Every finding on record at Arcadia Health and Rehabilitation Center

Based on observations, interviews, electronic medical record (EMR), and facility policy review, the facility failed to ensure the interdisciplinary team assessed and determined if a resident was capable of self-administration of medications for 2 of 23 residents sampled for self-administration of mediation. (Residents #118 and #392) The findings include: Resident #392 On 11/18/24 at 11:30 AM, Resident #392 was observed with a tube of Triamcinolone Acetonide (a cream meant to treat skin conditions such as eczema, dermatitis, and allergies) at the bed side. Resident #392 stated he uses this for general itching. He stated the nurses don't know he is using it, and he has been using this medication for [AGE] years. A second observation on 11/19/24 at 9:00 Am revealed the Triamcinolone cream was still at the bed side table. A review of the EMR for Resident #392 revealed diagnoses of Type 2 Diabetes Mellitus with other specified complication, presence of Cardiac Pacemaker, essential Hypertension, Hyperlipidemia, unspecified, benign Prostatic hyperplasia without lower Urinary tract symptoms, unspecified Atrial Fibrillation, Atherosclerotic Heart Disease of native Coronary Artery without Angina Pectoris, Peripheral Vascular Disease, personal history of Peptic Ulcer disease, other Asthma, Muscle weakness, and Chronic Obstructive Pulmonary Disease. A review of medication orders did not show any orders for Triamcinolone or a review by the physician on Resident #392's ability to self-administer his own medications. On 11/19/24 at 3:00 PM an interview with Staff A, a Licensed Practical Nurse (LPN) was performed. She was asked if any residents administered their own medications. Staff A stated that she did not know of any residents who self-administered medications. Staff A was shown Resdient #392's medication in his room. Staff A commented that this medication should not be there, and he does not have an order for it. She told the resident she will ask his doctor for an order. 28603 Resident #118 An observation of Resident #118 was conducted on 11/19/24 at 2:36 PM. The resident was in bed and a bottle of Osteo Biflex (a Glucosamine Chondroitin supplement) was observed on his over bed table. An interview was conducted with Resident #118 on 11/20/24 at 10:35 AM. Resident #118 stated he ordered the Osteo Biflex online, administers the medication to himself, and had previously discussed it with his physician. The bottle of medication remained on the over bed table. (Photographic evidence was obtained.) A review of Resident #118's EMR revealed no assessment for the resident to self-administer medications and no care plan for self-administration of medications. An interview was conducted with Employee G, an agency LPN, on 11/20/24 at 10:25 AM. She stated unless the physician approved otherwise, the facility should be administering and storing the Osteo Biflex. She did not know if Resident #118 had been assessed to self-administer medications. An interview was conducted with the Director of Nursing (DON) on 11/20/24 at 10:37 AM. She stated Resident #118 was not assessed to self-administer medications and he should not have the medication at bedside. She expected the staff to observe for medications at bedside and report to the nurse so the facility can screen the resident to determine if they are safe to self-administer medications. A review of the policy on Self Administration of Medication revealed, A resident may not be permitted to administer or retain any medications in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. Should the resident's attending physician permit resident to administer his/her medication(s), the following conditions will apply: The Physician's order must be given prior to self-administration Storage of medications in the resident's room must be such that it will prevent access by other residents. Only the medications permitted for self-administration shall be left at the bedside. The Interdisciplinary Care Plan Team must record in the resident's medical record that self-administration has been authorized and shall identify the name, strength, and quantity of each medication retained at the bedside.

Based on observation and staff interview, the facility failed to store resident care equipment in a sanitary manner in 3 of 24 sampled resident rooms. (rooms [ROOM NUMBER]) The findings include: An observation of room [ROOM NUMBER]'s bathroom was conducted on 11/18/24 at 4:02 PM. Three wash basins (2 labeled with 64 A and one not labeled) and an unlabeled bedpan were observed to be sitting on top of the sink. Further observations of room [ROOM NUMBER]'s bathroom was conducted in the presence of Employee F, the Licensed Practical Nurse Unit Manager, on 11/20/24 at 3:00 PM. Employee F observed and confirmed 3 basins stacked on top of each other and one unlabeled bedpan on top of the sink. She stated the items should be stored in the resident's bed side drawer. (Photographic evidence was obtained.) An observation of room [ROOM NUMBER]'s bathroom was conducted on 11/18/24 at 2:50 PM. Three unlabeled wash basins were stacked on top of each other and an unlabeled urinal was sitting on top of the sink. Further observation of room [ROOM NUMBER]'s bathroom was conducted on 11/20/24 at 3:05 PM in the presence of Employee F. Employee F observed the wash basins and urinal, then confirmed the items should be labeled and stored in the resident's drawer. (Photographic evidence was obtained.) An observation of room [ROOM NUMBER]'s bathroom was conducted in the presence of Employee F on 11/20/24 at 3:08 PM. An unlabeled wash basin, unlabeled emesis basin, and unlabeled urinal was observed sitting on top of the sink. Employee F observed the items and confirmed they should be labeled and stored separately. (Photographic evidence was obtained.)

Based on observations, interviews, and record reviews, the facility failed to implement the plan of care for 2 of 2 residents sampled for falls. (Residents #46 and #3) The findings include: On 11/18/24 at approximately 11:00 AM, Resident #46 was observed sitting on the fall mat beside the bed. Resident #46 was assisted by staff to return to their wheelchair. A review of the most recent care plan for Resident #46, dated 09/16/2024, described Resident #46 as having potential for falls/injury due to impaired safety awareness, being spontaneous, not remembering to use the call light or ask for assistance, and forgetting to use a walker. Part of her plan included using a Dycem mat in her wheechair's seat to prevent slipping out of the wheelchair. On 11/18/2024 at approximately 2:05 PM, and 11/19/2024 at approximately 1:20 PM and 2:50 PM, Resident #46 was observed using her wheelchair. The seat of the wheelchair was visible during observations and a cushion was used in the seat by Resident #46. However, no Dycem mat was observed in the wheelchair either above or under the cushion in the seat. During an observation and interview on 11/20/2024 at approximately 12:45 PM, Staff D, a Certified Nursing Assistant (CNA), was asked about Resident #46's Dycem mat. After checking Resident #46's chair, CNA D confirmed there was not a Dycem mat in the chair. CNA D proceeded to Resident #3's room and revealed that Resident #3 also did not have a Dycem in his wheelchair. CNA D immediately located the Dycem mat in Resident #3's room and placed it in the wheelchair. A review of Resident #3's care plan, dated 9/13/2024, indicated Resident #3 has a potential for falls/injury due to cerumen build-up, poor balance, seizure disorder, and attempts to remain independent. Interventions include Continue Dycem to w/c seat anti-lock brakes checked. On 11/20/2024 at approximately 2:15 PM, an interview was conducted with the Director of Nursing (DON), who, after reviewing resident #46 and #3's care plans, confirmed that both residents should have a Dycem mat in their wheelchairs. The DON stated the minimum data set (MDS) coordinator reviews and updates the quarterly assessments and audits to ensure interventions are completed.

Based on interview and record review, the facility failed to provide a Notice of Medicare Non-coverage for 1 of 6 residents reviewed. (Resident #8) The findings include: A review of the medical record on 1/16/2024 found no evidence of a Notice of Medicare Non-Coverage (NOMNC) issued to Resident #8 or the resident's representative. In an interview on 1/16/2024 at approximately 2:10 PM, the Director of Nursing (DON) was asked if Resident #8 had run out of Medicare covered days. She stated that, upon admission from the resident's previous facility, they thought Resident #8 had only utilized 32 bed days while at that facility. Resident #8 would have had 8-10 days left upon her discharge in September. They had not realized she had used 62 days at the previous facility. When they had last checked the billing days from the previous facility, it showed Resident #8 had used only 32 days. It was updated later by that facility to show she had 62 days had been used. The DON was asked if they had issued a Notice of Medicare Non-coverage (NOMNC) CMS-10123. She stated that they did not because they were under the impression, based on the first utilization review, that she had only used 32 days. Based on their calculations with the first utilization review of Medicare days from Resident #8's previous facility and her stay at Arcadia, they thought she had 8-10 days left when she voluntarily transferred to the ALF facility. They were unaware there was a bill sent to them until they received a certified letter from the sister of Resident #8, which was received on 1/12/2024. When asked if they should have issued a NOMNC, the DON stated that the days would have run out here if they had known about the 62 days utilized previously, so Resident #8 likely should have been issued a NOMNC. On 1/16/2024 at approximately 3:15 PM, the Director of Nursing brought a statement that noted an accounting of the Skilled Bed Days utilized by Resident #8. She stated that, on admission of Resident #8, the previous long term care facility had only billed for Skilled Nursing Care from 5/11/2023-5/31/2023. This is what they had when Resident #8 was admitted to the facility. The Resident was discharged on [DATE], and, when she left, the facility was unaware of the update to the previous facilities billing, so they thought she had bed days left. She validated that a Notice of Medicare Non-Coverage (NOMNC) was not issued because they thought Resident #8 had bed days left when she discharged . The facility Central corporate billing office found this in October and billed the family. The facility wasn't aware she had run out of Medicare days when she discharged from the facility.

Based on observations, resident interview, staff interviews, record review, and policy review, the facility failed to ensure the interdisciplinary team assessed and determined a resident was capable of self-administration of medications prior to allowing 1 of 33 sampled residents to self-administer medications. (Resident #106) The findings include: An observation and interview was conducted with Resident #106 on 6/20/2023 at 4:22 PM. A partial bottle of lanthanum carbonate, a partial Symbicort inhaler, and a bottle of Dakin's solution was observed to be sitting on the overbed table. Resident #106 stated he administers the lanthanum carbonate (a phosphate binder) himself because it must be taken when he eats. Further observations of Resident #106's room was conducted on 6/21/2023 at 2:00 PM. The medications remained on the overbed table, even though the resident was out of the facility. (Photographic evidence obtained.) Resident #106's record revealed no physician's order or assessment regarding the self-administration of the medications. A progress note dated 6/10/2023 indicated the resident had completed his own wound care. An interview was conducted with Employee A, a licensed practical nurse, on 6/21/2023 at 2:09 PM. Employee A stated the resident obtains medications on his own from a pharmacy. She confirmed there were some pills in the bottle of lanthanum carbonate after shaking the bottle. She stated there was no lock box in the resident's room. An interview was conducted with Employee B, a licensed practical nurse and unit manager, on 6/21/2023 at 2:27 PM. Employee B stated she was not aware of the process for residents to self-administer medications. An interview was conducted with the Director of Nursing (DON) on 6/21/2023 at 2:27 PM. The DON stated the resident should have been assessed to self-administer medications and she would expect staff to observe the medications at the bedside. The DON confirmed the resident had not been assessed to self-administer the medications. A review of the facility policy for self administration of medications states, A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. Should the resident's attending physician permit the resident to administer his/her medication(s), the following conditions the following conditions will apply: a. The physician's order must be given prior to self-administration; b. Storage of medications in the resident's room must be such that it will prevent access by other residents; c. Only the medications permitted for self-administration shall be left at the bedside; d. The Interdisciplinary Care Plan Team must record in the resident's medical record that self-administration has been authorized and shall identify the name, strength, and quantity of each medication retained at the bedside.

Based on observations, interviews, and record reviews, the facility failed to provide the necessary services needed to maintain personal hygiene to dependent residents for 2 of 3 residents sampled for Activities for Daily Living (ADL). (Residents #481 and #479) The findings include: Resident #481: On 06/19/23 at approximately 12:58 PM, an observation and interview were conducted with Resident #481. She complained of not receiving any help with a bath. Resident #481's hair appears matted and oily, and her general skin appearance noted an oily sheen. Resident #481's husband at bedside reported that he is upset that no one has helped her get a bath and confirmed no information was received upon admission about her plan of care, including bathing. On 06/20/23 at approximately 12:04 PM, an interview was conducted with Resident #481, in which she stated, I had therapy this morning, it went good, but I still haven't had a bath, haven't been offered any assistance with getting one since being here , I asked for some supplies a few days ago, but they didn't bring me any washcloths or towels, all I have is an empty basin, but what good is that going to do. I just need someone to help me, set me up so I can wash off. On 06/21/23 at approximately 10:19 AM, an observation of Resident #481 was made after she returned from hallway after visiting with husband. Resident #481 in bed, states I still haven't had a bath yet, remains in same gown, and confirms that she did not receive a bath at all. A review of Resident #481's Electronic Health Record (EHR) was conducted. Resident #481 was admitted to the facility on [DATE] from an acute hospital stay at a local hospital due to a fall at home in which she sustained a left hip fracture that required an Open Reduction and Internal Fixation (ORIF) procedure. An ORIF is a surgical procedure that puts pieces of a broken bone back into place using screws, plates, sutures, or rods to hold the broken bone together. Resident #481's 5 day Minimum Data Set (MDS) dated [DATE] reveals, Shower/bathe self: requiring substantial/maximal assistance. A review of Resident #481's care plan in the EHR includes, Requires assistance with self-care and mobility related to medical diagnosis with a goal stating I will have care needs met through the next review as evidenced by being clean, well-groomed and odor free daily. Date Initiated: 06/16/2023, and interventions allow resident to propel own wheelchair, discourage resident from attempting to ambulate independently, encourage resident to ambulate with care staff, provide adequate lighting. A review of Resident #481's Bathing Task reveals that the resident was not documented as bathed from the time of admission on 6/16/21 until 6/21/23 at 1:24 PM. On 06/21/2023 at approximately 1:00 pm an interview was conducted with LPN C, in which she was asked to explain bath schedules and how are they assigned, she replies, baths are assigned upon admission going by the 'shower schedule sheet', then it is input into the computer under task with specified dates and shift to be performed. Usually, I or the ADON input this into the computer, the admission nurse can do it if we aren't here, but we double check when we return. If a resident refuses a bath, the CNA documents the refusal under task in the EHR and on the 'shower schedule sheet', then has the nurse for the day to sign off on it as well, the ADON keeps a file of the 'shower schedule sheets'. A review of the Shower Schedule Sheet shows that bath/shower days and the shift to be received are assigned based on the room number a resident is admitted to, with Resident #481 assigned as Tuesdays, Thursdays, and Saturdays on the day shift. LPN C continues to explain, if a residents preference differs from the facility schedule, then it is changed on the task tab in the EHR as well as on the 'shower schedule sheet' paper. There is a question on admission assessment for shower preferences and the admission nurse goes over this with the resident or the family verbally upon admission, and they should receive a copy but doesn't know if [Resident #481] received this information or not. Residents or their families are usually notified of the scheduled bath days by the admission nurse. She stated that baths are double documented once under task on the EHR and again on the shower schedule sheet because nursing leaders want the CNA's or whoever gives the bath to document it both places, so that it can be monitored at a quick glance. LPN C was then asked when she would expect resident #481. LPN C accesses the EHR and confirmed Resident #481's bath/shower schedule under the task tab is set to occur on the 7am-3pm shift on Tuesdays, Thursdays, and Saturdays, and confirms the same schedule set for resident #481 on the paper shower schedule sheet. She confirmed that Resident #481 should have had a bath on Saturday 06/17/2023, but it was not documented as occurring. Nurse E sitting nearby at the nurses station during this interview voluntarily stated, I was [Resident #481's] nurse but I did not see if the resident had a bath that day or not, I was not told that she didn't by the CNA, and I don't remember signing the shower schedule sheet. LPN C confirms only one entry in the EHR for Resident #481 receiving a bath for the date of 06/20/21, and that it should have been more. RESIDENT #479: On 06/19/23 at approximately 12:40 PM, an observation was made of Resident #479 lying in bed with a food-stained gray T-shirt on, hair matted, and unshaven with dried brownish-yellow residue noted on bilateral sides of his beard. Resident #479 states, They haven't even gave me a bath since I've been here. I went and complained to someone in administration with short hair, earlier this morning because they haven't done anything for me since I got here. On 06/20/23 at approximately 11:50 AM, an interview was conducted with Resident #479. Resident #479 explains that physical therapy (PT) and occupational therapy (OT) came in yesterday, they did some exercising in the bed, and had him sit up to the edge of the bed, and OT had him to brush his teeth and do some weight lifting. Resident #479 states, a CNA changed my brief today but did not offer me a bath, did not wash my hair, or offer to shave. Resident #479 was wearing the same gray t-shirt as yesterday and appeared unkempt with food stains on shirt, unshaven, and with greasy hair. Resident #479 confirmed that no one has still discussed bath or shower days with him. A review of Resident #479's electronic health record (EHR) revealed Resident #479 was readmitted to the facility on [DATE] with a primary diagnosis of Pleural Effusion. Resident #479's MDS reveals an entry date of 06/15/2023 with the section Shower/bathe self scored as Dependent. A review of Resident #479's care plans included the following: Requires assistance with self-care and mobility related to medical diagnosis: Goal- will have care needs met through the next review as evidence by being clean, well-groomed and odor free daily; interventions include- allow resident to propel own wheelchair, discourage resident from attempting ambulation independently, encourage resident to ambulate with care staff, provide adequate lighting. Dated 05/24/23; revised 6/20/23; target date 8/22/23. A review of bathing documentation for Resident #479 on 06/19/23 reveals no bath documented as completed since admission on 06/15/2023. He is scheduled for baths to be performed on Tuesday, Thursday, and Saturday during the day shift. On 06/21/2023 at approximately 1:00 pm an interview was conducted with LPN C. LPN C confirmed that Resident #479 is scheduled to receive baths on Tuesdays, Thursdays, and Saturdays on the 7am-3pm shift and that he should have received a bath on Saturday 06/17/2023 and on Tuesday 06/20/2023, but maybe not on Thursday 06/15/2023 depending on what time he was admitted . LPN C was made aware of Resident #479's complaints of not receiving a bath since admission. LPN C agrees there is no additional clarifying documentation in the EHR from the CNA or a nurse on 06/17/2023 to clarify if the bath was received or not. Review of facility policy titled Shower/Tub Bath - Dependent Resident states: The purposes of this procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. Key Procedural Points: 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Insofar as practical, encourage the resident to participate in the bath care. 3. Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. 4. Use the emergency call signal to summon assistance, if needed. 5. Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters, or skin breakdown. 6. Trim the resident's toenails or fingernails unless otherwise instructed by the staff/Charge Nurse. 7. Should the resident become ill, faint, or uncooperative during the procedure, turn off the shower or open the drain plug. Cover the resident and summon the staff/Charge Nurse by using the emergency call system. Review of facility policy titled Shower/Tub Bath - Independent Resident states: The purposes of this procedure are to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin. Key Procedural Points: 1. Be sure that the bath area is at a comfortable temperature for the resident. 2. Observe the cognitive and functional ability of the resident to be independent in the shower/tub. 3. Assure the call bell is within reach of the resident and instruct the resident how to use the emergency call system to common assistance. 4. Observe the resident's skin for any redness, rashes, broken skin, tender places, irritation, reddish or blue-gray area of skin over a pressure point, blisters or skin breakdown. 5. Assure the care plan is up to date to reflect the resident's functional status and level of assistance/supervision needed. 6. If needed, assist the resident with the necessary equipment and supplies to perform the procedure and take them to the bath area. 7. Provide privacy to the resident, close the door/draw curtain. 8. Observe resident intermittently to ensure safety.

Based on observations, resident and staff interviews, and record reviews, the facility failed to provide appropriate care and treatment in accordance with professional standards to meet the physical needs for 2 of 5 residents sampled for non-pressure related skin conditions. (Residents #481 and #479). The findings include: Resident #481: On 06/19/2023 at approximately 12:55 PM, an observation was made of 2 adhesive gauze dressings to Resident #481's left hip after the resident voiced concerns that staff had not changed the dressings since admission. The dressings were not dated, timed, or initialed. When the resident was asked what the dressings were for, she stated, from surgery, I fell and broke my hip and they had to do surgery to repair it. On 06/20/2023 at approximately 12:00 PM, a second observation was made of 2 adhesive gauze dressings to Resident #481's left hip with no date, time, or initials. The dressing appeared to be the same dressing noted on the prior observation and was lifting on the sides. The resident confirmed that it was the same dressing and it had not been changed. When asked if staff assessed the area or offered to change it, she stated, no, I don't have any idea of what's going on or how it's supposed to be cared for. On 06/20/2023 at approximately 4:00 PM, an interview was conducted with Resident #481 in which she explained that she notified an unknown staff member upon returning from therapy just now, to please get a nurse to come look at the dressings on her left hip, stating it's hurting my skin, she said that she would let them know. On 06/21/2023 at approximately 10:15 AM, an interview was conducted with resident #481 who stated, a nurse or something came in last night and removed my dressings and said they were just going to leave it open to air. An observation of the site (left lateral hip area) reveals 2 surgical incisions each approximately 3 inches in length and currently uncovered. The upper incision appears well approximated with staples present, the lower incision appears well approximated with staples present, and both surgical incisions with minor redness near approximated edges. A review of resident #481's electronic health record (EHR) revealed no current, completed, or discontinued order for any wound treatment to left hip. A review of Resident #481's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of wound care to the left hip. The record reveals Resident #481 was admitted to the facility on [DATE] from an acute hospital stay at a local hospital due to a fall at home in which she sustained a left hip fracture that required an Open Reduction and Internal Fixation (ORIF). An ORIF is a surgical procedure that puts pieces of a broken bone back into place using screws, plates, sutures, or rods to hold the broken bone together. A review of Resident #481's 6/16/23 care plan in the EHR includes the following care plan: Potential/Actual Alteration in Skin integrity as evidence by risk factors decreased mobility and fracture with a goal stating I WILL HAVE A DECREASED RISK OF SKIN BREAKDOWN THROUGH THIS REVIEW PERIOD, with a target date of 09/14/2023 The care plan interventions include, assist with positioning as resident allows and tolerates, CNA to provide skin checks during delivery of care, CNA will report and skin changes, irritations or breakdown to Nurse, pressure reduction mattress, preventative treatment as ordered to bilateral heels, and provide and encourage adequate hydration and nutrition to maintain good skin turgor. A review of Resident #481's admission assessment dated [DATE] at 3:00 pm by Nurse C reveals the following documentation: Does resident have any skin issues? Yes. Skin conditions: Left hip ORIF with 2 incisions closed with staples. Moderate bruising to left hip and thigh. Moderate bruising to left upper arm. Scratch to left lower arm. Medium size bruise to right lower abdomen. Bilateral lower legs have some edema present. General skin condition: Warm Thick toenails Edema describe below). If edema present, describe: bilateral lower leg dependent edema. A review of resident #481's hard chart revealed a paper form titled Baseline Care Plan dated 06/16/2023, but does not address surgical incision wound care. On 06/21/2023 an additional record review of resident #481's current orders, MAR, and TAR revealed a new verbal order for Cleanse left hip and thigh incision area with Normal Saline, pat dry and cover with dry dressing. Use paper tape to secure per resident request, every evening shift dated 06/20/2023 at 2:02 pm and entered into the EHR by the Assistant Director of Nursing (ADON). Resident #481's MAR reveals this order as completed once on the evening shift of 06/20/2023 by Nurse E. On 06/21/2023 at approximately 10:30 AM, an interview was conducted with Nurse E, a Licensed Practical Nurse (LPN) assigned to care for Resident #481. When Nurse E was asked about Resident #481's wound care to left hip, she states, I looked at it yesterday and it was dry and intact, I took the dressings off yesterday around 6pm, I didn't cover it back up, but I did clean it with normal saline, and left it open to air. When asked to confirm the wound care order for Resident #481, Nurse E confirmed that the wounds should be covered at this time, and she did not cover it back up yesterday after removing it but should have. Nurse E was asked to explain the process of wound care or how orders are received when a resident is admitted . She stated, Usually the unit manager gets an admit packet and puts in orders, and allergies into the chart, so that all we have to do is an assessment and a skin sweep, and activate the orders. If the resident has a wound, we notify the Nurse Practitioner (NP) and they put in the order. If the NP is not here, we contact telehealth and they order it, and can even view the wound on the tablet. Nurse E continued to explain that if a resident is admitted with a wound, it should be addressed, and orders should be put into the chart. Nurse E confirmed there was no order for the care of Resident #481's wound prior to 06/20/2023, and stated, I wish that the wound care nurse had to see every new admission. Nurse E agreed that if it was not ordered and care was not documented that it was not done. Nurse E continued to explain that the Assistant Director of Nursing (ADON) is the primary wound care nurse and that LPN C, Unit Manager, will sometimes assist Nurse G with wound care. Nurse E states, [The ADON] put in an order yesterday for [Resident #481's] wound care, but I'm not sure how she knew to do that. On 06/21/2023 at approximately 1:00 PM, an interview was conducted with LPN C, Unit Manager, in which she was asked to explain the admission assessment process and how they identify and care for a newly admitted residents immediate needs. LPN C states, a baseline care plan is started by the unit manager, then handed off to the admission nurse who finishes it and gets the resident or family to sign. LPN C reviewed Resident #481's baseline care plan and agreed with surveyor findings that no skin or wound care is noted and confirms the admission paperwork sent from the local hospital does include a surgical wound to the left hip. LPN C continued to explain that the wound care nurse sees every new admission and sends out a weekly report via email to department heads, but Resident #481's assessment would not show up on the email until next week because Resident #481 was admitted on Friday. LPN C verifies that there was no documentation in the EHR by the wound care nurse for this resident. LPN C states, I don't think we even got a report from the hospital on this resident, sometimes we don't even know what all is wrong with the patient because the hospital doesn't send everything. When asked to review Resident #481's History and Physical (H&P) that was sent from the hospital upon admission to the facility, she confirmed that it did show a surgical incision to left hip and confirmed the primary admission diagnosis of Left Hip Fracture with Surgical Repair. LPN C continued to review Resident #481's hospital paperwork and stated, according to this, that dressing shouldn't have been removed until 7 days post operation. LPN C was asked if that order was entered into Resident #481's EHR upon admission or included in the baseline care plan so that staff would know how to care for Resident #481's basic needs. LPN C responds, not that I can see in the record, the admission nurse would have to activate orders for that. LPN C continued to explain, I know the NP saw her Monday. LPN C agreed that care for Resident #481's surgical incision should have been ordered upon admission into the facility and included in the baseline care plan but was not. On 06/21/23 at approximately 1:55 PM an interview with the ADON. She was asked to explain the process of assessment upon admission and caring for a resident with a wound. She stated, it depends on what type of wound first, but the nurses should assess each newly admitted resident and document any abnormal skin findings. If it's a surgical wound we would use the initial surgical incision care orders that come from the hospital or ortho doctor, etc., then they are entered into the EHR by either myself, the Unit Manager, or the admission nurse. If the resident is not admitted with orders for wound care, then we assess the wound and contact the NP for confirmation to continue the current order, change the order, or discontinue the order. [Resident #481] was admitted on Friday and was seen on Tuesday morning by me, and I contacted the NP and verified to continue the order and she said she would see the resident upon next round. The wound care nurse or alternate would assess the resident the next workday (because they work Monday- Friday) and obtain orders. The admission nurse should assess skin and document findings, if wound care is not present then they should contact the doctor or NP for further orders, and not wait for the wound care nurse. The ADON denied the facility uses any standing orders regarding wound care. The ADON agreed that any topical medication used for wound care would also require an order and this was not done on Resident #481. The ADON confirmed there is no documentation by the wound care nurse or any other nurse to support Resident #481's surgical wound being monitored, dressings changed, or wound care being performed since admission, other than on 06/20/23 by Nurse E. On 06/22/2023 at approximately 11:35 AM an interview was conducted with the wound care nurse. She explained that she usually sees every newly admitted resident with a Pressure Ulcer or any complicated wound that would require close monitoring, packing, that is infected, or is a dehisced surgical incision. She stated, I'm not certified in debridement so our Physician Assistant (PA) would do that. We usually round every Tuesday. She explained that she does not assess or round on every new admission with skin issues and also does not round on any resident that is receiving wound care from outside the facility. The nurse stated that her expectations in regard to a new admission with a skin tear or a surgical incision is that, the admission nurse would assess the resident and implement orders from either the 3008 or contact the doctor or nurse practitioner to get an order for wound care and enter it into the EHR. Resident #479: On 06/19/23 at approximately 12:40 PM, an observation was made of an adhesive gauze dressing to Resident #479's left forearm/elbow area. The dressing was not dated, timed, or initialed. When the resident was asked why the dressing was in place, he explained that it is covering a wound. Resident #479's confirmed that the wound to his left forearm/elbow area was present upon arrival to this facility. When Resident #479 was asked if staff here are caring for the wound and performing dressing changes, he states, no, they've only changed it once since being here. Resident #479's wife at bedside then states, it's from him hitting it on the bedrail at the hospital, it did look really bad, because it ripped a big piece of skin off, but I haven't seen it lately though because no one has done anything for it, that dressing has been there for days, I went and complained to someone in administration earlier this morning because they haven't done anything for him since he got here. On 06/20/23 at approximately 12:00 PM, an observation was made of Resident #479 with an adhesive gauze dressing in place to left forearm/elbow area, with a handwritten date on the exterior surface of the dressing of 6/19/23. Resident #479 was asked if his wound to the left forearm/elbow area is improving, in which he responded, I don't know because I haven't seen it. He was then asked to describe and confirm if wound care was completed since the dressing now included a date, he states, I don't think it was changed. On 06/20/23 at approximately 4:10 PM, an observation and interview were conducted with Resident #479, who states, I finally had a bath today and went to therapy, it was great. Resident #479 was observed sitting up in a chair at bedside, an adhesive gauze dressing remains in place to left forearm with the same appearance as earlier. An additional adhesive gauze dressing was noted to the right inner thigh with no date, time, or initial. Resident #479 explained that the dressing is in place due to a reaction he had to a medication while he was in the hospital that caused itching, which caused drainage. The resident's wife at bedside confirmed the dressing to his right thigh has not been changed since admission. A review of Resident #479's EHR was conducted and revealed no current, completed, or discontinued orders for wound treatment to left forearm/elbow area or right thigh since admission. A review of Resident #479's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of wound care to left forearm/elbow area or right thigh. The record reveals Resident #479 was readmitted to the facility on [DATE] with a primary diagnosis of Pleural Effusion. A review of resident #479's care plans included the following: POTENTAL/ACTUAL ALTERATION IN SKIN INTEGRITY with goal to have decreased risk of skin breakdown through this review period, with interventions include: assist with positioning as resident allows and tolerates, CNA to to provide skin checks during delivery of care, CNA will report any skin changes, irritation or breakdown to nurse, pressure reduction mattress, preventative treatment as ordered to bilateral heels, provide and encourage adequate hydration and nutrition to maintain good skin turgor. Date Initiated 05/24/23; revision on 05/24/23 with target date of 08/22/23,Potential for bleeding r/t anticoagulant therapy. A review of Resident #479's admission nursing assessment dated [DATE], reveals, Left ear small scab, Left forearm skin tear, General facial petechiae, Bilateral arms bruising, petechiae, Left hand swelling and bruising, Right hand bruising, Right arm IV sites x 3, Left shin skin tear, Petechiae/discoloration bilat lower legs, Edema, legs. A review of the provider progress note assessment dated [DATE] at 1:23 pm reveals, Skin: Warm and dry, no rashes, Scatter bruising. A review of Resident #479's H&P from a local hospital dated 06/06/2023 states, LUE has 3+ weeping edema as well as a 10cm skin tear. A review of resident #479's Patient Transfer Form dated 06/15/2023 from a local hospital reveals a documented skin tear to left forearm. On 06/21/23 at approximately 9:45 AM, an observation noted that Resident #479's left forearm/elbow area and right inner thigh dressings were no longer in place. Resident #479 reported that the dressings were not changed yesterday and that an unknown nurse or someone over the nurses came in this morning about 30 minutes ago and said that she was going to have someone else come in and put a bandage on it. Observation the left forearm/elbow area reveals a skin tear, approximately 10 cm in diameter with skin-flap missing, dried blood and yellow crusty drainage present, the wound is uncovered or open to air at this time. The right inner thigh wound had a scabbed circular area of less than 1 cm in diameter, no drainage noted. Per Resident #479, the nurse said that she was going to leave that dressing off. On 06/21/23 at approximately 10:54 AM, an interview was conducted with Nurse E, who confirmed that she was assigned to care for Resident #479 today. Nurse E was asked about the wound to Resident #479's left forearm/elbow area and she stated, I just did his wound care. Nurse E was then asked to explain or verify the orders for Resident #479's wound care. Upon review, she stated, well, I don't see any orders right now but I cleaned it with normal saline and applied triple antibiotic ointment to it and covered it with a dressing, The wound care nurse went in and removed the dressing to his left elbow and his right thigh this morning and got with me and told me to make sure that I get his wound care done on his arm. Nurse E continued reviewing Resident #479's EHR for wound care orders, explaining that she would expect an order to either be on the MAR or TAR. Nurse E confirmed there is no order for wound care and no other documentation to support or confirm that wound care, dressing change, or continued assessment of the wound has been performed on Resident #479 since admission. Nurse E agreed that an order should have been in place for Resident #479's wound care based on the admission assessment and prior to treatment. On 06/21/2023 at approximately 1:00 PM, an interview was conducted with LPN C, Unit Manager, who was asked if an order was obtained or entered into Resident #479's EHR upon admission or included in the baseline care plan so that staff would know how to care for Resident #479's basic needs and wounds. LPN C confirmed the admission paperwork sent to the facility does notate a skin tear to the left forearm/elbow area. LPN C verified that there was no documentation in the EHR by the wound care nurse for this resident. LPN C agreed with the surveyors findings that care for Resident #479's skin tear should have been addressed upon admission, an order should have been obtained or verified with the doctor or NP then placed in the residents chart/EHR and included in the baseline care plan but was not. Review of facility policy titled Admission Orders states: It is the policy of the facility to provide care and services related to admission orders, according to state and federal regulations. PROCEDURE: 1. The facility will have physician orders (standardized form 3008) for the resident's immediate care, at the time of a resident's admission. 2. The admitting nurse will call the attending physician and clarify all orders on admission. 3. The admitting orders will be and entered into the facility electronic medical record. 4. The EMR transmits electronically to the pharmacy and the nurse will call the pharmacy to ensure receipt of the resident's medications on the next pharmacy delivery. Review of facility policy titled Skin Tears, Care of states: The purpose of this procedure is to provide guidelines for the care and antisepsis of breaks in the skin, minor lacerations, and abrasions. Procedure Guidelines: 1. When a skin tear is discovered, render the following care: a. Wash hands or sanitize hands with ABHR (if not visibly soiled) and put on gloves. b. If wound is bleeding, apply compress gently. c. If the bleeding does not stop, or if the wound needs medical attention, notify the physician. d. If appropriate, wash the site with soap and water, then wash hands or sanitize hands with ABHR (if not visibly soiled). e. Treat per center protocol or MD order. f. Remove gloves and discard into appropriate receptacle. g. Wash hands or sanitize hands with ABHR (if not visibly soiled). 2. Perform wound care per Center protocol. a. Complete an Exception Report UDA. Review of facility policy titled Dressings Sterile states: Purpose: The purposes of this procedure are to provide guidelines for sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria; Step #22. Apply the ordered dressing and secure with tape; Reporting and Documentation - The following information may be documented in the resident's electronic medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care given. 3. If the resident refused the treatment and why. Review of facility policy titled Dressings Non-Sterile states: The purposes of this procedure are to provide guidelines for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria: Step #19. Apply the ordered dressing and secure with tape. Reporting and Documentation - The following information may be documented in the resident's electronic medical record: 1. The date and initials of the person that performed the procedure. 2. Type of dressing used and wound care given. 3. If the resident refused the treatment and why. Review of facility policy titled Care Plans- Baseline states: A baseline plan of care shall be developed for each resident admitted . Policy Interpretation and implementation: 1. To assure that the resident's immediate care needs are met and maintained, a Baseline Care Plan is developed upon admission. 2. The admitting nurse reviews the attending physician's order (e.g., diet, medications, treatment, etc.), and implements a nursing care plan to meet the resident's immediate care needs. 3. To assure that the resident's immediate care needs are met and maintained, a Baseline Care Plan is developed upon admission. 4. The admitting nurse reviews the attending physician's order (e.g., diet, medications, treatment, initial goals, therapy services, social services, PASRR recommendation, if applicable, etc.) and implements a nursing care plan to meet the resident's immediate care needs. 5. Baseline Care Plans are used until the Comprehensive Care Plan has been completed. 6. The center must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: o The initial goals of the resident o A summary of the resident's medications and dietary instructions o Any services and treatments to be administered by the center and personnel acting on behalf of the center o Any updated information based on the details of the comprehensive care plan, as necessary.

Based on record reviews and interview, the facility failed to follow the plan of care for 1 of 2 residents sampled for tube feeding (#68) and 1 of 5 (#63) sampled for unnecessary medications. The findings include: On 2/9/21 a record review was conducted for resident #68. The resident is dependant on tube feeding for nutrition. The plan of care was reviewed and included interventions to check gastric residuals before each feeding and administration of medications and check for tube placement before each feeding and administration of medications. A review of the electronic Medication Administration Record [REDACTED]. A record review was conducted for resident #63 who has [DIAGNOSES REDACTED]. The plan of care included the interventions for alteration in mood and behavior. The interventions included to monitor and document behaviors and to observe for side effects of medications. A review of the eMAR was conducted and revealed there was no documentation for monitoring for side effects on night shift on 12/2/20, 12/11/21, 12/20/20 and no documentation on evening shift (3PM to 11PM) on 12/29/20 and on day shift on 2/5/21 and 2/9/21. There was no documentation for behavior monitoring on night shift on 12/2/20, 12/11/20,12/20/20 or evening shift on 12/29/20, day shift on 1/26/21 or night shift on 1/4/21 or evening shift on 1/7/21 and 1/14/21. On 2/10/21 at approximately 2:11 PM, an interview was conducted with the Director of Nursing (DON). The DON stated blank spaces on the eMAR indicated the documentation was not completed. The DON stated she noticed a problem with the documentation when she started working at the facility about 3 weeks ago. The DON stated she has been educating the nurses on documentation but has not created a quality assurance performance improvement project as of yet.

Based on observations, record reviews, staff interviews, the facility's policy for medication and insulin administration, review of the Centers for Disease Control and Prevention guidelines, and the manufacturer's guidelines, the facility failed to adhere to infection control procedures by failing to use insulin pens per the manufacturer's specifications. The facility's failure to adhere to infection control procedures affected 2 of 10 sampled residents, out of a total of 22 residents currently receiving insulin via [MEDICATION NAME] and standard injection. The same [MEDICATION NAME] Insulin [MEDICATION NAME] was used for two separate residents (#69 & #27). This practice can lead to the spread of blood-borne pathogens such as [MEDICAL CONDITION] viruses and /or human immunodeficiency virus ,[MEDICAL CONDITION]. The situation resulted in a finding of Immediate Jeopardy. The facility's Administrator, Director of Nursing and corporate nurse were notified of the Immediate Jeopardy findings on (MONTH) 16, 2019 at 2:31 PM. Immediate Jeopardy was removed on (MONTH) 17, 2019 at 5:30 PM, prior to survey exit, when the facility provided evidence of immediate corrective actions, which included discarding the contaminated [MEDICATION NAME], immediate retraining of nursing staff on insulin administration, implementation of a two-step verification process for insulin injections and testing both residents for blood borne pathogen exposure. The scope and severity level of the deficient practice was reduced to a D. The findings include: On (MONTH) 16, 2019 at 10:48 AM, Employee C Registered Nurse (RN C) was observed with a [MEDICATION NAME] for insulin injection in his hand. RN C was about to go into resident #69's room. He was standing at the medication cart on South hall. He showed the electronic MAR (medication administration record) to the surveyor for resident #69 to receive 2 units of [MEDICATION NAME] before meals. He showed the pen to the surveyor with the amount dialed in for 2 units. The surveyor watched him give the insulin into the left side of resident #69's abdomen. Outside the room the surveyor asked him to show the name on the insulin pen. He checked the name on the pen and said, I must have used (resident #27's) pen by mistake. The pen was labeled with resident #27's name and the clear plastic bag it was stored in had an open date of the day before, (MONTH) 15, 2019. The surveyor asked him to show the pen for resident #69. He checked the drawer and could not find any pen with resident #69's name. He then found a medicine bottle container with a bottle of [MEDICATION NAME]inside. At that time he said she has a bottle of insulin not a [MEDICATION NAME] (Photographic evidence obtained). The surveyor asked him if he considered this a medication error? He said, Yes, in a way. A review of the Medication Administration Record [REDACTED]. A review of the MAR for resident #27 showed that his [MEDICATION NAME] which was opened on (MONTH) 15, 2019 (no open time) and the resident was given the [MEDICATION NAME]using a [MEDICATION NAME]: on Monday (MONTH) 15, 2019 at midnight, 06:00 AM, 12:00 PM, and 6:00 PM and on Tuesday (MONTH) 16, 2019 at midnight and 06:00 AM. An interview was conducted with the Corporate Consultant Nurse on (MONTH) 16, 2019 at 1:17 PM. The Consultant Nurse indicated that [MEDICATION NAME] use was the usual facility practice and was unsure why Resident #69 had a bottle of insulin instead. An interview was conducted with the Administrator on (MONTH) 17, 2019 at about 8:30 AM who stated that she was shocked that this happened and that the nurses were trained better than this. She stated that the facility had implemented immediate corrective actions and had audited all of the insulin on all nurse carts and had begun re-training staff. An interview was conducted with the Staff Development Coordinator on (MONTH) 17, 2019 at 9:19 AM who stated she was responsible for all new hire orientation, inservices and monthly all staff meetings. For new nurses, she conducts classroom orientation that goes over policies and procedures, assessing nursing knowledge and video education. Orientation includes Medication Rights and Medication Administration and includes how to properly utilize a [MEDICATION NAME]. After orientation, the nurses on the unit checks the competencies for all new nurses. It usually takes a couple of weeks to complete the review. On (MONTH) 18, 2019 an interview was conducted with the Medical Director. The Medical Director had ordered and reviewed the laboratory tests for bloodborne pathogens for both resident #27 and #69. The Medical Director stated that resident #69 had previously been vaccinated against [MEDICAL CONDITION], otherwise the laboratory tests showed that both residents were negative for bloodborne pathogens. On (MONTH) 18, 2019 at 2:35 PM, an interview was conducted with the administrator, the medical director, the risk Manager and the Corporate Consultant Nurse. The surveyor asked if they had a policy for infection control related to injections. The Corporate Consultant Nurse stated, No, but provided related policies on Medication Administration. A review of the facility policies and procedures on Medication Administration and insulin found 2 relevant policies. The policy entitled, Administration of Drugs from Nursing Services Procedures, Medications dated (MONTH) 2019, was reviewed. The policy stated, Drugs will be administered in a timely manner and as prescribed by the residents attending physician or the center's Medical Director. Line item #14 stated, Drugs ordered for a particular resident may not be administered to another resident and #15 stated, Prior to administering the resident's drug, the nurse should compare the drug and dosage schedule on the resident's eMAR (electronic Medication Administration Record) with the drug label. A second policy entitled, Insulin Administration from Nursing Services and Procedures, Diabetic Care dated (MONTH) (YEAR), was reviewed. The policy stated, Special precautions should be followed in the administration of insulin. Line item #3 stated, The type of insulin, dosage requirements, strength, and method of administration should be verified to assure that it corresponds with the order on the medication sheet and the physician's orders [REDACTED].#5, The resident's physician should be notified of any discrepancies or adverse drug reactions. On (MONTH) 17, 2019, an Internet search found a CDC (Centers for Disease Control and Prevention) currently published guideline for Injection Safety: CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person. The guidance states, the CDC has become increasingly aware of reports of improper use of insulin pens, which places individuals at risk of infection with pathogens including [MEDICAL CONDITION] viruses and human immunodeficiency virus ,[MEDICAL CONDITION]. This notice serves as a reminder that insulin pens must never be used on more than one person. Background: Regurgitation of blood into the insulin cartridge can occur after injection (1) creating a risk of bloodborne pathogen transmission if the pen is used for more than one person, even when the needle is changed. Recommendations: insulin pens continuing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person even when the needle is changed; insulin pens should be clearly labeled with the person's name or other identifying information to ensure that the correct pen is used only on the correct individual. Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices. https://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html A review of the manufacturer's guidelines Getting Started on [MEDICATION NAME] indicates the [MEDICATION NAME] should never be shared even if a new needle is attached. Important Safety Information: Do not share your [MEDICATION NAME] with other people even if the needle has been changed. You may give other people a serious infection, or get a serious infection from them. The immediate jeopardy was removed onsite after the receipt of an acceptable immediate jeopardy removal plan and verification of corrective actions. - The contaminated [MEDICATION NAME] was immediately discarded. A new [MEDICATION NAME] was obtained from emergency drug kit for resident #27 on (MONTH) 16, 2019. - The nurse was removed from the medication cart and immediately re-educated on [MEDICATION NAME] use with return demonstration, 6 rights of medication administration, and prevention of bloodborne pathogens through the use of Insulin [MEDICATION NAME]. After re-education, the nurse was suspended pending investigation on (MONTH) 16, 2019. - The facility Quality Assurance Performance Improvement committee held an ad hoc meeting to review and develop corrective actions on Tuesday (MONTH) 16, 2019. The medical director was present in the building and included in the discussions. - 100% of residents receiving insulin were audited on (MONTH) 16, 2019 totaling 22 to ensure orders and insulin were accurate and available on the cart. - Immediate retraining of nursing staff was conducted for all nurses regarding use of [MEDICATION NAME] with return demonstration. 100 % of nurses will be receiving education prior to working. The training also included the medication administration rights, and prevention of blood borne pathogens through correct use of insulin [MEDICATION NAME]. As of (MONTH) 17, 2019, 33 of 50 nurses had been retrained including return demonstration. - Immediately instituted a plan for a two person verification system for each resident for all insulin injections prior to administration. Both nurses will document initials verifying 6 rights of medication administration on a hard copy Medication Administration Record [REDACTED]. The new two-step verification process was observed in practice by the survey team on (MONTH) 17, 2019. The observed nurses were interviewed and able to explain the process. Nursing documentation of the 2 step verification system was reviewed. - The family of both residents were notified and laboratory tests for bloodborne pathogens were obtained on (MONTH) 16, 2019. Resident #27 did not test positive for any bloodborne communicable diseases.

Based on observation, record review, and interview, the facility failed to provide activities of daily living (ADL) care, specifically fingernail care, for 1 of 3 residents sampled for ADL care ( resident #113). The findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] for resident #113, the resident required extensive assistance with one person physical assistance to perform personal hygiene. On 7/16/19 at approximately 09:43 AM, it was observed that resident #113's fingernails were approximately ¼- ½ inch past the tip of the resident's finger for all fingers and had a yellowish-brown discoloration with visible debris underneath the nail. In interview at that time, the resident expressed that the facility's staff had not clipped or cleaned his fingernails nor offered fingernail clippers to do so himself since he had been there. He expressed that he would like that to be done. Record review of resident #113's medical record showed that he had been admitted to the facility in early (MONTH) 2019. On 7/17/19 at approximately 09:36 AM, during observation of care with resident #113's Certified Nursing Assistant (CNA) B, the resident's fingernails were in the same condition as observed on 7/16/19. When asked in interview about fingernail care for resident #113, CNA B expressed that nail care is to be done as needed and cleaned during showers by the CNAs. On 7/17/19 at approximately 11:59 AM, in an interview with the facility Director of Nursing (DON), the DON expressed that fingernail care is to be done as needed by the CNA's and that CNAs should clean and check the resident's fingernails during showers. According to record review of the resident's chart the resident had received a shower on 7/15/19 at 2:59 PM.

Based on observations and interviews, the facility failed to ensure resident dislikes and preferences were honored during meal times for 1 of 1 residents sampled for Choices (Resident #105). The findings include: On 07/15/19 at approximately 12:00 PM, Resident #105 was interviewed regarding the care and services received. Resident #105 stated that the food was not any good and they never serve what is on the menu. Observation of resident #105's lunch-time meal tray showed mashed potatoes and gravy, mixed vegetables, white bread, iced-tea and peaches. Resident #105 stated he already ate his meatloaf. The corresponding meal ticket indicated that the resident was on a regular diet with large portion meats. 'Dislikes/Restrictions' included: pasta, white potatoes and white bread. Both the white potatoes and white bread were noted on the resident's tray. The resident did not eat the potatoes or the bread. (Photo documentation obtained) On 07/17/19 at 08:55 AM, Resident #105 had his breakfast tray in front of him, but had already eaten the meal. He stated he enjoyed his breakfast, but stated they put his egg sandwich on white bread, instead of wheat. On 07/18/19 at approximately 10:15 AM, Resident #105 stated they brought him white bread again this morning. He stated, he doesn't know why they can't make his sandwich on wheat bread. On 07/17/19 at approximately 09:05 AM, an interview was conducted with a random Certified Nursing Assistant (CNA) working along Resident 105's hall. The CNA stated that each day there is a set meal. Any resident who doesn't want the meal offered can receive a meal ticket to choose an alternative. This then gets turned into the kitchen. She says part of her duties, when delivering meal trays, is to check for dislikes. If a resident has a wrong item or a dislike on the tray they are to offer the resident something else. On 07/17/19 at approximately 09:30 AM, an interview was conducted with the Director of Culinary Services (DCS.) He stated they do try to honor resident preferences and allergies and states one of the Dietary Techs usually obtains that information from the resident on admission. The DCS stated they get a copy of the resident's meal card which include dislikes and preferences, and that they put it on the meal-time tray every day. He stated that when they begin plating the food, the first person, reads out the diet and information on the card, to the cook. The last person on the trayline checks the card to make sure the tray is correct. The tray then goes down the hall out to the residents. The DCS stated the CNAs should also be checking the meal tickets for dislikes/preferences. If there is a mistake, he says usually the dietary manager will try to correct it right away. He also stated any complaints about food are addressed in morning meetings and are to be resolved. Resident council also has input on food.

Based on record review, staff interview, the facility failed to implement their written policies and procedures for Abuse and Potential Hires by rehiring an employee that had been terminated for conduct during an investigation for suspicion of verbal abuse(CNA A). The findings were: A review of the facility's, Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property policy was conducted. On page 37 (page one of the policy) under the heading, Mental and Verbal Abuse the policy stated: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. Verbal abuse may be considered a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples of mental and verbal abuse include, but are not limited to: - Harassing a resident; - Mocking, insulting or ridiculing; - Yelling or hovering over a resident with the intent to intimidate; - Threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends; and - Isolating a resident from social interaction and activities. On page 41, under the heading Investigation it stated, All suspected cases of abuse or misappropriation of resident's property will be fully investigated by the Administrator, Abuse Coordinator, or designee. The findings should be reported to the appropriate governing agencies. A review of Policy number GCHC 701, Disciplinary Action Effective date 12/04/08 and revised 08/01/10 revealed but was not limited to following: Category I: Category I offenses are most serious and subject to the associate's discharge. 1. Because of the seriousness of the nature of these offenses, the associate should be immediately suspended pending an investigation, and if found to have committed the offense, terminated. Category I Offenses were listed but was not listed to Verbal or physical threats against the facility, resident, visitor, or another associate ; and conduct that would be widely regarded as improper or inappropriate in a work group (to include, but not limited to resident abuse or neglect) or serious violations of Corporate Compliance Policies and Privacy Rules Policies Review of the Employment Reason Code sheet used revealed that the code T-Category 1 - Conduct was an involuntary termination that was not eligible for rehire. A review of staff files revealed that CNA A (Certified Nursing Assistant ), was terminated on 1/23/17 for an Allegation of inappropriate conduct with a resident (#53). On 5/7/18, CNA A was rehired to the facility, though the facilities policies indicated she was not eligible for rehire. Record review of the Nursing Homes Federal Reporting Immediate Report dated 1/19/17 revealed that resident #53 reported to the assigned nurse that she used the call light, but when the CNA A responded she told her don't push the damn call light again. Further review of the investigation following this incident conducted by the facility revealed that 3 statements obtained from staff during the preliminary investigation confirmed that CNA A had been witnessed raising her voice at resident #53 while saying to the resident, You don't need to be telling lies about me, I never told you not to push the damn call light. A statement from Staff L, a CNA, stated that CNA A stormed in the room while the staff was present and was pointing and shaming while making the previous statement about the call light. Statements were taken from resident #53 and her roommate (#82) which also confirmed the incident had occurred. On 07/24/18 at 10:12 am, an interview was conducted with Staff F, Registered Nurse (RN) and Staff Development. Staff F stated that the Director of Nursing (DON) at the time terminated CNA A over the telephone because she did not come back in to talk to her. Staff F witnessed the call and signed for it. Staff F stated, as far as us hiring her back. If we terminate someone it goes through the discretion of the administrator to hire them back. When asked about normal re-hire procedures to check for eligibility of re-hire Staff F stated, The normal process, normally we get the previous associate file. We look at it to see if they are eligible for rehire. They also have a corporate website that maintains information regarding re-hire eligibility. This, however, is wiped out when the associate is re-hired. She stated that the payroll coordinator would also know about employees re-hire eligibility. On 7/24/18 at 10:40 am, an interview was conducted with Staff G, the payroll coordinator. At that time it was stated that Staff Development could use the corporate website to determine if someone was eligible for rehire. Staff G also stated that there are codes in Kronos (a time and attendance information system) that can indicate whether staff are eligible for rehire or not. She supplied the survey staff with a form with the codes which stated that all involuntary terminations were not eligible for re-hire. She also printed a copy of what constituted a category 1 offense (the type for which CNA A was terminated per her employee file). On 7/24/18 at 10:44 am, an interview was conducted with Staff H, RN and Risk Manager. Staff H revealed that Resident #53 reported that CNA A told her not to press the damn call light. That was the initial allegation. When I went to interview her she denied saying that. CNA A said she did not normally work on the north hall and that she needed to get help. CNA A said that she told Resident #53, You don't need to press the call light again. I am not sure that CNA A was terminated for it. Staff H stated resident #53 denied the allegations when I went back and talked to her as well. On 7/24/18 at 10:53 am, an interview was conducted with the Administrator. She stated, when CNA A worked at the facility prior to her termination on 1/23/17, we did not have problems with her for the most part. The Administrator stated CNA A was suspended, we reported it as abuse and followed policies and procedures. She was working elsewhere in the community. After a year or so passed we decided to hire her back. The Administrator stated, we rehire based on this HR sheet with termination categories on it. A category 1 conduct would mean not eligible for rehire. The Administrator revealed that employees have been rehired, but a determination would have to be made based of the employee's individual situation. The Administrator stated any employee being rehired would be discussed with herself and the Corporate Office. When asked what category CNA A's termination was classed under, the Administrator pointed to her employee sheet and stated that she was a category 1 termination. She indicated that CNA A had been suspended of an allegation of disrespect to a resident. When asked about the facility's policy, the Administrator replied, We do not have a policy to say that we definitely do not hire back. The Administrator stated anyone that was fired would be categorized as not eligible for rehire, but if the facility decided to rehire, there would be an investigation in the employee's file. We would look too to see, Did she have a lot of disciplines? We would look at her evaluation. The only other discipline was a written counseling for leaving early from shift. The Administrator was further asked about CNA A's work history and she then stated that she also had issue with speaking disrespectfully to supervisor. The administrator stated, I really thought that we did not substantiate the claim because Resident #53 says things like this. When asked about the discrepancy in the AHCA (Agency for Health Care Administration) report and the signed statements in the HR file she stated, I just know that the Risk Manager did a lot of research on it. I know we decided to suspend her and let her go. The Administrator stated, I think at that point we think we thought we should suspended and fire CNA A. We terminate if it was even questionable. Even though it was not a confirmed case of abuse we would say that there were enough statements to corroborate abuse. On 7/24/18 at 3:39 PM, a group interview was conducted in the Risk Managers Office that included the Risk Manager, Administrator, and Corporate Nurse. All were asked to explain why it was determined that the abuse allegation was not substantiated when there were 3 employees and two residents that corroborated the story. And, even if staff had changed their story, why would the facility not follow up with the staff? And, if it was not substantiated, why was CNA A terminated? The following responses were provided but not limited to: The Corporate Nurse, staff J stated I don't think it was abuse. It was bad customer service. We were looking in the 5 day. We did not feel there was willful intent. She was terminated for poor customer service. The Risk Manager, staff H stated, When I went back and talked to the nurses and CNA A it was determined that it was more customer service. When asked for the follow up interviews Staff H stated there was no documentation of the follow up interviews with the staff members that brought the incident to managements attention. The Administrator stated, I don't think we considered it abuse. We would have submitted it to the board and never rehired. This surveyor then pointed out on the written statements taken during the preliminary investigation where the staff member re-entered the room and with a raised voice said, You don't need to be telling no lies about me I never told you not to push the damned call light. At that time the Administrator and Corporate Nurse agreed that the statement sounded intimidating.

Based on observation, interview, and policy review, the facility failed to store a schedule IV medication ([MEDICATION NAME]) in a separately locked, permanently affixed compartment in 1 of 2 medication rooms observed. Findings included: On 07/25/18 at 10:32 AM, an observation was conducted in the presence of a Staff D, LPN (Licensed Practical Nurse). The refrigerator in the Station 2 medication storage room had one box of a schedule IV medication ([MEDICATION NAME]) in a locked, permanently affixed box in the refrigerator and a second box of [MEDICATION NAME] that was not in a locked container, but was sitting on the shelf below the locked box. Both boxes of [MEDICATION NAME] had plastic tab locks. Staff D verified verbally that the box of [MEDICATION NAME] was not in the locked drawer and should have been locked inside the drawer. Staff D attempted to lock both boxes in the permanently affixed lock box, but the lock would not lock. Staff D called out to another nurse for assistance who came and let her use her key which worked to lock the box. A review of the facility's policy titled, Control of Drugs dated (MONTH) (YEAR), revealed that Controlled substances must be stored in a locked container in the drug room. This container must remain locked when not in use.

Based on observation, interview and record review The facility failed to maintain records that were accurately documented for 1 of 2 sampled residents with IV lines. (#105) The findings were: Observation of resident #105 on 7/23/18 at 9:49 am found an intravenous (IV) dressing to the top of left hand. The resident indicated she was not sure what medications she was receiving and for what. Record review found a physician order dated 7/16/18 to flush the IV with 10 milliliters Normal Saline (NS) 0.9% as needed until 7/22/18 before and after IV medication administration. Review of the medication record found the NS flushes were not signed as given from 7/16/18-7/22/18. Interview with Registered Nurse E on 7/25/18 at 10:51AM revealed standard flushes of NS should be conducted before and afterwards. Nurse E indicated that should be documented on the MAR (medication administration record). She stated, Maybe it wasn't signed as done because it was PRN, but usually this order is on the MAR with the med or near it. I know we have a standard is to flush before and after. I will call the pharmacy to find out if the NS was ordered for her. Record Review found the NS was ordered even though it was not documented as given. Review of the facility policy indicated to flush the IV with NS 10 milliliters before and after medication administration

Based on observation, record review, and staff and resident interviews, the facility failed to provide fall prevention monitoring and oral care in accordance with the plan of care for 1 of 2 residents sampled for accidents and for 1 of 5 residents sampled for activities of daily living (#122). The findings were: A review of the plan of care for resident #122 showed the resident to have a potential for falls/injury due to impaired vision ([MEDICAL CONDITION]), and stated that one of the interventions to prevent falls/injury was to keep the resident in a supervised area when up in her wheelchair. Resident #122 was also care planned for an activities of daily living self-care deficit with an intervention for staff to monitor the resident's oral cavity (inside the mouth) for gingivitis, swelling, inflammation, infection, bleeding, ulceration or increased pain. On 6/06/2017 at 2:21pm resident #122 was observed with thick, tan colored, secretions clinging between her lips and teeth as she spoke. Her breath was foul smelling, and she did not open her eyes while she talked. Her eyes appeared to be matted shut with a crusty substance, also tan in color. She was asked if she could open her eyes and she said, Yes. She was asked to demonstrate that she could open her eyes, but was only able to open her right eye half way. The corners were crusted closed and there were thick secretions between each eye lid. When asked if she had her teeth brushed and face washed that morning she replied, No. The Director of Nursing was located, and confirmed observations of resident #122's eyes and mouth. She immediately found a nursing assistant to assist the resident with care. On 6/07/2017 at 12:01pm observation showed the door to the room of resident #122 was closed. Upon entering the room, resident #122 was seen up in her wheelchair, seated at her bedside. No staff were in the room. On 06/07/2017 at 2:06pm Resident #122 was again observed to be up in her wheelchair at the bedside with no staff in the room. At the time of the second observation, the southwest unit manager was made aware of the resident being up in her wheelchair without supervision. The unit manager agreed that the care plan stated the resident was to be supervised when up in the wheelchair, and had the resident moved to a supervised area.

Based on observation, record review, and staff and resident interviews, the facility failed to carry out activities of daily living (ADLs) necessary to maintain good oral hygiene for 1 of 5 residents sampled for ADLs (#122). The findings were: A review of the plan of care for resident #122 showed the resident to have an activities of daily living self-care deficit with an intervention for staff to monitor the resident's oral cavity (inside the mouth) for gingivitis, swelling, inflammation, infection, bleeding, ulceration or increased pain. On 6/06/2017 at 2:21pm resident #122 was observed with thick, tan colored, secretions clinging between her lips and teeth as she spoke. Her breath was foul smelling, and she did not open her eyes while she talked. Her eyes appeared to be matted shut with a crusty substance, also tan in color. She was asked if she could open her eyes and she said, Yes. She was asked to demonstrate that she could open her eyes, but was only able to open her right eye half way. The corners were crusted closed and there were thick secretions between each eye lid. When asked if she had her teeth brushed and face washed that morning she replied, No. The Director of Nursing was located, and confirmed observations of resident #122's eyes and mouth. She immediately found a nursing assistant to assist the resident with care.

Based on observation, record review, and staff and resident interviews, the facility failed to ensure that 1 of 2 residents sampled for accidents (#122) received adequate supervision to prevent potential accidents. The findings were: A review of the plan of care for resident #122 showed the resident to have a potential for falls/injury due to impaired vision (blindness), and stated that one of the interventions to prevent falls/injury was to keep the resident in a supervised area when up in her wheelchair. On 6/07/2017 at 12:01pm observation showed the door to the room of resident #122 was closed. Upon entering the room, resident #122 was seen up in her wheelchair, seated at her bedside. No staff were in the room. On 06/07/2017 at 2:06pm Resident #122 was again observed to be up in her wheelchair at the bedside with no staff in the room. At the time of the second observation, the southwest unit manager was made aware of the resident being up in her wheelchair without supervision. The unit manager agreed that the care plan stated the resident was to be supervised when up in the wheelchair, and had the resident moved to a supervised area.

Based on observation and staff interview the facility failed to ensure medication was stored appropriately for 1 of 4 med carts randomly inspected. (south hall cart) The findings were: On [DATE] at 2:02pm an inspection was conducted of the medication cart on the south hall. At that time there three boxes of Major ear drops (used to aid in the removal of ear wax) that were expired. One expired ,[DATE], one ,[DATE] and one expired ,[DATE]. Staff Member A agreed that the medications were expired and would be disposed of immediately.

Based on observation,staff interview,and housekeeping record review the facility failed to maintain a sanitary environment for 4 of 10 rooms observed (Room's of resident #4, 5 and 7 and room 64). The findings are: Resident #5's room was observed to have items on the floor of her bedroom beside the bed on 7/29/16 at 9:20 am during tour of the building. One looked to be some type of food particle. There was also a plastic lid on the floor. An interview with Resident #5 revealed the items had been on the floor for several days. (Photographic evidence obtained). Returned to room after lunch the items were still on the floor. Resident #7's room 68 was observed during tour on 7/29/16 at 9:24 am. The room was observed to have a dark black substance around the door frame entering the room. Inside the room was observed to have a latex glove on the floor and a used thermometer cover under bed A. Resident #7 said the glove must have been dropped on the floor yesterday. On 7/29/16 on 7/29/16 at 10:30 am Room 64 was viewed. There was black stained floors in front of the closet. (Photographic evidence). The floor in the room is scarred with dark marks. (Photographic evidence) The bathroom has an area on the floor to the left of the commode on entering which is dark brown . (Photographic evidence). There is also an area underneath the sink that has black areas in both corners. (Photographic evidence). There was no housekeeping cart noted on the unit. The overall floor needed sweeping. Resident #4's room was observed on 7/29/16 at 10:37 am. Resident #4 says the room has not been cleaned today. The floor has dark brown/ black stains on the floor along the baseboard in front of both A and B bed which looks like dirt. The floor needs to be swept. The housekeeping records were viewed which showsed this room was stripped and waxed in April. Returned to room after lunch. The room still had not been swept. On 7/29/16 at 11:35 an interview was conducted with housekeeping supervisor (HS) and maintenance. The housekeeping supervisor said all rooms are cleaned daily. Looked at room 64 and Resident #7's room. The maintenance director said the area around the door of Resident #7's room and in front of the closet is wax build-up. He said the areas around the doors come from the outside floors being cleaned. The housekeeping supervisor confirmed there was staining. He is not sure what is causing the bathroom floor staining in the bathroom of Room 64. Confirmed the rooms looked dirty and needed to be cleaned. Requested the housekeeping log for stripping and waxing of the rooms. An interview with the Administrator, housekeeping supervisor, and maintenance director was conducted on 7/29/16 at 12 noon to discuss the floors. The administrator says the floors are stripped and waxed every 6 month. She says the floors are not dirty that it is wax buildup. She then said I know it is not aesthetically pleasing but it is the wax build-up it is not dirt it is an old floor. The log book for stripping and waxing floors was viewed with the housekeeping at 1:15 pm 7/29/16. The last time Resident #4's room was stripped and waxed was April 2016. He could not find any dates for the stripping and waxing of Room 64. He was asked again about the cleaning. He stated,Yes they should be stripped and waxed and cleaned. I will take care of it.

Based on observation, staff interviews and record reviews, the facility failed to prepare and store food under sanitary conditions, related to thawing frozen shrimp under hot water, having dented cans in dry storage, and 9 iced boxes of food underneath air vent of the freezer (photographic evidence obtained). The findings: On 4/27/2016 at 08:40 am, a walk through tour was conducted of the kitchen. In the kitchen sink, there was a package of frozen shrimp sitting in a pan under running water. The water was hot to touch and was running onto the frozen shrimp in a pan. An interview was conducted with the chef on 4/27/2016 at 08:40 am. The chef stated that you can thaw it that way. The surveyor asked for documentation showing that this was an acceptable method. Also interviewed at this time was the dietary manager. She said that it should in fact be thawed under cold water. The chef agreed that the water was not too hot, but was hot. The water was not cold when checked by the surveyor. The chef provided the food code policy. Food code policy : under Temperature and Time Control 3-5-1.13 Thawing: Shall be thawed under refrigeration that maintains the FOOD temperature at 41 degrees or less, or completely submerged under running water at a water temperature of 70 degrees or below. On 4/27/2016 at 09:35 am, the surveyor asked the chef to get a thermometer calibrated to 32 degrees in ice water. The chef placed the thermometer into running water into same sink shrimp was observed to be thawing under hot water in during the earlier visit. The thermometer temperature read 70 degrees Fahrenheit. The chef and surveyor both put their hands under the running water. The water is cool. The chef said the water was cool. The surveyor asked if this was the temperature of the water that was thawing the shrimp. The chef stated, No, it was warmer. The water temperature was hot thawing the shrimp. On 4/27/2016 at 1:30 pm, the dry storage areas are observed. Within the second storage area, there are multiple dented cans. There was a case of six cans of ravioli, all were dented. One can on the can cart was dented as well. The dietary manager stated that the procedure for dented cans was that they are taken out of storage and thrown away, or if seen before the food supplier leaves, they will return the cans to them. A second tour was conducted of the second storage area on 4/28/2016 at 08:20 am. Two additional dented cans are found with the dietary manager. Per the dietary manager, they took the cans back to the supplier this morning. As the surveyor was exiting the dry storage area, the chef was coming down the hallway and stated that he removed all the dented cans. ( Photographic evidence of the two cans found on 4/28/16 obtained). A tour was conducted of the outside kitchen freezer on 4/25/2016 at 1:30 pm. The inside temperature of the freezer read 0 degrees Fahrenheit. Icicles were observed hanging from the inside vent of the freezer. An interview was conducted with the chef at this time and he stated that this was due to food coming in and having the door open while putting the food supply up. He stated that it caused condensation. On 4/27/2016 at 08:45 a second tour of the outside kitchen freezer was conducted. Again, icicles were observed on the vent that were approximately four inches long. Also at this time, 9 boxed containers of food on top of an elevated shelf had ice covering them (picture indicates that water has been on them) underneath the vent. The top box was opened and contained seasoned wedge cut frozen potatoes, on box of house fries, one box of tater puffs, a box that did not have visible identification of product, one box of chicken drumsticks, and two more unidentified boxes underneath one box of ice cream. The chef reached into the box of broccoli with his uncovered hand and showed the broccoli to the surveyor showing it was frozen. He then put the broccoli he was holding back into the box. The chef was asked about the boxes with ice on them. He said that the boxes with ice indicate that water was on it. A plastic wrapped item has an icicle going down the entire length of the item and box. It is encrusted in ice (see picture). On 4/27/2016 at 09:30 am, the chef stated that there is a clogged line in the freezer which is causing the dripping of water onto the boxes. On 4/27/2016 at 09:50, a third tour of the outside kitchen freezer was conducted. A maintenance worker was inside the freezer sweeping out ice from the floor of the freezer. At this time, the frozen, iced over boxes were still inside the freezer.

Based on observation, staff and family interview and record review the facility failed to follow the plan of care to prevent and or failed to promote healing of multiple wounds to feet and to buttocks resulting in harm for 1 of 5 sampled residents. (#1) The findings are: Observation of resident #1 at 9:10 AM found her in bed sleeping without heel protectors, positioning pillows or pressure relieving mattress. Two pairs of heel protectors were lying in the chair next to the bed. The resident was lying on the left side. Observation of resident #1 at 9:50 AM found the resident on left side sleeping without heel protectors, positioning pillows or pressure reducing mattress. The heel protectors were seen in the chair at bedside. Interview with nurse manager at 9:40 AM stated the resident has stasis ulcers on feet. She wears heel protectors to relieve pressure. Observation of the resident while nurse was attempting to perform wound care at 10:40 AM noted 2 pair of heel protectors in a chair next to the bed. The resident was in the same position ( lying on the left side) without heel protectors, positioning pillows or pressure relieving mattress. Observation of the resident's right foot noted dry scaly skin and foot red/ purple in color. The nurse removed the dressing dated 4/6/11 from the back of the right calf where a small open area was found. The resident grimaced in pain while the nurse was attempting to do dressing change. The nurse stopped and stated they would medicate the resident. Further interview with the nurse indicated the resident has a history of wounds and has multiple wounds on left foot and heel. Interview with family at the same time stated she now has an open area to the buttocks. They (facility staff) stated last week they thought it may be a boil but today they said it may be from pressure due to weight loss. Observation at 11:30 AM noted the resident in the same position on left side without heel protectors, positioning pillow or pressure relieving mattress. Observation at 11:40 AM noted the resident in the same position without heel protectors, positioning pillows or pressure relieving mattress. The nurse attempted to perform wound care and the family stated the resident on occasion is still drawing up and may be in pain. The nurse stated the physician is here and we will ask for additional pain medication before doing wound care. Observation at 12:25 PM noted the resident still on the left side without heel protectors and positioning pillows. The resident had been medicated for pain 30 minutes prior to treatment. The resident was noted to have right leg pressing against left leg without positioning pillows. Observation of room lacked evidence of pillows. While the nurse was changing the dressings to both feet the surveyor noticed a pressure relieving mattress. The nurse stated they had just applied the air waffle mattress to reduce pressure. Surveyor asked to see buttocks. The nurses turned the resident from the left side where she had been lying since 9:10 AM. An area approximately 5 cm x 5 cm was noted which was pink in color. The nurses stated she developed this recently. The resident was observed on 4/7/11 lying in the same position on the left side putting pressure on the ischial tuberosity from 9:10 AM until 12:35 PM which is 3 hours and 25 minutes. Nurse assessment indicated a new open area to the left side on the ischial tuberosity on 4/4/11 with a measurement of 6 x 5 x 0.1 cm. The record lacked the new intervention to use a pressure reduction mattress until after surveyor investigation. Interview with wound nurse and the director of nursing on 4/7/11 at 2:00 PM revealed residents should be turned every 2 hours, use positioning pillows to float heels and in between legs to reduce pressure and skin to skin contact and to use heel protectors. The wound nurse stated skin can be compromised if pressure is not relieved with 60 minutes. Interview with CNA who cares for resident on a daily stated she has wounds and they float her heels to relieve pressure. Review of wound assessment dated [DATE] noted the following: Stage II wound to right calf measuring 2 x 2 x 0.1 cm. Unstageable wound to right top of foot measuring 2.4 x 3 x 0.1 cm. Stage III wound to left heel measuring 2 x 1.3 x 0.2 cm. Stage II wound to left ischial tuberosity measuring 6 x 5 x 0.1 cm found on 4/4/11. Record review of wound tracking and interview with wound nurse revealed wounds were acquired in facility and are not improving due to no pulses in feet and [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] indicates stasis ulcers to feet. Review of orders dated 4/6/11 indicates to use heel protectors at all times and treatment for [REDACTED]. Review of care plan for incontinence dated 4/6/11 listed as interventions to use Posey heel boots at all times. Review of care plan for chronic ulcers to feet dated 4/4/11 listed as intervention to use foam boots, turn and reposition every 2 hours while in bed. Protect bony prominences. Protect heels from pressure while in bed and use Posey lift boots to feet for protection when in bed.

Based on observation, staff and family interview and record review the facility failed to provide care and treatment to promote healing of wounds which caused harm for 1 of 5 sampled residents. (#1) The findings are: Observation of resident #1 at 9:10 AM found her in bed sleeping without heel protectors, positioning pillows or pressure relieving mattress. Two pairs of heel protectors were lying in the chair next to the bed. The resident was lying on the left side. Observation of resident at 9:50 AM found on left side sleeping without heel protectors, positioning pillows or pressure reducing mattress. The heel protectors were seen in the chair at bedside. Interview with nurse manager at 9:40 AM stated the resident has stasis ulcers on feet. She wears heel protectors to relieve pressure. Observation of resident while nurse was attempting to perform wound care at 10:40 AM noted 2 pair of heel protectors in chair next to bed. The resident was in the same position without heel protectors, positioning pillows or pressure relieving mattress. Observation of the resident's right foot noted dry scaly skin and foot red/ purple in color. The nurse removed the dressing dated 4/6/11 from the back of the right calf where a small open area was found. The resident grimaced in pain while the nurse was attempting to do dressing change. The nurse stopped and stated they would medicate the resident. Further interview with the nurse indicated the resident has a history of wounds and has multiple wounds on left foot and heel. Interview with family at the same time stated she now has an open area to the buttocks. They (facility staff) stated last week they thought it may be a boil but today they said it may be from pressure due to weight loss. Observation at 11:30 AM noted the resident in the same position on left side without heel protectors, positioning pillow or pressure relieving mattress. Observation at 11:40 AM noted the resident in the same position without heel protectors, positioning pillows or pressure relieving mattress. The nurse attempted to perform wound care and the family stated the resident on occasion is till drawing up and may be in pain. The nurse stated the physician is here and we will ask for additional pain medication before doing wound care. Observation at 12:25 PM noted the resident still on the left side without heel protectors and positioning pillows. The resident had been medicated for pain 30 minutes prior to treatment. The resident was noted to have right leg pressing against left leg without positioning pillows. Observation of room lacked evidence of pillows. While the nurse was changing the dressings to both feet the surveyor noticed a pressure relieving mattress. The nurse stated they had just applied the air waffle mattress to reduce pressure. Surveyor asked to see buttocks. The nurses turned the resident from the left side where she had been lying since 9:10 AM. An area approximately 5 cm x 5 cm was noted which was pink in color. The nurses stated she developed this recently. The resident was observed on 4/7/11 lying in the same position on the left side putting pressure on the ischial tuberosity from 9:10 AM until 12:35 PM which is 3 hours and 25 minutes. Nurse assessment indicated a new open area to the left side on the ischial tuberosity on 4/4/11 with a measurement of 6 x 5 x 0.1 cm. The record lacked new intervention to use a pressure reduction mattress until after surveyor investigation. Interview with wound nurse and the director of nursing on 4/7/11 at 2:00 PM revealed residents should be turned every 2 hours, use positioning pillows to float heels and in between legs to reduce pressure and skin to skin contact and to use heel protectors. The wound nurse stated skin can be compromised if pressure is not relieved with 60 minutes. Interview with CNA who cares for resident on a daily stated she has wounds and they float her heels to relieve pressure. Review of wound assessment dated [DATE] noted the following: Stage II wound to right calf measuring 2 x 2 x 0.1 cm. Unstageable wound to right top of foot measuring 2.4 x 3 x 0.1 cm. Stage III wound to left heel measuring 2 x 1.3 x 0.2 cm. Stage II wound to left ischial tuberosity measuring 6 x 5 x 0.1 cm found on 4/4/11. Record review of wound tracking and interview with wound nurse revealed wounds were acquired in facility and are not improving due to no pulses in feet and [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] indicates stasis ulcers to feet. Review of orders dated 4/6/11 indicates to use heel protectors at all times and treatment for [REDACTED]. Review of care plan for incontinence dated 4/6/11 listed as interventions to use Posey heel boots at all times. Review of care plan for chronic ulcers to feet dated 4/4/11 listed as intervention to use foam boots, turn and reposition every 2 hours while in bed. Protect bony prominences. Protect heels from pressure while in bed and use Posey lift boots to feet for protection when in bed.