Every finding on record at Villa Maria Health and Rehab CTR

Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 56 residents (R) with transporting clean linens uncovered through the facility, and Certified Nursing Assistant (CNA ) C not doffing prior used PPE or santizing hands, and applying clean gloves brfore assisting 1 of 1 residents observed (R16).-Facility staff did not transport linens in a manner to prevent the spread of infection.-Facility staff did not doff gloves, sanitize hands, and apply new gloves between residents R37 and R16. Example 1 The facility's policy titled, Laundry and Linen read in part, Ensure clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering linen carts. On 02/24/26 at 7:00 AM, Surveyor observed Director of Laundry Services F transporting clean linens in the hallway, uncovered. On 02/24/2026 at 12:58 PM, Surveyor observed Director of Laundry Services F taking clean linens from a closed room near the nurse's station and transporting them down the hall, past the kitchen, uncovered. Director of Laundry Services F stated only dirty linens are covered, not clean linens. On 02/25/26 at 7:13 AM, Surveyor interviewed Laundry Aide D. Laundry Aide D stated that all linens clean or dirty should be covered when transporting them in the hallways. On 02/25/26 at 8:00 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported the expectations for transporting linens is that clean or dirty, they are covered. Example 2 The facility policy titled, Handwashing/Hand Hygiene, states hand hygiene is indicated after touching a resident, after touching the resident's environment, and immediately after glove removal. R37 was admitted on [DATE]. Progress notes, dated 02/22/26, confirmed R37 developed a hoarse voice and occasional non-productive cough. R37 was placed on droplet precautions and, after testing, was identified as having a common cold. On 02/24/2026 at 7:45 AM, Surveyor observed Certified Nursing Assistant (CNA) C sanitize hands, don gown, mask, gloves, and delivered breakfast tray to R37. Signage outside the door indicated droplet precautions that required hand hygiene, gloves, gown, and masks prior to entering the room. CNA C set the tray on the over bed table, pushed R37's wheelchair next to the bed and stood by R37 while R37 transferred from the bed to the wheelchair. CNA C went directly to roommate R16, set up R16's breakfast tray, combed their hair and applied their glasses. Surveyor noted that CNA C did not change PPE and perform hand hygiene between the two residents that were assisted. On 02/24/2026 at 7:59 AM, Surveyor asked CNA C, When you assisted [R37], did you have to physically assist her into her wheelchair? CNA C replied, No, but moved [R37's] wheelchair next to the bed for [R37] to self-transfer. Surveyor asked, Do you need to change PPE, gloves, and sanitize hands before assisting roommate? CNA C replied, I wasn't sure. Surveyor asked, Did you? CNA C stated, No, I didn't know I could do that in the room. I moved [R37's] wheelchair but did not touch her and then assisted [R16] with glasses and hair without changing gloves, PPE, and sanitizing hands. I guess I should have done that. On 02/24/2026 at 1:37 PM, Surveyor interviewed DON B and asked what the expectation would be for CNAs that provide care to a resident on droplet precautions then assist with roommate right afterwards. DON B informed Surveyor they would expect the CNAs to doff PPE, gloves, sanitize hands, and don new PPE prior to caring for roommate, and there should always be hand hygiene between resident contact and environment regardless of precautions.

Based on observation, interviews, and record review, the facility did not ensure pain management interventions were provided for 1 out of 1 resident (R) reviewed for pain management (R49).R49 did not have an individualized pain assessment completed to monitor, assess, and evaluate for efficacy for pain management.This is evidenced by:Facility policy titled, Pain Management Policy revised 6/20/2025, states in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive care plan, and the residents' goals and preferences. Pain Assessment: 1. The facility will use a pain assessment tool, which is appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain.The facility's Pain Management Policy references the U.S. Department of Health and Human Services (2019, May). Pain Management Best Practices Inter-Agency Task Force Report: Updates, Gaps, Inconsistencies, and Recommendations, which states in part, 2.2 Medications. As outlined in recent guidelines, including . Clinical Practice Guidelines for Opioid Therapy for Chronic Pain, the Center for Disease Control (CDC) guideline, and the American Society of Interventional Pain Physicians guidelines, risk assessment, close follow-up, and pain reevaluation are important aspects of the treatment plan prior to and throughout the duration of opioid therapy for pain management.R49 was admitted to the facility on [DATE] with pertinent diagnosis of rheumatoid arthritis, unspecified osteoarthritis, chronic kidney disease, peripheral vascular disease, abnormal posture, dysphagia, and age-related cognitive decline. R49 also has a current diagnosis of adult failure to thrive and pain in an unspecified joint.R49's most recent quarterly Minimum Data Set (MDS) assessment, dated 02/13/26, noted a Brief Interview for Mental Status (BIMS) score of 12/15, indicating moderate cognitive impairment and suggests the individual is experiencing noticeable, but not severe, difficulties with memory, orientation, and decision-making. R49's care plan, with problem start date of 12/14/19, last reviewed 2/20/26, with a target date of 05/20/26, states is part: [R49] has alteration in comfort: Pain related to impaired mobility decreased strength, diagnosis arthritis, manifested by complaints of pain, signs/symptoms (s/sx) discomfort (facial grimace, moaning, guarded movement, etc.). Goal target date of 5/20/26, states in the next 3 months comfort will be attained through use of medication or comfort measures AEB [as evidenced by], [R49] stating relief of pain or resting quietly, or voicing pain goal of mild pain is met.R49's physician orders include:Morphine solution; 10 mg/mL; amount: 0.2-1 ml; injection, special instructions: inject 2-10mg (0.2 - 1 ml) under the skin every hour as needed for pain/discomfort r/t comfort care status, every 2 hour - as needed (PRN) - start date 6/17/24, changed to every 1 hour as needed on 2/24/26. Fentanyl patch every 72 hours; 100 mcg/hour, amount: 1 patch; transdermalspecial instructions: fentanyl 100mcg patch- change Q 3 daysdx: osteoarthritis, every 3 Days, evenings 02:30 PM - 06:00 PM, 10/21/2025 Acetaminophen suppository; 650 mg; amt: 650mg; rectal every 4 hours as needed (PRN)Special instructions: For pain/fever (acetaminophen not to exceed 3 grams per 24 hours). Note: call provider for any new fever episode > 101.3 or for temperature > 2 degrees above resident's baselineSurveyor reviewed R49's medication administration record (MAR) and noted that administration of pain medications did not include pain assessment prior to administration any of the 14 times morphine was given in December 2025. Pain location and pain scale done prior to giving was documented four of the ten times morphine was given in January 2026. Pain scale, not location, was documented 1 of the 6 times morphine was given to R49 so far in February 2026. The pain assessment after administration was documented as effective. Surveyor was unable to locate documentation of pain assessments, monitoring for changes in R49's chronic pain, including identifying and monitoring characteristics of pain, underlying cause of pain, effective pain tool to use, or acceptable level of pain that R49 considers mild. On 2/24/26 at 7:03 AM, Surveyor spoke with Certified Nurse Assistant (CNA) H, who reported R49 does not get out of bed usually and is not up longer than 10 minutes due to pain in her bottom. R49 rarely leaves R49's room. On 2/24/26 at 9:10 AM, Surveyor observed R49 in bed. R49 stated R49 has pain in butt and reported to Surveyor the pain was 10 out of 10 on pain scale. R49 stated if the staff put oil on it, it helps. R49 was crying, stating, It hurts. Surveyor noted that R49 had a soft touch call light paddle by her right elbow. Surveyor encouraged R49 to press her call light. R49 attempted to move her hands toward the call paddle, unsuccessfully, then tried to use her elbow to press call light and again was unsuccessful in turning on her call light. On 2/24/26 at 9:15 AM, CNA H came in and offered to reposition. R49 did not respond to offer and asked for oil to be put on her butt and stated R49 is in pain. CNA did not reposition and went to get nurse.On 2/24/2026 at 9:16 AM, Surveyor interviewed CNA H and asked how does R49 let them know if she is having pain. CNA H stated R49 would tell them by yelling out or putting on her call light. Surveyor asked CNA H how does R49 use her call light. CNA H stated R49 is usually able to hit it. Surveyor reported to CNA H that R49 was not able to turn on call light after several attempts. On 2/24/2026 at 9:18 AM, Registered Nurse (RN) G asked R49 to rate pain. R49 responded it hurts and asked for oil. RN G offered pain medication. Neither RN G nor CNA H repositioned or provided other comfort measures to R49 before leaving R49's room.On 2/24/2026 at 9:24 AM, R49 asked Surveyor to reposition her onto her stomach. Surveyor encouraged R49 to put call light on. R49 attempted to press it with her right elbow and was not able to. Surveyor located staff who came into R49's room and repositioned R49 on to her left side.On 2/24/2026 at 9:57 AM, Surveyor interviewed RN G and asked how does R49 let staff know R49 has pain. RN G stated R49 can put on the call light or tell the CNAs. Surveyor asked RN G if R49 is able to press call light. RN G stated R49 usually does with her elbow. Surveyor informed RN G of the observation made by Surveyor which indicated R49 was not able to do so. Surveyor asked RN G if they try non-pharmacological interventions prior to giving medications. RN G reported they will sometimes try to reposition or redirect R49. On 2/24/2026 at 10:10 AM, Director of Nursing (DON) B went into R49's room and asked R49 to rate pain and asked if R49 wanted to get out of bed to take a shower. R49 said pain is 10/10. DON B asked R49 if she wanted DON B to call the doctor to get more pain medication. DON B did not ask R49 where pain was located. On 2/24/2026 at 10:24 AM, Surveyor interviewed DON B asking if she assessed where R49's pain is. DON B stated DON B didn't know. Surveyor asked DON B if R49 was asked where R49's pain was located, and DON B stated, I don't know.On 2/24/2026 at 11:36 AM, Surveyor interviewed RN G about R49's pain monitoring. RN G stated every 2-hour pain monitoring had just been implemented for R49. Surveyor asked RN G if scheduled pain monitoring was in place before today, and RN stated it was not. On 2/25/26 at10:46 AM, Surveyor interviewed DON B. Surveyor asked what pain assessment tool is used to monitor R49's pain. DON B stated the assessment they use is the quarterly pain assessment in the MDS and the facility staff knows R49 well, that is why they don't track or document R49's pain assessments well. Surveyor asked DON B how the nurses know how much PRN morphine to give R49 if they don't assess and track pain regularly. DON B stated it is based on nursing judgement. R49 has been on pain meds for a long period of time, and the nurses look to see what she had been given previously. DON B stated the facility could probably improve their charting and frequency of the pain assessments.

Based on interview and record review, the facility failed to protect a resident's right to be free from abuse. The facility did not protect residents from abuse by a visitor or protect the resident immediately after the abuse occurred. This affected 1 of 4 residents (R1) reviewed for abuse. On 02/27/25, Certified Nursing Assistant (CNA) C witnessed R1 and Visitor G engaging in sexual conduct in R1's bathroom. CNA C left R1's room to report the incident. R1 was left alone with Visitor G for approximately 30 seconds. This left R1 at risk for further abuse from Visitor G. The facility's failure to protect vulnerable residents from sexual abuse created a finding of immediate jeopardy that began on 02/27/25. Surveyor notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of the immediate jeopardy on 03/17/25 at 2:55 PM. The immediate jeopardy was removed and corrected on 02/28/25. Based on this determination, this citation is being cited as past noncompliance. Findings include: The facility's policy titled, Resident Abuse, reads in part . Villa [NAME] Health and Rehab will not tolerate mistreatment, abuse, neglect, or exploitation, of its residents . 2. Sexual abuse is non-consensual sexual contact of any type with a resident. Requires all staff to report any suspicion of abuse .immediately to the Administrator, Director of Nursing, and SW to determine the direction of the investigation. A. First and foremost, the facility will ensure that the Resident receives appropriate immediate medical attention, if necessary, and is also protected from any further harm or potential for harm. The facility's policy titled, Sexuality, Intimacy, and Resident Capacity to Consent, reads in part . Sexual abuse is non-consensual sexual contact of any type with a resident. Sexual abuse includes but is not limited to: -Unwanted intimate touching of any kind especially of breast or perineal area; -All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; -Forced observation of masturbation and/or pornography . -This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual content is nonconsensual if the resident either: -Appears to want the contact to occur, but lacks the cognitive ability to consent; -Does not want the contact to occur. Capacity to Consent: at its most basic level means that a resident has the ability to understand potential consequences and choose a course of action for a given situation. Capacity -All residents are assumed to have capacity until, by process and assessment, they are found to lack capacity. General Procedure . -Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident. For example, the resident may not have the capacity to make decisions regarding medical treatment, but may have the capacity to make decisions on daily activities. R1 is a male resident admitted on [DATE]. Diagnoses include traumatic brain injury, expressive aphasia, and hemiplegia of non-dominant hand following a stroke. R1 has never been married and does not have children. R1 is able to answer questions with one word answers, yes/no, or by using hand gestures. R1's Minimum Data Set (MDS) assessment, completed on 01/03/25, indicated the following: -BIMS=4, indicating severe cognitive impairment -No Behaviors, same as previous MDS -PHQ9, depression screen=0 -Able to propel self in w/c using left arm, able to move about room and facility independently. -Requires mechanical lift for transfers. -Activated Power of Attorney (POA) on 06/25/18. Primary is POA H and secondary POA is Visitor G. POA H and Visitor G are husband and wife. Of note, R1 did not have a sexual intimacy assessment on admission or prior to incident on 2/27/25. R1's history explained R1 and Visitor G have been friends since 1st grade and served in the Army together. Facility sign-in log indicated Visitor G visited R1 primarily on weekends, and Visitor G had visited approximately four times since January. Staff reported no previous concerns during Visitor G's visits to the facility. On 02/27/25 at 11:45 AM, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Agency reporting the following: On 02/27/25 at approximately 10:15 AM, CNA C was walking past R1's door and noticed the bathroom door was open and R1 was in his wheelchair (w/c) in the doorway of the bathroom, the wheels of his w/c were partially exposed, and extending past the open bathroom door. CNA C went into R1's room to see if he needed assistance. CNA C observed R1 and Visitor G in R1's bathroom. Visitor G was standing, his pants and underwear were pulled down around his knees, exposing his erect penis, hands/arms were at his sides, and he was not touching R1. R1 was touching Visitor G's penis with his left hand. When R1 and Visitor G became aware CNA C was observing this, R1 removed his hand and Visitor G pulled his pants up. R1 began backing out of the bathroom, into his room. CNA C left R1's room to report the incident. CNA C reported this to Social Services Director (SSD) D, who was at the nurse's station. SSD D and CNA C returned to R1's room approximately 30 seconds after the incident was witnessed. Visitor G was sitting on R1's bed fully clothed and R1 was sitting in his w/c next to the bed. R1 did not appear agitated, frightened, or upset. CNA C and SSD D reported the incident to Director of Nursing (DON) B. Housekeeping staff was present in the hallway and reported not hearing anything abnormal coming from R1's room. On 02/27/25, the facility conducted an interview with R1 directly after the incident. R1 reported Visitor G was his friend. The following questions were asked: -Were you forced to do anything against your will? R1, No. -Do you have a sexual relationship with Visitor G? R1, No. -Do you like Visitor G being here? R1, Yes. -Do you feel safe here? R1, Yes. -Did Visitor G force you to touch his penis? R1, No. R1's care plan was updated on 02/27/25, to include: Sexual Abuse Incident. Interventions: 30-minute checks as needed. Assess for injury, treatments as indicated/ordered. Continue to observe and report any changes. Visitor G is not allowed at the facility or to have contact with the resident. If Visitor G is on facility grounds, assure resident safety, call 911, and refer to printed picture for identification (ID) if needed. SSD D evaluated R1 for capacity to consent on 2/27/25 and determined R1 was unable to consent. The facility completed the following monitoring of R1: -Primary provider visited R1 on 02/28/25, no psychological or emotional concerns noted. -Monitor of meal and fluid intake. Monitor weight. (Note, R1 had both an insignificant weight loss and gain related to fluid accumulation, however not related to meal intake.) -Increased 1:1 activity in room from 3 days/week to 6 or 7 days/week. -Behavior monitoring every shift. Change in daily routine, change in mood, weepiness, withdrawn. -Sleeping patterns. -SSD D visiting with R1 weekly and completing depression screening PHQ9 weekly. Depression screening scores have remained at 0. -Telehealth for counseling, weekly. -03/03/25, care conference with corporate guardian. On 03/06/25, the facility submitted a Misconduct Incident Report, stating the results of the investigation. The facility was unable to establish a prior sexual relationship between R1 and Visitor G. R1 did not show any evidence of physical or psychosocial harm. R1's review of behaviors, meals, sleeping patterns, and activities attendance remained normal. The facility confirmed the sexual conduct between R1 and Visitor G did occur and R1 did not have the capacity to consent. The facility's investigation identified CNA C did witness the incident and left R1's room to report the incident, leaving R1 and Visitor G alone in R1's room. On 03/17/25 at 10:00 AM, Surveyor interviewed R1 in his room. R1 was neat and clean and indicated no distress. Surveyor asked R1 if staff were taking good care of him. R1 laughed and stated, yes. R1 used his left hand to open dresser drawer and remove a hat and a photo album. R1 showed Surveyor pictures from album, and he seemed to enjoy this. R1 pointed at a picture of a young, tall, thin man. R1 laughed and pointed at himself and said, Me. R1 was not able to tell Surveyor when the picture was taken or how old he was in the picture. R1 stated he was not going to go to any of the facility activities on this date. R1 reported he feels safe at the facility. R1 reported knowing Visitor G. R1 stated no, when Surveyor asked R1 if he missed visiting with Visitor G. When asked if he remembered the incident when Visitor G visited, he said no and went back to showing Surveyor pictures in the book. R1 gave no indications of fear, distress, or anxiety during the interview. On 03/17/25, Surveyor interviewed R2, R3, and R4. There were no concerns prompted from the interviews. On 03/17/25, Surveyor interviewed housekeeping staff, Licensed Practical Nurse (LPN) E, CNA F, DON B, SSD D, Assistant Director of Nursing (ADON) I. Interviews confirmed no changes in R1's daily routine, no physical or psychological changes, and no changes in activity attendance. Staff verified reeducation related to abuse, and were able to identify Visitor G is not to visit facility, and printed pictures of Visitor G were available to staff. On 03/17/25, Surveyor was unable to secure a law enforcement report of the incident, as the report could not be released related to law enforcement's pending case and investigation of the incident. The facility's failure to protect vulnerable residents from abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 02/28/25 when staff were educated on the need to immediately protect residents from suspected abuse. The immediate jeopardy was corrected on 02/28/25 after the facility completed the following: -All staff education on abuse and ensuring residents are protected from further abuse. -Staff and resident interviews. -Law Enforcement was contacted and presented to the facility. Law enforcement ensured Visitor G was removed from the facility. -Ombudsman was present in the facility at the time of the incident. -Emergency guardianship was requested on 2/27/25 and granted on 2/28/25. -Immediate education to all staff on Abuse, Capacity to Consent, and Visitor Restriction occurred on 2/27/25 and 02/28/25. Pictures of Visitor G were placed in shift report books, for staff identification of Visitor G. -Facility staff interviewed 47 residents on 2/27/25, with no concerns prompted from the interviews. -Facility staff interviewed 89 staff on 02/27/25, with no concerns prompted from the interviews. -Incident reviewed at ad hoc Quality Assurance and Performance Improvement (QAPI) on 2/27/25, The facility will conduct monthly QAPI and review monitoring of R1, changes, and interventions. R1's care plan will be updated based on monthly QAPI reviews Based on this determination, the citation F600 is issued as past noncompliance.

Based on observation, interview and record review, the facility failed to identify and eliminate all known and foreseeable accident hazards in the resident's environment. This had the potential to affect 1 of 3 residents (R), R26, reviewed for accidents. Findings: The facility policy titled, Waste Disposal, revised March 2024 stated in part: 1 c. Immediately after use, sharps shall be disposed of in closable, puncture resistant, disposable containers that are leak-proof on the sides and bottom and are labeled or color-coded. R26 was admitted to the facility on [DATE] with a brief interview of mental status (BIMS) score of 3 out of 15 which indicated severe cognitive impairment. R26 had diagnoses that included dementia and sleep disorder. On 12/09/24 at 10:17 AM, Surveyor observed R26 had a lab draw needle left on bed with a dry gauze pad next to her in the bed. This sharp needle has the potential to cause an injury or accident for R26. On 12/09/24 at 10:24 AM, Surveyor asked Certified Nursing Assistant (CNA) C about this needle. CNA C replied, I don't know if she was supposed to have lab work, but I will get the nurse for you. On 12/09/24 at 10:26 AM, Registered Nurse (RN) D entered the room. Surveyor asked about the needle lying on the bed. RN D replied, I don't know if [R26] had a lab. I know that I didn't draw her blood, but I will remove it. Surveyor asked RN D to find out who drew the lab. On 12/09/24 at 10:29 AM, RN D returned to inform Surveyor that Assistant Director of Nursing (ADON) E was here and drew blood I think about an hour ago. Surveyor asked RN D to find out what time the blood draw occurred. RN D replied, I will, sure. On 12/09/24 at 10:31 AM, RN D returned and informed Surveyor that at 9:40 AM the lab was drawn. On 12/10/24 at 10:35 AM, Surveyor asked ADON E about the needle found in the bed next to R26. ADON replied, I cannot believe that I did that because I am very meticulous about those things. Surveyor asked ADON E to simulate a lab draw on a resident: I would verify the order. 1) Hand hygiene 2) Explain procedure to resident and verify it is ok to do. 3) Put on gloves 4) Set up needle in needle protector device. 5) Pull tape onto left gloved hand. 6) Bevel up, venipuncture 7) Remove blood tube from needle protector device. 8) Recap with protector device. 9) Dispose of needle 10) Remove gloves and perform hand hygiene. On 12/10/24 at 11:36 AM, Surveyor asked ADON E, Was that the needle you used to draw the resident's blood that morning, the one lying next to her? ADON replied, Yes. On 12/10/24 at 12:37 PM, Surveyor asked Director of Nursing (DON) B, What should [ADON E] have done with the needle after the blood draw to keep [R26] safe? DON B replied that ADON E should have disposed of the needle.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff did not perform or offer resident hand hygiene prior to meal service for 7 of 7 residents (R) R1, R2, R10, R13, R15, R30, and R56 who eat independently in their room. Staff did not perform sanitizing of durable medical equipment to prevent the spread of infection when warranted between resident transfers potentially affecting all 5 residents (R) R9, R10, R13, R15 and R30 who require a mechanical lift for transfers on the 300 wing. Example 1 Surveyor requested policy on resident hand prior to meal and received the policy dated March 2022, entitled Assistance with Meals, which did not include resident hand hygiene. On 11/06/23 at 12:57 PM, Surveyor observed staff deliver meal trays to residents R1, R2, R10, R13, R15, R30, and R56 who eat in in their room. No observation of offering or providing resident hand hygiene was observed. On 11/07/23 at 7:43 AM, Surveyor observed staff deliver breakfast trays to residents who eat in their room. No observation of offering or providing resident hand hygiene was observed. On 11/07/23 at 7:48 AM, Surveyor interviewed R56, who stated they were not offered hand hygiene prior to eating. On 11/07/23 at 7:51 AM, Surveyor interviewed R2, who stated they were not offered hand hygiene prior to eating. On 11/07/23 at 8:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D, who indicated hand hygiene was not offered to any residents who eat independently prior to receiving meal tray on 11/06/23 and 11/07/23. On 11/08/23 at 9:26 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectation regarding resident hand hygiene prior to meal. DON B stated expectation would be to offer hand hygiene to resident prior to eating. Example 2 Surveyor requested policy on sanitizing of mechanical lifts and received the undated facility policy entitled, Lifting, Machine, using a Mechanical lift, which states .Lift Care: disinfect lift surfaces. On 11/07/23 at 6:52 AM, Surveyor observed (CNA) E remove mechanical lift from a locked room labeled Soiled Utility and with assistance of CNA D, transferred R19 with the mechanical lift and returned the mechanical lift back to soiled utility room. Surveyor observed no disinfection of the mechanical lift, which had a bag hanging from the lift containing disinfecting wipes. On 11/08/23 at 6:50 AM, Surveyor observed CNA D remove mechanical lift from R10's room and returned the lift to the soiled utility room. Surveyor observed no disinfection of the mechanical lift, which had a bag hanging from the lift containing disinfecting wipes. On 11/08/23 at 11:03 AM, Surveyor observed CNA D remove the mechanical lift out of the soiled utility room and bring the mechanical lift to R9's room. CNA D transferred R9 from bed to wheelchair. Surveyor observed no disinfection of the mechanical lift, which had a bag hanging from the lift containing disinfecting wipes. On 11/08/23 at 11:05 AM, Surveyor observed the soiled utility room noting bins of soiled linens, containers carrying soiled resident clothing, a shower chair and wash basins. All of these soiled items are in close contact with the mechanical lift. On 11/08/23 at 11:16 AM, Surveyor interviewed CNA E, regarding sanitizing of mechanical lifts. CNA E stated she was taught to sanitize lift after use. On 11/08/23 at 11:29 AM, Surveyor interviewed DON B regarding sanitizing of mechanical lifts and storing of mechanical lifts in soiled utility room. DON B stated that staff never store mechanical lifts in soiled utility room and would expect that the soiled utility room is not used for storage of mechanical lifts. DON B stated the expectation would be to sanitize the lift prior to transferring a resident after removing the mechanical lift from the soiled utility room. DON B confirmed there are a total of 5 residents, R9, R10, R13, R15 and R30 on the 300 wing who use the mechanical lift. On 11/08/23 at 11:43 AM, Surveyor interviewed CNA D and CNA E who confirmed that it is not usual practice to store mechanical lifts in soiled utility room and confirmed that neither had completed any sanitization of mechanical lifts during observations.

Based on observation, interview and record review, the facility did not provide the necessary services in accordance with current standards of practice for 1 of 1 residents (R13) with urinary catheter in attempts to prevent urinary tract infection. R13's catheter bag was observed lying directly on a floor mat below his bed. The catheter was not covered. The resident room floor mat is presumed dirty. This practice has the potential to cause infection. This is evidenced by: Surveyor reviewed facility policy entitled Catheter Care, Urinary, revised August 2022, which states, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Under the policy section, General Guidelines the policy states .be sure the catheter tubing and drainage bag are kept off the floor if able. R13 was admitted to facility on 04/23/19 and has diagnoses that includes Benign Prostatic Hyperplasia (BPH) (age-associate prostate gland enlargement that can cause urination difficulty) and urinary retention. R13's most recent annual Minimum Data Set (MDS) dated [DATE] notes R13 had an indwelling catheter and is dependent on toileting. R13's care plan indicates: Problem: CATHETER: Impaired elimination: urinary as evidenced by need for a catheter: due to BPH with dx urinary retention, with potential for Urinary Tract Infection (UTI) due to same. Manifested by potential for s/s of UTI: fever, chills, cloudy malodorous urine, abdominal pain or distention, hematuria, change in mental status, malaise. Created on 12/11/2019. Approach: Attach drainage bag to the bedframe when in bed. Do not lay on the floor. Problem: Potential for recurrent Methicillin-resistant Staphylococcus aureus (MRSA) UTI related to history of MRSA urinary tract infection. Manifested by MRSA positive urine culture and sensitivity, cloudy urine, malodorous urine, fever, mental status change, blood in urine, concentrated urine. Created 12/11/2019 and revised on 08/23/23. Approach: Assure appropriate infection control/isolation procedures are initiated and followed. On 11/06/23 at 12:43 PM, Surveyor observed R13's catheter bag lying on floor mat on the left side of the bed. No protective covering was between the catheter bag and the dirty floor mat. On 11/07/23 at 7:04 AM, Surveyor observed R13's catheter bag lying on floor mat on the left side of the bed. No protective covering was between the catheter bag and the dirty floor mat. On 11/08/23 at 9:07 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E about catheter drainage bag care and placement. CNA E stated that R13's catheter bag should be in a protective covering either when in bed or chair. CNA E confirmed awareness of no protective covering on the urinary bag as the catheter bag lay on the floor mat. On 11/08/23 at 9:26 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectation regarding placement of a catheter drainage bag. DON B stated expectation would be to have the drainage bag in a protective covering not touching the floor and secured to the bed or wheelchair as R13 is at risk for UTI.

Based on record review and interview, the facility did not conduct testing of facility staff that is consistent with current standards of practice for conducting COVID-19 testing. This had the potential to affect all 59 residents. Facility failed to test symptomatic staff or document testing results for the COVID-19 virus for 16 of 19 staff members on the line list that were reviewed. This is evidenced by the following: On 10/26/22, Surveyor reviewed the facility employee vaccine matrix. The facility had a total of 84 employees including the contracted therapy staff, with 66 of those employees vaccinated and 18 with exemptions for a total of 78.6% vaccinated. The community transmission rate was Substantial. The community transmission rate was high and has been at a high rate from 5/9/22 until 8/29/22. It was at a Substantial rate from 9/5/22-9/26/22 and High again from 10/3/22-10/10/22. On 10/26/22, Surveyor reviewed the line list for employees who call into the facility with signs and symptoms of COVID-19. The line list consisted of 19 entries. The entries dated from 5/6/22 until 10/11/22 The date of onset of symptoms is listed. The symptoms were noted to be headache, vomiting, fever, body aches, nasal congestion, cough, with 3 listed as having other symptoms of which are not made evident. On 10/26/22, Surveyor reviewed the facility policy titled COVID Prevention and Response. Under the subtitle of Policy Explanation and Compliance Guidelines. There the policy lists the S/S of COVID-19. These are listed as fever, chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea, vomiting and diarrhea. The policy also states that Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-Co V-2 as soon as possible. On 10/26/22, Surveyor reviewed a policy titled COVID-19/ Testing/Villa [NAME]. Under subtitle Policy Explanation and Compliance Guidelines it states, Anyone with even mild symptoms of COVID-19 regardless of vaccination status, should receive a viral test as soon as possible. Under the subtitle Testing of Staff and Residents with COVID 19 Symptoms and Signs it states, Staff with signs and symptoms of COVID-19, regardless of vaccination status, will be tested as soon as possible and are expected to be restricted from the facility pending the results of COVID-19 testing. On 10/26/22, Surveyor reviewed the CMS (Centers for Medicare and Medicaid Services) Memo QS0-20-38. The memo states the following: Facilities must demonstrate compliance with the testing requirements. To do so, facilities should do the following: For symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results. On 10/26/22 at approximately 12:30PM, Surveyor interviewed Director of Nursing (DON) B who is also the facility's IP (Infection Preventionist). Surveyor spoke to DON B regarding testing of staff who were on the staff line list for surveillance but did not have testing dates or results listed. DON B stated that they don't keep track of negative test results. When asked how they would know if staff had tested prior to starting a work shift if it is not documented, DON B stated they did not have an answer for that. Surveyor pointed out the staff on the line list who had reported symptoms consistent with COVID 19 to DON B and inquired as to why they were not tested . DON B indicated that they did not test those with just a headache. DON B stated they are not documenting negative results for employees even though they are tested . The facility was not testing or documenting those who had signs and symptoms of COVID 19 thus putting residents and staff at risk for contracting the virus.

Based on observation, interview and record review the facility did not ensure safe and sanitary infection control practices for dining, TBP (transmission based precautions), personal cares, and catheter care. These issues affecting or having the potential to affect 15 sampled and supplemental residents (R19, R5, R11, R36, R61, R43, R56, R165, R58, R17, R57, R26, R38, and R48) out of 65 residents who reside in the facility. 9 residents who eat in smaller dining room were not offered the opportunity to wash their hands prior to meals. A smaller dining room are not given the opportunity to wash their hands before eating thereby potentially eating with soiled hands. There are 9 of 65 total residents that routinely eat in this dining area, R19, (Resident), R5, R33, R11, R36, R61, R43, R56, and R165. Staff assisting R58 and R17 with perineal care did not wash or sanitize their hands after doing so and then touched presumed clean areas on the residents' person, on resident supplies, and in the residents' environment. R57, R26, R38, and R48 have urinary catheters. On multiple occasions, the drainage bags were observed lying on the floor without a protective barrier. The facility placed R165 on droplet precautions for respiratory illness. Housekeeper-I did not follow appropriate protocols for doffing contaminated gown and gloves and did not follow hand hygiene protocols. This is evidenced by: Example 1: ~On 12/10/19 at 07:20 a.m. the surveyor observed breakfast service in the small dining room. R56 was observed to be eating toast and a half of a banana with her bare hands. At no time did the surveyor observe staff to offer hand hygiene to the residents before eating. ~On 12/10/19 at 11:30 AM, Surveyor observed staff taking R56 and R43 into the assisted dining area from the hallway. No hand hygiene was provided to R56 and R43 prior to entering the assisted dining area. ~On 12/11/19 07:23 AM Surveyor observed the breakfast meal service for the residents in the assisted dining room. It was noted that as each resident was brought into the room they were given a terry cloth clothing protector around their neck. None of the residents were offered the opportunity to wash or sanitize their hands. The meal consisted of scrambled eggs, toast, a donut, and a banana. On 12/11/19 at 7:35 AM Surveyor observed CNA-D (Certified Nursing Assistant) walk with R56 to the dining room. R56 had been observed prior to be walking about the facility. R56's usual activity is to wander about the facility and touch and feel her environment as she does so. She routinely runs her hands on furniture, the hand rail, and any item within reach. Surveyor noted that there was a dark gray residue under her fingernails. CNA-D commented to surveyor that R56 had her hand in the CNA-s back pocket as they were walking to breakfast. R56 was observed to eat some of her scrambled eggs and her banana with her fingers prior to staff assisting her. R36 was noted to propel her own w/c (wheel/chair) to the table to eat as she had been looking out the window prior to service. R36 was observed to use the actual wheel of her chair rather than handle to propel herself. R36 ate her own peanut buttered toast until CNA-F assisted her with her yogurt. R61 had also been observed to wheel himself to his table from his usual spot in the nurses' station rotunda. R61 ate his raisin toast with his fingers. Only one resident, R33 was offered a bottle of hand sanitizer with CNA-D and CNA-F commenting that R33 always washes her hands prior to a meal. At 8:55 AM Surveyor interviewed CNA-H, CNA-E and CNA-G about the facility's practice of resident hand hygiene prior to meals in this dining area in comparison to the residents in the main dining room that are offered sanitizer as they enter the room. CNA-H stated it is offered only to those persons that feed themselves and it is presumed those persons have had their hands washed during morning cares. When asked about other meals, CNA-E stated it is the responsibility of the staff member bringing the resident to the dining area to offer this. When asked about R56, R36, and R61, CNA-G stated that the responsible staff had forgotten. Offering to help the residents clean their hands prior to eating was not the practice noted prior to other meals in this dining room. On 12/11/19 at 11:31 AM Surveyor interviewed the DON regarding the expectations regarding hand hygiene for the residents prior to eating. The DON stated that all residents are to be offered hand hygiene prior to eating regardless of their ability to eat by themselves. The DON stated this was the reason the hand sanitizer dispensers were installed both inside and outside the small dining room door. In addition, the DON stated there are the handheld bottles of sanitizer that can to be offered. Example 2: R17 has [DIAGNOSES REDACTED]. According to her latest MDS (Minimum Data Set) assessment, dated 9/20/19, she is always incontinent of bladder and bowel, and is totaling dependent on the physical assistance of one staff member for hygiene. On 12/10/19 at 7:01 AM Surveyor observed CNA-C perform morning cares for R17. CNA-C was observed to wash R17's groin inner labia, buttocks, and anus and then open and apply barrier cream from a tube afterwards without removing her gloves or decontaminating her hands. With the same soiled gloves she pulled up and adjusted R17's clean clothing, and gathered up the garbage in to a plastic bag, and rinse out the resident's basin. CNA-C took off her gloves but did not wash her hands before placing a pillow under R17's feet, covering her with her blankets, and she lowered the bed by touching the buttons on the foot board. CNA-C was asked about the steps she took and when hand sanitizing is done during cares. CNA-C stated is was her understanding that hand washing was not needed as she was not going to go to another resident yet and that the cream was R17's personal supply and kept in her room. On 12/11/19 at 11:20 AM Surveyor interviewed CNA-E about key times to wash their hands when helping a resident with morning cares. CNA-E stated that handwashing is to be done prior to beginning cares, after getting supplies set up, after getting rid of the garbage and when going leaving the resident's room. It was only after prompting from Surveyor that CNA-E spoke of changing gloves and gelling her hands right after performing perineal cleaning. CNA-E stated hand washing is to be done before applying a barrier cream to the resident's bottom. At 11:23 AM Surveyor interviewed CNA-F and was told that hand washing is to happened before applying barrier cream or touching anything else after perineal cleansing. Example 3: ~On 12/09/19 at 2:55 PM, Surveyor observed R57 taking a nap in bed. The bed was lowered and the catheter drainage bag on the floor uncovered. On 12/11/19 at 6:35 AM, Surveyor and RN J observed R57 lying in his low bed and observed foley catheter drainage bag not covered and lying directly on the floor. Surveyor asked RN J about the placement of the drainage bag. RN J stated, the catheter bag is not to be directly on the floor due to infection control issues. ~On 12/9/19 at 9:30 AM., during initial tour, Surveyor observed R26 sitting in his recliner with the catheter drainage bag uncovered and lying directly on the floor. ~On 12/9/19 at 10:05 AM, during initial tour, Surveyor observed R38 asleep in a low bed with catheter drainage bag lying directly on the floor. ~On 12/9/19 at 12:47 PM, Surveyor observed R48 lying in bed with catheter drainage bag directly on the floor, the bag cover was near by. On 12/11/19 10:53 AM Surveyor spoke with RN B, who is the facility's infection preventionist, about the placement of the drainage bags. RN-B stated the catheter bags should never be uncovered and on the floor. Cover bags are supplied on all chairs. Surveyor shared the observation of residents in bed with the drainage bag on the floor. Example 4: R165 was admitted to the facility with [MEDICAL CONDITION] and [MEDICAL CONDITION]. The facility placed R165 on droplet precautions. Droplet precautions consist of mask, gown and gloves. On 12/10/19, Surveyor observed H-I (Housekeeper) in R165's room with gown and gloves on cleaning the bathroom. H-I came out of room wearing the contaminated gown and removed in hallway. The gown should have been doffed and disposed of in R165's room. H-I then brought supply bucket out of room and put it away. H-I did not perform hand hygiene before going to 3 additional rooms on the wing. On 12/11/19 at 11:00 AM, Surveyor interviewed H-I regarding procedure for cleaning rooms with residents with transmission based precautions. H-I stated she would apply PPE prior to entering and remove PPE prior to leaving the room. H-I acknowledged she had not done that during the observation. Surveyor asked H-I what do you do last after taking off the gown and gloves. H-I responded, I always sanitized my hands. Surveyor informed H-I of the observation of no hand hygiene. On 12/10/19 at 2:00 PM, Surveyor spoke with RN B and the facility's RN Consultant. RN-B stated all personal protective equipment is to be applied before entering room and before leaving the room. Example 5: On 12/10/19 at 7:29 AM, Surveyor observed CNA G check R58 for incontinence. CNA G gloved and removed soiled urine brief. CNA G did not remove the soiled gloves or perform hand hygiene before applying a barrier cream and a clean incontinence brief. After cleaning off the bedside table, CNA G then removed the soiled gloves and washed her hands. Surveyor interviewed RN B who stated the proper handwashing technique for peri care is to removed the soiled brief, remove gloves and perform hand hygiene. Then put new gloves to complete peri care, remove gloves and perform hand hygiene. Then with new gloves, place the clean incontinence product. Surveyor shared the above observation with RN B.

Based on record review, interview, policy review, and observation the facility did not prevent the development of a stage 4 pressure injury, nor implement current standards of practice to promote the healing of the pressure injury for 1 out of 2 sampled residents reviewed for pressure injuries. R10 developed a Stage 2 pressure ulcer on 09/11/17. The pressure injury required surgical debridement. Following the procedure, the pressure injury was considered a Stage 4. Despite this, the facility did not implement hourly repositioning and did not impelement an appropriate pressure relieving cushion in the wheelchair. This is evidenced by: The facility provided Surveyor a copy of the Nursing Services Policy and Procedure Manual for Long-Term Care Pressure Ulcer Risk. Prevention, and Treatment document. Noted in the document was the importance of identifying risk factors. The risk factors included were pressure, shear, friction, maceration, immobility, altered mental status, incontinent, poor nutrition, medications, and diagnoses. R10 required staff assistance with mobility, incontinence care, had a decline in cognition, had weight loss, [MEDICAL CONDITION]. The risk of shear, friction, maceration, and medications did not apply to R10. The Pressure Ulcer Prevention included to reposition any resident every 1 hour when in a wheelchair. The facility care plan included every 2 hour repositioning for R10. The NPUAP (National Pressure Ulcer Advisory Panel) document titled Prevention and treatment of [REDACTED]. In addition, the NPUAP instructs the providers to consider pressure risks for any medical devices. NPUAP advises providers to assess for skin integrity and signs of pressure at least twice daily with the addition of any medical device. NPUAP goes on to instruct providers for those residents at greater risk, conduct more than twice daily skin assessments where the medical device interfaces with the resident. R10 was admitted to the nursing facility on 07/25/17 with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an admission MDS (Minimum Data Set) on 08/02/17 for R10 with the following data noted: ~at risk for pressure injury; ~did not have any pressure reducing devices in the chair on on the bed; ~was not on any nutritional intervention for skin integrity; ~was not on any turning or repositioning program. Review of the care plan dated 08/02/17 noted R10 had potential for impaired skin integrity due to impaired mobility, decreased strength, cancer, weakness, weight loss, cognitive deficits, itching, and [MEDICAL CONDITION] (swelling of arms/legs). The care plan interventions included skin evaluations with shower, adequate rest, adequate hydration, dietary supplements, pressure reducing surfaces on the bed and in the chair, and manage pain. Review of the CNA (Certified Nursing Assistant) care plan noted R10 was to be assisted with repositioning every 2 hours, have skin checked every shift, and weekly skin checks by a licensed nurse. On 8/23/17, the CNA care plan was updated to include a wheelchair cushion. R10 left the facility with her son on 09/06/17 to attend her sister's funeral in Milwaukee with plans to return to the facility on [DATE]. R10 fell off of the toilet in the hotel room while out on pass on 09/06/17 and sustained a head injury as evidenced by bruising to the left side of her head. R10 returned to the facility on [DATE] at 11:40 p.m. as her son was concerned regarding R10's condition after the fall. Upon R10's return, RN-N assessed the skin integrity and found no bruises, excoriations, redness, discolorations, or open areas on R10's buttock. There was no documentation in the medical record of R10's skin integrity upon her return; however on 10/04/17 Surveyor interviewed RN-N who confirmed the buttock had no skin impairments including bruising, discolorations, excoriations, or signs of pressure injury. On 09/08/17, R10 had a fall at approximately 6:30 a.m. RN-N assessed R10 including a skin assessment and noted no bruises, discolorations, redness, or excoriations. The fall prevention intervention was to add an anti-locking wheelchair device to R10's wheelchair. These were added on 09/11/17. On 09/08/17 after the 6:30 a.m. fall, OT (Occupational Therapist)-F and PT(Physical Therapist)-E worked with R10. Both therapist reported to nursing R10 had declined in cognition, function, transfers, and was having increased right side pain. Both OT-F and PT-E assisted R10 with perineum hygiene and viewed R10's buttock and noted no bruising, redness, discoloration, or excoriations on the morning of 09/08/17. On 10/02/17 at 8:30 a.m., Surveyor interviewed PT-E regarding R10's therapy services. PT-E stated she had assisted R10 in the morning of 09/08/17. PT-E stated R10 required extensive assist of 2 staff for toilet use, transfers, and bed mobility. PT-E stated she had assisted R10 with perineum hygiene and denied seeing any redness, excoriations, bruising, or discoloration on R10's buttock. On 10/03/17 at 7:47 a.m., Surveyor interviewed OT (Occupational Therapist)-F OT-F stated she had assisted PT-E with toilet use and hygiene and did not see any redness, excoriations, bruising, or discolorations on R10's buttock on the morning of 09/08/17. On 09/11/17 at 8:49 p.m., RN-N noted a circular stage 2/deep tissue injury/ulcer to inner gluteal crease at coccyx. RN-N left a note for the DON regarding this skin problem. RN-N updated the primary physician as well as the on call physician. RN-N implemented side to side positioning using a flowsheet for every shift and placed a referral to the wound nurse who comes to the facility every Thursday. On 09/12/17 the facility began in investigation into the cause of the pressure injury on R10's buttock. The facility's investigation revealed a RN had documented R10's skin was intact on 09/09/17; however upon interview with staff the buttock was never examined. Also, from 09/05/17 through 09/11/17 R10's buttock was never visualized by any staff interviewed. According to nursing staff, R10 toileted herself and completed her own cares with the exception of the 1 instance on 09/08/17. Changes to the CNA care plan for R10 are as follows: ~09/12/17 pressure relief alternating pressure relief mattress on bed and ensure mattress is functioning; ~09/13/17 pressure relief sacral cut out cushion in wheelchair. The facility also developed temporary care plans on the following dates: ~09/12/17 add alternating pressure relief mattress and assure function every shift. ~09/13/17 add a Magic cup at lunch and supper for nutrition supplement. ~09/13/17 add sacral cut out wheelchair cushion to R10's chair. R10 was transferred to the hospital on [DATE] for surgical debridement of the pressure injury. Review of the surgical debridement progress note dated 09/18/17 noted R10 had a foul smelling necrotic unstageable decubitus ulcer, sacral area. The ulcer at the end of the debridement measured 5.5 cm by 5 cm by 1.5 cm with undermining. This is now a stage IV ulcer. The physician ordered moist gauze dressing twice daily. Review of the care plan dated 09/18/17 noted R10 had a stage 4 pressure ulcer on the sacrum (tailbone). The goal was for this injury to heal in 30 days. The interventions included to refer to the wound clinic, side to side positioning to avoid pressure to the sacrum, wound care as ordered, monitor for infection, and update physician with signs of worsening pressure injury. The care plan did not include to reposition every 1 hour when in wheelchair or up for 60 minutes three times daily as per the NPUAP guidelines. On 10/01/17 through 10/03/17 Surveyor noted R10 had a thin, approximately 2 inch, sponge foam cushion in the wheelchair that was uncovered. The cushion had an upside down V shaped cut out sacral area. This cushion did not have any identifiable make or model information because the cover was missing. Surveyor conducted a continuous observation of R10 beginning on 10/02/17 at 8:16 a.m. and ending at 10:22 a.m. R10 received no repositioning during that time. R10 was seated in her wheelchair for 2 hours and 6 minutes without offers or assistance to reposition hourly. On 10/03/17 at 7:47 a.m., Surveyor interviewed OT (Occupational Therapist)-F regarding R10's therapy services. OT-F stated she too had worked with R10 on the morning of 09/08/17. OT-F stated R10 was very different upon her return to the facility. OT-F stated R10 was confused, had poor balance, was dependent on staff for bed mobility and transfers. OT-F stated R10 had increased pain in her right side (chest abdomen area). OT-F stated the decline in function with R10 was discussed with nursing on 09/08/17. OT-F stated therapy had given R10 a sacral cut out foam wheelchair cushion; however was unsure of the dates of this service. OT-F stated the cushion was provided by COTA (Certified Occupational Therapy Assistant)-G. OT-F stated COTA-G had discussed with her the need for a pressure reducing wheelchair cushion. OT-F stated the best pressure cushion for R10 would have been a Roho cushion. OT-F stated both therapist considered a Roho cushion; however the facility did not have any Roho cushions in stock at this time. A Roho cushion is a name brand pressure relieving wheelchair cushion used to offload any pressure on the resident's buttock area. It has multiple pockets filled with air based on the resident's weight and pressure points. On 10/03/17 at 11:35 a.m., Surveyor interviewed COTA-G regarding therapy services provided R10. COTA-G stated she was unsure of the date the upside down V shaped cut out sacral cushion was trialed for R10. COTA-G stated the cushion was trialed several days before the decision to keep the cushion was made on 09/13/17. COTA-G stated she does not recall how she determined the sacral cut out cushion was acceptable for R10 other than to ask if R10 was comfortable. COTA-G stated a Roho cushion would have been a better choice; however the facility did not have a Roho cushion available.

Based on observation, record review, and interview the facility did not ensure a medication error rate of 5% or less. There were 2 errors in 27 opportunities which calculates to a 7.40% medication error rate. R18 was given Breo Ellipta, an inhaled medication to treat [MEDICAL CONDITIONS], and the LPN (Licensed Practical Nurse) did not instruct R18 to rinse mouth with water and spit. Breo contains a steroid which causes thrush of the oral cavity when inhaled without a rinse and spit. R19 was given the wrong dose of Vitamin D3. This is evidenced by: Example #1: R18 was admitted to the nursing facility on 06/29/17 with the following, but not all inclusive, Diagnoses: [REDACTED]. Review of the signed physician orders [REDACTED]. According to the manufacturer's administration instructions, it reads Rinse out mouth after each use. Do not swallow the rinse water. Spit it out. On 10/01/17 at 4:00 p.m., Surveyor observed LPN-D administer Breo Ellipta to R18. LPN-D instructed R18 to inhale, but never instructed or assisted R18 to rinse mouth with water and spit. LPN-D immediately administered crushed medications in pudding followed by a supplement drink. On 10/4/17 at 10:20 a.m. Surveyor interviewed RN-A regarding the expectation of nursing staff after administrating a steroid based inhaled medication like Breo Ellipta to decrease the potential side effect of a yeast infection in a resident's mouth and throat. RN-A stated that nursing staff was to have the resident wash out there mouth after and swish and spit. At 10:30 a.m. Surveyor interviewed LPN-B with the same question. LPN-B stated the staff was to have the resident rinse their mouth afterward . rinse and spit. Example #2: R19 was admitted to the nursing facility on 11/30/16 with the following, but not all inclusive, Diagnoses: [REDACTED]. Review of the signed physician orders [REDACTED]. On 10/01/17 at 4:08 p.m., Surveyor observed LPN-L dispense Vitamin D3 1000 IU, one tablet along with [MEDICATION NAME] 3.125 milligrams and then crush these medications and mix in pudding. LPN-L then administered these 2 medications to R19. On 10/4/17 at 10:20 a.m. Surveyor interviewed RN-A and confirmed this order and dosage was correct and on the MAR (medication administration record). Both tablets are to be given at 4:00 p.m. R19 had received the wrong dose.

Based on observations, staff interview and record review the facility did not ensure that the temperature of the wash cycle was at the level directed by the manufacturer. This has the potential to affect all residents. This is evidenced by: On 09/07/16 beginning at 8:24 a.m., Surveyor # observed dishawashing operations. DS-D (Dietary Staff) was placing dirty breakfast dishes on dish racks to put through the dishmachine for washing. DS-D ran a load of dishes through at 8:24 a.m. and the wash temperature reached 147 degrees. DS-D ran two more loads through the dishmachine at 8:25 a.m. and 8:27 a.m. and the wash temperature still was at 147 degrees. DS-D ran another load through at 8:28 a.m. and the wash temperature was 148 degrees and the next load ran at 8:29 a.m. was at 149 degrees. As each rack was completed, another staff person was putting all the dishes away. At 8:25 a.m., Surveyor asked DS-D what the wash temperature should be. DS-D indicated that the wash temperature should be at 150 degrees and referred to the recommended temperatures noted on the dishmachine faceplate. DS-D said that the machine is slow in getting up to temperature. Neither staff stopped the dishwashing process to allow the water temperature to reach the appropriate level. On 09/07/16 at 8:40 a.m., Surveyor # spoke with the DM (Dietary Manager). The DM said the wash temperature on the machine should be 150 degrees. Surveyor # showed the DM the temperatures recorded for the wash cycles observed. The DM indicated that the staff should have run the dishes back through the dish machine if the wash temperature was low. The DM told Surveyor # that they take dishmachine temperatures 3 times a day after every meal. Surveyor # and the Dietary Manager reviewed the 9/1/16-9/7/16 temperatures and noted that the wash temperature after the lunch on 9/1/16 was 149 degrees and on 9/7/16 after breakfast the recorded temperature was 147 degrees Fahrenheit. Surveyor # asked the Dietary Manager for the Dishwashing Logs for June and July of 2016. The following was noted: ~07/01/16: 147 degrees. ~07/02/16: 148 degrees. ~07/03/16: 147 degrees. ~07/07/16: 147 degrees. ~07/09/16: 149 degrees. ~07/11/16: 147 degrees. ~07/13/16: 147 degrees. ~07/21/16: 149 degrees. ~07/24/16: 147 degrees. ~07/29/16: 148 degrees. August 2016 Logs: ~08/07/16: 149 degrees. ~08/08/16: 147 degrees. ~08/16/16: 149 degrees. ~08/17/16: 149 and 148 degrees. ~08/18/16: 147 and 148 degrees. ~08/19/16: 149 and 147 degrees. ~08/20/16: 146 degrees. ~08/21/16: 148 and 149 degrees. ~08/22/16: 148 degrees. ~08/23/16: 147 and 149 degrees. ~08/24/16: 143 degrees. ~08/27/16: 144 degrees. ~08/28/16: 144 degrees. ~08/29/16: 145 degrees. ~08/31/16: 147 degrees.

Based on record review and staff interview, the facility did not ensure 1 out of 15 sampled residents reviewed met the PASARR (Preadmission Screening and Resident Review) requirements. Resident #14 medical record did not include a Level II PASARR screen based on the requirements of the completed Level I screen. Section A2 was not accurate. Section C was not completed. This is evidenced by: On 9/6/16 through 9/8/16, Surveyor # reviewed Resident #14 medical record. Resident #14 was admitted into the facility on [DATE]. On 2/8/16, temporary guardianship from Michigan was given to Resident #14 wife. Surveyor # observed and reviewed a PASRR level 1 screen dated 2/11/16. ~ Section A1 and A2 indicates, No. The answer should have been yes as Resident #14 was admitted with [MEDICAL CONDITION] medications of [MEDICATION NAME] and [MEDICATION NAME]. ~ Section B related to exemptions are all blank. ~C2 are questions pertinent for an Abbreviated Level II Screen such as severe cognitive deficits due to dementia, [MEDICAL CONDITION] or similar [MEDICAL CONDITION] process. C2 was blank. ~Section D Referring a person for a Level II Screen. If you have answered yes to any question in Section A and No to all of the exemptions listed in Sections B, follow these instructions: *Contact the PASRR Contractor to notify them that the person is being considered for admission. Forward a copy of the Level 1 Screen to the PASRR Contractor. The PASRR Contractor will perform a Level II Screen to determine if the person has a developmental disability and/or a serious mental illness as defined by the federal PASRR regulations. The screening agency will notify the nursing facility, the county of responsibility and the resident or his/her legal representative, in writing of the determinations. *If you answered Yes to any of the items in Section A, the nursing facility must obtain county approval, as evidenced by receipt of a signed F- form from the county, prior to admission. *Note: If a person has a developmental disability or a mental illness at the time of a proposed admission to a nursing facility, State statues only permit a health care agent to admit a person to a nursing facility for up to three months of post-hospitalization recuperative care or for up to 30 days of respite care. Otherwise, guardianship and protective placement is necessary prior to admission, except in the event of an emergency. Similary, if a person already has a guardian, the guardian is only permitted to consent to an admission to a nursing facility for up to 60 days of recuperative care or up to 30 days for respite care. Otherwise, a protective placement order is necessary prior to admission, except in the event of an emergency. There is no protective placement and Resident #14 remains in the facility. (Refer to F250). On 2/22/16, Resident #14 was transferred to Bethesda Behavior Health. Returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Antidepressant of [MEDICATION NAME] on schedule. There were no changes made to the 2/11/16 Level I screen. On 9/7/16 at 2:10 p.m., Surveyor # interviewed the facility Social Services Designee (SSD) who has worked in this position since September 2015. The facility provides a Social Worker Consultant from Villa Marina in Superior, Wisconsin for any questions if needed. The SSD stated that she recently attended a meeting (6/16) regarding PASRR Screening and learned that Level I screening form is a working progress. The SSD identified that the Level I screens were not completed appropriately. The SSD reviewed all residents Level I screens to ensure the [MEDICAL CONDITION] medications were identified and updated in Section A 2. SSD stated that Resident #14 was not updated since he is no longer taking any [MEDICAL CONDITION] medications. Surveyor # asked if another Level I screen was completed when Resident #14 was readmitted to the facility since he had a significant change in condition. SSD stated that Resident #14 did have a significant change in condition upon readmission and that she did not complete or update the Level I screen. The SSD stated that she did not consult with the Social Worker regarding the PASRR form. Surveyor # also discussed no protective placement or Wisconsin guardianship in place according to Section D on Level I screen. The SSD stated she called the court house who stated Resident #14 Michigan guardianship was appropriate and since there was not a problem she did not call her consultant. SSD was not aware of the State Statues of Protective Placement.

Based on observation, record review, and interview the facility did not ensure that every staff member assisting a resident that needs infection control isolation precautions followed the correct procedure. This was discovered for 1 of 6 residents reviewed with infections. CNA-A (Certified Nursing Assistant) and LA-C (Laundry Aide) came in contact with and close proximity to Resident #3 without wearing the required PPE (Personal Protective Equipment). Resident #3 is under droplet and contact precautions due to a URI (Upper Respiratory Infection). This is evidenced by: Resident #3 has [DIAGNOSES REDACTED]. A review of Resident #3's nursing notes finds that on 9/1/16 Resident #3 presented with a frequent moist couch, wheezes and rhonchi (rattling) in her lungs, and a low grade temperature of 99.3 degrees F (Fahrenheit). Resident #3 was placed on contact and droplet precautions and a CXR (Chest X-ray) was ordered. While the CXR showed no definitive [DIAGNOSES REDACTED]. As of 9/6/16 to 9/8/16 she continues with the cough and the precautions. Review of the care plan for Resident #3 found directions to the aides to wear gowns and gloves when coming into direct contact with her and a mask when coming within 3 feet of her to protect staff from her presumed infectious sputum. Example #1: On 9/7/16 at 6:25 a.m. Surveyor # observed CNA-A assisting Resident #3 with her bath. CNA-A was not wearing any PPE. After the bathing task CNA-A toweled off the resident and she began to cough on CNA-A's hands, back, and neck. CNA-A stated, Still got that cough huh? Afterwards the aide asked the resident to grab onto a shower rail attached to the wall in order to stand and finish dressing. Resident #3 began to cough a lot while at the bar and again coughed on the aides' hands and the bar itself. CNA-A wheeled Resident #3 to her room and washed her hands in the residents bathroom and disinfect the tub basin. CNA-A then went to find one of the 8 residents she was assigned to assist with their tub baths and showers. CNA-A assisted Resident #16 to the tub room. CNA-A instructed the resident to grab onto the bar to help with undressing. It was at this time that Surveyor # pulled CNA-A aside and interviewed her about the precautions for Resident #3. CNA-A stated that she did not know Resident #3 was under precautions until she saw the cart outside of her room when wheeling her back to her room. CNA-A stated she should have had the resident wear a mask when she was out of her room. CNA-A stated she herself should have worn gloves and a mask. When asked if she needed to wear a gown she initially stated no but then stated that gowns were there also. After the conversation, Surveyor # interviewed RN-B (Registered Nurse) about the expectations for staff when assisting Resident #3. RN-B stated that Resident #3 was on contact and droplet precautions for a URI and staff are to wear a gown, gloves, and a mask for any contact. In addition, Resident #3 is to wear a mask when out of her room and she normally eats her meals in her room so keeping to her room for meals was not an issue. When asked how this information was made known to the staff, RN-B stated that the aides should be aware of a resident's precautions from report and the report book in the office and that the kinds of PPE and precautions are part of the aides training. At 7:03 a.m. Surveyor # interviewed the DON (Director of Nursing) about the facility's expectations and the observation made. The DON showed the surveyor the neon green sheets in the report book that directed staff to use the precautions for Resident #3. The DON stated she would talk to CNA-A and advise her on disinfection of the environment also. Example #2: On 9/7/16 at 8:20 a.m. Surveyor # observed LA-C deliver incontinence products to Resident #3's room. Through the open doorway Surveyor # observed LA-C strike up a conversation with Resident #3. Resident #3 was in her wheelchair at her bathroom door and closet. LA-C was right next to her. LA-C was not wearing a mask as required when being that close to a resident with droplet precautions. At one point in the conversation, Resident #3 told LA-C, I'm on lock down right now. referring to her infection and the need to stay in her room and wear a mask. Surveyor # interviewed LA-C about the interaction. LA-C stated, Usually I put on rubber gloves and if she is coughing we can put on a mask. LA-C stated that the housekeeping staff wear gloves. mask, and a gown when cleaning a room with precautions but that she was . In and right back out with no real contact. I'm in and out of every room.

Based on random observation, interview, and record review, the facility did not ensure it was free of medications error rate of five percent or greater. 36 medications were observed. Of the 36 medications 2 errors were noted to equal a 5.5% medication error rate. This is evidenced by: Error #1 On 9/6/16 at 12:20 p.m., Surveyor # observed RN-B (Registered Nurse) administer medications to Resident #9. RN-B poured 5 cc's (cubic centimeters) of [MEDICATION NAME] into a medication cup. RN-B indicated to Surveyor # she was administering 1 Tablespoon of [MEDICATION NAME] into a cup of crystal light fluid. During reconciliation of medications, Surveyor # noted Resident #9 physician orders [REDACTED]. (Tablespoon) of [MEDICATION NAME] mixed in 8 oz. (ounces) of fluid. Resident #6 should have received 15 cc of [MEDICATION NAME] instead of 5 cc. On 9/8/16 at 10:50 a.m., Surveyor # spoke with RN-B regarding the medication error. RN-B stated, I must need glasses. Error #2 On 9/8/16 at 8:40 a.m., Surveyor # observed LPN-E (Licensed Practical Nurse) administer medications to Resident #2. LPN-E removed one tablet of Calcium 500 plus Vitamin D 3 200 IU (international units) from a stock bottle and placed into a medication cup along with other medications. During reconciliation of medications, Surveyor # noted Resident #2 readmission orders [REDACTED]. On 9/8/16 at 9:40 a.m., Surveyor # spoke with the Director of Nurses. The Director of Nurses stated that when Resident #2 returned from the hospital there was no order for Calcium with Vitamin D. The Director of Nurses and Surveyor # reviewed the Medication Record which clearly states to give Calcium [MEDICATION NAME] 500 mg BID. The Director of Nurses stated, the Calcium with Vitamin D should not have been given.

Based on interview and record review, the facility did not ensure 1 of 15 sampled residents were admitted in accordance to state law. Resident #14 had a guardian of person from outside of Wisconsin. The guardianship papers did not include a protective placement order which is required for admission of a ward to a nursing home in Wisconsin. This is evidenced by: Resident #14 was admitted to the facility 2/12/16. Upon admission, Resident #14 had a court appointed guardian from Michigan. On 9/7/16 at 2:10 p.m., Surveyor # asked the Social Services Designee (SSD) if Resident #14 was his own decision maker. SSD said, No, his wife is guardian. The SSD obtained a final guardianship papers from Iron County Court House. The Guardianship papers are from Gogebic County in Michigan. There was no order for proctective palcement. On 9/12/16 at 10:10 a.m., Surveyor # spoke with the Office of Aging Systems Developer, who stated that Adult Protective Services (APS) should have been notified by the facility and/or the county. The SSD should assist/direct the guardian to petition for protective placement and change of venue (guardianship) to Wisconsin if Resident #14 resides in Wisconsin.

Based on interview and record review, the facility allowed 1 of 5 staff reviewed, to work as a Certified Nurse Aide (CNA) without being included on the Wisconsin CNA Registry. This has the potential to affect all residents. NA-H is not included on the Wisconsin Certified Nursing Assistant Registry and therefore not eligible to work as a CNA in the state. This is evidenced by: On 8/17/15, Surveyor # received a list of all facility staff by name, start date and position from the Director of Nurses (DON). A review of the Wisconsin CNA Registry finds NA-H was not listed as a CNA and was not on Wisconsin CNA Registry making them ineligible to work as a CNA in Wisconsin. On 8/18/15, Surveyor # interviewed the DON who is responsible for hiring staff. The DON stated she was not present at the facility when NA-H was hired. On 8/18/15 at 4:00 p.m., Surveyor # interviewed RN-A (Registered Nurse) who stated NA-H told her she was on the Registry and was hired on 7/11/15. RN-A stated that she did not ask if she was registered in Wisconsin or Michigan. RN-A was unaware that each state had their own CNA Registry. Surveyor # requested NA-H time cards since 7/11/15. NA-H worked for 200 hours without being eligible to work in the state of Wisconsin.

Based on observation and interview, the facility did not ensure that all resident food was served under sanitary conditions. This has the potential to affect all residents. The nursing home administrator (NHA) was observed in the kitchen during food service without a hair restraint. A restorative/activity assistant (R/AA-J) was observed wearing the same pair of single-use food service gloves to cut the chicken off the bone for three residents in the main dining room. During the observation R/AA-J was noted to touch the food and commonly used condiments with these same gloves. This is evidenced by: Example #1: On 8/17/15 at 3:00 p.m., residents expressed dissatisfaction that they had seen the big shots go in and out of the kitchen all the time without any hair nets and felt that was not fair to the other staff who had to wear them. On 8/19/15 at 11:23 a.m. during observations of the tray line service, Surveyor # observed the NHA come into the kitchen and stay momentarily. The NHA then left through the door to the dinning area. A dietary staff member indicated the NHA frequently enters the kitchen without a hair restraint. The same dietary staff indicated other non-dietary staff enter the kitchen without hair restraints. On 8/19/15 at 9:30 a.m., Surveyor # interviewed the dietary manager (DM) regarding hair restraints in the kitchen. The DM stated all staff in the kitchen are required to wear a hair restraint. The DM stated she was aware of the NHA coming into the kitchen on several occasions without the proper restraint. Example #2: On 8/18/15 at 11:58 a.m., Surveyor # observed R/AA-J, with single-use gloves, handle and cut the chicken meat off the bone for Resident #20, Resident #21, and Resident #23 without changing his gloves. Also during this task R/AA-J was observed to touch the sugar dispenser on two other tables. After doing so, R/AA-J removed his gloves but did not clean his hands before exiting the dining area. On 8/19/15 at 9:30 a.m., Surveyor # interviewed the dietary manager (DM) regarding the use of single-use food service gloves. The DM indicated the single-use gloves are to be used for one task and then disposed of and hands are to be sanitized in between glove use. The DM stated this is the expectation for all kitchen staff and staff who serve in the dining area. The DM stated she had not conducted any education of the activity staff in the dining room of the expected procedures.

Based on observations and interviews, the facility did not ensure that staff caring for 2 of 15 sampled residents, performed hand hygiene at appropriate intervals. Resident #9 was provided incontinence cares on two occasions. Staff did not change their gloves and wash hands after removing a saturated brief and continued to touch clean items with the soiled gloves during two different observations involving four staff. CNA-F (Certified Nursing Assistant) did not perform hand hygiene when removing her gloves after performing a dirty task and donning clean gloves while assisting Resident #2 with her morning cares. This is evidenced by: Example #1: On 8/17/15 at 5:43 p.m., Surveyor # observed CNA-B and CNA-C completing incontinent care for Resident #9. Resident #9's brief was not checked or changed for five hours and the brief was saturated with urine. CNA-C and CNA-B's hands were gloved and both assisted in removing resident's soiled brief and placed into a plastic bag. CNA-B and CNA-B did not change their gloves after manipulating the soiled brief. CNA-C applied the clean brief, touched resident's pillow and applied the oxygen cannula to resident's face. CNA-B and CNA-C assisted pulling Resident #9's clean tee shirt down, adjusted the pillows and touched two other pillows to keep heels afloat. Resident #9 then was repositioned on her left side with a pillow behind her back, thus, contaminating all these items. CNA-B and CNA-C then removed their gloves and washed their hands. Surveyor # interviewed CNA-C on when she should wash her hands. CNA-C stated, I should have changed gloves and washed my hands after touching the wet brief. Example #2: On 8/18/15 at 9:30 a.m., Surveyor # observed CNA-D and CNA-E completing Resident #9 moring incontinent care. CNA-D and CNA-E's hands were gloved. Resident #9 was incontinent of urine. CNA-D removed the soiled brief and proceeded to complete peri care. Without changing gloves, CNA-D left the room to get more wash cloths and proceeded to complete morning cares and proceeded to touch clean items: clean brief, shirt, pants, Ted stockings and placed the Hoyer sling under Resident #9, thus, contaminating all these items with bodily fluids. CNA-D removed her gloves and washed her hands in the bathroom. Surveyor # interviewed CNA-D who stated she did not change her gloves and wash hands when she left the room. CNA-D stated she used her hip to open the door. When asked what practice the facility uses regarding glove changes and hand washing, CNA-D stated, I should have removed my gloves and washed hands after removing the brief. On 8/19/15 at 10:45 a.m., Surveyor # interviewed the Director of Nurses (DON) who stated staff should always remove their gloves and wash hands or sanitize hands whenever going from dirty to clean. The DON stated the facility always does audits on hand washing. Example #3: On 8/18/15 at 7:10 a.m., Surveyor # observed morning cares for Resident #2. CNA-F assisted Resident #2 to the bathroom and removed resident's brief with bare hands. CNA-F donned gloves, filled a basin with water and assisted Resident #2 with washing her back and underarms. CNA-F did not perform hand hygiene before donning her gloves. After washing Resident #2, CNA-F removed her gloves and continued assisting Resident #2. CNA-F did not perform hand hygiene. CNA-F handled Resident #2's perfume bottle, facial cream and other clean items. On 8/18/15 at 1:35 p.m., Surveyor # spoke with CNA-F about the observation. CNA-F indicated she should have washed her hands when removing her gloves. CNA-F further indicated she contaminated Resident #2's personal items due to lack of hand washing. On 8/19/15 at 8:10 a.m., Surveyor # spoke with the Director of Nursing (DON) about the observation. The DON indicated staff are educated on hand hygiene and it is the facility's expectation for staff to wash their hands whenever going from a dirty task to a clean task.

Based on observation, staff interview and record review, the facility did not ensure a homelike dining experience for every resident at the facility. This has the potential to affect 26 of 63 residents who eat in the two supervised dining areas. ~Visitors are not allowed to dine with their family members. ~The dining atmosphere in the supervised areas are not comparable to the dining area that is used by more independent residents, such as condiments, napkins, and utensils are not placed on the tables. ~The residents in these supervised dining areas are not given the choice to put on a terry cloth clothing protector as are the residents in the dining room for the more independent residents. This is evidenced by: Example #1: On 8/17/15 at 3:00 p.m., Residents #24, #25, and #19 expressed dissatisfaction regarding family members not being able to eat with them or even visit while they are eating their meals in the dining room. Resident #24, who eats in the main dining room, stated guests are not allowed in the dining room during meal and that on one occasion they told my sister to get out . they said she was not allowed and took her coffee away from her and she was asked to leave. Resident #25, who also eats in the main dining room, stated her son was once asked to leave too. Resident #19 stated, Even if food is brought in, the family has to get out. On 8/19/15 at 11:00 a.m., Resident #18 told Surveyor # that she has had guests in the main dining room. Resident #18 stated she might get preferential treatment. Example #2: Throughout the survey Surveyor # reviewed the environment of the main dining room (MDR) designated for residents who do not require assistance or supervision with eating with the two supervised dining rooms (SDR) designated for residents who need assistance, cueing, and supervision. At the beginning of each meal the residents in the SDR are seated at empty tables. The residents of the MDR have utensils, napkins, coffee cups and condiments already on the table, with a staff member filling coffee, serving drinks and dinner salad while they wait for the main meal service. The residents in the SDR are served their meal from a cart with their food already plated and with no condiments on the table. Example #3: On 8/18/15 and 8/19/15, Surveyor # observed the breakfast service in the two SDRs. Residents were not offered a choice in wearing a clothing protector. Staff were puting clothing protectors on all residents without asking their preference to wear one. On 8/17/15 at 4:00 p.m., Surveyor # observed the supper meal in the first SDR. Staff were observed placing clothing protectors on all residents who were served in the dining room. Staff did not offer residents the choice to wear the clothing protectors. Surveyor # noted no cloth napkins available in the dining room as an alternative to the large bib type clothing protectors. Additionally, no condiments were on the tables or available for resident use. Table cloths or table decorations were not present on the tables. The doors entering the dining room had signs posted that read No visitors are permitted in the dining areas during resident meal time. The dining room did not promote a homelike dining experience. On 8/18/15 at 11:15 am., Surveyor # observed the first SDR for lunch. At 11:40 a.m., Surveyor # observed the second SDR. Residents again were not offered the choice to wear a bib type clothing protector. No cloth napkins were available as an alternative. No table cloths or table decorations were present. The second SDR also contained a sign on the door stating No visitors are permitted in the dining areas during resident meal time. Surveyor # requested and received a list of residents who dine in the two SDRs. Together they serve 26 residents their meals.

Based on observation, record review and interview, the facility did not ensure that 1 out of 11 sampled residents reviewed for at risk for pressure ulcers, were provided with repositioning. On 8/17/15, Resident #9 was not repositioned for five hours. This is evidenced by: Resident #9 has [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 6/26/15, indicates Resident #9: ~Requires extensive assistance with two staff for transfers and toileting; ~Is nonambulatory; ~Requires a mechanical device (Hoyer) to be transferred; ~Had a 14 pound weight loss since last quarterly on 4/3/15; and, ~Is at risk for development of pressure ulcers. Review of Resident #9's care plan stated Resident #9 is to be repositioned every two hours. On 8/17/15 at 12:35 p.m., Surveyor # began a continuous observation of Resident #9 and noted the following: ~12:35 p.m., Resident #9 was sitting in a Geri chair in her room, blue Hoyer lift sling under her along with a comfort pad. Right foot tapping. ~1:28 p.m., two CNAs placed roommate back into bed. No one approached Resident #9. ~2:13 p.m., CNA went into room to pass fresh ice water. ~3:45 p.m., CNA-B and CNA-C (Certified Nurse Assistants) standing outside Resident #9's doorway. No one approached Resident #9. ~2:40 p.m., CNA-C went into Resident #9 room and helped roommate. During this time Resident #9 started flapping both hands. CNA-C looked at Resident #9 but did not offer or assist with toileting or repositioning. ~CNA-B and CNA-C were in the hallway assisting other residents. ~4:00 p.m., CNA-B took Resident #9 to the dining room. There were no offers or assistance with repositioning. ~4:40 p.m., A CNA pushed Resident #9 to her room. Resident #9 stated, Will you take me to bed? Can I take a rest? Could I lay down? How soon? The CNA told her she would be back in 20 minutes. Resident #9 stated, Why not sooner? There was no offers or assist with positioning. ~5:43 p.m., One hour later, CNA-B and CNA-C transferred Resident #9 to bed using a mechanical lift. Surveyor # observed red streaks on her buttocks and on the back of her thighs which lightened after being in bed. Resident #9's brief was saturated with urine. This was the first time Resident #9 had been repositioned in five hours and eight minutes. On 8/19/15 at 9:20 a.m., Surveyor # interviewed LPN-K (Licensed Practical Nurse) who stated Resident #9 should be repositioned and toileted every two hours. On 8/19/15 at 9:50 a.m., Surveyor # interviewed RN-A (Registered Nurse) who will become a Certified Wound Care Nurse on Friday. RN-A stated if a person is chair and bed bound they should be repositioned at least every two hours to prevent pressure ulcers from occurring.

Based on interview, record review, and observation, the facility did not ensure it maintained an Infection Control Program which included an Antimicrobial Stewardship Program, adherence to isolation precautions, and assurance that personal care items were cleansed between individual resident use. The facility does not have an effective Antimicrobial Stewardship policy and procedure. The facility provided an undated, unsigned outline of definitions and recommendations that does not constitute a policy and procedure by which staff and physicians can follow. 6 of 15 sampled residents (#8, #13, #9, #14, #15, and #12) have been treated with antibiotics without adequate indications for use. 2 of those residents (#8 and #13) have since developed multi-drug resistant organisms (MDRO). Resident #13 has a MDRO in his urine. Staff are to use gowns and gloves when providing incontinence care for Resident #13. CNA-F did not use appropriate PPE (Personal Protective Equipment) when providing incontinence care. The beautician does not consistently disinfect the hair rollers between each resident use but rather disinfects on a weekly basis. The deficient practices have the potential to affect all residents with actual harm identified for 2 (#8 and #13). This is evidenced by: Example #1: Surveyor # asked the facility for their policy and procedure for antimicrobial stewardship. The facility provided Surveyor # with an undated outline titled, "Antimicrobial Stewardship Program." The outline states: 1. Antibiograms=local susceptibility patterns. 2. Antimicrobial susceptibility reports and analysis of current trends. 3. Goal=optimize the use of the right drug for the right purpose and for the right duration in an effort to promote judicious use of the antimicrobial agent. 4. Basics for what constitutes an effective stewardship program: a. Written guidelines for use of specific antimicrobials. b. Accurate microbiologic results and prompt reporting. c. Antibiograms complied and disseminated with enable clinics to select the appropriate agent for therapy. d. Systems that minimize opportunities for inappropriate duration of therapy. e. Process that actively support de-escalate of therapy to a more narrow spectrum agent. 5. Steps to prevent antimicrobial resistance among LTC (Long Term Care) residents: a. Minimize use of broad spectrum antibiotics. b. Avoid chronic or long term antimicrobial [MEDICATION NAME]. c. Monitor antimicrobial use. d. Treat infection-not colonization or contamination. Culture collection proper antisepsis. Do not treat asymptomatic bacteriuria. e. Stop treatment when cultures are negative and asymptomatic. Although the outline identifies that a facility must have written guidelines and systems in place, there was no evidence this was completed. Resident #8 was on an extended course of [MEDICATION NAME] (an antibiotic). The facility completed a urinalysis even though documentation indicated she had no signs or symtpoms of a UTI (urinary tract infection). Resident #8 was found to have a resistance to [MEDICATION NAME] and was placed on an antibiotic despite being asymptomatic for a UTI. (Refer to F329.) Nursing staff would routinely complete a "dipstik" urine test on residents without signs or symptoms of a UTI. Nursing staff would subsequently request orders for a urinalysis and treatments. The following was noted: Resident #13 was treated 3 separate times with antibiotics without any indications or symptoms of a urinary tract infection (UTI). After treatment with [MEDICATION NAME] (a broad spectrum antibiotic), Resident #13 developed MRSA (Methicillin Resistive Staphylococcus Aureus). Later tests also identified the MRSA was resistant to [MEDICATION NAME]. Despite this, the physician started Resident #13 on a course of [MEDICATION NAME] without adequate indications for use. (Refer to F329) With the development of a MDRO, Residents #8 and #13 would be clinically compromised. There are now limited choices for treatment of [REDACTED]. Resident #9, #14, #15, #3, and #12 all received antibiotics prior to laboratory test results being received. (Refer to F329.) On 10/1/14 at 10:35 a.m., Surveyor # spoke with RN-D (Registered Nurse). Surveyor # asked RN-D what the facility's practice was for obtaining a urine dipstik. RN-D indicated they would obtain one anytime a resident had a change in condition, including fatigue, restlessness, or behaviors, if a resident had urinary complaints, or if staff noted a resident's urine had a strong odor, was concentrated, or had blood in it. Surveyor # asked RN-D if she would obtain a urine sample based on 1 symptom. RN-D stated she would. RN-D indicated if the urine dipstik was abnormal, they would call or fax the physician the information and request an order for [REDACTED]. On 10/2/14 at 1:30 p.m., Surveyor # spoke with RN-E. RN-E indicated she was the clinical manager and oversaw all residents in the facility. Surveyor # asked RN-E what the facility's practice was for obtaining a urine dipstik. RN-E indicated whenever there were 2 symptoms including a change in condition, increased confusion, a change in bladder habits, weight loss, or a decrease in fluid intake, the nurses would obtain a urine dipstik. RN-E stated depending on the circumstances, the nurse may obtain a urine dipstik based on only 1 symptom. Surveyor # asked RN-E if a resident just had weight loss would the nurse obtain a sample. RN-E indicated they would. RN-E also indicated residents were typically not placed on an antibiotic prior to receiving a urine culture report. RN-E indicated even if the culture report was positive, they would not treat with an antibiotic if the resident had no symptoms of a urinary tract infection. Example #2: On 10/1/14 at 7:40 a.m., Surveyor # observed CNA-F assist Resident #13 with his morning hygiene, dressing, and use of his urinal. CNA-F stated Resident #13 is usually helped with washing up and dressing in bed as he does not tolerate sitting on the toilet. CNA-F stated he had given Resident #13 a urinal in bed as he stated he had to void. CNA-F was wearing gloves during the care of Resident #13 but did not wear a disposable gown, in spite of a cart placed right outside the room with gowns in it. CNA-F removed the urinal but there was no urine. CNA-F also changed the resident's disposable brief that was dry. Surveyor # interviewed CNA-F regarding Resident #13's precautions and organisms. CNA-F stated Resident #13 had MRSA in his urine. CNA-F stated Resident #13 was MRSA positive a month ago and "it had come back." When asked if this meant wearing a gown, CNA-F stated, "I would if he had been incontinent." When asked how he had anticipated that the resident was not incontinent, the CNA stated he could not have known that the resident would be continent. CNA-F stated he should have worn a gown to protect his uniform as this was the facility's policy before doing direct cares for a resident with MRSA. Example #3: On 09/30/14 at 2:10 p.m., Surveyor # observed Beautician-C packing supplies into a bag, including hair curlers. Surveyor # asked Beautician-C when she cleans and disinfects the hair curlers. Beautician-C explained she comes to the facility 2 times a week on Monday and Tuesday, and at the end of the week she cleans the hair curlers using Ship Shape cleaner. Beautician-C was asked by Surveyor # if she disinfects the hair curlers between each resident use. Beautician-C stated she does not but always disinfects them at the end of the week.

Based on interview and record review, the facility did not ensure that 7 of 15 sampled residents' drug regimens were free from unnecessary medications. Resident #8 was on an extended course of [MEDICATION NAME] (an antibiotic). The facility completed a urinalysis even though documentation indicated she had no signs or symtpoms of a UTI (urinary tract infection). Resident #8 was found to have a resistance to [MEDICATION NAME] and was placed on an antibiotic despite being asymptomatic for a UTI. Resident #13 was treated 3 separate times with antibiotics without any indications or symptoms of UTI. After treatment with [MEDICATION NAME] (a broad spectrum antibiotic), Resident #13 [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistive Staphylococcus Aureus). Later tests also identified [MEDICAL CONDITION] was resistive to [MEDICATION NAME]. Despite this, the physician started Resident #13 on a course of [MEDICATION NAME] without adequate indications for use. Resident #2 was given the sleep aid,[MEDICATION NAME] milligrams (mg), every night since 2/10/14. This medication is indicated for short-term management of [MEDICAL CONDITION] for only 7 to 10 days. The medication is continued in spite of adverse side effects such as numerous falls out of bed, getting out of bed when not fully awake, increased confusion and anxiety. Prior to starting the medication, there was no assessment and no non-pharmacological interventions attempted to promote sleep. Resident #12, #9, #14, and #15 all received antibiotics prior to laboratory test results being received. This is evidenced by: Example #1: Resident #8 was on an ongoing regimen of [MEDICATION NAME] and [MEDICATION NAME] for the treatment of [REDACTED]. On 10/10/13, Resident #8 presented with signs and symptoms of a stroke. The facility obtained an order for [REDACTED]. The culture and sensitivity came back indicating a bacteria of e. faecium (a bacteria of the intestine) which was resistant to [MEDICATION NAME]. Despite having no symptoms of a UTI, the physician placed Resident #8 on [MEDICATION NAME], an antibiotic. On 10/2/14 at 1:30 p.m., Surveyor spoke with RN-E who indicated residents were typically not placed on an antibiotic prior to receiving a urine culture report. RN-E indicated even if the culture report was positive, they would not treat with an antibiotic if the resident had no symptoms of a urinary tract infection. Example #2: Surveyor # reviewed the clinical record and timeline of urine testing and results supplied from the facility for Resident #13. Resident #13 was admitted to the facility in June 2014. His [DIAGNOSES REDACTED]. Review of the nursing notes and lab work found that he was treated with antibiotics on 3 separate occasions since his admission. Review of the nursing notes prior to testing found no clinical indications of a UTI to warrant the testing: 1. 6/10/14. A dipstik was done for "increased agitation." It was positive for white blood cells, [MEDICATION NAME], and blood. The MD was called. (White red blood cell are not indicative of infection and can be from inflammation. [MEDICATION NAME] are normally found in urine and only when they change to [MEDICATION NAME] does this mean an infection.) There were no clinical symptoms of a UTI that were identified. The record indicated Resident #13 was complaining of pain related to the fractures and he denied having any symptoms of a UTI. On 6/12/14, a urine analysis (UA) was ordered. The resident was assessed to have no symptoms of a UTI. On 6/14/14, the MD ordered [MEDICATION NAME] for 10 days for Staphylococcus Lugdunensis greater that 100,000 col/ml (colonies per milliliter). He was treated with a broad spectrum antibiotic, thereby increasing his risk of developing a resistant strain of bacteria. ~On 7/2/14, a UA was completed along with blood tests as Resident #13 was combative with cares. There were no clinical symptoms of a UTI identified. The UA was negative and a culture and sensitivity was not done. 2. On 7/22/14, another UA was done as Resident #13 was having "angry outbursts" and his weight was going down. Another dipstik was done and was positive for white blood cells, protein, and [MEDICATION NAME]. Protein is indicative of possible kidney disease. This information was passed on to the MD and a UA was requested. The culture grew [MEDICAL CONDITION]. The bacteria is now also resistant to [MEDICATION NAME], the broad spectrum antibiotic given the previous month. Resident #13 was started on Bactrim DS (Double strength) for 10 days without adequate signs and symptoms of a UTI. ~On 8/6/14, another UA was done to test for the previous results [MEDICAL CONDITION]. As the resident had no symptoms the MD did not treat. ~On 8/28/14, a UA was ordered as the MD thought Resident #13 was a "chronic carrier" now. Surveyor # noted the UA results showed that [MEDICAL CONDITION] was resistive to [MEDICATION NAME] and the [MEDICATION NAME]. 3. On 9/14/14, a UA was ordered along with other blood work as Resident #13 was having increased difficulty with his transfers and decreased ambulation distance. There was no clinical symptoms of a UTI identified. This time the results were positive for protein, an "overwhelming number of white blood cells, and bacteria." The MD ordered Amoxicil ([MEDICATION NAME]) 500 for 10 days, which lab tests have shown Resident #13 to be resistant to. On 9/17/14, the final report came back indicating [MEDICAL CONDITION] was again resistant to [MEDICATION NAME]. The MD changed the order to [MEDICATION NAME]. On 10/2/14 at approximately 11:00 a.m., Surveyor # interviewed RN-E. RN-E stated she is aware of current standards of practice and if a resident test comes back with bacteria greater than 100,000 and the resident is not symptomatic, they do not treat with antibiotics. Surveyor # interviewed RN-E regarding antibiotic stewardship and when antibiotics are ordered for the residents. RN-E stated she is aware of current standards and they do not start an antibiotic until the culture comes back, but that the doctor may opt to initiate it anyway. Example #3: Resident #2 was admitted to the facility in February 2010. His [DIAGNOSES REDACTED]. On 2/10/14, he was started [MEDICATION NAME] milligrams (mg) at bedtime. The dose has continued in spite of the registered pharmacist's recommendation to the physician to decrease the medication on 5/28/14. The "Physician Communication Form" on this date, filled out by Registered Nurse (RN-E), states that in the past 7 nights the resident has slept for 6 1/2 to 8 hours per night but that it varies from week to week. Review of Residents #2's current plan of care states the resident has the inability to sleep related to his chronic health conditions and periods of wakefulness greater than one hour a night. The approaches are to observe for adverse effects of the medication such as a "hangover effect, lethargy, headache, and daytime drowsiness" and update the physician when these are seen. The second approach is to perform sleep assessment as needed, and assess the impact of his sleep on his physical status. Staff are to provide a quiet environment prior to bedtime, allow time to discuss his feelings, provide a comforting routine, assure his comfort at night, and offer a snack if he awakes. Review of the medical record found that staff was periodically checking on the resident every half hour to see if he was asleep. There was no assessment to determine his life-long sleep rituals, diet and caffeine intakes, the effect of his RLS on his sleep, the effect of pain on his sleep, napping, body and environment temperature, and environmental deterrents to sleep, etc. Ambien and hypnotic sleep aids have well documented side effects of strange behavior at night, vivid dreams, as well as increasing falls. Surveyor # reviewed Resident #2's falls since [MEDICATION NAME] started and noted the following 20 falls out of bed: ~2/11/14. Fall OOB (out of bed) at 4:20 a.m. Resident #2 was trying "to sit." Staff noted the recent medication changes. ~2/19/14. Fall OOB at 1:35 a.m. Resident #2 needed to "pee." No changes to the care plan. ~2/19/14. Fall OOB at 5:55 a.m. Resident #2 stated he "slipped." No changes to the care plan. ~2/19/14. Fall OOB at 8:55 p.m. No changes to the care plan, however the goal of care was changed to keep him injury free. ~2/21/14. Fall OOB at 3:35 a.m. Resident #2 had to "pee." His toileting plan was changed to every 2 hours. ~2/22/14. Fall OOB at 2:15 a.m. Resident #2 had to "pee." No changes to the care plan. ~2/23/14. Fall OOB at 4:15 a.m. Resident #2 was "feeding the chickens." No changes to the care plan. ~2/24/14. Fall OOB at 9:18 p.m. Resident #2 was going to "roast a pig." No changes to the care plan. ~4/20/14. Fall OOB at 2:15 a.m. Resident #2 was last checked at 12:30 a.m. No changes to the plan of care. ~5/11/14. Fall OOB at 11:15 p.m. he was last checked at 10:00 p.m. Resident #2 stated, "I just have to pee." No changes to the care plan. ~6/10/14. Fall with staff present during a transfer at 8:50 p.m. The fall investigation states the sleeping [MEDICATION NAME] a factor. Resident #2's knees buckled and he was lowered to the floor, and "resident stated he was sleepy." Although identified as a factor in the fall, there was no evidence of attempts to reduce the dose. ~7/20/14. Fall OOB at 9:20 p.m. The facility started a sleep assessment and is now checking on him every 30 minutes. ~7/22/14. Fall OOB 11:35 p.m. The doctor ordered an antianxiety medication to be given each night with the sleeping pill. An antianxiety may lead to further lethargy. ~7/24/14. Fall OOB at 12:05 a.m. There was no change to the care plan. Monitoring of the times awake and asleep were started. ~7/24/14. Fall OOB at 12:35 a.m. There was no change to the care plan. ~8/1/14. Fall OOB at 1:45 a.m. There was no change to the care plan. ~8/4/14. Fall OOB at 6:05 a.m. There was no change to the care plan. ~8/6/14. Fall OOB at 10:30 p.m. There was no change to the care plan. The monitoring of when he was asleep and awake continued. ~8/23/14. Fall OOB at 4:00 a.m. According to the falls investigation, the last time Resident #2 was seen was at 2:30 a.m. That is a 1 and 1/2 hour time span. ~9/19/14. Fall OOB at 11:00 p.m. There was no change to the care plan. There has been no attempt to taper the dosage in spite of the side effects. Example #4: Surveyor # reviewed the clinical record of Resident #12. A fax was sent to the resident's physician on 2/28/14 after the resident complained of burning with urination. The resident did not have any other symptoms to indicate a UTI. Even though she did not show clinical symptoms for a UTI, an in-house dipstik test was performed and showed positive results for white blood cells and blood. The MD ordered the antibiotic [MEDICATION NAME] DS twice daily to 10 days without waiting on culture results. On 10/2/14 at approximately 11:00 a.m., Surveyor # interviewed RN-E regarding antibiotic stewardship and when antibiotics are ordered for the residents. RN-E stated she is aware of current standards and they are not to start an antibiotic until the culture comes back, but that the doctor may opt to initiate it anyway. Example #5: On 6/5/14, the physician ordered a urinalysis and urine culture based on facility concerns regarding Resident #9's weight loss. The culture report indicated Resident #9 had 50,000 colony count of bacteria in her urine. On 6/9/14, the physician ordered [MEDICATION NAME] (an antibiotic). Even though Resident #9 had no signs or symptoms of a UTI, the antibiotic was started. On 6/9/14, the facility faxed the physician the urine culture and indicated Resident #9 was not symptomatic for a urinary tract infection [MEDICAL CONDITION]. The physician in response discontinued the [MEDICATION NAME]. On 7/2/14, the facility faxed to the physician a form titled "Medical Update/Change Order." The form indicated Resident #9 had increased fatigue had new episodes of incontinence and complained of burning with urination. The form also indicated the facility had obtained a urine dipstik which indicated abnormal values. The physician in response ordered a urinalysis and urine culture. The physician also ordered Bactrim (an antibiotic). The antibiotic was ordered prior to the urinalysis and urine culture being completed. The urine culture was negative. On 7/6/14, the facility faxed the physician the culture report. The facility indicated on the culture report that Resident #9 was not symptomatic for a UTI and an on-call physician had discontinued the antibiotic. Resident #9 received antibiotics for 5 days without adequate indications for use. On 9/24/14, the facility faxed the physician a form titled "Medical Update/Change Order." The form indicated Resident #9 had vaginal bleeding, had cloudy urine, and complained of frequency. The facility also completed a urine dipstik which indicated abnormal values. The physician in response ordered a urinalysis and urine culture. On 9/26/14, in response to the urinalysis, the physician ordered [MEDICATION NAME] (an antibiotic). The culture report had not yet been received. On 9/28/14, the facility faxed the physician the culture report. The culture report indicated Resident #9 had greater than 100,000 colony count of bacteria in her urine. The report indicated the bacteria was resistant to multiple antibiotics. The report also had handwritten information on it which indicated Resident #9 was not symptomatic for a UTI. The physician ordered to complete the antibiotic as ordered. Example #6: On 2/15/14, the facility completed a urine dipstik based on Resident #14's complaints of a burning sensation while voiding and cloudy urine. There were no other symptoms of a urinary tract infection [MEDICAL CONDITION]. The urine dipstik showed abnormal values. The facility faxed Resident #14's physician information regarding Resident #14's complaints as well as the abnormal urine dipstik. The physician, in response, ordered Bactrim (an antibiotic) and requested the facility to complete a urine culture. Resident #14 had a urine dipstik completed without definitive symptoms of a UTI and an antibiotic ordered prior to the results of a urine culture. Example #7: Surveyor # completed a review of Resident #15's clinical record and noted the following. On 3/2/14, the facility faxed the physician a form titled "Medical Update/Change Order." The form indicated Resident #15 had complaints of painful urination and cloudy urine. The form also indicated the facility completed a urine dipstik which indicated abnormal values. The physician in response ordered a urinalysis and urine culture. The physician also ordered [MEDICATION NAME] (an antibiotic). The antibiotic was ordered prior to a urinalysis and urine culture being completed. On 3/6/14, the facility faxed the physician a form titled "Medical Update/Change Order." The form indicated the urine culture for Resident #15 was never completed. The physician indicated to complete the course of antibiotics. On 10/2/14 at 1:30 p.m., Surveyor # spoke with RN-E. RN-E indicated she was the clinical manager and oversaw all residents in the facility. RN-E indicated residents were typically not placed on an antibiotics prior to receiving a urine culture report. RN-E indicated even if the culture report was positive, they would not treat with an antibiotic if the resident had no symptoms of a urinary tract infection.

Based on observation, interview, and record review, the facility did not ensure that 2 of 10 residents reviewed for falls, had an environment as free from accident hazards as possible. On 9/30/14, Resident #15 had a fall from the bed and was found face down on the floor. The post fall investigation indicated Resident #15's bed was not in low position and the floor mat was not in place at the time of the fall as directed by her plan of care. Resident #15 was subsequently transferred and admitted to the hospital and diagnosed with [REDACTED]. In addition, Resident #15 had a decline in condition including several falls. After each fall, the facility did not critically analyze the fall and implement new approaches to prevent further falls. Resident #2 had 33 falls since August 2013. The facility did not critically analyze the falls and implement new approaches to prevent future falls. This is evidenced by: Example #1: Resident #15 had current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) was dated 9/22/14 and indicated Resident #15: ~Had a BIMS (Brief Interview for Mental Status) score of 14, indicating Resident #15 was cognitively intact; ~Required extensive to total assist of 1 to 2 staff persons for all aspects of care; ~Did not walk; ~Weighed 194 pounds; and ~Had no falls. Resident #15's fall care plan was dated 5/22/13. The care plan had the following approaches: ~9/28/14, a bed and chair alarm which was handwritten in; ~9/29/14, a floor mat next to the bed which was handwritten in; and ~Undated, a low bed which was to be in low position except during cares. Resident #15's most current fall risk assessment was dated 9/2/14. The assessment indicated Resident #15 was at high risk for falls. An entry in Resident #15's nurse's notes, dated 9/29/14, stated, "...Clip alarm was sounding...found...kneeling next to her bed...stated 'I was trying to get a drink of water'...initiated 30 minute checks and a floor mat at bedside..." Surveyor # completed a review of a facility form titled "Investigation" dated 9/29/14. The form indicated Resident #15 was experiencing increased restlessness and had complaints of thirst. While the facility implemented a new approach of a floor mat, the reason for Resident #15's fall was not addressed. Resident #15 was blind, was thirsty, and was looking for something to drink. There were no approaches added to Resident #15's plan of care related to the cause of the fall. An entry on 9/30/14 stated, "...3:02 PM...found sitting upright at bedside on floor matt (sic) with BLE (bilateral lower extremities) in front of her...stating 'I wanted to get OOB (out of bed)'..." The facility's "Investigation" indicated Resident #15 was experiencing increased restlessness and increased thirst. Despite the facility's knowledge of Resident #15's increased restlessness and thirst, there were no new approaches added to Resident #15's plan of care to prevent further falls. A second entry on 9/30/14 states, "...8:24 PM...went into res (resident) room to check on an alarm going off...found res face down on floor. Blood noted to be coming from res nose...Large hematoma to R (right) forehead...Laceration to nose, Epistaxis (nose bleed) noted...Bed noted to not be in low position, floor mat found under bed...Res did begin c/o (complain of) headache...received order to send to...ER (emergency room )..." Resident #15 was admitted to the hospital. Resident #15's hospital records, dated 10/1/14, indicated, "...fall occurred from a bed. She fell from a height of 3 to 5 ft (feet)...landed on a hard floor. The volume of blood loss was large...The point of impact was the head...Nasal trauma with septal deviation. Massive blood from the right nare. Bridge of nose crooked and bruised. Massive blood from her mouth as well..." Resident #15 returned to the facility on [DATE]. On 10/2/14 at 10:45 a.m., Surveyor # observed Resident #15 in bed. The bed was in the lowest position and there was a mat on the floor next to Resident #15's bed. Surveyor # also noted 2 large bolsters on either side of Resident #15's bed. On 10/2/14 at 9:30 a.m., Surveyor # spoke with RN-E (Registered Nurse). RN-E indicated she was the clinical manager on the wing where Resident #15 resided. Surveyor # asked RN-E about their Fall Prevention Program. RN-E indicated when a fall occurs, the nurses working the floor are responsible to implement a new intervention. RN-E indicated each fall is then discussed during a "special needs" interdisciplinary meeting. RN-E indicated these occurred weekly or more often if needed. RN-E indicated the interdisciplinary team completes the investigation and determines the cause of the fall as well as the appropriateness of interventions in place. RN-E indicated she felt the facility had a good process in place for reviewing falls. On 10/2/14 at 10:30 a.m., Surveyor # spoke with the SW (Social Worker). The SW indicated she investigated Resident #15's injury fall on 9/30/14 and determined the CNA (Certified Nursing Assistant) responsible for Resident #15's care the evening of 9/30/14 had not followed Resident #15's plan of care. The SW indicated Resident #15's bed was not in the lowest position and the fall mat was noted underneath Resident #15's bed. The SW indicated it was the responsibility of CNAs to review each resident's plan of care prior to working. The SW stated the CNA caring for Resident #15 on the evening of 9/30/14 wasn't aware the floor mat hadn't been placed and didn't recall why Resident #15's bed had not been placed in the lowest position. The CNA who worked with Resident #15 on 9/30/14 was not available for interview. Example #2: Resident #2 is a long time resident of the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments, dated 1/21/14 and 8/22/14, found that Resident #2 requires the physical assistance of 1 caregiver to transfer and be mobile in bed. He also uses both a wheelchair and a wheeled walker. Resident #2's nursing notes, falls investigations, and timeline, revealed he has had 33 falls since August 2013. There was no root cause analysis of why he was falling out of bed, what he may have been trying to do, and no changes to the care plan. ~10/14/13. Fall onto the floor in his bathroom at 10:06 p.m. Resident #2 had his call light on, but stated he could not wait. A urine analysis was done and it was negative for an infection. No changes were made to Resident #2's care plan. ~1/13/14. Fall out of bed (OOB) at 5:10 a.m. Resident #2 stated he "slipped on the ice." An alarm was added to the bed, however, there was no root cause analysis completed in order to develop interventions to meet Resident #2's needs. Resident #2 had 2 more falls. The facility implemented a low bed and a mat following these falls. ~2/06/14. 2 falls OOB at 3:00 a.m. Resident #2 was found on his knees. The second time he was found on his bottom OOB. Resident #2 stated he "was experimenting." The staff helped him into his wheelchair (w/c) and brought him to the nurses' station to be observed. Resident #2 had just begun physical therapy. There was no assessment and no changes to the care plan. ~2/06/14. Fall from his w/c. Resident #2 was "trying to use his walker." The alarming Velcro self-release belt was placed on him. ~2/7/14. Fall from his w/c. Resident #2 was found when his alarming belt went off. Resident #2 was "trying to use the walker and I ended up on my hands and knees." Staff were then supposed to check on him every 30 minutes. ~2/8/14. Fall OOB at 3:45 p.m. Resident #2 was "trying to go to the bathroom." A concave mattress was put on his bed. There was no assessment of Resident #2's toileting needs even though he stated he needed to use the bathroom. ~2/8/14. Fall OOB at 11:40 a.m. Resident #2 was "changing belts on the generator." There was no assessment and no new intervention. ~2/10/14. Fall OOB at 1:30 a.m. Resident #2's alarm went off and he was found on the floor and stated he was "going to lunch." On 2/10/14, Resident #2 was started on Ambien for insomnia. ~2/11/14. Fall OOB at 4:20 a.m. Resident #2 was trying "to sit." Staff noted the recent medication changes but did not complete an assessment and did not make any changes to the care plan. ~2/19/14. Fall OOB at 1:35 a.m. Resident #2 needed to "pee." No changes to the care plan. ~2/19/14. Fall OOB at 5:55 a.m. Resident #2 stated he "slipped." No changes to the care plan. ~2/19/14. Fall OOB at 8:55 p.m. No assessment and no changes to the care plan, however the goal of care was changed to keep him injury free. ~2/21/14. Fall OOB at 3:35 a.m. Resident #2 had to "pee." His toileting plan was changed to every 2 hours. ~2/22/14. Fall OOB at 2:15 a.m. Resident #2 had to "pee." No changes to the care plan. ~2/23/14. Fall OOB at 4:15 a.m. Resident #2 was "feeding the chickens." No changes to the care plan. ~2/24/14. Fall OOB at 9:18 p.m. Resident #2 was going to "roast a pig." No changes to the care plan. ~4/20/14. Fall OOB at 2:15 a.m. Resident #2 was last checked at 12:30 a.m. No changes to the plan of care. ~5/8/14. Fall in the bathroom at 8:10 a.m. Resident #2's alarming seat belt alerted staff to the fact that he was already on the floor. There was no re-evaluation of the alarming seat belt. ~5/11/14. Fall OOB at 11:15 p.m. he was last checked at 10:00 p.m. Resident #2 stated, "I just have to pee." No changes to the care plan. ~6/10/14. Fall with staff present during a transfer at 8:50 p.m. The fall investigation states the sleeping pill Ambien was a factor. Resident #2's knees buckled and he was lowered to the floor, "resident stated he was sleepy." There was no evaluation of his transfer abilities or effects of his sleeping pill. ~7/5/14. Fall with staff present when he caught his foot on the mat at his bedside. The CNA was re-educated and and mat was changed out to one with a tapered edge. ~7/20/14. Fall OOB at 9:20 p.m. The facility started a sleep assessment and was now checking on him every 30 minutes. ~7/22/14. Fall OOB 11:35 p.m. The doctor ordered an antianxiety medication to be given each night with the sleeping pill. ~7/24/14. Fall OOB at 12:05 a.m. No change to the care plan. Monitoring of the times awake and asleep were started. ~7/24/14. Fall OOB at 12:35 a.m. No change to the care plan. ~8/1/14. Fall OOB at 1:45 a.m. No change to the care plan. ~8/4/14. Fall OOB at 6:05 a.m. No change to the care plan. ~8/6/14. Fall OOB at 10:30 p.m. There was no change to the care plan. The monitoring of when he was asleep and awake continued. ~8/23/14. Fall OOB at 4:00 a.m. According to the falls investigation, the last time Resident #2 was seen was at 2:30 a.m. That is a 1 and 1/2 hour time span. ~9/19/14. Fall OOB at 11:00 p.m. There was no change to the care plan. On 10/2/14 at 9:30 a.m., Surveyor # spoke with RN-E (Registered Nurse). RN-E indicated she was the clinical manager on the wing where Resident #15 resided. Surveyor # asked RN-E about their Fall Prevention Program. RN-E indicated when a fall occurs, the nurses working the floor are responsible to implement a new intervention. RN-E indicated each fall is then discussed during a "special needs" interdisciplinary meeting. RN-E indicated these occur weekly or more often if needed. RN-E indicated the interdisciplinary team completes the investigation and determines the cause of the fall as well as the appropriateness of interventions in place. RN-E indicated she felt the facility had a good process in place for reviewing falls.

Based on observation, interview, and record review, the facility did not ensure 1 of 8 residents sampled for falls had an environment as free from accident hazards as possible. Since 2/10/13, Resident #9 had 5 falls. After each fall, the facility did not complete a thorough investigation to determine the root cause in order to determine appropriate interventions to prevent further falls. 2 of the 5 falls resulted in injury, including a head trauma requiring an evaluation in the emergency room , and a pelvic bone fracture and thoracic spine compression fracture. This is evidenced by: According to the "Clinical Practice Guideline Falls and Fall Risk" after a fall occurs the following should be reviewed and/or assessed: ~ Medications; ~ Orthostatic hypotension; ~ The presence of underlying medical conditions affecting balance; ~ Dizziness or vertigo; ~ Bowel and bladder continence status at the time of the fall; ~ Foot wear at the time of the fall; ~ Changes in vision or hearing; ~ Illness; ~ Changes in functional status; ~ Lighting; ~ Bed height; ~ Loose carpeting or throw rugs; ~ Resident comments regarding the fall; ~ Changes in psychological status; and ~ Environmental factors at the scene of the fall. The guideline also indicated, "...Try to identify the causes of falling for each occurrence and for recurrent falling...recurrent falling often has fairly readily identifiable underlying causes...Managing the causes of falling requires working backwards through the chain of events ultimately resulting in the fall itself. Sometimes, the actual fall is just 'the tip of the iceberg'..." Resident #9 had current [DIAGNOSES REDACTED]. Resident #9's most current MDS (Minimum Data Set), dated 7/12/13, indicated Resident #9: ~ Had both long and short-term memory problems; ~ Required extensive assistance of 1 to 2 staff persons for transfers, toileting, bathing, dressing, and grooming; ~ Did not walk; ~ Was unable to maintain balance without staff assistance; and ~ Had 1 major injury fall. Resident #9's MDS dated [DATE], indicated Resident #9 walked with the assistance of 1 staff person in both her room and hallway. The MDS also indicated Resident #9 had 2 non-injury falls and 1 minor injury fall. Resident #9's most current CAA (Care Area Assessment) summary was dated 7/15/13. It indicated Resident #9 had historical falls. It also indicated, "...decreasing strength & (and) mobility with decline in ADL (Activities of Daily Living) function due to fracture left pubic ramus (pelvic bone) & T11 (11th thoracic spine) compression fracture s/p (status [REDACTED]. Resident #9's fall care plan was dated 9/12/12. The care plan had the following approaches: ~ Undated, "...Stationary alarm on in bed, assure proper alarm function...Do not leave unattended in bathroom...Bed in low locked position...Concave mattress..." ~ 9/17/12, "...Self Release Velcro Alarm Belt On In Wheel-chair, Assure Proper Function..." ~ 9/19/12, "...Hemi Tilt Back Wheelchair...Keep Wheelchair Away From Bed When In Bed..." ~ 2/12/13, "...Floor Mat Next To Bed When In Bed..." Resident #9's most current fall risk assessment was dated 5/20/13 and indicated Resident #9 was at high risk for falls. Surveyor # completed a review of Resident #9's current physician orders. The orders included daily Coumadin, a medication used to thin the blood. Resident #9's "Resident Incident Report" dated 2/10/13, "...Found laying on the floor at the bottom of her bed. Stated she was to going open the door...Immediate Post-Incident Action: Try to shorten the clip alarm string in bed..." Surveyor # completed a review of an "Incident Investigation" dated 2/12/13. It indicated, "...Requires assist 1 with transfers, ambulates with assist 1 with wheel walker...unsteady gait, poor concept safety, does attempt to self transfer, has stationary alarm on in bed, same was sounding...initially added clip alarm in bed but resident removes same...will change care plan and add floor mat at bedside..." According to the nursing notes, Resident #9 sustained no injuries. The "Resident Incident Report" for Resident #9 dated 3/11/13 indicated, "...stated 'called...didn't come...Ill (sic) do it myself'...transferring from w/c (wheelchair) to bed without requesting assist staff found sitting upright on buttocks..." Surveyor # completed a review of an "Incident Investigation" dated 3/22/13. It indicated, "...Attempted to self transfer from w/c into bed. Velcro alarm belt removed did not sound...Added clip alarm along with Velcro self release belt in w/c..." According to the nursing notes, Resident #9 sustained no injuries. To date, the facility had not completed a thorough investigation of each fall in attempts to identify the cause. The facility had relied upon different alarms which had been proven ineffective as well as a floor mat. The use of the floor mat is also in question as Resident #9 had the ability to walk. Surveyor # completed a review of a "Resident Incident Report" dated 3/18/13. The report indicated, "...CNA (Certified Nursing Assistant) walked into resident's room, found her sitting at floor by bedside. 2CM x 1CM (2.0 centimeter by 1.0 centimeter) abrasion to back of head, swelling apparent...Immediate Post-Incident Action: Clip alarm in bed..." On 3/18/13, Resident #9 was sent to the emergency room for an evaluation after changes were noted in her neurological assessment. According to the emergency room records dated 3/18/13, Resident #9 sustained a 7.0 cm by 6.0 cm bruise and abrasion to the posterior right head. Resident #9 was diagnosed with [REDACTED]. Surveyor # completed a review of an "Incident Investigation" dated 4/11/13. It indicated, "...Resident self transferred out of bed with fall at bedside. Stationary alarm on in bed same sounding....Added clip alarm on in bed..." This investigation was almost 1 month after the fall. The use of the clip alarm had been tried previously and was not effective. Surveyor # completed a review of a "Resident Incident Report" dated 4/9/13. The report indicated, "...Was being ambulated by CNA, when turning around feet got off balance and she lost her balance, was eased to the floor by CNA...Immediate Post-Incident Action: None..." Surveyor # completed a review of an "Incident Investigation" dated 4/15/13. It indicated, "...Isolated incident...No change in residents ability to transfer or ambulate...continue with current POC (Plan of Care)..." The facility identified balance issues. There was no indication the facility investigated the potential cause of the loss of balance. There were no new interventions put into place to prevent further falls. According to the nursing notes, Resident #9 sustained no injury from the fall on 4/9/13. Surveyor # completed a review of a "Resident Incident Report" dated 6/28/13. The report indicated, "...CNA told writer that res (resident) on the floor in bedroom. Stationary alarm was not ringing...R (right) big toe chipped and a 0.1 cm X 0.1 cm laceration under nail...Immediate Actions Taken: Initiated clip alarm & (and) changed stationary alarm on bed..." According to the nursing notes on the morning of 6/29/13, Resident #9 had difficulty transferring and had left hip and thigh pain. Resident #9 was subsequently sent to the emergency room and diagnosed with [REDACTED]. Resident #9 returned to the facility on [DATE]. Since returning to the facility there have been no new interventions added to Resident #9's care plan to prevent further falls. Surveyor # completed a review of an "Incident Investigation" dated 7/5/13. It indicated, "...Self transferred...stationary alarm...not sounding...No s/s (signs and symptoms) injury at time of fall...immediate intervention...replaced stationary alarm in bed and initiated clip alarm...DC (discontinue) clip alarm in bed." On 7/30/13 at 7:43 a.m., Surveyor # observed a foam floor mat under Resident #9's bed. The mat was noted to be approximately 1 inch thick. Resident #9 was noted to have balance problems. The use of a foam mat would significantly accentuate Resident #9's balance problems increasing the likelihood of falling should Resident #9 attempt to stand on it. On 7/31/13 at 9:15 a.m., Surveyor # spoke with LPN-I (Licensed Practical Nurse) about the facility's fall prevention program. LPN-I indicated the floor nurses were responsible to look at the cause of the falls and place new interventions, such as alarms and floor mats immediately to ensure a resident's safety. LPN-I indicated fall reports were then given to RN-E (Registered Nurse). LPN-I stated RN-E reviews the fall reports and determines the root cause of each fall. On 7/31/13 at 12:00 p.m., Surveyor # spoke with RN-E. RN-E indicated falls were evaluated by the nurses working the floor. RN-E indicated the nurses were responsible to place immediate interventions to prevent the reoccurrence of falls. RN-E indicated the nurses on the floor begin an investigation into every fall and she then completes it. RN-E indicated every fall is then reviewed with the interdisciplinary team. Surveyor # reviewed each of Resident #9's falls with RN-E. RN-E indicated the root cause of every fall was due to Resident #9's [DIAGNOSES REDACTED]. RN-E stated the root cause of each fall was Resident #9 had transferred herself and she was not safe to transfer independently.

Based on observation, interview, and record review, the facility did not ensure 5 of 6 residents reviewed for pressure ulcers received the necessary care and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. Resident #8 developed a stage II pressure ulcer to the back of her head. The ulcer deteriorated to an unstagable pressure ulcer with yellow slough and drainage. During this time the facility did not implement effective offloading strategies, did not measure and document the pressure ulcer according to current standards of practice, and did not follow current standards of practice for treatment of [REDACTED].#8's head. Resident #10 was admitted to the facility with a stage II pressure ulcer. To date, there was no dressing and/or barrier cream ordered. Observations revealed Resident #10 had a stage I pressure ulcer surrounding the stage II pressure ulcer. This had not been identified by the facility and no changes were made to Resident #10's care plan to promote healing. The facility did not accurately stage and treat Resident #4's pressure ulcer based on current standards of practice. Resident #6 has a stage II sacral area pressure ulcer. LPN-I did not follow the [MEDICATION NAME] insert instructions for management of superficial, dry to lightly exudating dermal ulcers. The [MEDICATION NAME] extra thin dressing that was applied did not extend at least 1 1/4 inch beyond the wound margin according to the [MEDICATION NAME] insert instructions. This would affect the healing process of the pressure ulcer. Resident #1 presented with a stage II pressure ulcer in March 2013. Documentation reviewed found only one assessment of the wound over the 16 days that the wound was present. This is evidenced by: Example #1: Resident #8 has a current [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) was dated 6/14/13 and indicated Resident #8: ~Had both long and short-term memory problems; ~Required extensive to total assistance of 1 to staff persons for bed mobility, transfers, bathing, dressing, grooming, eating, and toileting; ~Did not walk; ~Had a weight loss; ~Was at risk for the development of pressure ulcers; and ~Had no pressure ulcers. Resident #8's most current CAA (Care Area Assessment) summary for pressure ulcers was dated 3/25/13. It indicated Resident #8 had a decline in overall functioning, had no pressure ulcers, and was at risk for the development of pressure ulcers. The care plan interventions included a pressure relief cushion in the wheelchair, alternating pressure relief mattress on the bed, and regular repositioning. Resident #8's skin care plan was dated 7/20/10. It indicated Resident #8 had a stage II pressure ulcer on the back of her head directly on a fatty tumor. The goal was for the pressure ulcer to heal in 90 days. The approaches included: ~Undated, "...position every two hours in bed...Cushion on wheelchair seat...Keep linen & (and) clothing clean & dry, wrinkle free as able..." ~3/13/13, "...Alternating pressure relief mattress...gel foam cushion on wheelchair seat..." According to the care plan, the alternating air mattress was discontinued on 6/11/13, and re-instituted on 7/18/13. It indicated Resident #8 was at risk for the development of a pressure ulcer. Surveyor # completed a review of Resident #8's nursing notes and noted the following: ~7/16/13, "...Has new area to posterior head mass. size is 0.8cm x 1.3cm (0.8 centimeters by 1.3 cm) with yellow drainage noted...Dry dressing applied..." ~7/17/13, "...Dry dressing intact...small pea sized area of green drainage..." ~7/18/13, "...Open area on mass, moderate yellow drng (drainage) noted...Open area posterior head mass same size...0.8 x 1.3cm x 0.1 deep with yellow to green tinged drainage...repositioned frequently to keep pressure free does reposition self back..." ~7/23/13, "...Open area to back of head noted with increased size/drainage. This am (morning) measures 2.4 cm x 1.6 cm soft yellow tissue center with sloughing yelow (sic) tissue/drainage - slight odor...Currently cleansing...QD (every day) & applying DD (dry dressing) Q (every) shift until resolved...MD (Medical Doctor) updated..." No new interventions were implemented to reduce pressure even though deterioration of the pressure ulcer was evident. Nurse's notes continue: ~7/24/13, "...Pressure area...with no warmth or redness. Area with small yellow drainage...W/D (wet to dry) TID (three times a day)..." ~7/29/13, "...MD update on request to change res dressing from W/D...to dry dressing QD (every day)...This am measures 2.0 cm x 1.4 cm x 1.0 cm deep, scant amt (amount) of sloughing yellow tissue..." On 7/29/13 at 12:25 p.m., Surveyor # observed Resident #8 in bed and positioned on the left side. Surveyor # noted Resident #8's bed had an alternating bubble pad on the surface of the mattress. The pump was noted to be on and set at maximum pressure. Surveyor # noted the bubble pad to be firm to touch. On 7/30/13, Surveyor # observed LPN-I (Licensed Practical Nurse) with the assistance of CNA-M (Certified Nursing Assistant) complete a dressing change for Resident #8's pressure ulcer. Surveyor # noted Resident #8 had a lesion on the back of her head approximately the size of a large egg. LPN-I indicated it was a fatty tumor that Resident #8 has had since admission to the facility. LPN-I indicated the size of the tumor had not changed since admission. LPN-I also indicated Resident #8 had never had pressure related wounds on the tumor prior to the current pressure ulcer. LPN-I removed the old dressing. Surveyor # noted the dressing had a moderate amount of sero-sanguinous (bloody) drainage on it. LPN-I also stated the dressing had a small amount of yellow-green drainage. LPN-I cleansed the outer perimeter of the wound. Surveyor # noted the pressure ulcer was approximately 2.0 cm by 1.5 cm by 0.5 cm in depth. Surveyor # also noted the base of the wound was 100% covered with yellow slough. LPN-I obtained a sterile gauze pad, applied it directly onto the wound, and secured the gauze with kerlix. On 7/30/13 at 4:40 p.m., Surveyor # observed Resident #8 in bed lying on the left side. Surveyor # noted the dressing to Resident #8's pressure ulcer was off and that area of the head was resting directly on a regular pillow. Surveyor # also noted the bubble pad was still set at max and the pad was firm to touch. On 7/30/13 at 5:00 p.m., Surveyor # observed Resident #8 in bed positioned on her right side. There was no dressing on the pressure ulcer. Resident #8's head was resting directly on a regular pillow. On 7/31/13 at 7:44 a.m., Surveyor # observed Resident #8 lying in bed on her right side. There was no dressing noted on the pressure ulcer and Resident #8's head was again resting directly on a regular pillow. On 7/31/13 at 8:20 a.m., Surveyor # again observed Resident #8 lying in bed without a dressing on the pressure ulcer. Surveyor # noted a moderate amount of sero-sanguinous yellow tinged drainage on the pillow case. On 7/31/13 at 9:17 a.m., Surveyor # again observed no dressing on Resident #8's pressure ulcer. On 7/31/13 at 10:05 a.m., Surveyor # observed CNA-M and CNA-O assist Resident #8 with morning cares. There continued to be no dressing on Resident #8's pressure ulcer. CNA-O assisted Resident #8 with bathing and dressing. During the process of turning, Surveyor # observed the fatty tumor to the back of Resident #8's head was deeply red with a purple hue around the perimeter of the wound. Resident #8's hair was matted around the wound from drainage. On 7/31/13 at 10:55 a.m., Surveyor # observed RN-P (Registered Nurse) and RN-Q cleanse Resident #8's pressure ulcer and apply a dressing. RN-P also measured the pressure ulcer. RN-P began to measure the area in inches. Surveyor # questioned this and RN-P re-measured the area in centimeters as follows: 1.0 cm by 1.5 cm by 0.5 cm in depth. RN-P indicated the pressure ulcer would be staged as unstageable as the wound bed was 100% covered with yellow slough. Surveyor # also noted an area of tunneling at the 12:00 o'clock position measuring approximately 0.5 cm. Resident #8 had been without a dressing since 4:40 p.m. on 7/30/13 and with the pressure ulcer directly on a pillow. Although the length decreased, the width and depth remained unchanged. In addition, an area of tunneling was observed which was not previously identified. RN-P attempted to remove the matted hair from around the wound, then cleansed the outer perimeter of the wound and applied a dry dressing. On 7/31/13 at 11:12 a.m., Surveyor # spoke with CNA-O. CNA-O indicated Resident #8 did not have a dressing on the pressure ulcer when she arrived at 6:00 a.m. On 7/31/13 at 11:17 a.m., Surveyor # spoke with RN-P about the use of a dry dressing for Resident #8's pressure ulcer. RN-P indicated it was what the physician had ordered. According to Wound Care Education Institute, 2011, current literature demonstrates: -In an open wound with nothing to impede fluid evaporation, the tissue temperature has been measured at 21 degrees Celsius (69.8 degrees Fahrenheit). A gauze dressing placed in the wound does little to impede fluid evaporation and tissue temperature measures approximately 10 degrees below normal temperature. Reductions in tissue temperature have multiple physiologic effects all of which not only impede healing but increase susceptibility to infection. -Both retrospective and prospective clinical studies have shown that infection rates in wounds dressed with gauze are actually higher than that of wounds dressed with transparent films or [MEDICATION NAME]. -Gauze dressings (whether dry or moistened with saline) are substandard for optimal wound care. On 7/31/13 at 8:45 a.m., Surveyor # spoke with LPN-I. LPN-I indicated the facility did not have a wound team. LPN-I stated the nurses on the floor measure and document all new pressure ulcers and manage them on a day-to-day basis. LPN-I stated after the initial measurement, either RN-E or RN-R do the weekly measurement. On 7/31/13 at 12:00 p.m., Surveyor # spoke with RN-E about the facility's wound management program. RN-E stated they did not have a wound certified nurse and either herself or RN-R assessed wounds weekly. RN-E indicated the floor nurses were responsible to monitor and manage pressure ulcers on a day to day basis. RN-E stated the facility utilized several different dressing types depending on the specific needs of the resident, including the use of dry and wet to dry dressings. RN-E indicated Resident #8 was on a comfort care plan and was spending a lot of time in bed. RN-E indicated the staff turn Resident #8, however Resident #8 can turn herself back. RN-E stated Resident #8 had an alternating pressure relief pad, was being turned every 2 hours, and was getting up into a chair as tolerated. RN-E indicated there were no other pressure relieving modalities appropriate for Resident #8. Example #2: According to the "Clinical Practice Guideline Pressure Ulcers in Adults: Prediction and Prevention," skin should be protected from moisture due to incontinence, perspiration, or drainage by utilizing barrier creams. Resident #10 was admitted to the facility on [DATE]. According to the admission assessment dated [DATE], Resident #10 had a stage II pressure ulcer on the coccyx measuring 0.6 cm x 0.3 cm (0.6 centimeters by 0.3 cm). The admission assessment indicated a cushion was placed on Resident #10's chair and an alternating air mattress was placed on the bed. Surveyor # completed a review of Resident #10's admission skin care plan. It directed staff to treat the pressure ulcer as ordered. Surveyor # completed a review of Resident #10's admission orders [REDACTED]. On 7/31/13 at 8:30 a.m., Surveyor # requested to observe LPN-I complete a dressing change on Resident #10's pressure ulcer. LPN-I stated Resident #10 had no treatment ordered for the pressure ulcer. On 7/31/13 at 8:45 a.m., Surveyor # and LPN-I observed Resident #10's pressure ulcer. Surveyor # observed a stage II pressure ulcer measuring approximately 0.5 cm x 0.1 cm on Resident #10's coccyx. There was 3.0 to 4.0 cm of nonblanchable redness surrounding the pressure ulcer. Resident #10's buttock area was also deeply reddened. Resident #10 indicated the area was sore. Surveyor # completed a review of Resident #10's nursing notes. No nursing note identified with stage I pressure ulcer surrounding the stage II. On 7/31/13 at 9:20 a.m., Surveyor # spoke with CNA-N. CNA-N indicated she had assisted Resident #10 with morning cares. Surveyor # asked CNA-N if she had applied any type of barrier cream to Resident #10's buttocks. CNA-N indicated she had not. On 7/31/13 at 10:45 a.m., Surveyor # spoke with CNA-O about the facility's practice for applying barrier creams. CNA-O indicated CNAs never use any type of barrier creams for any residents. CNA-O stated the nurses applied all types of ointments including barrier creams. On 7/31/13 at 12:00 p.m., Surveyor # asked RN-E about Resident #10. RN-E stated she felt because Resident #10 was able to ambulate and adjust her position while seated and because Resident #10's pressure ulcer was healing with the use of the cushion and air mattress, no further treatment modalities were needed. Example #3: According to the standards of practice outlined by AMDA (American Medical Director Association), Pressure Ulcers in the Long Term Care Setting, "Clinical Practice Guideline" published in 2008: ~The first determination point is wound classification. ~If the ulcer is covered by eschar, the depth of the damage to the underlying tissue may not be initially evident and the ulcer can not be accurately staged. ~Wet to dry dressing; a form of mechanical debridement, is defined as an external force great enough to separate or break adhesive forces of necrotic tissue and can be painful. Designed to pull the scab away. The facility's own policy and procedures reflect the AMDA standards of care/classifications. According to Wound Care Education Institute, 2011: -Wet-to-dry dressings have little value for optimal wound management in today's health care environment. -Wet-to-dry debridement is not selective (it does not only remove the dead tissue) and often removes healthy tissues, causing re-injury. The patient may also suffer significant pain upon removal of a wet-to-dry dressing. -In an open wound with nothing to impede fluid evaporation, the tissue temperature has been measured at 21 degrees Celsius (69.8 degrees Fahrenheit). A gauze dressing placed in the wound does little to impede fluid evaporation and tissue temperature measures 25-27 degrees Celsius-still approximately 10 degrees below normal temperature. Reductions in tissue temperature have multiple physiologic effects, including local reflex [MEDICATION NAME] and [MEDICAL CONDITION], impairment of leukocyte mobility and phagocytic efficiency, and increased affinity of hemoglobin for oxygen- all of which not only impede healing but increase susceptibility to infection. -Both retrospective and prospective clinical studies have shown that infection rates in wounds dressed with gauze are actually higher that that of wounds dressed with transparent films or [MEDICATION NAME]. -In one dramatic in vitro study, it was shown that bacteria were capable of penetrating up to 64 layers of dry gauze. -Removing a dried dressing from a wound disperses significant amounts of bacteria into the air. Research has determined that airborne dispersal of bacteria was greatest from dry dressings; however, even removing moist gauze dressings released bacteria. -Gauze dressings (whether dry or moistened with saline) are substandard for optimal wound care. According to WCEI (Wound Care Education Institute), 2011, the temperature of a wound base covered in gauze is only 78.8 degrees Fahrenheit. Optimal temperature for healing a pressure ulcer is the individual's normal body temperature. The ideal dressing keeps the base of the wound the warmest. Resident #4 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the current MDS assessment, dated 4/19/13, Resident #4 requires extensive assistance of staff for bed mobility and transfers, is frequently incontinent of urine and is at risk for the development of pressure ulcers. Resident #4's "Assessment of Pressure Sore Potential," dated 1/24/13 and 4/20/13 indicated scores of 15 and 13 respectively. According to the form, staff should "follow pressure sore protocol" when a resident has a score of 7 - 39. Resident #4's care plan, dated 9/26/11, (sic) included a care plan for "Potential for skin breakdown." Approaches include to assist with repositioning and toileting every 2 hours, and gel foam cushion on wheelchair seat. Resident #4's care plan, dated 7/20/13, included "Temporary Problem: Pressure Sore, Location: Right medial superior buttock. Measurement: 2.5 open with 1.4 dark gray/black center. "Goal: pressure sore will be improved within ___ (left blank) days. "Approach: Assess pressure sore for severity, depth and size. Culture wound as needed, Refer to policy on pressure sores for specific interventions, measure wound weekly, report changes or lack of healing to the physician, assure CNAs (Certified Nursing Assistants) are providing for pressure relief, hydration, nutrition, supplementation, repositioning, meticulous skin care and other interventions as ordered per policy. Wet to Dry TID (three times a day) until resolved." Surveyor # reviewed faxes to the physician and nursing notes and noted the following: ~7/20/13-Nursing Note: Resident with stage II area to right medial superior buttock with stage II open area measuring 1.4 cm (centimeters) center dark gray/black. Surrounding tissue red granulating tissue measuring 2.5. Physician updated and ordered wet to dry dressing changes 3 times a day until resolved. Initiating alternating pressure relief mattress on bed. ~7/20/13-Fax to physician: Noted with stage II right medial superior buttock 2.5 cm, center soft dark gray/black slough 1.4 cm. Will assure clean dry pressure relief, ? (Question) w-d (wet to dry) tid (three times a day). Physician order: agreed. ~7/29/13 -Stage II to right medial superior buttock on 7/20/13 measured 2.5 centimeters by 1.4 centimeters with dark black slough. Currently being treated with wet to dry dressing 3 times a day. This a.m. (morning) decrease in size noted. Measures 1.5 cm by 1.4 cm center soft black sloughing tissue. 0 odor noted, 0 complaint of pain, Will continue current plan of care. Update sent to physician ? changes, reply pending. ~7/30/13 Physician order: agreed. On 7/30/13 at 1:11 p.m., Surveyor # observed LPN-D change the dressing on Resident #4's pressure ulcer. LPN-D stated the dressing was "wet to dry" and a "clean technique." Surveyor # questioned LPN-D as to the cause of the wound and she indicated she did not know. LPN-D did not measure the wound. Surveyor # observed an approximately 1 centimeter round dry, hard, black eschar located adjacent to the right side of the sacrum. The wound is an unstageable wound as the "scab" is substantial and covers 100% of the wound. On 7/31/13 at 10:30 a.m., Surveyor # met with RN-E, who is responsible for wound care in the facility. RN-E explained Resident #4 was first noted with a stage II pressure ulcer on 7/20/13 with staging done by the nurse. RN-E indicated the staging was inaccurate as a wound with eschar is unstageable. She explained she had not personally seen the wound until last Monday (7/22/13) or last Tuesday (7/23/13). RN-E indicated she did not note any changes to the wound classification or description in Resident #4's record; further indicating the care plan for Resident #4 was updated on 7/20/13 with a pressure relieving mattress being added and a physician order [REDACTED]. RN-E responded, it is what the doctor ordered. RN-E indicated the facility uses AMDA guidelines as the standard of practice for wounds. Example #4: Current MDS (Minimum Data Set) assessment dated [DATE], indicated Resident #6 requires extensive assistance of 1 staff with transfers, and extensive assistance of 2 staff for bed mobility and toilet use; does not ambulate; has 1 stage II pressure ulcer; and, significant weight loss. A nurse's note dated 7/9/13 at 12:56 p.m., indicated: "Resident noted with 2 stage II pressure areas on sacral area left side measuring 1 x 0.6 cm and right side measuring 1 x 1 cm with a 4 cm surrounding blanchable redness. 4 x 0.6 cm purple discoloration noted to left sacral area. MD (medical doctor) updated via fax ? [MEDICATION NAME] change Q (every) 3 days and PRN (as needed). Reply pending." This description is not on the Weekly Wound Assessment Report. On 7/16/13, Right Buttock, Wound Status: "Improved." Stage II, measuring, "1.50 cm x 0.60 cm x 0.00 cm. Wound Bed: [MEDICATION NAME] Tissue - 50%, Granulation Tissue - 50%." Wound Edges: same as above. Surrounding Skin is "pink, slight [MEDICAL CONDITION]." "Notes: Improvement in width noted, will cont. (continue) current comfort care plan, pressure relief care plan and [MEDICATION NAME]. Will observe for changes." Treatments: dated "(7/11/13) apply [MEDICATION NAME] to open area to sacral area Q (every) 3 days & PRN (as needed) until resolved." This description of the wound does not indicate improvement. On 7/23/13, Right Buttock, Wound Status: "unchanged," stage II, measuring "1.50 cm x 0.60 cm x 0.00 cm, no drainage. Wound Bed: [MEDICATION NAME] Tissue - 50.00%, Granulation Tissue - 50.00%, Wound Edges: Border definition-Distinct, Outline clearly visible. Description- Normal Health Skin. Surrounding skin: Normal...Notes: Cont. on Comfort Care Plan, Cont Current POC (plan of care), Assure pressure relief, 0 change at this timd (sic). Will cont [MEDICATION NAME] and monitor, 0 s/sx (signs/symptoms) of infection. Treatments: (7/11/13) Apply [MEDICATION NAME] to open area to sacral area Q 3 days and PRN until resolved." On 7/31/13 at 7:10 a.m., Surveyor # observed staff providing a.m. cares. There was no [MEDICATION NAME] on Resident #6's coccyx/buttock area. According to the treatment sheet, the night nurse initialed that at 4:00 a.m., the [MEDICATION NAME] was in place. Surveyor # observed the left buttock area and noted a dry open area, measuring approximately 2cm x 1 cm. The coccyx has a 0.5 cm area which is shiny and blanchable, thin, with redness surrounding the coccyx and buttock area. On 7/31/13 at 12:05 p.m., Surveyor # observed LPN-I reviewing Resident #6's buttock area to verify that the [MEDICATION NAME] was intact. LPN-I stated the [MEDICATION NAME] he put on this morning (approximately 7 a.m.) was curled up. The [MEDICATION NAME] was approximately 2.0 cm long and 0.5 cm wide and not on the open area. LPN-I removed the old [MEDICATION NAME], removed his gloves and washed his hands. Without cleansing the wound, LPN-I cut the [MEDICATION NAME] slightly beyond the wound margin and applied to the open area. Surveyor # asked LPN-I what is the size of the wound. LPN-I stated approximately 1cm x 2cm and that the wound does get measured once a week. On 7/31/13 at 12:15 p.m., Surveyor # asked LPN-I why he cut a 4 x 4 [MEDICATION NAME] to size and if the facility has different sizes of [MEDICATION NAME] dressings. LPN-I stated yes, the facility has different sizes but he cuts the [MEDICATION NAME] so it fits just over the size of the wound because the dressing is in a bad place and falls off a lot. According to the [MEDICATION NAME] Extra Thin insert instructions, "Preparing and Cleansing the Wound Site:" "[MEDICATION NAME] Extra Thin dressings are sterile and should be handled appropriately. Choose a dressing that will extend at least 1 1/4 inch beyond the wound margin. Cleanse the wound according to hospital practice. Irrigate with saline and dry the surrounding skin to ensure it is free of any greasy substance." The manner in which the [MEDICATION NAME] was cut did not extend 1 1/4 inch beyond the wound margins. On 7/31/13 at 1:53 p.m., LPN-I documented: "[MEDICATION NAME] to open area applied x 2 r/t (related to) same falling off...Admits to intermittent buttock discomfort which resolves with position changes.." There was no description of the wound documented. On 7/31/13 at 12:20 p.m., Surveyor # asked CNA-F if she knew Resident #6 was to have a [MEDICATION NAME] dressing on her buttock area. CNA-F stated no one mentioned Resident #6 had a dressing so she wouldn't have known it was off or else she certainly would have notified the nurse right away. Review of the CNA care plan found no mention that Resident #6 had a pressure ulcer with a dressing. Example #5: According to the NPUAP (National Pressure Ulcer Advisory Panel) position paper 2007, the minimum standard for wound assessment and and documentation is: When charting a description of a pressure ulcer, the following components should be a part of your weekly charting. ~LOCATION ~STAGE per NPUAP Definitions on previous page. ~DIMENSIONS: Always measure length, width, and depth and document it in that order. Always recorded in centimeters. *Length: Longest head-to-toe measurement. *Width: Longest hip-to-hip measurement. *Depth: Is measured by gently inserting a pre-moistened cotton tipped applicator into the deepest part of the wound. The measurement from the tip of the applicator to the level of the skin surface is the depth. If too shallow to measure record as "superficial." ~UNDERMINING/TUNNELING: Recorded in centimeters. Measurement done as if the resident is on a clock with the resident's head at 12 noon. *Undermining: Measure the extent of the undermining clockwise, then the deepest part of the undermining (i.e., 1.5 cm from 2-7 o'clock). *Sinus tracts/Tunneling: Measure the depth of the sinus tract/tunnel and give direction of the sinus tract/tunnel by the clock method (i.e., 3 cm at 3 o'clock). If there is more than one sinus tract/tunnel, number each clockwise. ~WOUND BASE DESCRIPTION: describe the wound bed appearance. If the wound base has a mixture of these, use the percentage of its extent (i.e., the wound base is 75% granulation tissue with 25% slough tissue). *Granulation: Pink or beefy red tissue with a shiny, moist, granular appearance. *Necrotic Tissue: Gray to black and moist. *Eschar: Gray to black and dry or leathery in appearance. *Slough: Yellow to white and may be stringy or thick and may appear as a layer over the wound bed. *[MEDICATION NAME]: New or pink shiny tissue that grows in from the edges or as islands on the wound surface. ~DRAINAGE: *Amount: Scant, moderate, or copious (small, medium, or heavy). *Color/Consistency: Serous, serosanguineous, purulent, or other. *Odor: If present or not. ~WOUND EDGES: Describe area up to 4 cm from edge of the wound. Measure in centimeters. Describe its characteristics (light pink, deep red, purple, macerated, calloused, etc.). ~ODOR: Present or not. ~PAIN: Associated with the wound. Interventions. ~PROGRESS: Improved, No Change, Stable, or Declined. Resident #1 has [DIAGNOSES REDACTED]. Surveyor # reviewed the current plan of care for Resident #1 and found the facility had determined that Resident #1 is at risk for skin breakdown due to "decreased strength & mobility, cancer, and incontinence." The plan of care indicated Resident #1 is dependent on the physical assistance of 1 or 2 staff members for all of his positioning, transfers, dressing, grooming, personal hygiene, and eating and drinking. Resident #1 has lost weight and is not eating enough to meet his body's requirements. Surveyor # reviewed the nursing documentation and treatment record for March 2013. The record states: ~3/11/13 at 10:48 a.m.: "(Resident) noted with stage II area to (sacrum) 0.8 cm open circumference with ICM (sic) redness surrounding same..." ~3/11/13 at 9:07 p.m.: "No change to pressure area to sacrum. No signs and symptoms infection at this time..." ~3/12/13 at 2:14 a.m.: "[MEDICATION NAME] applied to right sacrum area same center dry no drainage or redness..." ~3/12/13 8:56 p.m.: "[MEDICATION NAME] intact at this time no drainage noted no infection at this time..." This was the only documentation in the narrative notes until 3/27/13 that stated the pressure area has resolved. Surveyor # reviewed the treatment record and found the dressing was changed 5 times in that time period: 3/14/13, 3/17/13, 3/20/13, 3/23/13, and 3/26/13. There was no evidence of assessment or docuementation of the assessment of the wound.

Based on observation, interview, and record review, the facility did not provide care in a manner that allowed 2 out of 5 sampled residents to reach their highest practicable level of well-being. Resident #7 is receiving a [MEDICAL CONDITION] medication ([MEDICATION NAME] 0.5 mg) 1 hour prior to a shower once a week due to increase agitation and verbal outbursts during the shower. The facility had no evidence that a comprehensive assessment was completed to identify the reasons for the behaviors, no individualized approaches to address Resident #7's distress, and no monitoring of the individualized approaches to determine effectiveness. Resident #7 received 11 doses of [MEDICATION NAME] without proper indication for use, monitoring, or any attempt of non-pharmacological interventions prior to administering the [MEDICATION NAME]. Resident #6 began to display behaviors of attempting to leave the facility, restlessness, pacing, and striking out. There was no evidence the facility completed a comprehensive assessment to determine if the cause of the distress was remediable. There was no evidence that non-pharmacological interventions were attempted prior to obtaining an order for [REDACTED]." This is evidenced by: Example #1: Resident #7 has a [DIAGNOSES REDACTED]. Review of the most current MDS (Minimum Data Set) assessment, dated 7/5/13, indicated Resident #7 is severely cognitively impaired and requires total assist of 1-2 with all ADLs (Activities of Daily Living). [MEDICAL CONDITION] was identified. No behaviors indicated. Choosing a means of bathing is documented as being somewhat important for her. Resident #7's care plan included a problem of "Alteration in Thought Process...striking out, resistive with cares, spitting and kicking out, loud verbal outbursts, agitation..." dated 10/28/10. Interventions include diversional activities, gentle redirection, explain cares, and monitor behaviors. There was no indication the facility explored the reasons for Resident #7's behaviors and developed individualized approaches to reduce Resident #7's distress. Review of Resident #7's behavior monitoring roster does not indicate the targeted behaviors that were being monitored. The Behavior Monitoring Roster simply documents if a behavior is observed, if an intervention is tried, and the results. The MDSC (Minimum Data Set Coordinator) provided Surveyor # with a note which stated, "Behavior Monitoring - Angry Outbursts." According to facility staff, Resident #7 receives her shower on Sunday morning. Surveyor # reviewed all nurse's notes and behavior monitoring roster since 8/1/12 and found no documentation regarding any behaviors during the shower. Review of the Sunday behavior monitoring roster since 8/1/12, indicated behaviors 11 times with 4 of the times having no improvement with interventions of 1:1 or offering food/fluid. However, there was no documentation regarding what type of behaviors were happening during the shower nor any comprehensive assessment to determine what triggered the behavior: ~2/3/13, "Behavior not noticed." ~2/10/13, 12:23 p.m., "Behavior Noticed, Behavior Intervention: 1:1, Behavior Outcome: No change." ~2/17/13, 8:12 p.m., "Behavior Noticed, Behavior Intervention: 1:1, Behavior Outcome: Improved." ~2/24/13, 8:45 p.m., "Behavior Noticed, Behavior Intervention: Offer snack/fluids, Behavior Outcome: No change." ~3/3/13, "Behavior not noticed." ~3/10/13, "Behavior not noticed." ~3/17/13, "Behavior not noticed." ~3/24/13, "Behavior not noticed." ~3/31/13, 9:20 pm. "Behavior noticed, Behavior intervention: Other/refer to care plan. Intervention Outcome: Improved." ~4/7/13, "Behavior not noticed." ~4/14/13, "Behavior not noticed." ~4/21/13, 9:45 p.m., "Behavior noticed, Behavior Intervention: 1:1, Behavior Outcome: Improved." ~4/28/13, 9:00 p.m., "Behavior noticed, Behavior Intervention: 1:1, Behavior Outcome: Improved." ~5/5/13, 12:03 p.m., "Behavior Noticed, Behavior Intervention: 1:1, Behavior Outcome: Improved." ~5/12/13, 1:16 p.m.,"Behavior Noticed, Behavior Intervention: 1:1, Behavior Outcome: No Change." On 5/14/13, the facility obtained a physician's orders [REDACTED]. Beginning on that date, the MDSC indicated in a written note, "Behavior monitoring 1 - Increased s/s (signs and symptoms) anxiety/agitation, physical aggression, loud verbal angry outbursts during shower." Resident #7's "Alteration in Thought Process" care plan was updated on 5/16/13 to include "...striking out with shower..." Even though the facility had identified a trigger event, no non-pharmacological interventions were attempted to reduce Resident #7's distress in the shower. The approaches were updated to include "Medicate prior to shower as per MD order..." Review of the MAR (Medication Administration Record) found that Resident #7 received [MEDICATION NAME] at 8:00 a.m. every Sunday beginning on 5/19/13. Review of the Behavior Monitoring 1 Roster finds the following entries on Sundays: ~5/19/13, "Behavior not noticed." ~5/26/13, "Behavior not noticed." ~6/2/13, "Behavior not noticed." ~6/9/13, "Behavior not noticed." ~6/16/13, "Behavior not noticed." ~6/23/13, "Behavior not noticed." ~6/30/13, "Behavior not noticed." ~7/7/13, "Behavior not noticed." ~7/14/13, "Behavior not noticed." ~7/21/13, 1:26 p.m.,"Behavior not noticed. 8:49 p.m., Behavior noticed, Behavior Intervention: Medication, Behavior Outcome: Improved." ~7/28/13, "Behavior not noticed." There was no evidence that non-pharmacological interventions were attempted prior to the shower. There was also no evidence that changes to Resident #7's means of bathing were attempted to decrease her distress related to showering. On 7/5/13, the facility completed a quarterly [MEDICAL CONDITION] medication evaluation for Resident #7. The form indicated [DIAGNOSES REDACTED]. Episodes per month indicated: ~April 2013 for 1) - 15 episodes; ~May 2013 for 1) - 22 episodes, and 2) - 1 episode; ~June 2013 for 1) - 14 episodes, and 2) - 0 episodes. This amount included all behaviors on all days and does not specifically address the shower days as identified above. On 7/29/13 at 2:05 p.m., Surveyor # interviewed Resident #7's husband who stated his wife never complained about anything. He stated she loved to take a shower, sometimes twice a day depending on what she was doing. He also stated she loved to have her hair done weekly at the beauty shop. He stated no one ever talked to him about her shower or hair, but knew about the [MEDICATION NAME] prior to the shower and thought it was fine because he didn't want her to be so upset. On 7/29/13 at 3:25 p.m., Surveyor # spoke with CNA-L who stated Resident #7 is kind of mean with cares or getting up. CNA-L stated staff just let her be. CNA-L stated Resident #7 does like a bed bath, but doesn't like peri care. CNA-L stated Resident #7 will call other residents names and will sometimes spit food or medications. CNA-L stated the CNAs report all behaviors to the nurse and they document it. CNA-L stated on the evening shift there is no consistent staff; "our assignments are different almost every day." On 7/30/13 at 6:30 a.m., Surveyor # interviewed RN-K (Registered Nurse) who stated she does not give Resident #7 any [MEDICAL CONDITION] medications before her shower. RN-K stated Resident #7 gets her shower on Sunday morning and her behaviors consist of having loud angry outbursts. Showers are done on the day shift. "One time when I was training on day shift, Resident #7 had an angry outburst and I just talked nice to her, calmed her down, redirected her which was very effective." On 7/30/13 at 10:35 a.m., Surveyor # spoke with LPN-I (Licensed Practical Nurse) regarding Resident #7's behaviors. LPN-I stated he has given Resident #7 [MEDICATION NAME] prior to her shower as the computer prompts you to give it at 8:00 a.m. LPN-I stated Resident #7 gets extremely anxious and agitated regardless of approach, and with 2 people diversion will help. Her dementia makes it hard to determine what will work or not. LPN-I stated the [MEDICATION NAME] does work prior to the shower, as she will strike out and scoot herself to the edge of the chair making this behavior a hazard. On 7/30/13 and 7/31/13, Surveyor # observed a.m. cares. Resident #7 was not resistant to cares nor had any loud outbursts. On 7/31/13 at 10:00 a.m., Surveyor # spoke with CNA-B who stated Resident #7 does scream and yell out with her showers and that she is better with the [MEDICATION NAME]. On 7/31/13 at 10:20 a.m., Surveyor # spoke with SS-H (Social Services), who stated today she made up a sheet, "Interventions for a Calm Bathing Experience" to help identify triggers and what interventions work or not before administering medication. SS-H indicated the facility does not have a policy and procedure related to Dementia Care. At 2:00 p.m., SS-H stated the facility just identified the event which triggers Resident #7's distress as being staff washing her hair. This was all done after the surveyor started questioning the weekly [MEDICATION NAME] prior Resident #7's shower. Example #2: Resident #6 has [DIAGNOSES REDACTED]. On 1/1/13, Resident #6 was sent to the emergency room for left lower extremity swelling and was diagnosed with [REDACTED]. On 7/10/13, Resident #6 went on comfort care. Resident receives [MEDICATION NAME] Extended Release (MS04 ER) 60 mg twice a day. On 3/2/13 at 7:46 a.m., Resident #6 was having increased behaviors and was found in the shower room, sitting on the floor with her head against the register. According to the nurse's notes on 3/2/13 there was no injury noted. Neuro checks were within normal limits. Resident #6 complained of multiple aches and pains upon assessment but later denied pain. The Power of Attorney Health Care and the physician were notified. Neither felt it necessary to send Resident #6 to the hospital. An addendum was added under the 3/2/13 note: on 3/3/13 at 1:16 p.m., "2 cm abrasion to spine. [MEDICATION NAME] given 2.5 mg IM (inter muscular) to prevent injury to self or others. poa aware and agrees. dr...aware." Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Behavior monitoring sheets for 3/2/13 at 9:09 p.m., indicated: *Behavior Monitoring 1 (attempts to leave facility), Behavior noticed. Behavior intervention 1: redirection. Intervention outcome: no change. *Behavior Monitoring 2: (restless, obsessive pacing in wheelchair). Behavior intervention: 1:1. Behavior outcome: no change. *Behavior Monitoring 3: striking out at staff and increased anxiety. Behavior Intervention: Redirection. Behavior Outcome: no change. There was no documented description of the behavior or what triggered this behavior and if any other medical reasons could be the trigger, especially since Resident #7 fell earlier in the day. The facility implemented a temporary care plan on 3/2/13, for "Altered in mood state r/t (related to) agitation, anger, anxiety, confusion and wandering." There was no comprehensive assessment to determine the triggers or type of interventions that were effective prior to administering an antipsychotic medication. This care plan was resolved on 3/6/13. Resident #7 also received [MEDICATION NAME] 2.5 mg IM on: ~3/5/13 at 7:42 p.m. for increased anxiety and trying to get outside multiple times with no change in outcomes; and, ~3/8/13 at 6:17 p.m. with improvement for attempts to leave the facility. This is not an adequate indication to administer an antipsychotic medication. There was no harm to injury self or others. On 4/29/13 at 9:59 p.m., nurse's note, "Resident noted with increased agitation/anxiety, multiple attempts to exit facility, striking out at staff, 1 on 1, Redirection not effective. Primary MD updated via phone. Received T/O (telephone order) to give 1 mg [MEDICATION NAME] PO (by mouth) Now. May repeat in 6 hours if needed. Same administered per order. Not effective. Resident continued with behaviors. Resident still up at 9:45 p.m. hollering out. NOC shift to administer 11 p.m. dose. Will continue to monitor r/t behaviors. MD updated via Fax ? (questioning) PRN for increased agitation/anxiety. Reply pending..." Review of the MAR indicated [REDACTED] On 4/30/13, a nurse's note at 6:55 a.m. stated, "Res (resident) with increase behaviors this shift. Res with clenched fists, striking out at staff, biting, kicking, scratching, trying to leave facility and trying to stand unattended. Res was a danger to self and others. PRN [MEDICATION NAME] given was not effective. Called oncall MD for an order for [REDACTED]. On 4/30/13, a physician order [REDACTED]. On 4/29/13, a temporary care plan for altered mood state: r/t agitation, anger, anxiety, wandering and other: striking out at staff and attempting to exit building. Resolved 5/1/13. On 5/1/13, the facility developed a care plan related to "Alteration in Thought Process." The care plan did not address Resident #6's specific triggers and did not include individualized approaches to limit distress. According to the MAR, behavior monitoring and nurse's notes: ~5/15/13 at 8:21 p.m., [MEDICATION NAME] 5 mg IM given for combativeness and severe agitation. Follow up at 9:21 p.m., effective. Behavior Monitoring 1: Behavior not noticed. Behavior 2: Behavior not noticed. 3. Behavior Monitoring: Behavior not noticed. ~5/20/13 at 12:12 p.m., [MEDICATION NAME] 5 mg IM given for severe agitation. Behavior Monitoring 1: Behavior noticed. Behavior Intervention: 1:1. Behavior Outcome: No change. Behavior Monitoring 2: Behavior Noticed. Behavior Intervention: 1:1. Behavior Outcome: No change. 3. Behavior Monitoring: Behavior not noticed. Nurse's notes: Day shift, concerns with elevated INR to hold [MEDICATION NAME] and give Vit K 5 mg IM Now, PT/INR in a.m., Upper Respiratory Infection, Z-Pak medication for pneumonia. Open area on buttocks, apply [MEDICATION NAME] and had a fall while trying to ambulate self, lowered to the floor. "...required prn [MEDICATION NAME] for continued restless agitated combative behaviors..." Resident had an underlying illness for the behavior. [MEDICATION NAME] administration was not indicated. ~5/21/13 at 5:18 p.m., [MEDICATION NAME] 5 mg IM given for severe agitation, combative, multiple attempts to leave the facility and redirection and 1:1 not effective. Follow up at 7:02 p.m. medication not effective. Behavior Monitoring 1: at 9:21 p.m., Behavior noticed. Intervention: 1:1, Outcome: no change. Behavior Monitoring 2: 6:08 a.m. Behavior noticed. Intervention: redirected. Outcome: no change. 12:31 p.m., Behavior not noticed. 10:08 p.m., Behavior noticed, Intervention: 1:1, Outcome: No change. Behavior Monitoring 3: Behavior Noticed, Intervention: Medication. Outcome: No change. Nurse's notes, "...noted with increase agitation after supper leading to severe agitation after supper, PRN [MEDICATION NAME] administered. Same not effective. Resident continued with combative, aggressive behavior, attempts to self transfer > (more than) 20 times noted. Attempts to leave facility x 6 noted. 1:1, redirection not effective Resident in other resident rooms going through their belongings. No s/sx (signs/symptoms) of injury noted r/t fall..." On 5/22/13, physician ordered [MEDICATION NAME] (antipsychotic) 2.5 mg every day for Atypical [MEDICAL CONDITION]. This was later discontinued on 5/30/13. On 5/30/13, [MEDICATION NAME] 5 mg IM was discontinued. From 5/30/13 through 6/22/13, Resident #6 displayed behaviors as follows: *Behavior Monitoring 1 (attempts to leave facility), 3 times. *Behavior Monitoring 2: (restless, obsessive pacing in wheelchair), 9 times. *Behavior Monitoring 3: (striking out at staff and increased anxiety), 4 times. ~On 6/23/13 at 1:47 p.m., physician order [REDACTED]. Behavior monitoring 1: 12:17 p.m., Behavior Noticed. Intervention: Medication. Outcome: improved. Behavior monitoring 2: 12:17 p.m., Behavior Noticed. Intervention: Medication. Outcome: No change. Behavior monitoring 3. Blank # at 12:17 p.m., Behavior noticed. Intervention: Medication. Outcome: No change. Nurse's notes: "...agitation resolved following significant 1:1 as well as [MEDICATION NAME] x 1 now as ordered." There was no evidence that any non-pharmacological interventions besides 1:1 were tried. ~On 6/26/13 at 3:19 p.m., [MEDICATION NAME] 5 mg po was given for exiting the building and was resistant with coming back into the facility. Behavior monitoring 1: 9:07 p.m. Behavior noticed. Interventions: redirection. Outcome: no change. Behavior monitoring 2: 9:07 p.m., Behavior noticed. Interventions: medication. Outcome: no change. Behavior monitoring: at 9:07 p.m., Behavior noticed. Intervention: medication. Outcome: no change. Nurse's notes: "Res found outside of facility doors with activities staff coming to retrieve Res. as this was happening, Res struck staff several times with angry outbursts. [MEDICATION NAME] 5 mg po given at 3:30 p.m. with effect..." On 7/3/13, physician order [REDACTED]. This was discontinue on 7/9/13. ~On 7/13/13 at 8:52 a.m., [MEDICATION NAME] 5 mg po was given. Behavior Monitoring 1: Not noticed at this time. At 9:15 p.m. Behavior noticed. Intervention: Redirection. Outcome: improved. Behavior Monitoring 2: at 1:12 p.m., Behavior noticed. Intervention: Medication. Outcome: Improved. Behavior Monitoring: Behavior not noticed. Nurse's notes: no documentation related to behaviors. On 7/30/13 at 10:35 a.m., Surveyor # asked LPN-I about Resident #6. LPN-I stated Resident #6 gets agitated and tries to get up and walk. LPN-I stated Resident #6 displays physical aggression towards another resident. LPN-I stated staff will intervene with activities, snacks, and walking, then administer the IM [MEDICATION NAME] if those interventions are not effective. There was no evidence in the medical record of Resident #6 becoming aggressive with another resident and no evidence that non-pharmacological interventions were attempted prior to the administration of the [MEDICATION NAME].