data Set (MDS) with an assessment reference date of 2/4/25 documents R9 had a Brief Interview for Mental Status score of 15 (cognitively intact). R9 is their own person/responsible for self. R9's change of condition progress note dated 12/7/24, at 9:00 am, documents: Situation: C/O (complains of) sharp, constant chest pain rated 5/10 since 0300 (3:00 AM); Pain radiates down to abdomen. Resident states pain feels better when she eats. Resident did not report symptoms to nurse until 0830 (8:30 AM). Resident states she feels dizzy and lightheaded . Surveyor noted R9 was admitted to the hospital for chest pain and shortness of breath from 12/7/24 until 12/11/24. Surveyor noted R9 was admitted to the hospital for acute respiratory failure with hypoxia from 1/22/25 until 1/29/25. Surveyor requested to view the transfer notice that was provided to R9 and to R9's responsible party at time of R9's hospitalization. The form Bed Hold Notice was provided by the Facility. No information was included that the resident or their representative were provided in writing of date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. On 04/09/25, at 03:01 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator (NHA)-A, Surveyor informed of the concern a transfer notice was not provided to R9 or R9's representative. Per NHA-A the form facility used got lost in the shuffle when switched to new computer system, the form has been reinstated.

Based on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice affected 1 of 2 residents with a mechanically-altered diet. R15 was served pureed food that was not brought up to the correct temperature to prevent bacteria growth in the danger zone (below 135 degrees F) The [NAME] was observed changing gloves with no handwashing after gloves were removed, before a new pair of gloves were put on. Findings include: The Facility Policy and Procedure titled, Food: Preparation last revised 9/2017, states in part: Policy Statement All foods are prepared in accordance with FDA (Food and Drug Administration) Food Code. Procedures 1. All staff will practice proper hand washing techniques and glove use. 2. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination . 4. The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that foods are exposed to temperatures greater than 41 degrees and/or less than 135 degrees, or per state regulation . 11. When hot pureed, ground, or diced food drop into the danger zone (below 135 degrees), the mechanically altered food must be reheated to 165 degrees for 15 seconds if holding for hot service. 12. When reheating, foods will be rapidly heated to 165 degrees for 15 seconds. If the food is not reheated within 2 hours it must be discarded . The Facility Culinary Professionals Training titled, Gloves with no revision or review date, states in part: How to Properly Put On Gloves -Start with properly washed and dried hands -Remove gloves from box by their cuffs -While hanging onto the cuff, place your hand in the glove while pushing your hand down while pulling the glove up . **You must remember to always wash your hands in between gloves.** **Gloves do not give you the right to not wash your hands-do not keep them on, reuse them or anything else. Change gloves, wash hands and let's keep our patients/residents and coworkers safe.** 1) On 04/09/25, at 09:15 AM, Surveyor observed Cook-G take the temperatures of individually pureed foods that were just prepared for R15. Cook-G used the temperature probe and took the temperature of the pureed toast, the temperature read 102 degrees. Cook-G proceeded to take the temperatures of the pureed eggs which read 106 degrees and the pureed oatmeal which read 108 degrees. Cook-G then placed the plated food onto a serving tray, put a lid over R15's plate and staff took tray out of kitchen. On 04/09/25, at 09:19 AM, Surveyor interviewed Food Services Manager-D about taking the temperature of food after preparing, before serving to a resident. Food Service Manager-D stated the temperature was done before the food was served. Surveyor stated none of the temperatures reached 135 degrees. On 04/09/25, at 03:01 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator-A, Surveyor relayed the concern of R15's puree diet not being served at a temperature to prevent bacteria growth in the danger zone (below 135 degrees F). 2) While completing the kitchen task, Surveyor observed R15's pureed breakfast meal being prepared. On 04/09/25, at 08:58 AM, Surveyor observed Cook-G remove gloves being worn and put on a new pair with no handwashing being completed before the new pair was put on. On 04/09/25, at 09:06 AM, Surveyor observed Cook-G take gloves off, then at 09:11 AM, Surveyor observed Cook-G put new gloves on with no handwashing between. On 04/09/25, at 09:11 AM, Surveyor observed Cook-G take one glove off and open a drawer to gets out tongs, Cook-G then reapplied the same glove with no handwashing or new glove used. On 04/09/25, at 09:19 AM, Surveyor interviewed Food Services Manager-D about the expectation of handwashing when staff change gloves. Food Services Manager-D stated staff should wash hands before putting gloves on and when changing gloves. Surveyor let Food Services Manager-D know there were several observations of glove changes by Cook-G without handwashing i between. On 04/09/25, at 03:01 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator-A, Surveyor relayed the concern of Cook-G performing glove changes with no handwashing between. A Summary Report of Meeting was provided to Surveyor that documented training being completed on 4/9/25, at 10:05 am, by Food Service Manager-D and Dietician-F.

Based on observations, interview, and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R22) of 1 residents reviewed for falls. *R22 had three unwitnessed falls that were not thoroughly investigated to determine a root cause and develop interventions that addressed the cause and prevent future falls. Findings include: The facility policy and procedure titled Accidents and Supervision dated 7/14/2022 documents: Policy: The resident environment will remain as free of accident hazards as possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, which includes prior accidents/incidents, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc. 3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions . 5. Supervision- supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency b. Based on the individual resident's assessed needs and identified hazards in the resident environment. 1.) R22 was admitted to the facility on [DATE] with diagnoses of intracerebral hemorrhage, atrial fibrillation, epilepsy, dementia with psychotic disturbance, mood disorder, depression, and psychosis. R22's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R22 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5, was frequently incontinent of bladder, and always incontinent of bowel. The MDS documented R22 had behaviors not directed toward others 1-3 days, rejection of care 1-3 days, and wandering 1-3 days in the seven day look-back period. R22 had an activated Power of Attorney. R22's Physical Functioning Deficit Care Plan initiated 4/11/2022 had the interventions of transfer with supervision with a wheeled walker, walking with assistance of one with a wheeled walker, and toileting assistance of one every 2-3 hours as needed. R22's At Risk for Falls Care Plan was initiated on 4/14/2022 with interventions in place on 11/30/2024: -Mark placed on the wall to alert staff on bed level. -Assess for pain. -Gait belt with transfers. -Grip strips next to the bed. -Keep environment well lit and free of clutter. -Keep walker within reach of resident at all times. -Observe for side effects of medications. -Safety checks during shifts. -Therapy referral. On 11/30/2024, at 1:54 PM in the progress notes, nursing documented R22 had an unwitnessed fall in the hallway sustaining abrasions to the forehead, a small laceration to the bridge of the nose, and superficial abrasions to the left hand fourth and fifth fingers. R22 complained of a headache and was sent to the hospital for evaluation and treatment. R22 returned to the facility later in the day with no new orders. The Post Fall assessment dated [DATE] documented R22 fell on [DATE], at 1:30 PM while walking in the hallway without the use of the walker or assistance. R22 had been seen a few minutes prior to the fall sitting at a table in the dining room. R22 was unable to state a reason for the fall. On the Risk Management tool, Director of Nursing (DON)-B documented R22 was reinterviewed after returning from the hospital to determine what R22 was doing at the time of the fall. R22 told DON-B R22 was going outside to pee. The Interdisciplinary Team (IDT) met on 12/2/2024 to review R22's fall and agreed with the initial intervention to change R22's toileting plan to every 1-2 hours. Surveyor noted the fall investigation did not include the last time R22 was toileted or if R22 was incontinent at the time of the fall. R22's Physical Functioning Deficit Care Plan was revised on 2/6/2025 with the intervention: toileting assistance of one every 1-2 hours as needed. Surveyor noted the intervention was added to the care plan two months after the fall. On 1/15/2025, at 7:43 PM, in the progress notes, nursing documented R22 had an unwitnessed fall in R22's room. The Post Fall assessment dated [DATE] documented the fall occurred while R22 was getting out of bed with the use of a walker. R22 had been seen approximately 15 minutes prior to the fall lying in bed. R22 was unable to state what R22 was attempting to do when the fall happened. An immediate intervention was to replace the soft touch gray small call light with a large flat white call light. On the Risk Management tool, Certified Nursing Assistant (CNA)-C stated CNA-C had given R22 a shower, toileted R22, and put R22 to bed. The IDT met on 1/15/2025 to review R22's fall and DON-B documented the IDT was in agreement to replace the small call light with the larger flat soft call light and staff is to attach the call light to the outside of the fitted sheet when R22 is in bed. Surveyor noted the fall investigation did not include if R22 was incontinent at the time of the fall and if R22 had the capacity to use a call light to request assistance. R22's At Risk for Falls Care Plan was revised on 1/15/2025 with the intervention: soft touch gray small call light replaced with large flat white call light; staff to attach call light to outside of fitted sheet when resident is in bed. On 3/1/2025, at 9:33 PM, in the progress notes, nursing documented staff noted R22 on the knees on the bedroom floor, holding onto the side of the bed. Vital signs were stable and R22's knees were starting to bruise. The Post Fall assessment dated [DATE] documented R22 stated R22 was trying to fix the sheets on the bed and had last been seen 15-30 minutes prior. Nursing documented a wheelchair was in use at the time of the fall. An immediate intervention was to have staff make sure sheets and blankets are straightened out when R22 is in bed and at night. The Risk Management tool documented the IDT met on 3/3/2025 and agreed with the intervention that was put in place to straighten out the sheets and blankets. Surveyor noted no documentation was found stating when R22 was last toileted or if R22 was incontinent at the time of the fall. R22's At Risk for Falls Care Plan was revised on 3/1/2025 with the intervention: staff to make sure sheets and blankets are straightened out when resident is in bed and at night. On 4/8/2025, at 9:52 AM, Surveyor observed R22 in bed. The bed was in a low position and grip strips were observed on the floor parallel to the bed. A flat white soft touch call light was attached to the outer side of the bed on the sheet within R22's reach. R22 was leaning to the left with R22's head resting on the wall. Two pillows were placed in the middle of the head of the bed, but R22 was not using either of the pillows. R22 declined to be interviewed at that time. On 4/9/2025, at 12:27 PM, Surveyor observed R22 in the dining room waiting for lunch to be served. The flat soft touch call light was in the middle of R22's empty bed. In an interview on 4/9/2025, at 2:56 PM, Surveyor asked Certified Nursing Assistant (CNA)-C if R22 ever pushes the call light for assistance. CNA-C stated no, R22 pushes the call light but only when R22 is playing with the pad. CNA-C stated R22 does not have any intention behind the use of the call light. In an interview on 4/10/2025, at 9:52 AM, Surveyor reviewed R22's falls with DON-B and Nursing Home Administrator (NHA)-A. Surveyor shared with DON-B and NHA-A the concern the falls were not thoroughly investigated, and information was not documented to help determine a root cause analysis for the falls. Surveyor asked DON-B and NHA-A when R22 fell on [DATE], where was the walker that R22 walks with per care plan. NHA-A stated the walker was most likely left behind in the dining room. NHA-A stated all staff know spontaneously getting up, walking, and leaving everything behind is something R22 would do. Surveyor shared with NHA-A and DON-B the Risk Management tool documented DON-B interviewed R22 after R22 returned from the hospital and R22 needed to urinate. Surveyor shared the concern the facility did not know when R22 was last toileted or what R22's incontinence status was at the time of the fall. Surveyor shared the concern the toileting care plan was not revised until 2 months after the fall, on 2/6/2025. DON-B stated DON-B revised the care plan right away. DON-B stated the care plans are updated during the IDT meeting. DON-B stated DON-B would look into the care plan revision. Surveyor shared with DON-B and NHA-A the concern when R22 fell on [DATE], the Post Fall Assessment documented R22 fell when getting out of bed using the walker and there is no further documentation of where the walker was prior to the fall or after the fall. Surveyor shared the concern the documentation did not indicate if R22 rolled out of bed or was attempting to ambulate at the time of the fall, if R22 was incontinent at the time of the fall, or when R22 was last toileted; the CNA statement indicated R22 had a shower, was toileted, put to bed, and had last been seen 15 minutes prior, but did not document the time R22 was assisted with ADLs. The care plan intervention was to provide R22 with a flat soft touch call light. Surveyor shared with DON-B and NHA-A the interview with CNA-C stating R22 does not have the capacity to use a call light to ask for assistance. NHA-A stated the call light that was in place was a round bulb call light and the flat soft touch call light is to be attached to the outer side of the bed so when R22 moves, the touch call light is touchy and would be bumped by the body when moving to prevent another fall. Surveyor noted the call light was being used as an alarm rather than the facility increasing the amount of supervision. Surveyor asked NHA-A and DON-B to clarify what R22 was doing when R22 fell on [DATE] because nursing documented R22 was using a wheelchair at the time of the fall. NHA-A stated NHA-A and DON-B would have to look into the documentation from that fall. On 4/10/2025, at 10:34 AM, NHA-A and DON-B requested Surveyor come to DON-B's office so DON-B could show Surveyor the computer system and how care plans are updated and reviewed. DON-B brought up R22's Physical Functioning Deficit Care Plan with the toileting intervention. After Surveyor reviewed the care plan with DON-B, DON-B agreed the toileting intervention had not been revised until 2/6/2025 when the fall occurred on 11/30/2024. DON-B stated DON-B did not know why the care plan was not revised until 2/6/2025 and that it did not make any sense to either DON-B or NHA-A why it had not been revised right after the fall. NHA-A stated the fall on 3/1/2025 indicated a wheelchair had been involved with the fall, which did not make sense because R22 uses a walker and the only wheelchair in the room was the roommates. NHA-A agreed the staff checked the wheelchair was in use and NHA-A and DON-B sign the Post Fall Assessment and they should have caught that. Surveyor shared with NHA-A and DON-B the concern the falls were not thoroughly investigated to determine a root cause and develop an appropriate intervention to prevent future falls.

Based on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R15) of 1 residents reviewed for a mechanically-altered diet. R15 has a puree diet order (level 1), R15 was served a meal tray with a banana cut in half, not pureed as per R15's diet order and meal ticket specification. Findings include: The Facility Diet/Texture Conversion Chart states in part: L1/Puree . follows the regular diet when possible and menu items are pureed . According to the Swallowing Disorder Foundation a Level 1: Pureed Nutrition Therapy diet consists of pureed, homogenous, and cohesive foods. Food should be pudding-like. No coarse textures, raw fruits or vegetables, nuts, and so forth are allowed. The diet recommendation is that fresh bananas be served well-mashed. On 4/9/25, at 08:52 AM, during the kitchen task, Surveyor observed R15's breakfast meal being prepared, the toast, omelet and oatmeal were individually pureed and plated for service. The plate was placed on a food service tray which had half of a banana, in the peel, on it. Per R15's meal ticket the banana should be L1/Puree. Surveyor observed the tray being picked up by staff. On 04/09/25, at 09:19 AM, Surveyor interviewed Food Service Manager-D regarding R15's meal ticket reading L1/Puree Banana and the banana served cut in half still in the peel. Food Service Manager-D stated that the banana should have been pureed. On 04/09/25, at 09:38 AM, Surveyor went to R15's room and observed R15 had eaten the pureed toast and a couple bites of the pureed oatmeal. The half of banana was laying on R15's bedside table and R15 was sleeping. On 04/09/25, at 09:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E and asked CNA-E to look at the food served to R15 with the Surveyor. CNA-E stated R15 has a diet of puree but the banana is not. R15's physician order with a start date of 3/18/25 documents L1/Puree texture, Honey consistency, for may have thin soda. & ice cream related to dysphagia . R15's care plan documents at nutritional risk r/t (related to) altered texture diet (pureed, . r/t dysphagia), Wt (weight) gain complicated by having thin liquids. swallowing difficulties r/t dysphagia, edentulous aeb (as evidenced by) altered diet. R15's care plan documents the following pertinent goals: -Follow RD (Registered Dietician) recommendation and MD (Medical Doctor) orders for diet type and texture Diet as ordered -Monitor tolerance to food textures and fluid consistencies during meals and report increased chewing or swallowing difficulties -Pureed diet with honey thickened liquids. May have cold soda on ice by straw. Pt (patient) to eat & (and) drink sitting upright @ (at) midline (Not leaning to R15's left or right side). Remind R15 small sips, turn head to right with swallow and cough and clean after several sips. On 04/09/25, at 03:01 PM, during the end of day meeting with Director of Nursing-B and Nursing Home Administrator-A, Surveyor relayed the concern of R15's puree diet not being adhered to due to the banana being served in whole form. A Summary Report of Meeting was provided to Surveyor that documented training being completed on 4/9/25, at 10:05 am, by Food Service Manager-D and Dietician-F.

Based on observation, interview, and record review the facility did not ensure food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens. This had the potential to affect all 32 Residents. *On 1/30/24 and 1/31/24, during the main kitchen tour, Surveyor observed multiple pieces of kitchen equipment that were not clean. *On 1/31/24, at 7:40 AM, Surveyor observed the robot coupe food processor with splattered food dried on the outside, and crumbs in the crevices. *On 1/30/24 and 1/31/24, Surveyor observed Resident room trays being distributed without lids on the main entree, all cups of liquid, and side dishes were not covered. *The internal dishwashing machine temperature was not being monitored and staff in the dish machine area did not know how to monitor the dishwashing temperatures to ensure dishes & utensils were being sanitized correctly. Findings Include: Surveyor reviewed the facility's General Sanitation of Kitchen policy and procedure and notes the following: .General Sanitation of Kitchen Food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Policy Explanation and Compliance Guidelines 1. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. 2. Tasks will be assigned to be the responsibility of specific positions. 3. Frequency of cleaning for each task will be defined. 4. Methods and materials/cleaning compounds to be used for cleaning/sanitizing will be written for each task. 5. Employees will be trained on how to perform cleaning tasks. Surveyor also reviewed the facility Dish Machine Temperature Log policy and procedure: .Dish Machine Temperature Log Dishwashing staff will monitor and record dish machine temperature to assure proper sanitizing of dishes. Policy Explanation and Compliance Guidelines 1. Staff will monitor dish machine temperatures throughout the dishwashing process. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. a. The director of food and nutrition services/dietary manager will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. 3. Staff will be trained to report any problems with the dish machine to the director of food and nutrition services or designee as soon as they occur. 4. The director of food and nutrition services/dietary manager will promptly assess any dish machine problems and take action immediately to assure proper sanitation of dishes. Equipment Cleanliness On 1/30/24, at 8:50 AM, Surveyor completed the initial tour of the main kitchen and storage room with Dietary Manager (DM)-C who has been in the position for about a year. In the lower level, the first refrigerator, Surveyor observed the bottom of the refrigerator on the outside to be dirty with splatters of dried food. The second refrigerator, Surveyor observed the same thing as the first, the bottom of the refrigerator on the outside was dirty with splatters of dried food. Surveyor observed the tall refrigerator next to the stove to have a dirty door, and has a buildup of grease that has dripped down the right side. On 1/31/24, at 7:40 AM, Surveyor observed Cook-D puree eggs using the Robocoup. Surveyor observed the outside of Robocoup to be dirty with dried splattered food and crumbs in the crevices. Surveyor observed the two lights above the stove to have a thick coating of dust. Breakfast was being cooked on the stove. Surveyor observed the front of the freezer, located in the kitchen and the front of the tall refrigerator are dirty with splatters of dried substances, and the side of refrigerator is still dirty with drippings of grease. On 1/31/24, at 11:55 AM, Surveyor observed the ice machine, located in the dining room, to have vents on the left side that were covered with a large amount of dust. On 1/31/24, at 1:35 PM, Surveyor observed the back of the refrigerator located in the middle of the room, has food stuck to the back that has dripped down. Cook-D stated there is no current schedule for cleaning the equipment. Cook-D stated that Food Service Manage-F stated today that Food Service Manager-F needs to develop a list of items to be cleaned on a regular basis. On 2/1/24, at 8:18 AM, Surveyor spoke with Maintenance Director-H who stated Maintenance Director-H completes a hood cleaning above the stove two times a year and cleans the coils on the refrigerator, but is not involved in any other routine cleaning and that should be the responsibility of the dietary department. On 2/1/24, at 8:56 AM, Food Service Manager-F informed Surveyor that Food Service Manager-F is from a contracted company and Food Service Manager-F just started with the facility last week. Food Service Manager-F stated there was no schedule for routine cleaning of the kitchen equipment during the survey process. Food Service Manager-F stated there is a schedule now. Surveyor notes the facility cleaned the kitchen equipment yesterday after being notified by Surveyor of the concern Meal Delivery On 1/30/24, at 12:34 PM, Surveyor observed Resident trays being distributed without lids on the main entree plate, all cups of liquid, and side dishes were not covered. Surveyor observed lunch trays being distributed to Resident rooms located down each hallway past the dining rooms. Surveyor observed the main entree had a cover, but no other items on the tray had lids or anything else was covered. On 1/31/24, at 9:07 AM, Food Service Manager-F informed Surveyor all food items should be covered once it leaves the kitchen. Food Service Manager-F stated ideally Food Service Manager-F would like direct plate service to serve from a steamtable but the facility does not provide direct plate service at this time and Food Service Manager-F understands all food items should have been covered. On 1/31/24, at 9:12 AM, both Cook-D and Dietary Manager-C stated since both have worked at the facility, no food items have been covered when leaving the kitchen, and the facility has no covered food carts. On 1/31/24, at 12:11 PM, Surveyor observed lunch trays being distributed to both dining rooms and Resident rooms and all food items on the tray were covered. Surveyor asked Food Service Manager-F where the lids for the bowls and drinks came from. Food Service Manager-F stated the facility found them and confirmed everything on the trays should have been covered. The facility provided a list of Residents who received room trays on a regular basis. Surveyor notes there are four Residents listed whom receive room trays on a daily basis and Food Service Manager-F stated the number of Residents can increase from day to day. Dishwasher Internal dishwashing temperature was not being monitored and staff in the dish machine area did not know how to monitor the dishwasher to ensure dishes & utensils were being properly cleaned and sanitized. On 1/30/24, at 8:50 AM, Surveyor observed Dietary Aide-E run the dishwashing machine. The temperature for wash cycle was 167 degrees and rinse cycle was 191 degrees which was calculated by using the thermostat panel of the dishwasher door. Dietary Manager-C stated no test strips are being used in the dishwashing machine to confirm the temperature inside the machine. On 1/31/24, at 8:40 AM, Surveyor reviewed the dishwashing machine manual to confirm the temperature requirements and the sanitization process of a high temperature dishwashing machine. On 1/31/24, at 9:14 AM, Dietary Manager-C stated test strips are supposed to be used in the dishwasher every shift. Dietary Manager-C stated the Food Service Manager-F taught Dietary Manager-C how to do the test strips for the dishwasher yesterday (1/30/24). Dietary Manager-C stated no one else has been trained on how to use the test strip. Surveyor noted that Dietary Aide-E was running the dishwashing machine yesterday. Surveyor asked if all dietary staff should know how to do the test strips and Dietary Manager-C stated yes. Dietary Manager-C ran a load of dishes in the dishwasher and demonstrated to this Surveyor how the test strip should have been used a minimum of three times a day. Dietary Manager-C stated it is supposed to turn dark orange when it is the right temperature. On 2/1/24 at 8:18 AM, Surveyor spoke with Maintenance Director-H confirmed the dishwasher at the facility is a high temperature dishwasher. Maintenance Director-H confirmed that Maintenance Director-H does not monitor the dishwasher on a regular basis. Maintenance Director-H stated the facility uses a contracted company to service the dishwashing machine. On 2/1/24, at 8:56 AM, Food Service Manager-F confirmed the facility staff had not been trained on the process of the dishwashing machine test strips before the survey. Food Service Manager-F confirmed that Food Service Manager-F implemented the test strips because that process was missing. Food Service Manager-F stated test strips for the dishwasher should be done three times a day. Food Service Manager-F stated the test strips is the guarantee to make sure the dishwasher process is being done correctly. Food Service Manager-F stated usually a contracted company should come in to the facility on a regular basis to calibrate the dishwasher. On 2/1/24, at 9:13 AM, Maintenance Director-H stated a company does not come in on a regular basis to calibrate the dishwasher. On 2/1/24, at 9:34 AM, Surveyor interviewed a Representative from the contracted dishwasher company-G who confirmed the facility has a high temperature dishwashing machine and test strips should be done three times a day to verify the wash cycle is at 150 degrees and rinse is at 180 degrees. Representative-G verified that test strips would turn dark orange if at the correct temperature is reached. On 1/31/24, at 3:42 PM, Surveyor shared the kitchen concerns with Nursing Home Administrator(NHA)-A and Director of Nursing (DON)-B. No further information was provided at this time by the facility. On 2/1/24, at 9:26 AM, Surveyor reviewed the above kitchen concerns again with NHA-A and requested polices and procedures for the kitchen.

Based on observations, interviews and record review, the facility did not maintain an effective infection prevention and control program to prevent and control the spread of infections such as COVID-19. The facility did not ensure staff wore appropriate and correct personal protective equipment (PPE) when working in Resident care areas, including the use of N95's for Residents in isolation. Additionally upon leaving residents in isolation, staff did not complete appropriate hand hygiene. This deficient practice has the ability to affect all of the 33 residents who reside within the facility as facility staff float the building. *R282 was in droplet and contact precautions/isolation during the survey process due to not being vaccinated. Employees were observed not wearing the appropriate PPE including an N95 per facility policy and procedure. *Certified Nursing Assistants (CNA)-D, CNA-E, and RN-G were observed, not wearing face shields correctly in Resident care areas. The face shields were observed positioned up on their forehead. Findings include: Surveyor reviewed several facility policies and procedures and notes the following applicable: 1.) Suspected Or Confirmed Positive COVID 19 Management Policy revised 12/21/20: Procedure b. The center will implement isolation procedures (contact and droplet) for Residents who are positive for or suspected positive for COVID-19 1. The center will isolate infected Residents and care for them using all recommended COVID-19 PPE: c. The center will increase transmission-based precautions in center 1. The center will reinforce universal use of facemasks for all staff while in center (depending on PPE supply, see Strategies for Optimizing PPE policy) 2. Health care personnel(HCP) will wear all recommended PPE for the care of all Residents (depending on PPE supply, see Strategies for Optimizing PPE policy). 4. Considerations for new admissions or readmissions to the center c. All recommended COVID-19 PPE will be worn during care of Residents under observation which includes an N-95 or higher respirator, eye protection, gown, and gloves. Newly admitted or readmitted Residents will be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. 6. Staffing support and Education a. The Director of Nursing(DON-B) or designee will be responsible for coordinating education, training and staff competency verification on COVID-19. This education will include: 1. Infections Control measures to prevent spread of COVID-19 2. Hand Hygiene 3. Respiratory Cough 4. Standard precautions as well as Contact and Droplet Precautions 5. Use of PPE including how to DON/DOFF, optimization of PPE and how to report concerns with PPE supply 2.) Quarantine Requirements for Fully Vaccinated Individuals revised 9/12/21 Policy This center will follow current CDC and State Department of Health guidance on quarantine requirements for employees and Residents, including newly admitted Residents, as it relates to the [CONDITION(S)]-COVID-2 virus. Procedure If vaccination status is unknown at the time of admission, center should quarantine Resident. Once full vaccination status is confirmed, quarantine may be discontinued. If vaccination status cannot be confirmed, Resident should remain in quarantine for the recommended 14-day time period. 3.) Strategies For Optimizing PPE When In Limited Supply revised 10/27/20 Conventional Capacity- measures consist of providing Resident care without any change in daily contemporary practices. This set of measures, consisting of engineering, administrative, and PPE controls should already be implemented in the center. 2. Strategies to Optimize Face Masks a. Conventional Capacity Strategies 1. Use facemasks according to manufacturer recommendations and local, state, and federal requirements. 3. Strategies to Optimize Isolations Gowns a. Conventional Capacity Strategies 1. Use isolation gown alternatives that offer equivalent or higher protection. 4. Strategies to Optimize Eye Protection a. Conventional Capacity Strategies 1. Use eye protection according to manufacturer recommendations and local, state, and federal requirements. 5. Strategies to Optimize N95 Respirators a. Conventional Strategies iii. Implement qualitative fit testing and consider just-in-time fit testing; staff to complete N95 initial fit testing as resources become available. 4) Isolation-Categories of Transmission-Based Precautions-Revised 10/18 Policy Statement Transmission-Based Precautions(TBP) are initiated when a Resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other Residents. Policy Interpretation and Implementation 5. When a Resident is placed on TBP, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for a Resident, staff will change gloves after having contact with infective material b. Gloves will be removed and hand hygiene performed before leaving the room. c. Staff will avoid touching potential contaminated environmental surfaces or items in the Resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions 3. Masks will be worn when entering the room. 4. Gloves, gowns, and goggles should be worn if there is risk of spraying respiratory secretions. 5) N95 Fit Testing, dated 11/2/20 . The policy states All staff that work in direct resident care will have an initial and annual fit-test for respirator use in accordance with Occupational Safety Health Administration (OSHA) regulations. 6) Respiratory Protection Program, dated 11/10/20 The document indicates Supervisors are responsible for ensuring that the Respiratory Protection Program is implemented. Responsibilities of the supervisor include: -Ensuring that employees under their supervision (including new hires) have received appropriate training, and medical evaluation and fit test for duties involve use of a respirator. -Enforcing the proper use of respiratory protection when necessary. Employees have the responsibility to: -Wear their respirators when and where required and in the manner in which they were trained for donning and doffing. Proper PPE use and hand washing concerns: R282 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R282 has an activated Health Care Power of Attorney (HCPOA). There is no completed Minimum Data Set (MDS) for R282. R282 was placed in isolation with contact and droplet precautions in place upon admission to the facility due to documentation from hospital of R282 not being vaccinated against COVID-19. On 9/15/21 at 10:29 AM, Director of Nursing (DON)-B confirmed R282 is in isolation due to not being vaccinated and coming from the hospital. DON-B stated that R282 would be out of isolation on 9/16/21. Surveyor notes that R282's isolation status is not on R282's signed physician orders. R282's isolation status with identified precautions is not documented on R282's care card which was updated on 9/15/21. Surveyor also notes that R282's isolation status and required precautions are not documented on R282's plan of care. Surveyor made the following observations and conducted interviews during the survey process of employees going into R282's and providing cares without proper personal protective equipment(PPE). On 9/15/21 at 9:35 AM, Certified Nursing Assistant (CNA-C) was observed in R282's room moving R282's personal items around, cleaning up, making R282's bed. CNA-C was observed wearing a surgical mask with protective shield. Surveyor noted that CNA-C is not wearing an N95 mask, gown or gloves. On 9/15/21 at 9:42 AM, CNA-C left R282's room without washing CNA-C's hands or applying hand sanitizer. Surveyor noted CNA-C had no gown or gloves on. CNA-C then was observed going into another resident room [ROOM NUMBER] rooms from R282's room. Surveyor noted at that time there were 2 carts outside of R282's room that are full of PPE. Surveyor also noted the following signs are on R282's door: One sign in yellow states contact precautions Everyone must: clean their hands including before entering and when leaving the room Providers and staff must also: Put on gloves before room entry. Discard gloves before exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than 1 person One sign in blue states Droplet precautions Everyone must: Clean their hands, including before entering and when leaving the room Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protection before room exit On 9/15/21 at 9:44 AM, CNA-J confirmed that both CNA-C and CNA-J were doing cares in room [ROOM NUMBER]. On 9/15/21 at 2:26 PM, Surveyor asked Administrator (NHA-A) about PPE expectations when a resident is in quarantine including the use of N95 masks. NHA-A stated that if a Resident is in quarantine the expectation is that wearing an N95 is required to go into a Resident room and then a surgical mask can be put on afterwards. The facility educates the agency staff on COVID-19 policies and procedures. NHA-A confirmed that the PPE supplies are adequate and the facility is operating in contingency mode. On 9/15/21 at 2:29 PM, Surveyor observed 2 gowns hanging on the outside of R282's door. On 9/15/21 at 2:37 PM, Surveyor asked CNA-C why they were not wearing a gown or gloves when in R282's room. CNA-C stated that they were moving so fast to get everything done CNA-C informed Surveyor that they washed their hands in the other Resident's room before they did cares and stated the following; but I probably should have washed them before I entered. On 9/16/21 at 8:25 AM, Surveyor observed CNA-D answering R282's call light. CNA-D had a surgical mask on with a faceshield. R282 stated they had to go to the bathroom and CNA-D opened the bathroom door and turned on the light and then shut the door to the room. Surveyor observed CNA-D not wearing an N95, gown or gloves at this time. On 9/16/21 at 8:37 AM, Surveyor asked CNA-D what cares were they doing in R282's room, and CNA-D stated they assisted R282 to the bathroom and R282 is still sitting in the bathroom. Surveyor asked CNA-D if they had a gown or gloves on when assisting R282. CNA-D stated, No, I'm not going to lie. This is my first day ever in this building. I am agency, Surveyor asked if CNA-D learned in report that R282 was in contact and droplet precautions. CNA-D stated, No, nobody told me anything about isolation for (R282). CNA-D then turned their head and looked at the signs posted on the door. CNA-D stated, I just saw the signs now. CNA-D then stated, Are there even any gowns in the drawers? CNA-D then pulled open a drawer of the cart, shut it and went down the hall. On 9/16/21 at 8:40 AM, CNA-D went back into R282's room with a roll of toilet paper that CNA-D had obtained from housekeeping. Surveyor observed CNA-D put gloves on, but did not wash their hands prior to putting gloves on. CNA-D did not put on a gown or N95. Surveyor observed CNA-D had the same surgical mask on. On 9/16/21 at 8:47 AM, CNA-D exited R282's room and was observed to have a pair of gloves in their right hand as the went into another resident room. CNA-D spoke to the other resident and came out of the room with gloves still in CNA-D's right hand. On 9/16/21 at 11:38 AM, Surveyor observed Licensed Practical Nurse (LPN-F) removed masks from the cart and place a box of N95 masks in the drawer of the cart. Surveyor was informed by LPN-F that they had removed the cone shaped mask and replaced them with regular N95 masks in the drawer. LPN-F stated they were instructed to do so by the administrator. On 9/16/21 at 11:48 PM, Surveyor observed Speech Therapist (ST-I) in R282's room. ST-I is observed to be wearing a gown, surgical mask, and eye protection. ST-I is not wearing an N95 or gloves. ST-I is standing at R282's bedside and handed R282 a paper of exercises. On 9/16/21 at 12:07 PM, Surveyor interviewed Director of Clinical Services (DCS-H) asking what the mask expectations are for staff including agency staff. DCS-H stated that the expectation is that staff change their surgical mask to an N95 before going into a Resident room who is being quarantined. DCS-H stated that agency staff should be educated on policies and procedures of the facility before they get to the facility. DCS-H again confirmed that the expectation is that full PPE plus N95 must be worn before going into R282's room. On 9/16/21 at 12:22 PM, Surveyor spoke to ST-I who confirmed that ST-I was not wearing gloves or an N95 when ST-I was in R282's room and stated, I should have been wearing both. On 9/16/21 at 2:01 PM, DON-B stated that staff know a Resident is on quarantine and precautions because it is posted on the door of a Resident room and the nurses should communicate that in report to staff on every shift. Surveyor also observed the following staff walking around the facility with their face shields up on their forehead. On 9/16/21 at 11:32 AM, Surveyor observed CNA-D walking around with shield up on CNA-D's forehead, is seen in the dining room and resident room providing cares. On 9/16/21 at 12:12 PM CNA-D went into a resident room with a surgical mask and shield up on forehead. On 9/16/21 at 1:15 PM, CNA-E assisted a Resident in the bathroom with face shield up on forehead. On 9/16/21 at 1:35 PM, Registered Nurse (RN-G) was observed pushing a wheelchair of a Resident down the main hallway to take the Resident outside for an appointment. RN-G's face shield was up on RN-G's forehead going down the main hallway and up on forehead coming back down the main hallway. On 9/16/21 at 3:25 PM, Surveyor shared the concern with NHA-A, DON-B, and DCS-H about the staff not wearing the required PPE upon entering R282's room, specifically an N95, gown, and gloves. Surveyor discussed staff walking around with their shield up on their forehead. Surveyor also discussed the concern not having N95's readily available in the cart. Surveyor shared R282's care card and care plan had not been updated with R282's isolation status and required PPE. DCS-H shared that the speech therapist had been re-educated today on the expectation for PPE. No further information was provided at this time. On 9/20/21 at 10:08 AM, during interview, NHA-A stated that the policy for PPE for COVID-19 is the same for unvaccinated quarantine Residents. On 9/20/21 at 11:22 AM, Surveyor interviewed DCS-H in regards to PPE for COVID-19. DCS-H confirmed that an N95, gown, gloves, and eye protection should be worn at all times when in the room of a quarantine unvaccinated Resident for 14 days. DCS-H stated that the therapist knew what the procedure should be for PPE based on the signage on the door but did not pay attention. DCS-H also stated that there was confusion about when R282 was coming out of isolation. R282 was out of isolation as of 9/17/21. DCS-H also confirmed that isolation and required PPE should have been on R282's care card and on the care plan. DCS-H is agreement with Surveyor's concerns. On 9/20/21 at 11:51 AM, Surveyor was informed by NHA-A that training was last done on facemasks, PPE, handwashing, masks, face shields, policy's and procedures of COVID-19, quarantine on 3/10/21.

Based on observation, interview and record review the facility did not ensure 1 of 2 (R3) residents reviewed for pressure injuries received care and services to promote healing of existing pressure injuries and prevent new pressure injuries from developing. The resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a decline in condition, was refusing to eat and was placed on Hospice care on 5/26/21. According to Director of Nursing (DON)-B, R3 has since rebounded and is now doing better. Hospice services were discontinued on 9/4/21. R3's admission Braden score documented a score of 13 indicating moderate risk for pressure injuries. R3's Quarterly Minimum Data Set with an Annual Reference Date of 8/26/21 documented: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, as extensive 1 person assist. R3's current Care Plan documented: History of pressure injuries to left buttock, left and right heel, right upper foot and current right lateral foot due to: Decreased mobility, incontinence, poor intake complicated by affects of [CONDITION(S)] ([CONDITION(S)]) complicated by the end of the life and unlikely preventable. Resident at times takes both boots off. Intervention included: Prevalon boots on at all times. Float resident heels on heels up pad or pillow when in bed. Reposition side to side when in bed. Encourage resident to stay off back. R3's current CNA (Certified Nursing Assistant) Care Card documented: Reposition every 1-2 hours and as needed. Side to side when in bed. Prevalon boots to feet as tolerated. Gripper socks on at all times. Encourage resident to keep boots on. Float heels on heels up pad or pillows when in bed. The Facility Policy Pressure and Non-pressure injuries dated 8/2/21: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in out residents. For those residents admitted with, or who subsequently developed a pressure injury or impaired skin integrity, they will received care, treatment and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity. Surveyor noted R3's pressure injury to left buttock healed 6/29/21, left heel was healed on 7/5/21 and right heel was healed on 7/20/21. Measurements of the current unstageable pressure injury on the right lateral foot taken on 9/14/21 were 0.3 cm (centimeters) x 0.1 cm. On 9/15/21 at 9:35 AM Surveyor observed R3 sitting in her wheelchair in the dining room eating breakfast. She was wearing red gripper socks and no shoes. There were no foot pedals on the wheelchair. On 9/16/21 at 7:15 AM Surveyor observed R3 asleep in bed, lying flat on her back. She was wearing a gown, red gripper socks on her feet and her heels were resting directly on the (air) mattress. On 9/16/21 at 8:23 AM Surveyor observed R3 asleep in bed, in the same position, lying flat on her back. She was wearing a gown and her heels were resting directly on the mattress. On 9/16/21 at 9:25 AM Surveyor observed R3 in the same position, lying flat on her back, awake (her eyes were open). She was wearing a gown and her heels were resting directly on the mattress. On 9/16/21 at 9:27 AM Surveyor observed a staff member serve R3 her breakfast in bed. The staff member assisted with cutting up the pancake and left the room. Surveyor noted the resident was positioned with the head of the bed only slightly elevated and was having difficulty reaching her plate. Surveyor noted she was still lying on her back and her heels were resting directly on the mattress. Surveyor asked R3 if she had been out of bed, to which she replied: No. On 9/16/21 at 9:33 AM Surveyor asked Licensed Practical Nurse (LPN)-F to accompany Surveyor to R3's room to observe R3's positioning in bed for meal and advised her the resident was having difficulty reaching her tray. LPN-F proceeded to raise the resident's bed to an upright position for R3 to eat. LPN-F stated: She usually eats in the dining room, but was left in bed because the Surveyor wanted to watch the treatment. On 9/16/21 at 10:25 AM Surveyor observed LPN-F perform wound care to R3's right lateral foot pressure injury. Surveyor observed R3 was in the same position, lying on her back, wearing a gown and red gripper socks with her heels resting directly on the mattress. Observation of the pressure injury revealed a shallow filled ulcer, white in appearance which did not appear to be open. There was no redness to surrounding skin. The nurse applied skin prep to the ulcer and surrounding skin. No concerns were identified with wound care. Surveyor observed R3's right and left heels which revealed intact skin, normal color with no redness. After Surveyor observed R3's heels, LPN-F put R3's gripper socks on her feet and covered her with a blanket. Surveyor noted LPN-F did not float R3's heels, she left them resting directly on the mattress. Surveyor asked LPN-F if R3 is to have her heels floated. LPN-F stated: Yes. She added: Or we have boots for her to wear, but she doesn't always want to wear them or kicks them off. She had them on this morning when I came in. Maybe they took them off for you to watch the treatment. Surveyor asked LPN-F what time she came in this morning, to which she replied: Around 6 AM. Surveyors' observations since 7:15 AM revealed R3 lying in the same position on her back. She was not repositioned every 1-2 hours as indicated on her Care Plan. She was not positioned side to side as indicated on her Care Plan. Her heels were resting directly on the mattress during each observation, and not floated as indicated on her Care Plan. Surveyor located no Prevalon boots or heels up pad in R3's room. On 9/16/21 at 11:00 AM Surveyor observed a heels up device and Prevalon boots on both of R3's feet. Surveyor asked CNA-D and CNA-E what time R3 would be getting up out of bed. CNA-E stated: I didn't even know she was a get up. CNA-D stated: I didn't either. This is my first time in this building. Surveyor asked CNA-D and CNA-E: Have either one of you been in by her yet today? Both CNA-D and CNA-E said No. Surveyor advised both CNA's to notify Surveyor when they do ADL's (Activity of Daily Living) and get her up. On 9/16/21 at 11:17 AM Surveyor observed the door to R3's room was closed. Surveyor knocked and entered. Both CNA-D and CNA-E were in the room. CNA-E reported they were waiting for the nurse to bring them a wash basin. Surveyor asked to see R3's buttocks. CNA-D and CNA-E assisted with opening R3's blue incontinence brief and turned R3 onto her left side. Surveyor noted the brief was dry. As CNA-D held R3 on her left side, Surveyor observed R3's buttocks. R3's skin was pink, dry and intact - no pressure injuries were identified. On 9/16/21 at 12:19 PM Surveyor met with Director of Nursing (DON)-B and Director of Clinical Services- H. Surveyor advised of concern since 7:15 AM - R3 was not turned or repositioned every 1-2 hours as indicated on her Care Plan, was lying flat on her back (not side to side as indicated on her Care Plan), her heels were resting directly on the mattress/not floated and she was not wearing Prevalon boots. Surveyor advised that at 11:00 AM CNA-D and CNA-E reported neither of them had been in to care for the resident and did not know she was a get up therefore no change of position or ADL's had occurred. DON-B reported agency CNA's are educated before starting their shift to follow the CNA care cards. No additional information was provided.

Based on interview, observations, and record review, the facility did not ensure that 2 (R2, R3) of 3 residents received the necessary care and services to prevent UTIs (Urinary Tract Infections) and catheter obstruction by monitoring the urinary output of residents with indwelling catheters. R2 had an indwelling catheter and the urinary output was not being measured. R3 had an indwelling catheter and the urinary output was not being measured. Findings include: Surveyor reviewed the facility policy for Catheter Care, Indwelling Catheter, dated June 2017, Revision 2/22/21 which indicated in part . Encourage resident to have a good fluid intake to discourage infection and maintain urinary flow. Documentation may include Intake and Output & evaluation of intake and output per facility procedure. Example 1: R2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] after hospitalization . R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was being anticoagulated (on blood thinner medication) for blood clots. R2 was cognitively intact and able to direct care. R2's progress notes on 3/9/21 indicated the urine was dark, cola colored, and the physician was informed. The physician ordered a urine specimen and to hold the blood thinner medication for 2 days. On 3/10/21, at 11:09 AM, Surveyor conducted an interview and observation of R2. Surveyor noted R2's urine was brown in the catheter tubing and the bag was covered with a privacy bag. R2 stated the urine has been bloody for months. Surveyor reviewed R2's medical record for fluid intake and urinary output, noting R2's urinary output was not being monitored to ensure adequate output, or clogging of the catheter by potential blood clots. On 3/10/21, at 11:09 AM, Surveyor interviewed CNA-C (Certified Nurses Assistant) who stated the method of catheter care every time she changed a resident and emptying the catheter bag urine in a hat or urinal. Surveyor questioned if CNA-C had emptied R2's urinary bag today to document output and CNA-C stated not yet but she would not enter any output for R2 because it was not a category in the kiosk as a task to be documented. Example 2: R3 was admitted to the facility on [DATE]. R2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3 had impaired vision and hearing. On 1/20/21, R3 was diagnosed with a UTI and treated with antibiotics. Urology consult noted the catheter tubing was clogging therefore they increased the catheter size with the exchange of catheters. On 2/17/21, the Urology consult indicated no further issues with the catheter. On 3/10/21, at 11:20 AM, Surveyor conducted an observation of R3 sitting in a wheelchair, with R3's catheter draining urine and the bag was covered with a privacy bag. R3 was nonverbal to Surveyor interaction and/or attempt to interview. Surveyor reviewed R3's medical record for fluid intake and urinary output, noting R3's urinary output was not being monitored to ensure adequate output, or clogging of the catheter. On 3/10/21, at 12:00 PM, Surveyor shared the information with DON-B (Director of Nursing) and NHA-A (Nursing Home Administrator) regarding R2's urinary catheter output, color of urine as well as R3's urinary catheter output. On 3/10/21, at 1:30 PM, NHA-A stated R2 and R3 do not have urinary catheter output as a task for monitoring and measuring, and DON-B added the tasks in each medical record. On 3/10/21, at 1:56 PM, Surveyor reviewed the facility catheter care policy with NHA-A and asked what would be the facility procedure for intake and output evaluation considering the possibility of catheter clogging and abnormal urine. NHA-A stated R2 and R3 should have had urinary output in the tasks for monitoring. DON-B provided a copy of R2's task which indicated urinary output of 100 ml for the first entry on 3/10/21. DON-B provided a copy of R3's task which indicated urinary output of 475 ml for the first entry on 3/10/21. On 3/10/21, at 3:25 PM, Surveyor conducted a facility exit with DON-B and NHA-A. No further information was provided.

Based on interview and closed record review, the facility did not ensure that a resident who enters the facility without a PI (Pressure Injury) does not develop a PI and a resident that develops a PI receives appropriate care, treatment, and preventative interventions to promote healing for 1 of 2 residents reviewed (R184) for PI's. R184 was admitted to the facility without a PI and was identified to be at risk for easy bruising and PI development. R1 was observed to have a bruise with a blister in the center over the sacrum (the sacrum is situated at the back part of the pelvic cavity, between the two wings of the pelvis), four days after a fall in the facility. The facility did not recognize that the wound (bruise with a blister) was a deep tissue injury and did not implement measures to address this. When the facility recognized that the wound was a (DTI) the facility ordered an air mattress for the bed, but did not get a different cushion for the wheelchair and did not monitor the frequency of repositioning. The resident stated the pressure injury was from sitting too much. When the wound clinic ordered a ROHO cushion for the wheelchair on 6/11/19 the facility did not get one until nine days later. R184 developed a Stage 4 tunneling PI that required negative pressure wound therapy (Wound vac). The facility's failure to recognize a bruise with a blister as a deep tissue injury and to implement timely interventions to address the DTI, such as monitoring the frequency of repositioning, ensuring pressure relieving devices utilized were rated for the appropriate staging of a pressure injury, and implementing recommendations made by the wound clinic timely such as the use of a Roho cushion. The deep tissue injury developed into a Stage 4 pressure injury requiring the use of wound vac therapy, which created a finding of Immediate Jeopardy that began on 5/14/19. Nursing Home Administrator A and the Director of Nursing B was notified of the immediate jeopardy on 9/10/19 at 11:50 am. The immediate jeopardy was removed on 9/10/19, however the deficient practice continues at a scope/severity level of a D (potential for harm/isolated) as the facility continues to implement their removal plan with the Director of Nursing and the wound nurse conducting weekly rounds to ensure accurate documentation of wounds This is evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated (YEAR), states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear. .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer; and identify related causes and complications. The National Pressure Ulcer Advisory Panel (NPUAP) at www.NPUAP.com defines PI's in the following categories: Category/Stage I: Non-blanchable [DIAGNOSES REDACTED] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum-filled or serosanguinous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Category/Stage IV: Full thickness tissue loss - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Suspected Deep Tissue Injury (DTI) - depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. The facility's policy, entitled Skin Management System, dated 1/02/17, states in-part: 1. A head to toe body evaluation will be completed on every resident upon admission or readmission and weekly thereafter. These evaluations will be documented on the Weekly Skin Integrity Review form or Electronic Medical Record (EMR). If skin is intact, no further action is required. If skin is compromised, proceed to the appropriate form below. [NAME] Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented on the Ulcer, Surgical Site Treatment and Progress Record: form of the EMR. Use on form per wound. Wound progress is to be documented each week with measurements and wound descriptions. Daily treatments are also documented on the same form. B. Non-ulcer/surgical skin issues such as skin tears, bruises, rashes, abrasions,[MEDICAL CONDITION]. will be documented on the Altered Skin Integrity Treatment & Progress Record. Use a separate record for each area. C. Keep open lines of communication with physicians, families, and residents regarding status of wounds. D. Responsible Party will be notified at the onset of an identified area as well as with all treatment changes, decline in the status of the area, and when the area is healed. Documentation of the notification is to be in the Nurses Notes in the clinical record or EMR. Progress of the identified area, will be documented on the back of the Altered Skin IntegrityTreatment & Progress Record form or EMR at least every 7 days, or less if the wound shows a decline or is healed. The Physician is to be contacted after 14 days if the area has not shown improvement or immediately if it shows a decline. Documentation of the Physician notification is to be in the Nurses Notes in the chart or EMR. 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a Ulcer, Surgical Site Treatment and Progress Record form or EMR will be started. b. Certified Nursing Assistants (CNAs) will note any alteration in skin integrity during routine care on the Skin Care Alert form or EMR and turn in/reported to the Charge Nurse responsible for the resident at that time, for their attention. 3. Braden Scale will be completed upon admission, readmission, weekly for three weeks, change of condition and then quarter thereafter on the Braden Scale for min the EMR. [NAME] Interventions will be noted on the Interim Plan of Care. 4. Refer to Protocol for Pressure Ulcers by AMT (American Medical Technologies), and/or AMT binder, for assistance with wound identification, staging and recommended treatments. Contact Physician for treatment recommendation approval. 6. Follow the specialty bed algorithm should a specialty mattress be needed. 8. The facility DON (Director of Nursing) is responsible to establish a system to monitor and assure skin management system compliance. R184 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R184's initial Minimum Data Set (MDS) assessment, dated 4/10/19, indicated that R184 is cognitively intact with clear speech and is able to make herself understood and the ability to understand others. Section [NAME] - Behavior indicated that R184 has displayed no behaviors including rejection of care. Section G - Functional Status indicated R184 requires extensive physical assistance of two staff with bed movement, transfers, and toilet use. R184 has a functional limited Range of Motion (ROM) in her upper extremities. Section J- Health Conditions indicated R184 is almost constantly in pain and receives scheduled and as needed pain medication. R184 rated her pain as a 9 on a pain scale of 00-10. Section M - skin conditions, indicated that R184 is at risk of developing pressure injuries, but does not currently have any pressure injuries. R184 has a pressure reducing device for her chair and bed. R184's MDS assessment, dated 5/05/19, indicated that R184 remained cognitively intact with no behaviors including rejection of care. R184 remained at risk for PI development with no current PI. Section J - Health Conditions indicated R184 is almost constantly in pain and receives scheduled and as needed pain medications. R184 reports that pain has made it hard for her to sleep at night and has limited her day to day activities. R184 rated her pain at a 10 out of 10. R184's Care Plan (CP), dated 4/17/19, states: R184 is at risk for abnormal bleeding, hemorrhage and or increased easy bruising related to Aspirin usage. R184's CP, dated 4/17/19, states: R184 is at risk for falls related to deconditioning, weakness, gait balance problems, history of fall with injuries, and pain. R184's CP, dated 4/17/19 and revised on 5/23/19, states: Pressure injury to the sacrum related to a fall with a DTI. Interventions include: Conduct weekly skin inspection initiated 4/17/19, Provide thorough skincare after incontinent episodes and apply barrier cream initiated 4/17/19 Provide a pressure reduction/relieving mattress initiated on 4/17/19 and revised on 5/23/19 Provide pressure redistribution wheelchair cushion initiated 4/17/19 and revised on 5/23/19 Air Mattress initiated 5/22/19. (R184) is able to independently reposition self initiated 6/19/19, Turning and repositioning every two hours and as needed initiated on 4/17/19 and revised on 6/19/19. NOTE: Director of Nursing (DON-B) indicated that the dates on the care plan may not reflect the actual date the care plan was initiated. R184's Care Plan related to the PI shows it was initiated on 4/17/19 when the facility did not identify the PI and a DTI until 5/21/19. Review of R184's Braden (skin breakdown risk) dated 4/03/19, identified a score of 16 indicating R184 is at risk for skin breakdown. R184's Medical Record/Progress Notes, shows in-part the following timeline of events: *On 4/3/19, R184 is alert, cooperative, makes needs known. Her skin is warm and dry with bruising noted over body. R184 was admitted status [REDACTED]. Right arm is in a hard cast from below the shoulder to the wrist .R184 has [DIAGNOSES REDACTED]. *On 5/11/19, at 3:50am, R184 is on follow up for an unwitnessed fall on 5/10/19, at 10:15pm. R184's current status is stable and no complaints of acute pain at this time. *On 5/11/19, at 4:23am, R184 was found by staff sitting on the floor in the bathroom doorway. R184 attempted to transfer her-self without assistance. R184's background is a fall with a fracture to the right elbow, [MEDICAL CONDITIONS], irritable bowel syndrome, and chronic pain issues. The Licensed Practical Nurse (LPN) appearance shows R184 has good range of motion R184 has reopened a skin tear to her left elbow and two small scratches to her left hand. Band-Aids were applied to the scratches to the left hand and a steristrip to the skin tear to the left elbow. No other injuries seen. *On 5/11/19, at 11:01, Assistant DON (ADON-E) documented R184 had a new fall on 5/10/19 with no injuries. *On 5/14/19, at 12:50, Wound Nurse/Registered Nurse (RN-I) documented R184 has a blister to the sacrum. R184 sustained this blister after a fall in which she landed on her sacrum. The blister is located in the middle of a bruise, which R184 also sustained during this fall. The bruise measures 5 X 4 X 0cm. There is no open area, redness, or increased warmth noted. The Medical Doctor (MD) was updated with an order to apply skin prep to the blister on the sacrum two times a day. The Blister is intact and fluid filled and the fluid is clear. R184 offers no complaint of pain or discomfort to the area at this time and the plan of care is appropriate. NOTE: From the time of the fall on 5/10/19 to 5/14/19 at 12:50pm, where R184's sacrum was identified as bruised with a fluid filled blister none of the nursing assessments identify R184 had any injury or bruising to the sacrum. Because R184 was at risk for abnormal bleeding, hemorrhage and or increased easy bruising related to Aspirin usage, one would have expected bruising from the fall to appear before the fourth day following the fall. On 9/09/19, at 2:33pm, Surveyor interviewed Medical Doctor (MD-O) who stated that R184 was boney and had a lot of pain. The bruise could have been a deep tissue injury from 5/14/19 in prospective time. Maybe it got worse from her immobility. NOTE: NPUAP identified a Suspected DTI evolution may include a thin blister over a dark wound bed. *On 5/21/19, at 1:50pm, Wound Nurse/RN-I documented that an SBAR form was completed for a change of condition in R184's skin wound or ulcer. This started on 5/21/19 in the morning. R184's Skin Evaluation shows: Pressure ulcer new onset grade 2 or higher pressure ulcer or progression of a pressure ulcer despite interventions. New orders were received to clean sacrum with NaCl and apply petroleum gauze cut to size followed by foam dressing once daily and monitor functioning of the air mattress each shift. NOTE: Surveyor reviewed R184's progress notes, no documentation was reviewed related to nursing assessments that show R184's fluid filled blister or bruise were monitored and described on R814's sacrum until 5/21/19. *On 5/22/19, at 4:17am, DON-B documented that she pulled R184's dressing back to the left sacrum with the area of a DTI. It was dark purple/black base at 85% with small area of pink tissue noted. R184 denies pain to the area and stated to DON-B You know when I fell I landed on my butt there where you are looking. The surrounding tissue is pink in color however it does blanch readily. *On 5/27/19, at 12:13pm, Wound RN-I documented: R184's dressing was changed to the sacrum where the DTI is present. R184 is encouraged to re-position herself frequently when in bed and to shift her weight when she is sitting in a chair. R184 is in agreement with the plan. R184 complained of mild pain during cleaning of the wound and her pain medication was effective. *On 5/29/19, at 2:23pm, LPN-J documented: The dressing to R184's sacrum is clean and dry. No shadowing or sign of drainage. R184 offers a complaint of pain of 6 out of 10 when she is siting up too long. The air mattress is in place and R184 was repositioned by staff. *On 5/31/19, at 10:15am, The LPN documented R184's air mattress is in place but R184 is often declining staff to reposition her on to her side. R184 was observed putting a blanket down back of pants. LPN asked R184 why she is doing this and R184 denied doing it. R184 was educated about the benefits of repositioning and she voiced understanding even though she is often noncompliant. NOTE: R184's MDS assessments and Care Plan do not address R184 being non-compliant and why she may be refusing to reposition or why she may be putting the blanket down the back of her pants. *On 6/01/19, at 4:50pm, Wound RN-I documented: R184 continues to have a dressing to the sacrum due to a DTI. The dressing is clean, dry, and intact. R184 is encouraged to re-position herself frequently when in bed and to shift her weight when she is in a chair. R184 is noted sitting on balled up towels, blankets directly to her sacrum. R184 was educated on the risks of doing this such as her wound worsening, however R184 continues to choose to do so. The air mattress is on and functioning properly. R184 was encouraged to keep taking a nutritional supplement to promote wound healing and prevent further skin breakdown. NOTE: The facility did not address in the plan of care why R184 is balling up linen and placing it by her sacrum and why she may be lying flat on her back. Surveyor interviewed LPN-J who stated R184 would be repositioned or attempted every two hours. R184 would go a little longer at times. R184 would refuse to reposition due to pain. *On 6/02/19, at 2:01pm, The LPN documented R184's treatment was completed. The wound base is 50% brown slough tissue and a strong odor was noted. There was a moderate amount of drainage noted to the old dressing. The right lower base of the wound has tunneling present. The surrounding tissue is red. R184 complained of pain to the area and her scheduled pain pill was given. R184 was encouraged to re-position every two hours and to lay down on her right side. R184 was compliant this morning but up in the wheelchair most of the afternoon visiting with her son. R184's appetite is poor. *On 6/04/19, at 11:45am, Wound Nurse RN-I documented: R184's PI remains to the sacrum and measures larger this week. The wound is now classified as a Stage 4 PI that measures 7.6 X 3.5cm with a 7.5cm tunnel to the 12 o'clock position. The wound is 85% granular tissue and 15% slough. A moderate amount of serous drainage was noted to the wound during cleaning. A foul odor was noted during the treatment. The surrounding tissue is within normal limits. R184 offers a moderate complaint of pain at this time and the pain is mainly due to pre-existing fractures. R184 complained of discomfort during cleaning of the wound and pain medication was effective. The MD and power of attorney were updated. The treatment changed. R184 is to be sent out to wound clinic for an evaluation and treatment. The air mattress is on and functioning properly. R184 encouraged re-positioning frequently to offload pressure. The plan of care is appropriate at this time. *On 6/04/19, at 12:32pm, Wound Nurse RN-I initiated a SBAR Change of Condition report that showed: The change of condition started on 6/04/19 in the morning. Skin evaluation: pressure ulcer new onset grade 2 or higher or progression of a pressure ulcer despite interventions. Labs tests, none to report. R184 does not like the air mattress and wants to have it discontinued. The risk and benefits were explained to R184. The MD's recommendations are for R184 to be seen at outpatient wound clinic for evaluation and treatment. The new treatment ordered is to clean the sacrum with NaCl (Sodium Chloride) and pack the wound to the 12 o'clock position with calcium alginate rope and to cover with a large comfort foam dressing. NOTE: on 6/02/19, at 2:01pm, the LPN documented that the wound had progressed to a tunneling wound, two days prior to the wound nurse assessing the progressing wound. R184 was scheduled to be seen in the wound clinic on 6/11/19. R184's MDS assessment, dated 6/04/19 indicated that R184 remained cognitively intact with no behaviors including rejection of care and that R184 remains at risk for PI, but now has an unhealed stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often included undermining and tunneling. Section J indicated that: On 6/04, R184 is frequently in pain and that pain has made it hard for her to sleep at night and has limited her day to day activities. R184 rated her pain at 8 out of 10. Progress notes continue: *6/06/19, at 5:28pm, Wound Nurse RN-I documented: R184 continues to have dressing to her sacrum for a stage 4 pressure area. The dressing is clean dry and intact. *On 6/07/19 at 12pm, ADON-E documented: R184's MD was updated on R184's pain assessment and current pain regimen. A new order was received to refer R184 to pain clinic for pain management. *On 6/10/19, at 12:55pm, The LPN documents: R184's treatment was done to sacrum per the MD order. The wound base pink with a strong odor noted. A moderate amount of purulent drainage was noted to old dressing. The upper right of the wound has tunneling present. The surrounding tissue is pink. R184 complains of pain to area and the scheduled pain pill and PRNs were given. R184 is encouraged to re-position ever two hours and lay down on right side, R184 is often non-compliant with repositioning side to side while in bed or she will lie down for 15/30min and want to get back into her wheelchair. R184's appetite remains poor. *On 6/10/19, at 6:01pm, LPN-J documents R184's dressing to the sacrum is clean and dry. R184 offers a complaint of pain at 7 out of 10 and her scheduled [MEDICATION NAME] were given. R184 was repositioned by staff. R184 is up in her wheelchair .R184 continues to propel herself up and down the hall seeking out her pain medication. *On 6/11/19, at 8:20am, Wound nurse RN-I documents: The Stage IV pressure injury remains to R184's sacrum and it measures smaller this week. 6.0cm of tunneling present to the 12 o'clock position. Wound is 100% granular tissue. A large amount of serous drainage was noted to wound during cleansing, old calcium alginate was completely saturated upon removal. A foul odor was noted during treatment the surrounding tissue is within normal limits with no open areas, redness, or increased warmth noted. R194 reports a minimal complaint of pain at this time, pain is mainly due to pre-existing fractures. R184 complained of discomfort during cleansing of wound and the pain medications were effective. R184 is to be seen by the outpatient wound clinic today. The air mattress is on and functioning properly. Cushion remains to wheelchair. R184 is encouraged to re-position frequently to offload pressure at least every two hours re-positioning when resident is in bed. The plan of care is appropriate at this time. R184's Medical Record/Consultation wound clinic referral, dated 6/11/19, shows: R184 has a Stage 3 (Nearly Stage 4) pressure injury to the sacrum. The wound clinic directed new orders for R184 to be treated with a Stage 4 Pressure Mattress or Equivalent. R184 needs to be turned side to side every two hours and should spend no time her back. R184 should be awakened from sleep to be turned every two hours. R184 needs a ROHO wheelchair cushion. Walking is ok and wound care clinic follow-up appointment in one week. Progress notes continue: *On 6/15/19, at 7:08pm, Wound nurse RN-I documented: The dressing was changed to R184's sacrum for the stage 4 pressure area. A large amount of drainage was present .The tissue is pink and granular. R184 encouraged to re-position herself frequently when in bed and to shift her weight when she is sitting in a chair. The air mattress is on and functioning properly. R184 is encouraged to keep taking the nutritional supplement to promote wound healing and to prevent further skin breakdown. *On 6/16/19, at 7:52am, Wound Nurse RN-I documents: The Stage IV pressure injury remains to R184's sacrum. Tunneling remains present to the 12 o'clock position. The wound is 100% pink/red granular tissue. A large amount of [MEDICAL CONDITION] drainage was noted to wound during cleansing. Old kerlix and dressing were completely saturated upon removal. No odor was noted during treatment. Surrounding tissue is within normal limits. R184 offers minimal complaint of pain at this time and the pain is mainly due to pre-existing fractures. R184 complains of discomfort during cleansing of wound and the pain medications were effective. R184's air mattress is on and functioning properly. Cushion remains to wheelchair. R184 is encouraged to re-position frequently to offload pressure, at least every two hours re-positioning when resident is in bed. *On 6/17/19, at 7:31am, Wound Nurse RN-I documented in part: The stage 4 PI remains to R184's sacrum. *On 6/17/19, at 9:30pm, the LPN documented R184's sacrum wound has brown drainage on the old dressing. There is no increased warmth or odor. The base is beefy red granulating tissue with undermining at 10, 11, 12, and 1 o'clock. The Periwound is pink and intact. R184 complains of tenderness with the dressing change. R184 is medication with [MEDICATION NAME]. The wound has no sign or symptom of infection. *On 6/19/19, at 10:12pm, the dressing to R184's sacrum is clean, dry and intact. R184 is encouraged to move in bed frequently. R184 is to have an application of a wound vac to the area. A therapy note On 6/20/19, at 1:28pm, notes that R184 was educated on the ROHO cushion and R184 was given a ROHO cushion. This is nine days after the ROHO cushion was ordered. MDS assessment on 7/04/19 notes R184 is frequently in pain and that pain has made it hard for her to sleep at night and has limited her day to day activities. R184 rated her pain at 7 out of 10. *On 7/09/19, at 11:28am, Wound Nurse RN-I documented: The Stage IV pressure injury remains to R184's sacrum and measures smaller this week. 3.5 cm of tunneling remains present to the 12 o'clock position. Wound is 100% granular tissue. A small amount of sanguineous drainage was noted to wound during treatment. No odor was noted during treatment. Surrounding tissue is within normal limits. R184 offered no complaint of pain during assessment and treatment. The Wound vac dressing was changed and the vac is functioning properly at this time with no leaks noted. R184's pain medications are effective. R184 is being seen by the outpatient wound clinic. R184's air mattress is on and functioning properly and the cushion remains to wheelchair. R184 is encouraged to re-position frequently to offload pressure. Every two hour re-positioning when resident is in bed. The plan of care remains appropriate at this time. *On 7/11/19, at 8:30pm, Wound Nurse RN-I documented: R184 continues to have a wound vac to the sacrum. The vac is functioning appropriately. R184 offers no complaint of pain or discomfort to the area at this time. R184 is encouraged to re-position frequently in bed and was repositioned with staff assistance. R184 has a pressure redistribution mattress in place and functioning appropriately. The cushion remains in place to the wheelchair. On 9/09/19, at 12:57PM, Surveyor interviewed DON-B who identified that she was aware on 5/14/19 that R184 had a bruised area on the sacrum and on 5/21/19 that the bruise was now a stage 2 PI. On 5/22/19 DON-B notes, I assessed R184 and recognized the wound as a DTI and not a stage 2 PI or a bruise. R184 would have had a gel cushion on her wheelchair before she was given a ROHO cushion. I think the gel cushion is good till a stage 3, but I am not sure I will need to get back to you. At 1:47PM, DON-B stated I am not able to tell you what stage of wound the house mattress or gel wheelchair cushion is rated for. If any resident had a DTI, I would expect them to receive an air mattress right away. On 9/10/19, Surveyor interviewed the Facility Corporate Consultant (CC-C) who identified she received an e-mail from their mattress and wheelchair cushion provider related to the cushion and mattress the facility uses as their house standard equipment. The Gel cushion is rated for residents with a Braden score of 15 or higher and for residents at risk for PI of a stage 1 or stage 2. The Bed Mattress is rated for residents who are at risk with a Braden score of 16 or higher, at risk for PI stage 1 or stage 2. On 9/10/19, Surveyor interviewed Wound Nurse RN-I, who identified that R184 was in a regular house mattress and wheelchair cushion until 5/21/19 when she completed the SBAR, R184 was given an Air Mattress. NOTE: Surveyor identified that the air mattress is rated for stage 1 - 4 pressure injuries. RN-I notes I do not know what the house wheelchair cushion is rated for, I think it is rated for a Stage 1 or 2. I do not know if the wheelchair cushion would have been appropriate for R184. NOTE: The facility identified via a timeline provided to Surveyor and the MAR/TAR that R184 did not receive a ROHO wheelchair cushion until 6/20/19. The wound care clinic physician ordered a ROHO cushion 9 days earlier on 6/11/19 and R184 was diagnosed with [REDACTED]. The gel wheelchair cushion was not an appropriate intervention for R184's DTI or a Stage 4 PI. On 9/09/19, at 2:33pm, Surveyor interviewed Medical Doctor (MD-O) on the telephone who noted that he remembers that R184 was thin and bony and had a lot of pain. The bruise on the sacrum could have been a DTI on 5/14/19 and that maybe it got worse from her decreased mobility. The facility did not recognize that R184 had pain in the low back and hips due to the PI and that the pain caused her to sit guarded and decreasing her mobility. On 9/10/19, at 9:15am, Surveyor interviewed RN-I who noted on 5/14/19 she identified R184 with a bruise from the fall she had on 5/11/19. Surveyor questioned if the bruise to her sacrum was documented anywhere in R184's medical record prior to 5/14/19. RN-I stated she went into the risk manager report and it was documented there. Surveyor reviewed the risk manager report that showed on 5/14/19 it was documented that R184 had a bruise on her sacrum. The facility refused to give Surveyor a complete copy of the risk manager report stating it was privileged and confidential information. Surveyor questioned if the DTI discovered on 5/22/19 was in the same location as the blistered bruise found on 5/14. RN-I identified that it was the same injury and that on 5/22/19 the big intervention implemented was an air mattress. R184 often declined to reposition in bed and her wheelchair. RN-I stated that on 6/04/19 she staged R184 sacrum as a stage 4 pressure injury. Surveyor questioned DON-B if she viewed the wound and she stated that she did view the wound and staged it as a stage 4 because of the inability to visualize the complete base of the wound. RN-I notes the major piece to the progression to R184's wound is that she declined our interventions. It was difficult to get her to reposition. It was hard to convince R184 to use the air mattress. She would ball up in bed and roll up a blanket or sweater and place it under bottom. R184 had many refusals that were documented. Surveyor questioned if R184's care plan showed she had been refusing care. RN-I stated she did not know if the care plan ever showed refusal in care. NOTE: Surveyor identified the MDS assessments for R184 all show there was no refusal in care and the care plan also did not show any refusal in care with identified interventions or the root cause on why R184 was refusing care like repositioning. On 9/09/19, at 1:30pm, Surveyor interviewed LPN-J who noted she was familiar with R184. R184 came in with a hip and elbow fracture and was here for rehabilitation. R184 had a couple of falls here and had a lot of pain while here. R184 had developed a PI here after she had a fall with bruising on the coccyx. In the middle of the bruise there was a blister. I did not see the injury too much at first as it was a treated on day shift, but then it became a two time a day treatment so I started treating it on 2nd shift. The area progressively got worse. LPN-J notes she saw R184's bruise in the beginning and it was dark purple w(TRUNCATED)

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 32 residents. The microwave in the kitchen and front dining room was dirty. Visible food particles were observed on the inside walls and top of the microwave. The front dining room refrigerator was dirty spilled food and liquids were observed on the inside and on top of the door gasket. Inside the refrigerator open and undated drinks were observed. The back dining room tables were left uncleaned after lunch, food debris and red sticky liquids were spilled on the table top. The facility did not use detergent to clean the tables in the dining room. The heat register and cold air return vent in the back dining room had food debris spilled on them and they were rusty leaving them uncleanable. The facility did not ensure appropriate glove usage and handwashing. Staff did not wash hands when entering the kitchen to work with food and when moving from dirty areas to clean areas, or when changing tasks. Findings include: The facility policy, entitled Cleaning & Sanitizing, undated, states in part: Working in a nursing facility and keeping residents safe is a huge undertaking and keeping areas sanitized is of the up most importance. Sanitizing is the process of removing bacteria to a safe level. Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to keep our operation safe for our residents. There is a big difference between cleaning and sanitizing. *Cleaning: When you clean a surface you remove all visible debris from an area. Cleaning solution is kept in green buckets only. No used food buckets can be used, no red buckets can be used, a clean towel can be stored in the soap water, but not out of the soap water. *To clean a surface remove all items from the work area, wipe off all dry debris with a clean towel into the trash, remove the towel from the soap water and wring out, wipe area clean with soapy towel, than sanitize surface. *Sanitizing: When you sanitize a surface you remove most harmful bacteria from the area. *To sanitize a surface, clean the surface properly before beginning to sanitize, remove towel from sanitizer solution and wring out, wipe area completely with sanitizer towl, and allow area to air dry. Example 1 On 9/03/19, at 1:24pm, Surveyor observed the facility kitchen with the Dietary Manager (DM-F). Surveyor observed the microwave to be visibly dirty with dried flaked food debris on the inside of the microwave. When the door was opened a large flake of dried food debris fell out of the microwave. DM-F notes that this microwave is so bad it just needs to be thrown away. On 9/03/19, at 1:45pm, Surveyor observed the front dining room. *The microwave had dried food debris splattered on the inside of the microwave including the top and sides. *The refrigerator was opened and observed to be dirty with food and liquid debris in and on top of the microwave. *Inside the refrigerator Surveyor observed open and undated drinks. Thickened cranberry cocktail nectar thick, thickened honey thick lemon flavored water, nectar thick lemon flavored water, and liquid coffee creamer all were open and undated. On 9/03/19, at 1:56pm, Surveyor observed the back dining room. The tables had visible food debris and a spilled red sticky liquid on the top of the table surface. Resident (R-24) stated to Surveyor that lunch was at noon today. Surveyor observed the heat register and the cold air return vent in the dining room to be dirty with food debris on the surface. The cold air return vents were rusty and uncleanable. Surveyor observed the sign on the dining room wall that states: Dining room hours Breakfast 8am to 8:30am, Lunch 12pm to 1230pm, and dinner from 5:30pm to 6pm. On 9/03/19, at 2:11pm, Surveyor interviewed Certified Nursing Assistant (CNA-G) who observed the front dining room microwave stating that there is food debris in the microwave and it is dirty. On 9/03/19, at 2:13pm, Surveyor interviewed Housekeeping Manager (HM-S) who stated that the microwave should be cleaned once a week. The top, bottom and glass rotator on the inside of the microwave is dirty with food debris. On 9/03/19, at 2:18pm, Surveyor interviewed Cook (CK-T), who stated we use sanitizer on the washcloth for cleaning the tables. CK-T observed the front dining room refrigerator stating the fridge is not good. I am not sure who is responsible to clean it. On 9/03/19, at 2:25pm, Surveyor interviewed DM-S who stated that the fridge was cleaned this morning. DM-S observed the fridge and stated there is food debris spilled in it. The open cranberry cocktail should not be stored in the fridge and it does not have an open date on it. The coffee creamer has no name or open date written on the container. Surveyor questions DM-S on the process of cleaning the table tops of the tables that the residents eat off of. DM-S states we use the sanitizer to wash the tables. Surveyor questions if any detergent us used to wash the tables first before sanitizing. DM-S states soap and water should be used first. It looks like we have some education to do. Example 2: The facility policy titled Handwashing/Hand Hygiene, dated (MONTH) (YEAR), states in part . This facility considers hand hygiene the primary means to prevent the spread of infection. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. Before and after direct resident contact f. Before and after eating or handling food g. Before and after assisting a resident with meals s. After handling soiled equipment or utensils 8. The use of gloves does not replace handwashing/hand hygiene. On 9/04/19 at 7:56 AM, Surveyor observed the residents during breakfast meal service in the facility dining rooms. On 9/04/19 at 8:48 AM, Surveyor observed ADON-E (Assistant Director of Nursing) stop feeding R8 and proceed to pick up R27's toast without gloves to spread jelly on the toast. After giving the toast to R27, ADON-E returned to assist R8 with her meal. On 9/04/19 at 9:03 AM, Surveyor interviewed ADON-E about picking up R27's toast to spread jelly without gloves on her hands. ADON-E stated she knew it was an infection control issue and she would remember to wear gloves next time. On 9/04/19 at 8:58 AM, Surveyor observed DM-F (Dietary Manager) walking in and out of the kitchen with gloves on her hands serving plates of food to residents in the dining room. Surveyor observed DM-F return to the kitchen, touch kitchen utensils and door knobs, plating food then serving the food to residents without changing her original pair of gloves or handwashing. On 9/04/19 at 09:39 AM, Surveyor interviewed DON-B (Director of Nursing) who stated that spreading jelly on toast without gloves is an infection control issue. DON-B stated that walking in and out of the kitchen while plating and serving food to residents without changing gloves or handwashing is an infection control issue. On 9/5/19, at daily exit conference, DON-B and NHA-A (Nursing Home Administrator) presented the paperwork for a facility educational meeting held on 9/4/19 at 10:00 AM on Dining Room Etiquette with 23 employee signatures including ADON-E and DM-F. The education included in part .Staff is not to touch resident food. Utilize gloves and/or utensils to put condiments on resident items. Hand Hygiene between residents is a must. On 9/10/19 at 8:18 AM, Surveyor observed DM-F walking in and out of the kitchen with gloves on her hands. Surveyor observed DM-F walking around the dining room talking and touching residents. Surveyor observed DM-F return to the kitchen, plate food and serve food to residents without changing her original pair of gloves or handwashing. On 9/10/19 at 8:25 AM, Surveyor noted NHA-A in the dining room. Surveyor brought the NHA-A's attention to DM-F's practice of not changing her gloves or handwashing. NHA-A observed and confirmed DM-F was wearing gloves entering and exiting kitchen, touching residents, and plating/serving food without handwashing or changing gloves. NHA-A stated it was a concern and there would be follow-up with DM-F. Surveyor was unable to interview DM-F. Surveyor noted the infection control issue with gloves and handwashing during meal service continued on 9/10/19 by DM-F after she had been provided Dining Room Etiquette education on 9/5/19.

Based on facility and hospital medical record review, family and staff interviews and review of facility policy, the facility did not always ensure that 1 (R1) out of 5 residents reviewed involved consultation with their physician when there was a need to alter treatment significantly. R1 did not have consultation with a physician related to abnormal lab results. R1 had diagnostic lab work completed on 1/17/17 at an outside physician office. This lab work was FAXED to the facility for follow up on 1/18/17. On 1/18/17, the facility FAXED this lab work to the attending physician. On 1/18/17 and 1/19/17, the attending physician was not consulted regarding the FAXED lab work. On 1/19/17, R1 was discharged to an Assisted Living facility as planned. On 1/20/17, R1 was admitted to the hospital from the Assisted Living. On 1/20/17, R1 was hospitalized and treated for [REDACTED]. Findings include: 1) R1 was admitted to the nursing facility on 11/21/16 following hospitalization for right hip pain. Resident has a known history of Acute [MEDICAL CONDITION] and [MEDICAL CONDITION] upon admission to the nursing home. R1 also has a known history of Urinary Tract infections. R1 received the following medications while residing at the nursing home that had effects on resident's kidney function: [MEDICATION NAME], 0.1 mg daily, [MEDICATION NAME], 10 mg tablet, daily, [MEDICATION NAME], 50 mg, three times a day, [MEDICATION NAME], 20 mg, twice daily, Potassium Chloride, 10meq, three times a day; R1 had a planned discharge from the facility to an Assisted Living facility, planned for 1/19/17. In preparation for this discharge, R1 saw her new physician, Physician-D, on 1/17/17 for a New Patient, establish care, visit. The facility did receive progress notes following this visit with Physician-D on 1/17/17 that indicated that R1 had been complaining of diarrhea that has been persistent for 3 weeks and states that it is mucousy. R1 does complain of increased fatigue and tiredness. Prior to the appointment, patient had diarrhea here where my medical assistants had to clean her and diarrhea was green in color. Vital signs on this 1/17/17 physician visit were: Blood pressure, 116/58, pulse 62, Temperature 97.2, Respirations 20, pulse oxygen 95%. Resident's general exam indicated resident to be alert, cooperative, conversive and fatigued. Resident was oriented X 4. It is noted in this 1/17/17 progress note that Physician-D did review previous lab work results, indicating knowledge of blood work, specifically, Creatinine of 1.44 on 12/6/16 and 1.01 on 11/20/16. A Creatinine test determines whether kidneys are functioning normally. Physician-D planned to get a stool test and a blood test and R1 would be informed of these results 1/18/17. The nursing home medical record indicated lab test results, dated 1/17/17, from Physician-D office were received on 1/18/17 and FAXED to Physician-E. This lab work of 1/17/17 revealed the following abnormal lab values that were important for kidney function review by a physician: Potassium of 6.2 mmol/L (normal range is 3.4-5.1) BUN (blood urea nitrogen) of 81 mg/dL (normal is 10-20) Creatinine of 2.99 (normal is 0.51-0.95) BUN/Creatinine ratio 27 (normal is 7-25) These lab tests were FAXED to the nursing home on 1/18/17. A nursing progress note written by Licensed Practical Nurse (LPN)-C on 1/18/17 at 9:07 am, indicated this lab work was FAXED to Physician-E for review. LPN-C did write that that FAXED to Physician-E, 1/18/17, then LPN-C wrote her initials on the paper copy of this lab work. All nursing home documentation following this note on 1/18/17 did not address any response from Physician-E regarding this lab work. On 4/3/17 at 3:52 PM, Surveyor spoke with LPN-C regarding this issue of the lab work being FAXED to Physician-E. LPN-C told the surveyor that there is normally a failuresheet produced by the FAX machine if a FAX does not go through. LPN-C indicated she did not recall receiving a failure response. LPN-C indicated that Physician-E usually responds back to lab work within hours after lab work is FAXED. LPN-C indicated that this situation was unusual because the nursing home usually doesn't get lab work FAXED to them from an outside physician office. LPN-C explained to the surveyor that when lab work is done in the nursing home, a yellow sheet is left in a folder that indicates what lab work had been done and is a reminder for nursing staff to check that results had come back and that the physician had addressed the lab work. In this case, there was no yellow sheet for nurses to check to make sure a physician addressed the lab work. On 4/3/17 at 1:45 PM, the surveyor spoke with Physician-E by telephone regarding this issue of not acknowledging abnormal lab work. Physician-E told the surveyor that he did not recall receiving this lab work and if the facility did FAX it to his office, he did not have a chance to review it. There is no evidence the facility consulted with the physician when there may have been a need to alter treatment significantly. The facility does have a written policy, titled Notification of Change in Resident Health Status, dated 10/12/16. This policy indicates the guideline statement was to ensure that proper notifications are made when a resident has a change in health status. This policy indicates that the term immediate, means as soon as possible, no longer than 24 hours. This policy indicates: .the center will consult the resident's physician, nurse practitioner or physician assistant, and if known, notify the resident's legal representative or an interested family member when there is: (C) A need to alter treatment significantly (i.e, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Criteria: A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences (e.g. an adverse drug reaction), or commence a new form of treatment to deal with a problem (e.g. abnormal laboratory results, the use of any medical procedure, or therapy that has not been used on that resident before.) Nursing documentation indicated that on 1/19/17 at 8:06 AM, resident was alert and oriented X 2 with forgetfulness and intermittent confusion noted. Resident requires limited assist with ADL's (activities of daily living) and transfers with assist of 1. Appetite generally poor to fair-much encouragement provided. Resident often incontinent and requests assistance with toileting prn (as needed). Skin is warm, pale, dry. Lung sounds diminished with infrequent cough noted. Abd (abdomen) soft with BS X 4 (bowel sounds). Call light with in reach. Family/friends involved. Resident discharging to (Assisted Living name) today. VS (vital signs) 99.0-20-80-146/78, 94% on RA (room air). Nursing documentation indicated that on 1/19/17 at 10:30 AM, R1 was discharged from the nursing home with family to transport. Resident in general condition stable upon discharge. On 3/29/17 at 3:00 PM, Surveyor spoke with the Director of Nursing (DON) about communication with the family of R1. The DON told the surveyor that she did speak with the niece of R1 the day after discharge and did know that R1 went to the hospital. The DON indicated she did look at R1's chart and did discuss the lab work with the family. The DON did provide documentation, dated, 1/24/17, from an internal soft file of this conversation. This documentation indicated that the DON received a call from the family and stated that the day after discharge from the facility, R1 had been admitted to the hospital after collapsing at the Assisted Living. Stated that she had been to see what would be her new MD upon discharge, Physician-D, and that his orders had not been followed. The DON reviewed the chart with the family over the phone. Discussed the labs from the visit with Physician-D and the labs that were done prior at the facility. The DON compared these labs with her and discussed the medications R1 had been taking. Informed the family that Physician-E had been made aware of the orders from Physician-Dand that he chose to disregard them. The DON wrote that upon conclusion of this discussion, she felt that the facility was not at fault for doing anything wrong and that it was a disagreement between the two physicians regarding R1's care. There is no evidence that the facility called Physician-E to see if and why he did not respond to the abnormal lab work FAXED to him on 1/18/17 and why there was no documentation in the medical record of nursing staff addressing the follow up to FAXED lab work prior to R1 discharging from the facility on 1/19/17. Surveyor reviewed the hospital record for R1 on 4/4/17. The hospital record indicated that R1 arrived in the emergency department by ambulance on 1/20/17 at 9:37 AM from her assisted living facility complaining of not feeling well. R1 was complaining of feeling drunk. The emergency department physician wrote that the clinical impression of R1 was acute Urinary Tract Infection, dehydration, [MEDICAL CONDITION] (high potassium), acute [MEDICAL CONDITION] and unspecified [MEDICAL CONDITION] type were also pertinent to this visit. Resident would be admitted to the ICU in fair condition. The emergency department lab work indicated that on 1/20/17 at 10:37 AM, resident sodium was 137 (normal), potassium 7.1 (normal is 3.4-5.1), elevated chloride of 109 (normal is 98-107), BUN of 97 (normal is 10-20) and Creatinine 4.38 (0.51-0.95). Vital signs on 1/20/17 at 10:46 a.m. in the emergency room department indicated Temp of 98, pulse 80, resp 14, Blood pressure of 128/96, pulse oxygen 99%. A nephrology consult was done on 1/20/17 while in the hospital that indicated resident having a [DIAGNOSES REDACTED]. Resident remained hospitalized in ICU, treated and was discharged at baseline back to the assisted living on 1/23/17.

Based on interview and record review, facility staff did not ensure 3 of 4 residents (#8, #3, and #4) who experienced a decline in bowel continence received necessary care and services to attain their highest practicable level of physical and psychosocial well-being. Staff did not investigate and assess for possible causes of the residents' decline in bowel continence nor did they assess and care plan for possible interventions to improve their bowel incontinence. Findings include: 1. Surveyor # reviewed Resident #8's medical record 3/18/14- 3/19/14. Resident #8's Annual MDS (Minimum Data Set) dated 11/4/13 indicates she was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement). Resident #8's Quarterly MDS dated [DATE] indicates she was now always incontinent of bowel (no continent episodes). Surveyor # reviewed Incontinence Tracking completed 11/4/13- 11/6/13 and a Bowel Assessment Form dated 11/7/13, indicating Resident #8 was currently incontinent of bowel, late stage [MEDICAL CONDITION] may affect Resident #8's bowel continence, and staff should provide scheduled incontinence care and comfort. The Incontinence Tracking indicates Resident #8 had only one bowel movement during that time- she was incontinent of bowel on 11/5/13 at 6:00 p.m., though some of the hourly checks were left blank. Surveyor # also reviewed Incontinence Tracking conducted when Resident #8 experienced a change of condition in November, 2012 (the last tracking conducted before November, 2013). That tracking (11/20/12- 11/22/12 and 11/27/12 - 11/29/12) showed Resident #8 was incontinent of bowel on 11/20/12 at 7:00 p.m., 11/21/12 at 4:00 p.m. and 6:00 p.m., 11/22/12 at 4:00 p.m., and 11/27/12 at 4:00 p.m. and 7:00 p.m. It is not unusual for a person's bowel habits to stay relatively constant, as Resident #8's tracking a year apart indicates she has bowel movements in late afternoon or early evening. Surveyor # did not observe any assessment or review of Resident #8's bowel continence after the Quarterly MDS revealed her bowel continence had declined from frequently incontinent to always incontinent. This is necessary to try to identify possible reversible causes of the increased incontinence (looking to see if staff were unable to toilet Resident #8 at appropriate times, if she had been ill, if her diet or medications changed, etc). Surveyor # interviewed MDS RN (Registered Nurse)-C on 3/19/14 at 12:00 p.m., asking if she or other staff assessed Resident #8's bowel decline after it was identified on the 2/3/14 Quarterly MDS. RN-C stated they had not further assessed Resident #8's bowel decline, and Resident #8 had dementia and was not able to tell staff when she needed to use the bathroom. Surveyor # asked if they conducted Incontinence Tracking after the decline in bowel continence was identified, to try to identify times Resident #8 was most likely to have a bowel movement, and assist Resident #8 to the toilet at those times. RN-C stated the last tracking they conducted was November 2013 with the annual MDS, before the decline was identified. RN-C provided Surveyor # with a CAA (Care Area Assessment) for Urinary Incontinence dated 11/6/13, stating: Resident is incontinent of bladder and bowel. She requires Sara lift for transfers. She is assisted with toileting Q (every) two hours and prn (as needed) during days and pm's. Check and change or assist with toileting needs Q (every) two hours and prn at night. On 3/18/14 at 11:00 a.m., Surveyor # observed Resident #8 resting in bed. At 11:05 a.m., CNA-I entered Resident #8's room to get her up for lunch. CNA-I lowered Resident #8's slacks while she was in bed, checked her brief which was wet, provided peri-care and changed Resident #8's brief before transferring her to her wheelchair. On 3/18/14 at 12:42 p.m., after lunch, Surveyor # observed CNA-I take Resident #8 to the toilet in the shower room next to Resident #8's room. Resident #8 was wet and also voided in the toilet. Pericare and fresh brief were provided by CNA-I before transferring Resident #8 to her wheelchair and them to bed for a nap. On 3/19/14 at 1:30 p.m., Surveyor # informed NHA (Nursing Home Administrator)-A of concerns regarding not further assessing Resident #8's decline in bowel continence. No further information was provided. Cross reference F279. 2. Surveyor # reviewed Resident #3's medical record on 3/13/14 to 3/19/14. The Alteration in elimination of bowel and bladder Functional incontinence of B&B (bowel and bladder) care plan initiated on 7/23/13 has interventions also dated 7/23/13 of "bowel medication as ordered. Monitor use and effectiveness" "Call bell within reach and reminders to use call bell as needed" "Check and change Q (every) 2 hours and prn (as needed)" "Discuss medications with physicians which may be contributing to incontinence" "Encourage exercise" "Encourage fluids" "Evaluate timing of medications which may cause increased urination" "Evaluate frequency/timing of incontinence episodes" "Labs as ordered" "Monitor and report changes in ability to toilet or continence status" "Monitor and report S&S (signs and symptoms) of UTI (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain" "Monitor bowel status frequency" "Praise and encourage to be as independent as able" and "Use of briefs/pads for incontinence protection." The significant change MDS (Minimum Data Set) with an assessment reference date of 9/23/13 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Resident #3 does not ambulates and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #3 is frequently incontinent of bowel. Surveyor # noted that the last completed bowel assessment was dated 10/10/13. The quarterly interdisciplinary resident review dated 12/16/13 under Section D Bladder Evaluation includes a question "Complete bowel and bladder assessment." Surveyor # noted that "No" is checked and also noted that "Yes" is grayed out indicating one cannot answer yes to this question. Surveyor # noted there was not a section for bowel on the quarterly interdisciplinary resident review form. The Resident continence by day report for the quarterly assessment reference period documents that Resident #3 was incontinent of bowel one time on 12/14/13, two times on 12/15/13, one time on 12/16/13, one time on 12/17/13, one time on 12/18/13, one time on 12/19/13, and one time on 12/20/13. This report did not show that Resident #3 was continent of bowel at any time during this period. The quarterly MDS with an assessment reference date of 12/20/13 has a BIMS score of 9 which indicates moderately impaired. Resident #3 does not ambulate and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #3 is always incontinent of bowel. The nurses note dated 3/5/14 documents, "Incontinent of B & B (bowel and bladder) wears adult briefs." The CNA (Certified Nursing Assistant) care cards updated 3/10/14 and provided to Surveyor # on 3/13/14 documents for Resident #3 "incontinent of bowel and bladder. Check and change q (every) 2 hrs (hours)." On 3/13/14 at 2:45 p.m. Surveyor # observed CNA (Certified Nursing Assistant)-F inform Resident #3 that she was going to go to the bathroom and wheel Resident #3 down the hall to the shower/bathroom outside room [ROOM NUMBER]. CNA-L placed a shower chair over the toilet, staff placed gloves on, and CNA-F asked Resident #3 if she was ready. CNA-F placed a sling around Resident #2, the sit to stand lift was placed in front of Resident #3, CNA-L hooked the sling to the lift and Resident #3's legs were strapped. Resident #3 was then lifted off the wheelchair and wheeled over to the toilet. Resident #3 pants were lowered, the incontinence product was unfastened, removed, and Resident #3 was lowered onto the shower chair over the toilet. Surveyor # observed that the incontinence product was wet with urine and had BM (bowel movement). CNA-F and CNA-L removed their gloves and washed their hands. On 3/18/14 at 8:43 a.m. Surveyor # asked LPN (Licensed Practical Nurse) Charge Nurse-H when bowel and bladder assessments are completed. LPN Charge Nurse-H informed Surveyor # upon admission, quarterly, annually, and if there is a change in continence status. Surveyor # asked LPN Charge Nurse-H how does she know when a patterning and assessment needs to be completed. LPN Charge Nurse-H informed Surveyor # that the nurse on the floor would start them for an admission and the MDS coordinator would know which assessment needs to be done and she will put them out for them. Surveyor # inquired where the bladder/bowel assessments would be located. LPN charge nurse-H replied under the assessment section in the chart. On 3/18/14 at 11:06 a.m. Surveyor # asked MDS/RN (Registered Nurse)-C if there are any bowel assessments that were completed in the last year that are in the thinned record. At 11:14 a.m. MDS/RN-C provided Surveyor # with a bowel assessment dated [DATE] and informed Surveyor # that this was the only one that she found. On 3/18/14 at 11:20 a.m. Surveyor # informed MDS/RN-C that Surveyor # was unable to locate a bowel assessment after Resident #3 had a decline in her bowel continence which was identified on the quarterly MDS with an assessment reference date of 12/20/13. Surveyor # informed MDS/RN-C that Resident #3 is identified as always being incontinent of bowel and the previous significant change MDS 9/23/13 identified that she was frequently incontinent of bowel. MDS/RN-C informed Surveyor # that they do not do bowel assessments for quarterly MDS. They complete bowel assessments with admission, annual and significant changes. MDS/RN-C informed Surveyor # that Resident #3 only changed from frequently to always incontinent and she would not have done an assessment and would do an assessment if there was more than one area that changed. Surveyor # informed MDS/RN-C that Surveyor # had spoken with LPN Charge Nurse-H who informed Surveyor # that bowel assessments are done quarterly. MDS/RN-C again informed Surveyor # that they do not do bowel assessments with the quarterly MDS and a bowel assessment was not done for Resident #3. On 3/18/14 at 3:33 p.m. during the daily exit conference Administrator-A and Director of Nursing-B were informed that a bowel assessment was not completed after Resident #3 declined in her bowel continence. On 3/19/14 at 10:38 a.m., MDS/RN-C informed Surveyor # that she wanted to clarify what she told Surveyor # yesterday. MDS/RN-C informed Surveyor # that she would do an assessment with the quarterly MDS if there was a change and it her practice to do an assessment quarterly, annually, upon admission, and change of condition. Surveyor # asked if a bowel assessment for Resident #3 was completed after a decline was identified on the December 2013 quarterly MDS. MDS/RN-C replied "no, I should have probably done one" and it is her practice to do them. 3. Surveyor # reviewed Resident #4's medical record on 3/13/14 to 3/17/14. Resident #4 was admitted to the facility on [DATE]. The Alteration in elimination of bowel and bladder Functional Incontinence of B&B (bowel & bladder) care plan r/t (related to) [MEDICAL CONDITION], dementia with cognitive deficits and the Hospice services for end of life care initiated on 3/5/13 has interventions also dated 3/5/13 of "Bowel medications as ordered. Monitor use and effectiveness" "Call bell within reach and reminders to use call bell as needed" "Check and change Q (every) 2 hours and prn (as needed)" "Discuss medications with physicians which may be contributing to incontinence" "Encourage exercise" "Encourage fluids" "Evaluate timing of medications which may cause increased urination" "Evaluate frequency/timing of incontinence episodes" "Labs as ordered" "Monitor and report change sin ability to toilet or continence status" "Monitor and report S&S (signs and symptoms) of UTI (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain" "Monitor bowel status frequency" "Praise and encourage to be as independent as able" "Provide assistance to toilet\use bedpan" "Rehab services per physicians order" and use of briefs/pads for incontinence protection." An intervention was added dated 4/3/13 of "Use bedpan at NOC (night)." The last bowel assessment is dated 3/28/13. The significant change MDS (minimum data set) with an assessment reference date of 3/29/13 documents that Resident #4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #4 does not ambulates and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #4 is frequently incontinent of bowel. The quarterly interdisciplinary resident review dated 12/16/13 under Section D Bladder Evaluation includes a question "Complete bowel and bladder assessment." Surveyor # noted that "No" is checked and also noted that "Yes" is grayed out indicating one can not answer yes to this question. There is not a separate section for bowel. The Resident continence by day report for the quarterly assessment reference period documents that Resident #4 was incontinent of bowel one time on 12/14/13, two times on 12/15/13, two times on 12/16/13, did not have a bowel movement on 12/17/13 and 12/18/13, one time on 12/19/13, and three times on 12/20/13. This report did not show that Resident #4 was continent of bowel at any time during this period. The quarterly MDS with an assessment reference date of 12/18/13 documents Resident #4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #4 does not ambulate and requires extensive assistance with one person physical assist for transfer and toileting. Resident #4 is always incontinent of bowel. The CNA (Certified Nursing Assistant) care cards updated 3/10/14 and provided to Surveyor # on 3/13/14 documents, "Incontinent of bowel and bladder, Toilet with the assist of 1 and w/c (wheelchair). Check and change q (every) 2 hrs. (hours). Use bed pan for toileting at night." On 3/13/14 at 1:28 p.m., Surveyor # observed CNA-I wheel Resident #4's Broda chair into her room. CNA-I removed the mat from the floor, placed gloves on, and informed Resident #4 "lets lay down now." CNA-I placed the Broda chair near Resident #4's bed, placed a gait belt around her, asked Resident #4 if she was ready, stood Resident #4 up and transferred Resident #4 onto the bed. CNA-I swung Resident #4's leg so she was laying in bed and told Resident #4 that she was going to check to see if she needed to be changed. CNA-I lowered Resident #4's pants, checked the incontinence product and stated "lets change you." CNA-I unfastened the incontinence product, washed Resident #4's frontal perineal area, positioned Resident #4 on her left side and washed her rectal area and buttocks. CNA-I then removed the incontinence product. Surveyor # observed the incontinence product was wet with urine but Resident #4 did not have a bowel movement. CNA-I then placed an incontinence product on Resident #4. On 3/17/14 at 7:38 a.m., Surveyor # observed morning cares for Resident #4 with CNA-F. At 7:53 a.m. after CNA-F had washed and dressed Resident #4's upper body, CNA-F removed her gloves, washed her hands and placed new gloves on. CNA-F informed Resident #4 that she was going to check her brief to see if it was dry. CNA-F unfastened the incontinence product and informed Resident #4 that she was going to wash her private parts. CNA-F washed Resident #4's inner thighs and frontal perineal area, positioned Resident #4 on her left side, removed the incontinence product, and washed Resident #4's buttocks. Surveyor # observed that the incontinence product that CNA-F removed was wet with urine. On 3/18/14 at 8:43 a.m., Surveyor # asked LPN (Licensed Practical Nurse) Charge Nurse-H when bowel and bladder assessments are completed. LPN Charge Nurse-H informed Surveyor # upon admission, quarterly, annually, and if there is a change in continence status. Surveyor # asked LPN Charge Nurse-H how does she know when a patterning and assessment needs to be completed. LPN Charge Nurse-H informed Surveyor # that the nurse on the floor would start them for an admission and the MDS coordinator would know which assessment needs to be done and she will put them out for them. Surveyor # inquired where the bladder/bowel assessments would be located. LPN charge nurse-H replied under the assessment section in the chart. On 3/18/14 at 11:06 a.m. Surveyor # asked MDS/RN (Registered Nurse)-C if there are any bowel assessments that were completed in the last year that are in the thinned record for Resident #4. At 11:14 a.m. MDS/RN-C informed Surveyor # that she did not find any. On 3/18/14 at 11:20 a.m., Surveyor # informed MDS/RN-C that Surveyor # was unable to locate a bowel assessment after Resident #4 had a decline in her bowel continence which was identified on the quarterly MDS with an assessment reference date of 12/18/13. Surveyor # informed MDS/RN-C that Resident #4 is identified as always being incontinent of bowel and the previous significant change MDS 3/29/13 identified that she was frequently incontinent of bowel. MDS/RN-C informed Surveyor # that they do not do bowel assessments for quarterly MDS. They complete bowel assessments with admission, annual and significant changes. MDS/RN-C informed Surveyor # that Resident #4 only changed from frequently to always incontinent and she would not have done an assessment and would do an assessment if there was more than one area that changed. Surveyor # informed MDS/RN-C that Surveyor # had spoken with LPN Charge Nurse-H who informed Surveyor # that bowel assessments are done quarterly. MDS/RN-C again informed Surveyor # that they do not do bowel assessments with the quarterly MDS and a bowel assessment was not done for Resident #4. On 3/18/14 at 3:33 p.m. during the daily exit conference Administrator-A and Director of Nursing-B were informed that a bladder assessment was not completed after Resident #4 declined in her bowel continence. On 3/19/14 at 10:38 a.m. MDS/RN-C informed Surveyor # that she wanted to clarify what she told Surveyor # yesterday. MDS/RN-C informed Surveyor # that she would do an assessment with the quarterly MDS if there was a change and it her practice to do an assessment quarterly, annually, upon admission, and change of condition. Surveyor # asked if a bowel assessment was completed after a decline was identified on the December 2013 quarterly MDS for Resident #4. MDS/RN-C replied, "no, I should have probably done one" and it is her practice to do them.

Based on observation, interview, and record review, the Facility did not provide appropriate care and treatment to promote bladder continence for 2 (Residents #3 & #4) of 3 Residents who had a decline in their bladder continence. Findings include: The incontinence management/bladder function guideline revised 2013 documents under purpose: "The purpose of a bladder management program is to: - Enable the resident to control urination without a catheter whenever possible - Avoid possibility of urinary infection - Prevent skin problems such as pressure areas and excoriation - Improve the morale of the resident - Restore the resident's dignity - Manage urinary incontinence, restore or maintain as much normal bladder function as possible." Under General Guidelines When Working To Retrain Bladder function documents: - "The resident will be assessed (evaluated) on admission and with MDS (Minimum Data Set) significant change - Bladder management program effectiveness will be reviewed with quarterly MDS." 1. Surveyor # reviewed Resident #3's medical record on 3/13/14 to 3/19/14. The Alteration in elimination of bowel and bladder Functional incontinence of B&B (bowel and bladder) care plan initiated on 7/23/13 has interventions also dated 7/23/13 of "bowel medication as ordered. Monitor use and effectiveness" "Call bell within reach and reminders to use call bell as needed" "Check and change Q (every) 2 hours and prn (as needed)" "Discuss medications with physicians which may be contributing to incontinence" "Encourage exercise" "Encourage fluids" "Evaluate timing of medications which may cause increased urination" "Evaluate frequency/timing of incontinence episodes" "Labs as ordered" "Monitor and report changes in ability to toilet or continence status" "Monitor and report S&S (signs and symptoms) of UTI (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain" "Monitor bowel status frequency" "Praise and encourage to be as independent as able" and "Use of briefs/pads for incontinence protection." The significant change MDS (Minimum Data Set) with an assessment reference date of 9/23/13 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Resident #3 does not ambulates and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #3 is frequently incontinent of bladder. The urinary incontinence and indwelling catheter CAA (care area assessment) dated 9/27/13 under the area that states describe impact of this problem/need on the resident and your rationale for care plan decision documents, "Resident scored a 15 on the bims. She is alert with periods of confusion. She has dx (diagnoses) of [MEDICAL CONDITION] disease and anxiety. She is diabetic with [MEDICAL CONDITION]. She is able to make needs known. Her mood and behaviors are stable. She requires limited to extensive assist with all adls (activities of daily living), bed mobility and positioning. She is receiving OT/PT/SP (occupational therapy/physical therapy/speech pathology) for strengthening, endurance, therapeutic activity and exercise. She is frequently incontinent of B & B (bowel and bladder). She is here for LTC (long term care). She is at risk for falls/injury and she has a floor mat and low bed. She has intact skin and preventative measures. Will proceed to care plan." Surveyor # noted that the last completed bladder assessment was dated 10/10/13. The quarterly interdisciplinary resident review dated 12/16/13 under Section D Bladder Evaluation includes a question, "Complete bowel and bladder assessment." Surveyor # noted that "No" is checked and also noted that "Yes" is grayed out indicating one cannot answer yes to this question. The Resident continence by day report for the quarterly assessment reference period documents that Resident #3 was incontinent of bladder three times on 12/14/13, three times on 12/15/13, three times on 12/16/13, three times on 12/17/13, three times on 12/18/13, three times on 12/19/13, and three times on 12/20/13. This report did not show that Resident #3 was continent of bladder at any time during this period. The quarterly MDS with an assessment reference date of 12/20/13 has a BIMS score of 9 which indicates moderately impaired. Resident #3 does not ambulate and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #3 is always incontinent of bladder. The nurses note dated 3/5/14 documents "Incontinent of B & B (bowel and bladder) wears adult briefs." The CNA (Certified Nursing Assistant) care cards updated 3/10/14 and provided to Surveyor # on 3/13/14 documents for Resident #3 "incontinent of bowel and bladder. Check and change q (every) 2 hrs (hours)." On 3/13/14 at 2:45 p.m., Surveyor # observed CNA (Certified Nursing Assistant)-F inform Resident #3 that she was going to go to the bathroom and wheel Resident #3 down the hall to the shower/bathroom outside room [ROOM NUMBER]. CNA-L placed a shower chair over the toilet, staff placed gloves on, and CNA-F asked Resident #3 if she was ready. CNA-F placed a sling around Resident #2, the sit to stand lift was placed in front of Resident #3, CNA-L hooked the sling to the lift and Resident #3's legs were strapped. Resident #3 was then lifted off the wheelchair and wheeled over to the toilet. Resident #3 pants were lowered, the incontinence product was unfastened, removed, and Resident #3 was lowered onto the shower chair over the toilet. Surveyor # observed that the incontinence product was wet with urine and had BM (bowel movement). CNA-F and CNA-L removed their gloves and washed their hands. On 3/18/14 at 8:43 a.m., Surveyor # asked LPN (Licensed Practical Nurse) Charge Nurse-H when bowel and bladder assessments are completed. LPN Charge Nurse-H informed Surveyor # upon admission, quarterly, annually, and if there is a change in continence status. Surveyor # asked LPN Charge Nurse-H how does she know when a patterning and assessment needs to be completed. LPN Charge Nurse-H informed Surveyor # that the nurse on the floor would start them for an admission and the MDS coordinator would know which assessment needs to be done and she will put them out for them. Surveyor # inquired where the bladder assessments would be located. LPN charge nurse-H replied under the assessment section in the chart. On 3/18/14 at 11:06 a.m., Surveyor # asked MDS/RN (Registered Nurse)-C if there are any bladder assessments that were completed in the last year that are in the thinned record for Resident #3. At 11:14 a.m. MDS/RN-C provided Surveyor # with a bladder assessment dated [DATE] and informed Surveyor # that this was the only one that she found. On 3/18/14 at 11:20 a.m., Surveyor # informed MDS/RN-C that Surveyor # was unable to locate a bladder assessment after Resident #3 had a decline in her bladder continence which was identified on the quarterly MDS with an assessment reference date of 12/20/13. Surveyor # informed MDS/RN-C that Resident #3 is identified as always being incontinent of bladder and the previous significant change MDS 9/23/13 identified that she was frequently incontinent of bladder. MDS/RN-C informed Surveyor # that they do not do bladder assessments for quarterly MDS. They complete bladder assessments with admission, annual and significant changes. MDS/RN-C informed Surveyor # that Resident #3 only changed from frequently to always incontinent and she would not have done an assessment and would do an assessment if there was more than one area that changed. Surveyor # informed MDS/RN-C that Surveyor # had spoken with LPN Charge Nurse-H who informed Surveyor # that bladder assessments are done quarterly. MDS/RN-C again informed Surveyor # that they do not do bladder assessments with the quarterly MDS and a bladder assessment was not done for Resident #3. On 3/18/14 at 3:33 p.m. during the daily exit conference Administrator-A and Director of Nursing-B were informed that a bladder assessment was not completed after Resident #3 declined in her bladder continence. On 3/19/14 at 10:38 a.m. MDS/RN-C informed Surveyor # that she wanted to clarify what she told Surveyor # yesterday. MDS/RN-C informed Surveyor # that she would do an assessment with the quarterly MDS if there was a change and it is her practice to do an assessment quarterly, annually, upon admission, and change of condition. Surveyor # asked if a bladder assessment was completed after a decline was identified on the December 2013 quarterly MDS. MDS/RN-C replied "no, I should have probably done one" and it is her practice to do them. 2. Surveyor # reviewed Resident #4's medical record on 3/13/14 to 3/17/14. Resident #4 was admitted to the facility on [DATE]. The Alteration in elimination of bowel and bladder Functional Incontinence of B&B (bowel & bladder) care plan r/t (related to) [MEDICAL CONDITION], dementia with cognitive deficits and the Hospice services for end of life care initiated on 3/5/13 has interventions also dated 3/5/13 of "Bowel medications as ordered. Monitor use and effectiveness" "Call bell within reach and reminders to use call bell as needed" "Check and change Q (every) 2 hours and prn (as needed)" "Discuss medications with physicians which may be contributing to incontinence" "Encourage exercise" "Encourage fluids" "Evaluate timing of medications which may cause increased urination" "Evaluate frequency/timing of incontinence episodes" "Labs as ordered" "Monitor and report changes in ability to toilet or continence status" "Monitor and report S&S (signs and symptoms) of UTI (urinary tract infection): changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain" "Monitor bowel status frequency" "Praise and encourage to be as independent as able" "Provide assistance to toilet\use bedpan" "Rehab services per physicians order" and use of briefs/pads for incontinence protection." An intervention was added dated 4/3/13 of "Use bedpan at NOC (night)." The last bladder assessment is dated 3/28/13. The significant change MDS (Minimum Data Set) with an assessment reference date of 3/29/13 documents that Resident #4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #4 does not ambulates and requires extensive assistance with two plus persons physical assist for transfer and toileting. Resident #4 is frequently incontinent of bladder. The urinary incontinence and indwelling catheter CAA (care area assessment) dated 4/1/13 under the area that states, describe impact of this problem/need on the resident and your rationale for care plan decision documents, "Resident is incontinent of B & B (bowel and bladder). She has severe cognitive deficits and is unable to make her toileting needs known at all times. She will at times ask to use bathroom but will be wet already. She does not always feel the urge to void/defecate. Resident wears brief for dignity. She is checked and changed Q (every) 2 hours and toileted per request. She is kept clean and dry. She has declining condition and is receiving hospice services for end of life care. Will proceed to careplan." The quarterly interdisciplinary resident review dated 12/16/13 under Section D Bladder Evaluation includes a question, "Complete bowel and bladder assessment." Surveyor # noted that "No" is checked and also noted that "Yes" is grayed out indicating one can not answer yes to this question. The Resident continence by day report for the quarterly assessment reference period documents that Resident #4 was incontinent of bladder three times on 12/14/13, three times on 12/15/13, three times on 12/16/13, three times on 12/17/13, two times on 12/18/13, three times on 12/19/13, and three times on 12/20/13. This report did not show that Resident #4 was continent of bladder at any time during this period. The quarterly MDS with an assessment reference date of 12/18/13 documents Resident #4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. Resident #4 does not ambulate and requires extensive assistance with one person physical assist for transfer and toileting. Resident #4 is always incontinent of bladder. The CNA (Certified Nursing Assistant) care cards updated 3/10/14 and provided to Surveyor # on 3/13/14 documents, "Incontinent of bowel and bladder, Toilet with the assist of 1 and w/c (wheelchair). Check and change q (every) 2 hrs. (hours). Use bed pan for toileting at night." On 3/13/14 at 1:28 p.m., Surveyor # observed CNA-I wheel Resident #4's Broda chair into her room. CNA-I removed the mat from the floor, placed gloves on, and informed Resident #4 "lets lay down now." CNA-I placed the Broda chair near Resident #4's bed, placed a gait belt around her, asked Resident #4 if she was ready, stood Resident #4 up and transferred Resident #4 onto the bed. CNA-I swung Resident #4's leg so she was laying in bed and told Resident #4 that she was going to check to see if she needed to be changed. CNA-I lowered Resident #4's pants, checked the incontinence product and stated "lets change you." CNA-I unfastened the incontinence product, washed Resident #4's frontal perineal area, positioned Resident #4 on her left side and washed her rectal area and buttocks. CNA-I then removed the incontinence product. Surveyor # observed the incontinence product was wet with urine but Resident #4 did not have a bowel movement. CNA-I then placed an incontinence product on Resident #4. On 3/17/14 at 7:38 a.m., Surveyor # observed morning cares for Resident #4 with CNA-F. At 7:53 a.m. after CNA-F had washed and dressed Resident #4's upper body, CNA-F removed her gloves, washed her hands and placed new gloves on. CNA-F informed Resident #4 that she was going to check her brief to see if it was dry. CNA-F unfastened the incontinence product and informed Resident #4 that she was going to wash her private parts. CNA-F washed Resident #4's inner thighs and frontal perineal area, positioned Resident #4 on her left side, removed the incontinence product, and washed Resident #4's buttocks. Surveyor # observed that the incontinence product that CNA-F removed was wet with urine. On 3/18/14 at 8:43 a.m., Surveyor # asked LPN (Licensed Practical Nurse) Charge Nurse-H when bowel and bladder assessments are completed. LPN Charge Nurse-H informed Surveyor # upon admission, quarterly, annually, and if there is a change in continence status. Surveyor # asked LPN Charge Nurse-H how does she know when a patterning and assessment needs to be completed. LPN Charge Nurse-H informed Surveyor # that the nurse on the floor would start them for an admission and the MDS coordinator would know which assessment needs to be done and she will put them out for them. Surveyor # inquired where the bladder assessments would be located. LPN charge nurse-H replied under the assessment section in the chart. On 3/18/14 at 11:06 a.m., Surveyor # asked MDS/RN (Registered Nurse)-C if there are any bladder assessments that were completed in the last year that are in the thinned record for Resident #4. At 11:14 a.m. MDS/RN-C informed Surveyor # that she did not find any. On 3/18/14 at 11:20 a.m., Surveyor # informed MDS/RN-C that Surveyor # was unable to locate a bladder assessment after Resident #4 had a decline in her bladder continence which was identified on the quarterly MDS with an assessment reference date of 12/18/13. Surveyor # informed MDS/RN-C that Resident #4 is identified as always being incontinent of bladder and the previous significant change MDS 3/29/13 identified that she was frequently incontinent of bladder. MDS/RN-C informed Surveyor # that they do not do bladder assessments for quarterly MDS. They complete bladder assessments with admission, annual and significant changes. MDS/RN-C informed Surveyor # that Resident #4 only changed from frequently to always incontinent and she would not have done an assessment and would do an assessment if there was more than one area that changed. Surveyor # informed MDS/RN-C that Surveyor # had spoken with LPN Charge Nurse-H who informed Surveyor # that bladder assessments are done quarterly. MDS/RN-C again informed Surveyor # that they do not do bladder assessments with the quarterly MDS and a bladder assessment was not done for Resident #4. On 3/18/14 at 3:33 p.m., during the daily exit conference Administrator-A and Director of Nursing-B were informed that a bladder assessment was not completed after Resident #4 declined in her bladder continence. On 3/19/14 at 10:38 a.m., MDS/RN-C informed Surveyor # that she wanted to clarify what she told Surveyor # yesterday. MDS/RN-C informed Surveyor # that she would do an assessment with the quarterly MDS if there was a change and it her practice to do an assessment quarterly, annually, upon admission, and change of condition. Surveyor # asked if a bladder assessment was completed after a decline was identified on the December 2013 quarterly MDS for Resident #4. MDS/RN-C replied "no, I should have probably done one" and it is her practice to do them.

Based on observation, record review, and staff interview the Facility did not ensure that 1 (Resident #5) of 7 Residents with urinary incontinence was assessed, careplanned for and provided with services to improve their incontinence status. Resident #5 was admitted to the Facility with a Foley catheter. Resident #5 was subsequently hospitalized and during hospitalization the Foley catheter was removed. The Facility did not monitor Resident #5's usual voiding patterns, did not complete a bladder assessment, did not identify the type of incontinence and did not explore reversible causes of the incontinence in order to assist Resident #5 with restoring, or maintaining as much bladder function as possible after she was readmitted . After Surveyor brought this to the attention of the Facility a voiding pattern was started for Resident #5. Findings include: 1. Surveyor # reviewed Resident #5's medical record on 5/2/12 & 5/3/12. Resident #5 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was admitted with a Foley catheter due to [MEDICAL CONDITION]. The admission MDS (minimum data set) with an assessment reference date of 3/1/12 documents that Resident #5 has a Foley catheter. The urinary incontinence and indwelling catheter CAA (care area assessment) dated 3/2/12 documents, "Resident has indwelling Foley catheter and is incontinent of bowel. She wears pad/brief for dignity and comfort. Offer toileting Q (every) 2 hours and prn (while awake). Check and change Q 2 hours prn." The bowel and bladder summary dated 3/8/12 documents, "Resident with a Foley catheter due to [MEDICAL CONDITION]. Catheter is medically necessary has had a catheter for over two years. Which is previous to admission to our facility. Resident was admitted with[DIAGNOSES REDACTED]. Culture done. [MEDICAL CONDITION] persists. Antibiotics restarted. Resident is toileted if she agrees otherwise check & changed q 2 hours. Resident wears depends for dignity. Staff will continue to check and toilet q 2 hours, and do catheter cares as per CNA (Certified Nursing Assistant) plan of care. The nurses note dated 4/12/12 documents Resident #5 was admitted to the hospital for altered mental status and UTI (urinary tract infection) The nurses note dated 4/14/12 documents, "Res. (Resident) returned from SLMC (St. Luke's Medical Center) at 1345 (1:45 p.m.) today via ambulance. Alert and verbal, very agitated and confused upon return, attempting to crawl out of bed, combative with staff. After getting up in w/c (wheelchair) and husband came to visit res. calmed down. Did have an extra large loose BM (bowel movement) after returning. Foley was Dc'd (discontinued) in the hospital and res. has been incontinent of urine, no bladder distention noted upon palpation." The clinical health status dated 4/14/12 under Section F urinary incontinence is checked for "frequently incontinent," "history of catheter use last 48 hours," and "liners/briefs used." The nurses note dated 4/15/12 documents, "Voiding without difficulty." The significant change MDS with an assessment reference date of 4/23/12 documents that Resident #5 is always incontinent of bladder. The urinary incontinence and indwelling catheter CAA dated 4/23/12 documents, "Resident has history of indwelling Foley catheter and is incontinent of bladder and bowel. She wears pad/brief for dignity and comfort. Offer toileting Q 2 hours and prn while awake. Check and change Q 2 hours and prn. Provide peri-anal care after each incontinent episode. Currently on ABT (antibiotic) for UTI (urinary tract infection). Goal is for skin to remain intact. Will proceed to care plan." The nurses note dated 4/30/12 documents, "Incontinent bowel and bladder. Transfers with Hoyer. Total assist." On 5/2/12 at 9:04 a.m., Surveyor # observed continence care for Resident #5 with CNA (Certified Nursing Assistant)-F and CNA-H. Surveyor # asked CNA-F if Resident #5's incontinence product that she removed was wet. CNA-F replied, "yes." On 5/2/12 at 12:47 p.m., Surveyor # informed LPN (Licensed Practical Nurse)-C that during Resident #5's record review Surveyor # was unable to locate a voiding pattern and bladder assessment after Resident #5 returned from the hospital without the Foley catheter and was identified as being incontinent. LPN-C informed Surveyor # that she didn't know if one was every done. LPN-C informed Surveyor # that she would look into this and get back to Surveyor # . On 5/2/12 at 1:03 p.m., LPN-C informed Surveyor # that a voiding pattern and bladder assessment was not completed and it would be started tomorrow at 6:00 a.m. On 5/2/12 at 2:07 p.m. during the daily exit conference Surveyor # informed the Administrator and Director of Nursing that a voiding pattern and bladder assessment was not completed after Resident #5 returned from the hospital without the Foley catheter and was identified as being incontinent of urine. On 5/3/12 at 10:15 a.m., Surveyor # met with the Director of Nursing and RN (Registered Nurse) Corporate Consultant-L regarding Resident #5. The Director of Nursing informed Surveyor # that they did miss the bladder assessment on Resident #5 and have changed their admission process to now included the bowel and bladder assessment along with incontinence tracking form. RN Corporate Consultant-L informed Surveyor # that they spoke with Resident #5's husband who informed them that Resident #5 was incontinent prior to the Foley catheter being placed in August 2011. RN Corporate Consultant-L informed Surveyor # that they did not feel that this was a decline in Resident #5's bladder status. Surveyor # informed the Director of Nursing and RN Corporate Consultant-L that there is no information in Resident #5's medical record regarding Resident #5's prior continence status, that the Facility did not reassess Resident #5 in order to improve her continence status after Resident #5 returned from the hospital and was identified as being incontinent. On 5/3/12, Surveyor # reviewed the bowel and bladder detail for Resident #5 from 4/14/12 through 4/30/12. This report shows whether a Resident is continent or incontinent and is completed once a shift by the CNA's (Certified Nursing Assistant). Surveyor # noted that Resident #5 was incontinent of urine during this time period except during the day shift on 4/21/12 and during the day shift on 4/25/12.