Every finding on record at Aspen Transitional Rehabilitation

Based on staff interview, record review, and review of the State Long Term Care Reporting System, it was determined the facility failed to ensure residents were free from abuse, neglect, and misappropriation of resident property and exploitation. This was true for 1 of 3 residents (Resident #50) reviewed for abuse and neglect. The facility failed to protect Resident #50 when she experienced neglect from CNA #1 during transfer from a chair to standing resulting in a fall with injury requiring hospitalization and surgery. Findings include:The facility's Abuse Policy and Procedure, version F1005, documented the facility would protect all residents from any and all forms of abuse, mistreatment, neglect, misappropriation, exploitation, or deprivation of goods and /or services.The CMS SOM, Appendix PP, dated 7/23/25, defined:Abuse, as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.Willful, in the definition of abuse as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Neglect, as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Resident #50 was admitted to the facility on [DATE], with multiple diagnoses including congestive heart failure (CHF), bilateral lower leg lymphedema, and diabetes. Resident #50's Discharge MDS assessment dated [DATE], documented under section GG she was a 2-person assistance to transfer from a chair to standing. Resident #50's care plan created on 3/28/25, documented an alteration in mobility/ safety and staff were directed to transfer her using a Hoyer mechanical lift or a 2-person assist. Resident #50's Progress Notes with dates ranging from 4/1/25 through 4/12/25 documented, extensive 2-person assistance required for transferring.Resident #50's Physical Therapy Progress Report dated 4/10/25, documented she had the following precautions in place and were communicated to the Interdisciplinary Team:weight bearing as toleratedextensive assistance of 2 people with four-wheel walkerAn Abuse Investigation Report completed by the facility documented on 4/14/25 at 1:10 PM, Resident #50 had a fall with injury in her room while being assisted by CNA #1 from her chair to standing. As a result of the fall, Resident #50 was sent to the emergency room via Urgent transport and was diagnosed with a fracture of the right distal knee requiring surgical repair.On 12/18/25 at 2:30 PM, the DON with the Administrator present stated, at the time of Resident #50's fall, she was on a 2 person assist for all transfers per Physical Therapy and the care plan. The DON stated CNA#1 was aware of Resident #50's transfer status and chose to transfer her by himself when [Resident #50's] knee buckled, and she fell.These findings represent past non-compliance with these regulatory requirements, and the facility did the following:-Resident was her own representative-Resident was transferred to hospital for higher level of care.-CNA was retrained on resident transfer status and following care plans.-All direct care staff including CNA's and licensed nurses were given an in-service training on transfer status and following resident care plans on 4/16/25.-Transfer audits for all residents completed by therapy on: 5/16/25 6/16/25 7/16/25-Audit of transfer care plans on all patients in building and CNA's performing transfers as care planned dated 4/16/25.There was sufficient evidence the facility corrected the non-compliance as of 4/16/25 as there was no further resident Neglect related to transfer status and following care plans after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on record review and staff interview, the facility failed to ensure the presence of a registered professional nurse for at least 8 consecutive hours per day, as required. This failure had the potential to affect all residents in the facility who may require a higher level of nursing assessment or intervention. Findings include: Review of the facility's nursing schedule dated 11/23/25 through 12/13/25 documented the facility did not provide 8 consecutive hours of registered professional nursing coverage on the following dates: 11/23/25 - No consecutive hours 11/29/25 - No consecutive hours 11/30/25 - No consecutive hours 12/6/25 - No consecutive hours 12/7/25 - No registered nurse hours 12/13/25 - No consecutive hours On 12/18/25 at 12:12 PM, the DON stated she was unaware that the required 8 hours of registered professional nursing must be consecutive. She also confirmed the facility did not have a registered professional nurse on duty on 12/7/25.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences, goals, and address the resident's medical, physical, mental and psychosocial needs. This was true for 1 of 2 residents (Resident #50) reviewed for care plans. This deficient practice placed residents at risk for harm when their care plan was not followed. Findings include:Resident #50 was admitted to the facility on [DATE] with multiple diagnoses including congestive heart failure (CHF), bilateral lower leg lymphedema, and diabetes.Resident #50's care plan created on 3/28/25, documented an alteration in mobility/ safety and staff were directed to transfer her using a Hoyer mechanical lift or a 2-person assist. An Abuse Investigation Report completed by the facility documented, on 4/14/25 at 1:10 PM, Resident #50 had a fall with injury in her room while being assisted by CNA #1 from her chair to standing. As a result of the fall, Resident #50 was sent to the emergency room via Urgent transport and while there she was diagnosed with a fracture of the right distal knee requiring surgical repair.On 12/18/25 at 2:30 PM, the DON with the Administrator present stated at the time of Resident 50's fall, she was on a 2 person assist for all transfers per Physical Therapy and the care plan. CNA #1 knew her [Resident #50's] 2-person transfer status and chose to transfer her by himself when her [resident #50's] knee buckled, and she fell.These findings represent past non-compliance with these regulatory requirements, and the facility did the following:-Resident was her own representative-Resident was transferred to hospital for higher level of care.-CNA was retrained on resident transfer status and following care plans.-All direct care staff including CNA's and licensed nurses were given an in-service training on transfer status and following resident care plans on 4/16/25.-Transfer audits for all residents completed by therapy on: 5/16/25 6/16/25 7/16/25-Audit of transfer care plans on all patients in building and CNA's performing transfers as care planned dated 4/16/25.There was sufficient evidence the facility corrected the non-compliance as of 4/16/25 as there was no further resident Neglect related to transfer status and following care plans after this date. At the time of the survey, the facility was in substantial compliance and therefore does not require a plan of correction.

Based on record review and staff interview, the facility failed to ensure nurses followed provider orders in accordance with professional standards of practice. This was true for 3 of 12 residents (#4, #27, and #38) reviewed for professional standards of care. This failure created the potential for uncontrolled pain, sedation and adverse health outcomes. Findings include:1.Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis with pathological fracture and a history of falls. Review of Resident #4's MAR dated 12/1/25 through 12/17/25 documented the following provider order:Oxycodone 2.5 mg by mouth three times a day for pain level 6-10, as needed. The MAR documented the following oxycodone 2.5 mg administrations outside the ordered pain range: 12/3/25 - pain level 5 (outside ordered range) 12/4/25 - pain level 5 (outside ordered range) 12/7/25 - pain level 4 (outside ordered range) 12/10/25 - pain level 5 (outside ordered range) 12/11/25 - pain level 3 (outside ordered range) 12/16/25 - pain level 5 (outside ordered range) 2. Resident #27 was admitted to the facility on [DATE] with multiple diagnoses including displaced fracture of the right femur and compression fracture of the fourth lumbar vertebra. Review of Resident #27's MAR dated 12/1/25 through 12/17/25 documented the following provider orders:Ibuprofen 200 mg by mouth every 6 hours for pain level 1-4, as needed.Oxycodone 5 mg by mouth every 4 hours for pain level 5-10, as needed.The MAR documented: 12/2/25 - Ibuprofen 200 mg administered for pain level 6 (outside ordered range). 12/9/25 - Oxycodone 5 mg administered for pain level 4 (outside ordered range). 3. Resident #38 was admitted on [DATE] with multiple diagnoses including periprosthetic fracture around an internal prosthetic right knee joint and displaced fracture of the right femur. Review of Resident #38's MAR dated 12/4/25 through 12/17/25 documented the following provider order:Oxycodone 5 mg by mouth every 4 hours for pain level 1-4, as needed. The MAR documented two consecutive PRN administrations of Oxycodone 5 mg on 12/5/25 for a pain level of 5, which was outside the ordered range. On 12/18/25 at 8:44 AM, the DON stated the nurse did not fail to follow the provider's order because the nurse followed the resident's preference. When asked whether a resident's preference supersedes a provider's order, the DON stated, no.

Based on observation, review of the CMS SOM-Appendix PP, and staff interview, it was determined the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. This was true for 1 of 2 medication carts observed and 1 of 1 medication storage rooms. This deficient practice had the potential for harm to a resident if they were to obtain medications which were left unattended and unsecured by staff. Findings include:CMS SOM-Appendix PP, revised on 7/24/25 and accessed on 12/19/25, documents, in accordance with State and Federal laws, the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.1) On 12/17/25 at 7:25 AM, the medication cart located in Hall One was observed to be unlocked and unmonitored by staff for several minutes. On 12/17/25 at 7:30 AM, LPN #1 stated, Yes, I guess I did leave the cart unlocked and unsupervised and I should not have done that. On 12/17/25 at 8:45 AM, The DON with the CNM present stated, the expectation was that the medication cart was always locked when not in sight of the nurse. 2) On 12/17/25 at 7:40 AM, after a resident refused most of her morning medications, citing she wanted to wait until after breakfast to eat. LPN #1 stated she would label the medication cup with resident's initials and store them in the medication cart until the resident was ready to take them later. LPN #1 stated that was what she normally does when residents don't want their medications after she has prepared them. On 12/17/25 at 8:48 AM, The DON with the CNM Present stated, the expectation was that the prepared medications that were refused be disposed of, and the nurse prepare the residents medications again when the resident was ready for them. The DON further stated the nurse should not store prepared medications in the medication cart as it could lead to a medication error. 3) On 12/17/25 at 7:55 AM, LPN #1 was observed preparing medications for a resident when she found she needed to retrieve a stock medication from the medication room, she placed prepared medications in the cart, locked the cart and walked away leaving a liquid mixture resembling orange juice, (cholestyramine 4 gram mixed in water) on the med cart unsupervised. She entered a closed room out of sight of the cart. When she returned the SA asked if she should have left the medication unattended on her med cart, LPN #1 stated No I should not have left resident medications unattended on top of the medication cart.12/17/25 at 8:50 AM, The DON with the CNM present stated, the expectation is for the nurse to not ever leave medications unattended on the med cart for safety. 4) On 12/17/25 at 8:30 AM, with the DON and CNM present, observed the following in facility's medication storage room: narcotic storage refrigerator was unlocked and unmonitoreda black metal box inside the refrigerator labeled Lorazepam 2 mg/ml was not permanently affixed inside the refrigerator.On 12/17/25 at 8:35 AM, the DON with the CNM present stated, the narcotic box does not need to be secured inside the refrigerator because the door to the medication room was locked.

Based on observation, CDC recommendation review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained during medication preparation and administration. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and transmission of infection. Findings include:The Centers for Disease Control and Prevention (CDC) web page titled, Clinical Safety: Hand Hygiene for Healthcare Workers, updated 2/27/24, documented hand hygiene should be performed:Immediately before touching a patient.Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices.Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or patient's surroundings.After contact with blood, body fluids, or contaminated surfaces.Immediately after glove removal.The following was observed for hand hygiene and Personal Protective equipment (PPE):On 12/17/25 at 8:08 AM, LPN #1 was observed preparing a resident's insulin at the medication cart. She donned gloves, picked up the resident's insulin pens, walked to his room, knocked on the door and pressed the door open with her gloved hand. No hand hygiene was observed. She proceeded to administer the resident's insulin injections. LPN #1 removed her gloves and performed hand hygiene prior to leaving the resident's room.On 12/17/25 at 8:15 AM, LPN #1 stated she should have performed hand hygiene prior to donning gloves after entering the resident's room and prior to administering the insulin injections.On 12/17/25 at 9:00 AM, the DON with the CNM present stated the expectation for her nurses would be that they perform hand hygiene and don fresh gloves after entering a resident's room and prior to administer injections.

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 28 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food Storage policy, updated on 1/9/24, documented: - Date marking will be visible on all high-risk food to indicate the date by which a ready-to-eat, TCS (Time/Temperature for Safety Food) food should be consumed, sold, or discarded. - Foods will be stored and handled to maintain the integrity of the packaging until ready for use. - All food should be covered, labeled, and dated. - All freezer units will be always kept clean and in good working condition. The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS food, Date Marking, states marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. 1. The initial kitchen inspection was conducted on 9/9/24 at 8:26 AM with permission from [NAME] #1. The following was observed: - In the dry food pantry, baking trays, pots, and pans, were stored on the bottom shelves of a cart adjacent to a water heater pipe. The pipe insulation had flaked and peeled, with debris located on the shelves and floor around the pipe. - A box of cornmeal was open and undated. - Refrigerated green onions were opened and undated. - Frozen bread loafs and veggie sausage patties were not dated. - The lids of four large ice cream containers were covered with ice and were not completely closed. - Ice droplets were noted on the ceiling above the containers of ice cream. - A large amount of ice was on the inside of a plastic bin containing wrapped frozen bread. - Ice droplets were on the ceiling above the plastic bin and a cardboard box located on the top back shelves of the freezer. 2. A second kitchen inspection was conducted on 9/11/24 at 8:30 AM with the NSD (Nutritional Services Director). The following was observed: - The water heater pipe had a layer of dust, and the insulation was flaking, peeling, and covered in dust particles, adjacent to the shelves of the storage cart where the pots, pans, and baking dishes were stored. - The floor behind the cart had a layer of dust and more pipe insulation residue. - Two large containers of ice cream had lids that were not fully covering the ice cream. - The cardboard-type lids had water spots on them. - Ice droplets from the ceiling were located above the containers of ice cream. - Ice build-up was observed on the inside of a plastic container containing wrapped frozen bread. - An unopened cardboard box on the top shelf of the freezer had a layer of ice on it. - Ice droplets were located on the ceiling above the plastic container and cardboard box. On 9/11/24 at 8:45 AM, the NSD stated that the door to the freezer does not close well, and the facility is looking to fix it so it will remain closed. She stated the freezer door had opened and ice cream had melted. The NSD stated she believed the ice droplets on the ceiling, and the accumulation of ice in the back of the freezer, were most likely due to that same incident. When asked about the ice cream container lids, the NSD stated the lids of the paper containers frequently get warped. The NSD also stated the storage shelves affected by the pipe insulation particles contained pots, pans, and baking containers that were no longer used by the facility and should have been stored elsewhere.

Based on resident and staff interview, and review of grievances, it was determined the facility failed to file a grievance which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 1 of 12 residents (Resident #135) reviewed for grievances and had the potential to impact residents in the facility who may want to file a grievance. This failure created the potential for Resident #135 to experience psychological harm if her grievances were not heard or acted upon. The findings include: The facility Grievance policy and procedure, updated on 9/28/22, documented that patients or representatives can voice a grievance without discrimination or reprisal from the facility. Prompt investigations and resolutions will be made for all grievances patients may have. Patients and families may file an oral or written grievance by completing the Compliment and Concern form or by a staff member. These forms should be given to either the Administrator or Director of Nursing. Facility staff may also complete the form per patient request. Resident #135 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the left thigh and Parkinson's disease. On 9/9/24 at 2:25 PM, Resident #135 stated, Last Saturday night, after I pressed the call-light, two black ladies told me to go pee in my pad and were rude after I asked them to help me go to the bathroom. When asked if she had reported the incident or filed a grievance, Resident #135 stated, I didn't file an official grievance, but I did report it to LPN #1. A review of the grievance log for September 2024 had no documentation that Resident #135's incident had been reported or filed. On 9/11/24 at 2:07 PM, during a telephone interview, LPN #1 stated on 9/7/24, Resident #135 pulled her aside during medication pass and told her she did not like the black aides that responded to her call light to go the bathroom. Resident #135 stated she was told to pee in her pad. LPN #1 stated CNA #1 was educated that she should not use those terms with the residents. All staff need to help any residents who want to use the restroom. LPN #1 further stated since CNA #1 was educated, she did not believe more had to be done about the situation.

Based on observation, record review and staff interview, it was determined the facility failed to ensure residents were free from medication errors. This was true for 2 of 5 residents (#134 and #136) whose medication administration were observed. This failure created the potential for harm to residents who received insulin to experience low or high blood sugars when they received an incorrect amount of insulin. Findings include: The American Diabetes Association website, accessed on 9/16/24, stated Priming insulin pens is recommended to remove air from needles to ensure full dose administration. The Insulin Lispro Kwikpen website accessed on 9/16/24, documented to prime insulin pen before each injection. Priming the insulin pen means removing air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. 1. Resident #134 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. A physician's order documented, Resident #134 was to receive the following: - Insulin Lispro, insulin pen 100 unit/ml (milliliter), 5 units subcutaneously. - Lantus U-100 insulin glargine 100 units/ml, 15 units subcutaneously. On 9/11/24 at 7:01 AM, LPN #3 took the insulin lispro Kwikpen, replaced the needle with a new one and dialed the pen to 5 units. LPN #3 also took the insulin glargine pen, replaced the needle with a new one and dialed the pen to 15 units. LPN #3 then went to Resident #134's room and injected the insulin to Resident #134's lower abdomen. LPN #3 was not observed to prime the insulin pens before dialing the prescribed dose of insulin for Resident #134. On 9/11/24 at 11:03 AM, when asked about the preparation of insulin pen injections, LPN #3 stated she had not primed the insulin pen. LPN #3 stated she should have primed the insulin pen before dialing the prescribed amount of insulin for Resident #134. 2. Resident #136 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. A physician's order, documented Resident #136 was to receive the following: - Humalog u-100 insulin lispro 100 units/ml, 3 units subcutaneously as a sliding dose. - Lantus u-100 insulin glargine 100 units/ml, 12 units subcutaneously. LPN #3 took the insulin lispro Kwikpen, replaced the needle with a new one and dialed the pen to 3 units. LPN #3 also took the insulin glargine pen, replaced the needle with a new one and dialed the pen to 12 units. LPN #3 then went to Resident #136's room and injected the insulin to Resident #136's lower abdomen. On 9/11/24 at 11:03 AM, when asked about the preparation of insulin pen injections, LPN #3 stated she had not primed the insulin pen. LPN #3 stated she should have primed the insulin pen before dialing the prescribed amount of insulin for Resident #136.

Based on policy review, observation and staff interview, it was determined the facility failed to ensure infection control measures were consistently implemented. This was true for 2 of 2 residents (#83 and #85) observed during dressing change and resident's cares when staff failed to don a gown and perform hand hygiene during dressing change and resident cares. These deficient practices placed residents at risk of infection from cross contamination. Findings include: The facility's Hand Hygiene policy and procedure, effective 11/3/23, documented handwashing should be performed before applying and removing gloves and after personal use of the toilet. 1. Resident #85 was admitted to the facility on [DATE] with multiple diagnoses including dementia. On 9/10/24 at 10:19 AM, CNA #2 assisted Resident #85 to the bathroom. After using the toilet, CNA #2 asked Resident #85 to stand up, Resident #85 was observed to hold on the hand rail and on the sink as she was standing up and being wiped by CNA #2. CNA #2 then assisted Resident #85 to her recliner. CNA #2 was not observed to assist Resident #85 to perform hand hygiene after using the restroom. On 9/10/24 at 10:30 AM, CNA #2 stated she did not assist Resident #85 to wash or sanitize her hands after using the restroom. CNA #2 stated she should have assisted the resident to wash her hands after using the restroom. 2. Resident #83 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following stroke. An MDS (Minimum Data Set) assessment, dated 9/11/24 documented Resident #83 had a feeding tube. On 9/10/24 at 4:31 PM, a signage was observed on Resident #83's door which stated, Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. The signage also documented providers and staff must wear gloves and a gown for the following high-contact resident care activities including device care such as for central line, urinary catheter, feeding tube, and tracheostomy. On 9/10/24 at 4:31 PM, upon entering Resident #83's room, LPN #2 was observed changing the dressing on Resident #83's percutaneous endoscopic gastrostomy (PEG) tube site. LPN #2 was not wearing a gown while performing the dressing change. LPN #2 was also not observed to perform hand hygiene in between changing her gloves during the dressing change. On 9/10/24 at 4:45 PM, LPN #2 stated she did not wear a gown before entering Resident #83's room to change the dressing on her PEG tube site. LPN #2 stated she should have worn a gown before entering Resident #83's room. When asked about the hand hygiene, LPN #2 stated she performed hand hygiene before entering Resident #83' room. LPN #2 stated she did not perform hand hygiene when she was changing her gloves during the dressing change. LPN #2 stated her hands were clean and it was the gloves which were dirty. On 9/12/24 at 9:20 AM, the IP (Infection Preventionist) stated the gown should be worn by the staff when they are performing a dressing change on a resident. The IP also stated hand hygiene should be performed in between changing gloves during the procedure.

Based on observation, document review, and staff interview, it was determined the facility failed to ensure posted contact information of independent entities with whom grievances may be filed, such as, the State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system was accurate. This failure had the potential for residents and/or their representatives to be unaware of who to voice their care concerns/complaints to. Findings include: The facility lobby was observed on 7/25/23, beginning at 9:07 AM. During the observation, a posted form titled KNOW YOUR RIGHTS was reviewed. The form included the following inaccurate information: - The form included the address of the State Agency as, 3232 Elder Street, however, the correct address is, 450 W State Street. - The form included the telephone number of the Area Ombudsman as, [PHONE NUMBER], however, the correct telephone number is, [PHONE NUMBER]. - The form included the telephone number of Adult Protection as, [PHONE NUMBER], however, the correct telephone number is, [PHONE NUMBER]. The facility Administrator was interviewed on 7/25/23, beginning at 10:15 AM, and the KNOW YOUR RIGHTS form was reviewed in his presence. He confirmed the information was not accurate. The facility failed to ensure that posted contact information of independent entities with whom grievances may be filed, such as, the State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system was accurate.

Based on observation, policy review, nursing manual review, competency review, CDC infection control guidelines review, medical record review, and staff interview, it was determined the facility failed to ensure nursing staff had competencies and skill sets to assure resident safety. This was true for 1 of 1 resident (Resident #281) whose PICC line dressing change was observed and whose record was reviewed. This had the potential for increased risk of infection and mechanical failure for all facility residents with PICC lines. Findings include: The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 state, Summary of Recommendations .Education, Training, and Staffing .1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the .maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections .2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the .maintenance of intravascular catheters .3. Designate only trained personnel who demonstrate competence for the .maintenance of peripheral .catheters. These guidelines were not followed. A facility nursing standard of practice titled, [NAME] Nursing Manual, undated, stated, .Temporarily secure the catheter with a piece of tape to prevent catheter migration .Before redressing the site, use a sterile tape measure to measure the external length of the catheter from hub to skin entry to ensure that the catheter hasn't migrated since originally inserted. Compare the measurement with the baseline external length documented at the time of insertion. Report a discrepancy of more than 2 cm to the doctor. This practice standard was not followed. Resident #281 was a [AGE] year-old female who was admitted to the facility on [DATE], with a primary diagnosis of infection. Secondary diagnoses included sepsis and immunodeficiencies. She was a current resident at time of survey. Resident #281's medical record included a documented left arm peripherally inserted central catheter (PICC) line which was inserted prior to her facility admission. Her medical record did not include her initial baseline, facility admission, or current PICC line external catheter hub-to-skin-entry measurements. The Mayo Clinic website, accessed on 7/26/23 at 5:19 PM, states, A peripherally inserted central catheter (PICC), also called a PICC line, is a long, thin tube that's inserted though a vein in your arm and placed through the larger veins near your heart .A PICC line gives your doctor access to the large central veins near the heart. It's generally used to give medications or liquid nutrition. A PICC line can avoid the pain of frequent needle sticks and reduce the risk of irritation to the smaller veins in your arm. A PICC line requires careful care and monitoring for complications, including infection and blood clots. 1. Resident #281's PICC line dressing change performed by LPN #1 was observed on 7/26/23, beginning at 1:35 PM. The following competency and skill set concerns were observed during the course of Resident #281's PICC line dressing change: a. LPN #1 had difficulty removing Resident #281's PICC line transparent dressing and catheter securement device. Resident #281's PICC line was manipulated back and forth during transparent dressing and catheter securement device removal and not temporarily secured with a piece of tape to prevent catheter migration. Additionally, LPN #1 did not measure the external length of the catheter from hub to skin entry to ensure the catheter had not migrated since originally inserted. b. LPN #1's hair, which was longer than shoulder-length, was not secured via PPE. LPN #1's hair was observed approximately 6 to 8 inches directly over Resident #281's PICC line insertion site before, during, and after PICC line dressing change. c. LPN #1 opened the PICC line dressing kit package, attempted to don the included sterile gloves, but stated she was unable to due to size of gloves. LPN #1 requested surveyor ask facility staff to bring a larger pair of sterile gloves. It was unclear why LPN #1 did not organize her supplies prior to initiating the procedure. d. LPN #1's hair, which was longer than shoulder-length, was not secured via PPE. LPN #1's hair was observed approximately 6 to 8 inches directly over the larger sterile gloves she was attempting to don. e. LPN #1, after cleaning Resident #281's PICC line insertion site, requested surveyor ask facility staff for assistance in procuring and opening supplies needed to complete the procedure. The CNM responded, donned PPE, and assisted LPN #1. It was unclear why LPN #1 did not organize her supplies prior to initiating the procedure. f. Prior to applying new transparent dressing, LPN #1 requested Resident #281 elevate and externally rotate her arm. While doing so, Resident #281's patient gown brushed the upper right corner of her PICC line insertion site after it had been cleaned with chlorhexidine. g. Prior to applying new transparent dressing, LPN #1 could not get the new catheter securement device to close correctly. While attempting to get new catheter securement device to close correctly, LPN #1 was observed to touch the recently cleaned PICC line insertion site area with her non-sterile procedure glove and sterile procedure glove. h. LPN #1 affixed the new PICC line transparent dressing over Resident #281's PICC line insertion site and catheter securement device, but it was unclear if the device was closed correctly. i. LPN #1 was not observed to label the new PICC line dressing with the date, time, and her initials. The CNM was interviewed on 7/26/23 at approximately 1:58 PM and LPN #1's PICC line dressing change observation was reviewed in her presence. The CNM stated she was responsible for the facility's infection control program as well as signing-off on facility nursing staff competencies. When asked what nationally recognized infection control guidelines the facility followed for its infection control program, the CNM was initially unsure, but then confirmed, CDC guidelines. When asked if the facility had a PICC line dressing change policy, she stated, No, but nursing staff followed [NAME] Nursing Manual. The CNM confirmed the above competency and skill set concerns observed. Due to observation concerns during Resident #281's PICC line dressing change, the CNM stated she would perform a new dressing change now. 2. LPN #1's LICENSED NURSE COMPETENCY CHECKLIST, dated 9/22/22, was reviewed. Her skills competency did not include PICC line dressing changes. It could not be determined how the facility assessed and evaluated LPN #1's competency and skill set to safely perform PICC line dressing changes. LPN #2's, the second of two LPNs assigned to direct resident care on day shift 7/26/23, LICENSED NURSE COMPETENCY CHECKLIST was requested, but not provided. It could not be determined how the facility assessed and evaluated LPN #2's competency and skill set to safely perform PICC line dressing changes. The CNM was interviewed a second time on 7/26/23, beginning at 2:27 PM, and LPN #1's LICENSED NURSE COMPETENCY CHECKLIST was reviewed in her presence. She confirmed LPN #1's competency did not include PICC line dressing changes. When asked who was allowed to perform PICC line dressing changes, the CNM stated, RNs and LPNs. When asked if the same LICENSED NURSE COMPETENCY CHECKLIST was used for all facility nursing staff (RNs and LPNs), she stated, Yes. The CNM confirmed the LICENSED NURSE COMPETENCY CHECKLIST did not include PICC line dressing changes for facility nursing staff. With lack of documented nursing PICC line dressing change competency and skill set, it could not be determined if facility nursing staff could safely perform this task. The CNM was interviewed a third time on 7/26/23, beginning at 3:01 PM, and Resident #281's medical record was reviewed in her presence. She confirmed Resident #281's baseline, admission, and current PICC line external length measurements were not documented as that had not been part of their PICC line dressing change process. The [NAME] President of Clinical Services was interviewed on 7/26/23, beginning at 3:19 PM. When asked if nursing staff should be measuring PICC line external lengths per the [NAME] Nursing Manual, he stated, Yes. The [NAME] President of Clinical Services stated the facility did not have sterile PICC line tape measures as part of their available supplies as required by the [NAME] Nursing Manual. The Regional [NAME] President of Operations and the [NAME] President of Clinical Services were interviewed together on 7/26/23, beginning at 3:30 PM. The Regional [NAME] President of Operations confirmed LPN #1's skills competency did not include PICC line dressing changes. Additionally, she confirmed the facility's LICENSED NURSE COMPETENCY CHECKLIST, used by all facility RNs and LPNs, did not include PICC line dressing changes. The DON was interviewed on 7/26/23, beginning at 4:47 PM, and the facility's, ANNUAL INSERVICE SCHEDULE 2023 was reviewed in her presence. The form included numerous training topics including emergency preparedness, patient rights, and fall prevention. The DON confirmed the facility's ANNUAL INSERVICE SCHEDULE 2023 did not include education or training related to PICC line dressing changes. The facility failed to ensure nursing staff had competencies and skill sets to ensure resident safety.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure that residents' advance directives were obtained and this information was documented in their record. This was true for 2 of 12 residents (#128, and #177) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcome if the resident's wishes were not followed or documented regarding their advance care planning. Findings include: As defined in the State Operations Manual (SOM), Appendix PP, an advance directive is a written instruction, such as a living will or durable power of attorney for health care, relating to the provision of health care when the individual is incapacitated. An Idaho Physician Orders for Scope of Treatment (POST) is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency. A POST form is not an advance directive. The SOM further stated, If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents must be obtained and maintained in the same section of the resident's medical record readily retrievable by any facility staff. Facility staff must communicate the resident's wishes to the resident's direct care staff and physician. The facility policy for Advance Directives, version A0717, stated, prior to or upon admission the facility will ask about the existence of any written advance directives and information will be displayed in the medical record specifying whether the resident has an advance directive or has declined the opportunity to create one. This policy was not followed. Examples include: The facility used a form titled Acknowledgement of Patient Information on Advance Directives. This form indicated the facility provided written education to the resident, and/or their representative about advance directives and their rights to create or decline to execute one. The form contained places to mark that a copy was provided to the facility, acknowledgement that the resident representative will provide a copy as soon as possible if they don't have it on hand at admission, and a place to document the substance of the advance directive until the copy of the advance directive can be added to the medical record. 1. Resident #177 was admitted on [DATE] with diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), a fractured pelvis and ribs, and a history of falls. Resident #177's medical record included An Acknowledgement of Patient Information on Advance Directives form, dated 7/13/23, documented he had a POST and a DNR on file. Additionally it documented his family has living will. A copy of the Advanced directive was not present in Resident #177's record. Additionally, the acknowledgement form had a checkbox that indicated whether the resident provided the facility a copy of the advance directive and a area which stated, Although the patient is instructed to bring in a copy of his/her advance directive to be placed in the medical record, the substance/instructions of patient's advance directive states: Both areas on the form were blank. On 7/24/23 at 3:42 PM, the DON was asked for a copy of Resident #177's advanced directive. The DON stated the advanced directive was not able to be located. 48400 2. Resident #128 was admitted to the facility on [DATE] with multiple diagnoses including Endocarditis (inflammation of the lining of the heart) and sepsis (life threatening complication of infection). Resident #128's record contained medical record included An Acknowledgement of Patient Information on Advance Directives form, dated 7/11/23, documented he had a POST and a DNR on file. Additionally it documented his family has living will. A copy of the Advanced directive was not present in Resident #128's record. Additionally, the acknowledgement form had a checkbox that indicated whether the resident provided the facility a copy of the advance directive and a area which stated, Although the patient is instructed to bring in a copy of his/her advance directive to be placed in the medical record, the substance/instructions of patient's advance directive states: Both areas on the form were blank. During an interview on 7/26/23 at 8:45 AM, when asked for Resident #128's advanced directive, the DON stated at admission the facility talked with the resident and/or their family about advance directives. She stated the resident, or their family, filled out a form indicating they had an advance directive and would bring it in, or that they refused to have an advance directive. The DON stated they have a part time social worker who followed up with the residents and family as needed to get a copy of the residents' advance directives. She stated the social worker would document any attempts in a progress note or on the acknowledgement form. On 7/26/23 at 9:58 AM, the DON stated to the surveyor the facility is looking for the resident's advanced directive. The facility failed to ensure that residents' advance directives were obtained and this information was documented in their record.

48401 Based on record review, policy review, and staff interview, it was determined the facility failed to ensure baseline care plans were individualized for 3 of 12 residents (#131, #179, and #188) whose baseline care plans were reviewed. This failure created the potential for resident specific needs to go unrecognized due to lack of information for caregivers. Findings include: Facility policy titled Baseline Care Plans, version A1012, stated the Interim Care Plan is developed during the admission process to direct patient care prior to the development of the Comprehensive Care Plan. The Interim Care Plan is developed from a nursing assessment of the patient's needs, strengths, and weaknesses. The Interim Care Plan is written to include care to be given, goals to be accomplished, and actions necessary to attain the goals. This policy was not followed. 1. Resident #131 was admitted to the facility on [DATE] with multiple diagnoses including depression and metabolic encephalopathy (a chemical imbalance that effects brain function) with behaviors. Resident #131's MAR, dated July 2023, documented orders for the following: - Quetiapine (Seroquel) 50 mg (an antipsychotic medication). - Sertraline (Zoloft) 100 mg (an antianxiety medication) Resident #131's TAR, dated July 2023, documented the following behavior which were being monitored: - Target behaviors for Seroquel: hallucinations, yelling out, and verbal and physical aggression. - Target behaviors for Zoloft: verbalizing feeling sad, trouble concentrating, and low interest. Resident #131's Consent to Use Psychotherapeutic Medications forms, signed 7/19/23, documented how his episodes of depression and metabolic encephalopathy were exhibited. The consented documented depression was exhibited by verbalizing feelings of sadness and having low motivation. Resident exhibited behaviors due to his metabolic encephalopathy by being physically aggressive, yelling and cursing. Resident #131's Baseline Person Centered Care Plan, dated 7/19/23, documented his prescribed psychotropic medications per physician order. Additionally, the care plan stated to monitor and document signs and symptoms of adverse reactions. Resident #131's baseline care plan did not include resident specific behaviors to be monitored, as stated in his consent. 2. Resident #179 was admitted to the facility on [DATE] with multiple diagnoses including depression and psychosis secondary to delirium (a serious change in mental state that results in confused thinking). Resident #179's MAR, dated July 2023, documented orders for the following: - Lexapro 10 mg (an antidepressant medication). - Seroquel (Quetiapine) 50 mg (an antipsychotic medication). Resident #179's TAR, dated July 2023, documented the following behavior monitors: - Target behaviors for Lexapro: verbalizing feeling sad and tearful. - Target behaviors for Seroquel: agitation and aggressive behavior. Resident #179's Consent to Use Psychotherapeutic Medications forms, signed 7/13/23, documented how his episodes of depression and psychosis were exhibited. The consented documented depression was exhibited by verbalizing feelings of sadness and being tearful. His psychosis was exhibited by aggressive behavior, agitation, and yelling out without provocation. Resident #179's Baseline Person Centered Care Plan, dated 7/13/23,documented his prescribed psychotropic medications per physician order. Additionally, the care plan stated to monitor and document signs and symptoms of adverse reactions. Resident #179's baseline care plan did not include resident specific behaviors to be monitored, as stated in his consent 3. Resident #188 was admitted on [DATE] with multiple diagnoses including depression and anxiety, and required aftercare following a knee replacement surgery. On 7/26/23, Resident #188's physician orders stated she received escitalopram (a medication used to treat depression and anxiety) and was to be monitored for target behaviors identified by Resident #188 at admission. Resident #188's Consent to Use Psychotherapeutic Medications, dated 7/18/23, stated that when Resident #188 felt depressed she would verbalize feeling anxious or sad. Resident #188's interim care plan, dated 7/18/23, documented his prescribed psychotropic medications per physician order. Additionally, the care plan stated to monitor and document signs and symptoms of adverse reactions. Resident #188's baseline care plan did not include resident specific behaviors to be monitored. On 7/26/23 at 2:15 PM, the DON stated she oversees adding psychotropic medications, the behavior monitors, and side effect monitors to the MAR and the care plan. She stated when a resident was admitted , the facility asked the resident or family what behaviors and symptoms the resident showed for their mental health diagnoses. The DON stated the information is documented on the Consent to Use Psychotherapeutic Medications form, then added to the TAR. She stated the specific symptoms do not always go on the care plan because they could change. The DON stated the specific behaviors are listed in the TAR and other documents, so specific behaviors did not need to be in the care plan. The facility failed to ensure baseline care plans were individualized.

Based on policy review, record review, and staff interview it was determined the facility failed to provide a comprehensive, person centered care plan. This was true for 1 of 12 Residents (Resident #6) whose comprehensive care plan was reviewed. This failure created the potential for the resident to receive inappropriate care. Findings include: The facility's policy Comprehensive Care Plan, version A1021, stated the facility will develop a comprehensive person-centered care plan. It stated an individualized care plan should be developed with the input from the patient and/or representative. The policy stated there should be individual-specific interventions and parameters for monitoring progress. This policy was not followed. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses including anxiety and depression. Resident #6's MAR, dated July 2023, documented orders for the following: - Buspirone 7.5 mg (an antianxiety medication),. - Duloxetine 60 mg (an antidepressant medication). Resident #6's TAR, dated July 2023, documented the following behavior monitors: - Target behaviors for Buspirone: verbalizing feeling anxious and restless. - Target behaviors for Duloxetine: verbalizing feeling sad, withdrawn, and tearful. Resident #6's Consent to Use Psychotherapeutic Medications forms, signed 6/21/23, documented how his episodes of depression and anxiety were manifested. For depression the form documented verbalizing feeling sad, tearful, and withdrawn. For anxiety the form documented Resident #6 verbalizing feeling anxious and restless. Resident #6's Comprehensive Care Plan, last reviewed/revised 7/5/23, included goals for depression and anxiety. It documented altered mood status would not interfere with daily functions. It directed the staff to encourage the patient to express needs and feelings, as well as monitoring for signs and symptoms of withdrawal or increased depression. For Anxiety it directed staff to monitor for signs and symptoms of increased anxiety. There were no resident specific behaviors to be monitored on the care plan. On 7/26/23 at 2:15 PM, the DON stated she oversees adding psychotropic medications, the behavior monitors, and side effect monitors to the MAR and the care plan. She stated when a resident was admitted , the facility asked the resident or family what behaviors and symptoms the resident showed for their mental health diagnoses. The DON stated the information is documented on the Consent to Use Psychotherapeutic Medications form, then added to the TAR. She stated the specific symptoms do not always go on the care plan because they could change. The DON stated the specific behaviors are listed in the TAR and other documents, so specific behaviors did not need to be in the care plan. The facility failed to provide a comprehensive, person centered care plan.

Based on observation, staff interview, and policy review, the facility failed to implement infection control measure by not ensuring visitors and staff were screened prior entering the facility and by failing to provide a separation of clean PPE (including gowns, gloves, goggles, and masks) and dirty PPE. These failures had the potential to increase the risk for the spread of COVID-19, and other infectious agents to the 19 residents residing at the facility and all staff and visitors due to a lack of consistent screening and the increased possibility for cross contamination of PPE. Findings include: 1. The facility's policy Soiled Laundry & Linen Handlings, undated, stated, . 1. Separate soiled and clean linen at all times . 3. Consider all soiled linen to be potentially infectious . 5. All soiled linen must be placed directly into a covered laundry bag or clean, disposable plastic bag . This policy was not followed. On 12/10/20 beginning at 9:40 AM, Hall 1 had residents residing there who were under quarantine, which included rooms 101 to 113. The following was observed: - rooms [ROOM NUMBERS] had an alcove area outside their doors. Directly outside the door of room [ROOM NUMBER], was a three-drawer dresser which held clean PPE. Next to the side of the clean PPE dresser was a laundry basket, lined with a dissolvable liner, which held used gowns. Next to the laundry basket was a garbage can which held used surgical masks and gloves. The laundry basket and garbage can did not have lids and all contents were exposed to the air. Between room [ROOM NUMBER] and 103 was an additional three-drawer plastic dresser which held clean PPE. On the top of the clean PPE dresser was a brown paper bag where used glasses were deposited after being doffed. Directly outside of the door to room [ROOM NUMBER] was another three-drawer plastic dresser which held clean PPE and next to the dresser was a laundry basket, lined with a dissolvable liner which held used gowns. A small garbage can was next to the laundry basket that held used masks and gloves. Next to the garbage can was a small portable oxygen concentrator. The laundry basket and garbage can did not have lids and all contents were exposed to the air. - rooms [ROOM NUMBERS] had an alcove area outside their doors. Directly outside the door to room [ROOM NUMBER], was a three-drawer dresser which held clean PPE. Next to the side of the clean PPE dresser was a laundry basket, lined with a dissolvable liner, which held used gowns. Next to the laundry basket was a garbage can which held used surgical masks and gloves. The laundry basket and garbage can did not have lids and all contents were exposed to the air. Between room [ROOM NUMBER] and 104 was an additional three-drawer plastic dresser which held clean PPE. On the top of the clean PPE dresser was a brown paper bag labeled dirty glasses. Directly outside of room [ROOM NUMBER] was a three-drawer dresser which held clean PPE. Next to the side of the clean PPE dresser was a laundry basket, lined with a dissolvable liner, which held used gowns. Next to the laundry basket was a garbage can which held used surgical masks and gloves. The laundry basket and garbage can did not have lids and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer plastic dresser which contained clean PPE supplies. A brown paper bag labeled dirty glasses, was on top of the dresser and held dirty glasses. A bottle of hand sanitizer was next to the brown paper bag. A laundry basket, lined with a dissolvable liner, was next to the dresser and a garbage can was next to the laundry basket, which held used masks and gloves. The laundry basket and garbage can did not have lids and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer dresser which contained clean PPE. A brown paper bag labeled dirty glasses, was on top of the dresser and held dirty glasses. Next to the dresser was the laundry basket, lined with a dissolvable liner, which held used gowns. The laundry basket did not have a lid and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer dresser which contained clean PPE. A brown paper bag labeled dirty glasses, was on top of the dresser and held dirty glasses and a bottle of hand sanitizer was up against the brown paper bag. Next to the dresser was the laundry basket, lined with a dissolvable liner, which held dirty gowns. One gown was looped over the handrail on the wall and draped into the laundry basket. A garbage can was next to the laundry basket. The laundry basket and the garbage can did not have lids and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer dresser with a brown paper bag labeled dirty glasses, which held dirty glasses. A laundry basket, lined with a dissolvable liner, was next to the dresser and held used gowns and a garbage can was next to the laundry basket which held used masks and gloves. The laundry basket and garbage can did not have lids and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer dresser which held clean PPE. On top of the dresser was a brown paper bag labeled dirty glasses, and a bottle of hand sanitizer was next to the brown paper bag. Next to the dresser was the laundry basket, lined with a dissolvable liner, which held used gowns. An empty brown paper bag bridged the space between the dresser and the laundry basket. A garbage can which held used masks and gloves was next to the laundry basket. The medication cart which was stationed along the wall in the hallway touched the garbage can. The laundry basket and garbage can did not have lids and all contents were exposed to the air. - Outside of room [ROOM NUMBER] was a three-drawer dresser which held clean PPE. There was a second three-drawer dresser next to the first. On the top of the second dresser was a brown paper bag labeled, dirty glasses. Clorox wipes were next to the dirty glasses bag and Micro-kill wipes were next to the Clorox wipes. Against the second set of drawers was a garbage can which held used masks and gloves. The garbage can did not have a lid and all contents were exposed to the air. In an interview on 12/10/20 at 4:07 PM, regarding the set up for PPE, the laundry baskets, and the garbage cans in the 100-hall, the DON said, We did a walk through with Centers for Disease Control on a Zoom call and they didn't disagree with it (the setup). The DON stated, Health and Welfare was on the same phone call and were not particularly concerned because the clean PPE is inside drawers. The DON and the Administrator stated that the facility did not have a specific policy that addressed the setup they were using outside of the rooms, for the PPE, the laundry baskets, and the garbage cans. The facility failed to ensure opportunities for cross contamination of PPE were minimized. 2. The facility's policy, titled Keeping COVID-19 Out of the Facility, undated, stated all visitors and staff were to be screened prior to entry to the facility which included temperature checks and questions related to signs or symptoms consistent with COVID-19. Staff Surveillance Tracking sheets, dated 12/1/20 - 12/10/20, were reviewed and documented that on 12/4/20, a staff signed in and no temperature was documented for the staff person. On 12/8/20, a staff signed in and no temperature was documented for the staff person. Visitor Sign-In Sheets, dated 12/1/20 - 12/10/20, were reviewed and documented that on 12/10/20, a visitor signed in and no temperature was documented for the visitor. When asked, the DON who was also the ICP, stated during an interview on 12/10/20 from 4:00 - 4:50 PM, she was not aware there were no documented temperatures for the staff and the visitor and temperatures were to be taken and documented accordingly for all staff and visitors. The facility failed to ensure all visitors and staff were screened prior to entry to the facility.

Based on observation, policy review, nationally recognized standards of practice, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's policy for Cleaning Blood Pressure Equipment, dated 3/12/18, documented the purpose was to prevent cross contamination between residents. The policy directed staff to clean the blood pressure cuff in the following manner: * Use disinfecting wipes to clean the blood pressure cuff, tubing, and sphygmomanometer (the gauge that provides the blood pressure measurement) in a circular motion. * Remove gloves and discard them. Wash and dry hands thoroughly. * Use disinfecting wipes to clean and disinfect the surface area used to clean the blood pressure cuff. The facility's policy for Cleaning a Stethoscope, dated 3/12/18, documented the purpose was to prevent cross contamination between residents and/or when a stethoscope was used by multiple staff members. The policy directed staff to clean the stethoscope in the following manner: * Use disinfecting wipes to clean the stethoscope ear pieces, tubing, diaphragm, and bell in a circular motion. * Remove gloves and discard them. Wash and dry hands thoroughly. * Use disinfecting wipes to clean and disinfect the surface area used to clean the stethoscope. These policies were not followed. On 8/12/20 at 9:12 AM, a plastic storage chest which contained PPE was outside the door of Resident #1's room, and a sign was on top of the storage chest that provided directions regarding cleaning equipment. The sign directed staff to clean equipment in the following manner: 1. Perform hand hygiene. 2. Put on gloves. 3. Using the Blue Top (Micro-Kill bleach disinfectant wipes): a. Wipe the equipment b. Wipe the table top. 4. Remove gloves. 5. Perform hand hygiene. A container of Micro-Kill bleach wipes was on top of the storage chest, and the directions on the container stated the required contact time was 30 seconds. On 8/12/20 at 9:45 AM, CNA #1 donned (put on) the appropriate PPE and entered Resident #1's room carrying a stethoscope and blood pressure cuff. CNA #1 checked Resident #1's blood pressure, and after she exited the room she obtained a Micro-Kill bleach wipe from the container on the storage cart outside the room. CNA #1 wiped down the stethoscope and immediately draped it around the back of her neck. CNA #1 then wiped down the blood pressure cuff, and immediately draped it around her the back of her neck. She did not allow for 30 seconds of contact time after wiping them with the Micro-Kill bleach wipe. CNA #1 then wiped down the top of the storage cart and walked down the hall to Resident #2's room with the stethoscope and blood pressure cuff still draped around the back of her neck. CNA #1 then donned the appropriate PPE and entered Resident #2's room with the blood pressure cuff and stethoscope around the back of her neck. On 8/12/20 at 9:52 AM, CNA #1 exited Resident #2's room, and she was holding the blood pressure cuff and stethoscope in her hand. CNA #1 laid the blood pressure cuff and stethoscope on top of the storage cart outside Resident #2's room, removed her PPE, and performed hand hygiene. CNA #1 then donned gloves, obtained a Micro-Kill bleach wipe from the container on top of the storage cart outside Resident #2's room, and wiped down the stethoscope. CNA #1 immediately placed the stethoscope around the back of her neck, wiped down the blood pressure cuff, and hung the blood pressure cuff over her arm near her wrist. She did not allow 30 seconds of contact time with the Micro-Kill bleach wipe. CNA #1 wiped down the top of the storage cart while outside of Resident #2's room. She removed her gloves, and then she walked down the hall to Resident #4's room with the blood pressure cuff over her arm and the stethoscope around the back of her neck. CNA #1 said it was probably not a good practice to wipe down the stethoscope and blood pressure cuff and then immediately place them around her neck. CNA #1 said she thought the required contact time for the Micro-Kill bleach was 20 seconds, and she had received training for wiping down equipment between residents. CNA #1 said she was in a hurry at the time she was observed. On 8/12/20 at 1:37 PM, the DON said when staff entered a resident's room that was on precautions, they should don the appropriate PPE and clean any equipment they used. The DON said the required contact time for the Micro-Kill bleach wipes was 30 seconds, and staff should clean the stethoscope and blood pressure cuff and place it on top of the storage cart to dry outside the resident's room. 2. The facility provided a document from the CDC with guidance for donning PPE, which was undated. The document provided the following directions for donning a gown: * Fully cover the torso from the neck to the knees and from the arms to the end of the wrists and wrap the gown around the back. * Fasten the gown behind the neck and waist. This guidance was not followed. On 8/12/20 at 12:54 PM, the housekeeper was observed entering Resident #3's room to clean. An orange caution sign was posted on Resident #1's doorframe. A plastic storage chest that contained PPE was outside the door, and directions for donning PPE were posted near the door. The housekeeper was wearing a blue washable gown which was tied in the front of her neck and waist instead of behind her neck and waist. The housekeeper wiped down Resident #3's room and cleaned the bathroom. On 8/12/20 at 1:03 PM, the housekeeper exited Resident #3's room carrying a bottle of cleaning product and a toilet bowl brush. The housekeeper's gown, which was tied in front, had a gap in the lower portion of the gown between the ties and her scrubs were exposed. The bottle of cleaning product and toilet bowl brush were in direct contact with the housekeeper's scrubs as she returned them to her cart. The housekeeper said she had received hands-on training for proper use of PPE, and her gown should have been tied in the back. The housekeeper said she had her gown tied in the front because she forgot the correct way to wear it. On 8/12/20 at 1:37 PM, the DON said if there was a gap in the gown that was not good, and most people tied their gown in the back.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 6 of 9 residents (#1, #2, #3, #6, #7, and #9) who were observed for infection prevention practices. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination. Findings include: 1. The facility's Hand Washing policy, dated 5/26/20, directed staff to perform hand hygiene: * Before applying and removing any PPE. * Before and after applying and removing gloves. * After contact with any equipment or environmental surface that might have been soiled or contaminated. The facility's Covid-19 Emergency Plan, dated 5/20/20, directed staff to place newly admitted residents and residents who returned from outside appointments, on quarantine for 14 days, even with negative Covid-19 test results. The plan directed staff to wear surgical masks, gowns, goggles, and gloves when working with residents in quarantine. These policies were not followed. The CDC website, accessed on 6/17/20, under Coronavirus Disease 2019 Using PPE and Strategies for Optimizing the Supply of Isolation Gowns, documented health care providers were to perform hand hygiene prior to donning (putting on) and after doffing (taking off) PPE. Extended use of cloth isolation gowns may be worn by a single health care provider. Each resident room had either a triangle or star sign outside their door. The rooms with a triangle sign had directions from the CDC and/or printed instructions by the facility on how to appropriately don and doff PPE. On 6/9/20 at 8:15 AM, CNA #2 said resident rooms with a triangle sign outside their door were residents under quarantine and staff had to wear PPE before entering these rooms. CNA #2 said the resident rooms with a star sign outside their door were residents who were out of the quarantine period. CNA #2 said the facility placed all their new admissions in quarantine for 14 days. a. On 6/9/20 at 11:15 AM, LPN #2 carried a medication cup containing pills in her hand and walked towards Resident #6's room. Resident #6's room had a triangle sign outside his door and a PPE cart was observed outside his room with written instructions directing staff how to don and doff PPE. LPN #2 placed the medication cup on top of the PPE cart, knocked on the door, turned the door handle down and opened the door. LPN #2 then took the cloth gown that was hanging on the wall inside the room and put it on. LPN #2 then put on the goggles and gloves. LPN #2 did not perform hand hygiene before donning PPE according to the instructions outside of the room. LPN #2 then picked up the medication cup and entered Resident #6's room. On 6/9/20 at 11:25 AM, LPN #2 said she should have performed hand hygiene before donning her PPE. On 6/9/20 at 11:35 AM, during delivery of meal trays, CNA #1 knocked on Resident #6's door. CNA #1 opened the door and took the cloth gown that was hanging on the wall which was used previously by LPN #2. CNA #2 then performed hand hygiene and put on the goggles and gloves. CNA #2 then took Resident #6's tray from the food cart and delivered it to Resident #6. At 11:37 AM, CNA #1 stepped out of Resident #6's room, took off the gown and put it in the basket labeled dirty gowns outside Resident #6's room and performed hand hygiene. On 6/9/20 at 12:00 PM, LPN #2 was asked if she recognized the gown on the basket outside Resident #6's room. LPN #2 said it was the gown she used earlier when she administered Resident #6's medication. When asked if she put the gown in the basket, LPN #2 said she did not put the gown in the basket. LPN #2 said she hung the gown on the hook inside Resident #6's room with the intention to re-use it later. On 6/9/20 at 12:07 PM, CNA #1 said she was not aware she re-used the gown that was hanging on the wall of Resident #6. CNA #1 said she usually used a new gown and goggles when she entered any residents' room. b. On 6/9/20 at 11:15 AM, Resident #2's room had a triangle sign outside his door and a PPE cart was observed outside his room with written instructions directing staff how to don and doff PPE. Physical Therapy Assistant #1 (PTA) was in Resident #2's room and assisted her with her therapy exercises. PTA #1 had on a reusable PPE gown, goggles, a surgical mask, and gloves. PTA #1 assisted Resident #2 with her walker with both gloved hands on the walker and then stepped out of the room into the hallway to give Resident #2 privacy while she used the restroom. At 11:17 AM, PTA #1 then removed his goggles with his gloved hands and wiped the inside and outside of the goggles with the front of his gown and placed the contaminated goggles back on his face. He did not sanitize or replace the goggles and did not perform hand hygiene. At 11:22 AM, Resident #2 told PTA #1 he could go back into the room and he went into the room and closed the door. At 11:30 AM, PTA #1 came out of Resident #2's room and removed the gown, gloves, goggles, and performed hand hygiene. On 6/9/20 at 11:35 AM, PTA #1 put on a new gown, goggles, and gloves prior to entering Resident #3's room. Resident #3's room had a triangle sign outside his door and a PPE cart was observed outside his room with written instructions directing staff how to don and doff PPE. At 12:00 PM, PTA #1 exited the room and removed his gown, gloves, and goggles without performing hand hygiene. He then picked up a box of therapy equipment (theraband, weights, a ball, and a laptop computer) that he brought out of the room. He walked down to the therapy gym where he disinfected the equipment and the box with sanitation wipes. He did not perform hand hygiene prior to or after disinfecting the equipment. On 6/9/20 at 12:08 PM, PTA #1 said he did not remember touching his mask when he was outside of Resident #2's door. He said he had wiped down his goggles with his gown because they had fogged up. He said he should have performed hand hygiene after removing his gloves. c. On 6/9/20 at 8:25 AM, CNA #2 delivered Resident #1's food to her room. Resident #1's room had a triangle sign outside her door and a PPE cart was observed outside her room with directions from the CDC on how to don and doff PPE. CNA #2 left the room and removed her gown, gloves, and mask. She did not perform hand hygiene according to the instructions outside of the room. She then reached into a box of new masks, which potentially contaminated the masks in the box, and placed a mask on her face. She then performed hand hygiene. On 6/9/20 at 8:58 AM, CNA #2 said she should have performed hand hygiene after she doffed her PPE. d. On 6/9/20 at 8:35 AM, LPN #1 carried a syringe and medication cup containing pills in her hand and walked towards Resident #9's room. Resident #9's room had a triangle sign outside her door and a PPE cart was observed outside her room with written instructions directing staff how to don and doff PPE. LPN #1 placed the syringe on top of the glove box which was on top of the PPE cart and the medication cup on top of the PPE cart. LPN #1 put on gloves, then she opened the PPE cart, took one of the cloth gowns and put it on. LPN #1 then picked up the syringe and the medication cup and entered Resident #9's room. LPN #1 did not perform hand hygiene before donning her PPE as the instructions directed. On 6/9/20 at 10:48 AM, LPN #1 said she thought she performed hand hygiene before she donned her PPE. LPN #1 said she should have performed hand hygiene before donning her PPE. On 6/9/20 at 2:08 PM, the DON said she expected staff to perform hand hygiene before donning and doffing PPE. The DON said the staff could reuse the goggles, but they should be sanitized after each use, and gowns could be reused only by the same staff, provided it was not soiled. The DON said staff should not be using gowns that were used by another staff. 2. The facility's Clean Linen Handling policy and procedure, dated 3/12/18, documented clean linen was transported, stored, and distributed in a sanitary way. This policy was not followed: On 6/9/20 at 1:25 PM, Housekeeper #1 was observed as she delivered residents' clothing in Hall 1. The laundry cart had some of the residents' clothing on a hanger and some clothes were folded. The laundry cart had a cover on one side and the other side was open. On top of the laundry cart were about 4-5 folded clothes items. Housekeeper #1 was asked why there were clothes on top of the laundry cart and why they were not inside the laundry cart. Housekeeper #1 said those clothes were unlabeled and she did not know who they belonged to. Housekeeper #1 said the clothes were on top of the laundry cart for about two days. Housekeeper #1 said the laundry cart was always open on one side whenever she delivered the clean clothes to the residents. On 6/9/20 at 2:45 PM, the Housekeeper Supervisor said the laundry cart should be covered on both sides when it left the laundry room. The Housekeeper Supervisor also said unlabeled clothes should not be left on top of laundry cart. The Housekeeper Supervisor said the unlabeled clothes should be kept in the laundry room until they determined who they belonged to.

Based on observation, staff interview, and policy review, it was determined the facility failed to ensure kitchen equipment was maintained in a sanitary manner. This was true for 12 of 12 residents (#1, #14, #15, #76, #78, #79, #80, #128, #129, #130, #131, and #133) and the other 17 residents who dined and resided in the facility. This placed residents at risk for potential contamination of food and adverse health outcomes. Findings include: The facility's kitchen cleaning policy, dated 5/2013, documented staff cleaned the range after each use and spills were cleaned as they occurred on the range and in the ovens. This policy was not followed. On 9/3/19 at 9:15 AM, the following observations were made in the kitchen with Cook #1: * There was a build-up of blackened food debris which covered 4 of 4 gas top grill burners. * There was a build-up of grease and blackened food debris in the bottom of 1 of 2 ovens. On 9/3/19 at 9:17 AM, Cook #1 said the build-up on the gas burners was at least a week's worth and he said the oven was not cleaned because staff did not have the time to clean it. On 9/3/19 at 1:32 PM, the Certified Dietary Manager said the gas burners were not cleaned as expected. She said the oven debris was from a cake spill a few days prior and it was not cleaned after the spill.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' records included a copy of the Advance Directives, or documentation of their decision not to formulate an Advance Directive and residents were provided accurate information regarding Advance Directives upon admission. This was true for 12 of 12 residents (#1, #14, #15, #76, #78, #79, #80, #128, #129, #130, #131, & #133) reviewed for Advance Directives. These failures created the potential for harm should residents not have their decisions documented, honored, and respected when they were unable to make or communicate their health care preferences. Findings include: The State Operations Manual, Appendix PP, defines an Advanced Directive as .a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. The State Operations Manual also states a Physician order [REDACTED]. medical condition into consideration. A POLST [MEDICATION NAME] form is not an Advance Directive. The facility's Advance Directives policy, dated 2/21/18, documented the following: * Prior to or upon admission, the Admission Coordinator or designee will provide information to the patient their right to make decisions concerning medical care and the right to formulate Advance Directives. * Prior to or upon admission, the Admission Coordinator or designee will inquire of the patient and/or their family members, about the existence of any written Advance Directives previously executed. * Information will be displayed in the medical record about whether or not the patient has executed an Advance Directive. The facility's policy was not followed. Examples include: a. Resident #76 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #76's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with her. On 9/5/19 at 9:45 AM, Resident #76 said she had a living will and said she did not remember facility staff asking for a copy of her living will. b. Resident #80 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #80's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with him or his representative. On 9/5/19 at 9:45 AM, Resident #80 said he had a living will and said facility staff did not ask him for a copy of his living will. c. Resident #78 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #78's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with him or his representative. On 9/4/19 at 3:05 PM, Resident #78 said facility staff did not ask if he had a living will. d. Resident #79 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #79's record did not include documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. e. Resident #14 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #14's record did not include documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. f. Resident #1 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's record did not include documentation the facility's policy for Advance Directives was provided to or discussed with him or his representative. g. Resident #15 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #15's record did not include documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. On 9/5/19 at 10:37 AM, Resident #15 said she did not remember if she was asked about an Advance Directive. h. Resident #128 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #128's record record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. i. Resident #129 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #129's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. j. Resident #130 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #130's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with her or her representative. On 9/5/19 at 10:20 AM, Resident #130's representative said Resident #130 had a living will, but she did not remember if the facility staff asked her for a copy of Resident #130's living will. k. Resident #131 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #131's record did not include an Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with him or his representative. l. Resident #133 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #133's record did not include and Advance Directive or documentation the facility's policy for Advance Directives was provided to or discussed with him or his representative. On 9/5/19 at 9:57 AM, Resident #133 said he had a living will, but did not remember if the facility staff asked for a copy his Living Will. On 9/6/19 at 8:34 AM, LPN #1 said if residents had a living will or Advance Directives, they were kept in the residents' charts under the Advance Directives tab. LPN #1 said the facility's admissions staff did not always obtain a copy of residents' Advance Directives or living wills. On 9/6/19 at 9:13 AM, LPN #2 said when residents were admitted she offered them Advance Directive information and said she was not documenting the information was offered to them. LPN #2 said if residents had a living will or Advance Directives, she asked them or their representatives to bring those to the facility to be placed in the chart. On 9/6/19 at 8:36 AM and 9:16 AM, the DON said the POST form was used for code status and was considered the Advance Directive. The DON said if residents had a living will they placed it in the chart under the Advance Directive's tab. The DON said the admitting nurse asked the residents upon admission if they had an Advance Directive and if they did not have one, she expected staff to offer them assistance to formulate an Advance Directive.

Based on observation, staff interview, and medical record review, it was determined the facility failed to ensure laboratory results were known to ensure appropriate treatment of [REDACTED]. This was true for 3 of 11 (#s 2, 4, and 9) sample residents. 1. Resident #9 was admitted on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's admission MDS assessment, dated 8/10/15, documented moderately impaired cognition with a BIMS score of 10, 1 person extensive assistance for toileting needs, and always continent of urine and bowel. The resident's Care Plan for Altered Urinary Status documented the following approaches: *Administer medication per MD order; *Educate patient on proper hygiene practices to minimize risk as needed; *Encourage fluids and offer cranberry juice; *Labs per MD order; *Monitor for side effects of medication; *Monitor for signs and/or symptoms of UTI, (ie. frequency, burning, foul odor, cloudy urine, increased confusion, flank/abdominal pain, etc.); and, *Provide incontinent products and assist with peri-care as needed. On 7/22/15, the resident's Nurse Practioner's Progress Note documented, .She was hospitalized for [REDACTED]. It sounds from her H&P (history & physical) that she was a very sick woman .PICC line to left upper extremity .Assessment/Plan- 1. Septic shock secondary to urinary tract infection. She does continue to be on IV [MEDICATION NAME]. 2. Acute kidney injury from the hospital . On 8/3/15 , a physician's orders [REDACTED]. The first laboratory report documented the urinalysis was collected on 8/5/15, received at the laboratory 3:40 AM on 8/6/15 and reported to the facility on [DATE] at 8:00 AM documented, Urine culture to follow. The report was noted by a LN at the facility on 8/6/15. The second laboratory result for the urine culture, reported on 8/6/15 at 1:00 PM documented, no growth after overnight incubation .This is a preliminary report. The report was noted by a LN at the facility on 8/6/15. The third laboratory result for the urine culture reported on 8/7/15 at 11:00 AM documented, 50,000 CFU/ML Non-lactose Fermenter, Identification to follow .This is a preliminary report. The report was noted by a LN at the facility on 8/7/15. On 8/7/15, a PO documented, Discontinue PICC (Peripherally Inserted Central Catheter) to right upper arm. The PICC had been placed at the hospital prior to the resident's admit to the facility. A corresponding PN documented this was done ast 1:43 PM. The fourth laboratory report for the urine culture reported on 8/8/15 at 11:00 AM documented, Non-lactose fermenter identified as Pseudomonas aeruginosa .This is a completed report. The report also contained the antibiotics which would be susceptible and resistant for the gram negative bacterium. There was no corresponding facility PN or PO noting or responding to this laboratory result. On 8/11/15 4:00 AM, a PN documented, .patient seems alert and oriented .voiding yellow clear urine w/o (without) urgency . On 8/11/15 at an unknown time, Resident #9's Physical Therapy note documented, .Pt (patient) lifted hand to face and started shaking, eyes shut, having difficulty responding. Nsg (nursing) notified .Pt able to report where she was, had difficult time keeping eyes open . The fourth laboratory report was noted by a LN at the facility on 8/11/15, three days after the facility should have had the report with a note that the NP has also been contacted on 8/11/15. On 8/11/15 11:26 AM, a PN documented, Final urine culture results received. Called .NP. Order received to send pt for further evaluation to (hospital's name) ER. Pt is growing pseudomonas aeruginosa. Pt presents this AM with convulsions intermittently and states she has a headache. Pt resistant to go to ER but strongly suggested she do so given hx (history) of septic shock . On 8/11/15, a PO documented, Send patient to emergency room for evaluation. The resident's 8/11/15 Emergency Department report documented, .Chief Complaint .[MEDICAL CONDITION] .[DIAGNOSES REDACTED].She was there because of the recovering from septic shock. She recently had a urinary tract infection but is currently not on any antibiotics .Medications Administered IV's .Normal Saline IV 500ml bolus .Ordered medication from a 500 ml bag was given via an intravenous route, peripheral catheter, initiated at this time .the differential [DIAGNOSES REDACTED]. Intracranial abnormality . On 8/12/15 at 8:02 AM, Resident #9 was observed eating breakfast in the dining room. The resident stated she had to go to the ER yesterday and they had determined she had a UTI. The resident said it was frightening because she was worried she was going to become, Really sick, like the last time. Resident #9 stated the ER had started her on antibiotics and she was feeling so much better today. On 8/12/15 at 11:00 AM, LN #1 was interviewed in regards to Resident #9's laboratory results. The LN said she realized she did not have the resident's final lab results, until the resident had the reported convulsions/tremors. The LN said she called the laboratory in order to find out about the final urine lab results and then proceeded to inform the NP. The LN stated the NP told her to send the resident to the emergency room for further evaluation. On 8/14/15 at 2:04 PM, the laboratory was called by the surveyor that had performed the resident's urine lab tests. The microbiologist stated, urine test results are finalized from 2 to 3 days, dependent on when the specimen has been collected. Resident #9's final urine lab tests results would have been finalized on 8/8/15 at 11:00 AM. The laboratory's system documented those results were sent to an unkown number on 8/8/15 at 11:00 AM. 2. Resident #4 was admitted to the facility 7/30/15 with multiple [DIAGNOSES REDACTED]. The July and August 2015 physician recapitulation orders documented hold hypertension medications for systolic blood pressure less than 100 or diastolic blood pressure less than 65. [MEDICATION NAME] 37.5 mg was ordered for [MEDICAL CONDITION] and hypertension and was to be given twice a day. [MEDICATION NAME] 12.5 mg was ordered for [MEDICAL CONDITION] and hypertension and was to be given once a day. The resident's August 2015 MAR indicated [REDACTED] 8/3/15 - BP 126/62 8/9/15 - BP 120/51 8/6/15 - BP 100/57 The [MEDICATION NAME] and the [MEDICATION NAME] were documented as administered on the above dates, even though the diastolic blood pressure was below the Physician ordered parameters. On 8/12/15 at 8:59 a.m., the DON said the blood pressure parameters were standing orders and the Physician also had blood pressure parameters on each individual medication and this was the orders the LNs followed. The DON stated she would to see if the Physician would discontinue the standing orders, since it had caused some confusion with different parameters. 3. Resident #2 was admitted to the facility 6/25/15 with multiple [DIAGNOSES REDACTED]. The July and August 2015 physician recapitulation orders documented [MEDICATION NAME] was to be given once a day for hypertension with instructions to hold the medication for a systolic blood pressure less than 105 or heart rate less than 60. The July 2015 TAR documented one instance in July and one instance in August when the resident's systolic blood pressure was less than 105 and the medication was not held. On 8/13/15 at 10:15 a.m., the DON stated [MEDICATION NAME] should have been held in these instances.

Based on observation, interviews with staff and a Nurse Practitioner (NP), record review, policy review, and complaint from the general public, it was determined the facility failed to notify the physician and seek treatment when existing stage II pressure ulcers (PUs) deteriorated to unstageable for 1 of 5 residents (#4) reviewed for pressure ulcers (PUs). The facility failed to ensure Resident #4's PUs were appropriately assessed by the physician, NP or facility nursing staff; appropriate devices were utilized to prevent pressure; physician orders [REDACTED]. In addition, topical medication and dressings were applied to the resident's buttocks/PUs without physician orders. The resident was hospitalized with septic shock attributed to a large necrotizing gangrenous sacral wound. The resident received IV (intravenous) fluids and an IV medication "for resuscitation." Two broad spectrum IV antibiotics were started in the emergency department (ED), and the wound was promptly surgically debrided. These failures resulted in immediate jeopardy for Resident #4's health and safety. The facility also failed to conduct thorough initial and at least weekly PU wound assessments for the other 4 residents (#s 1, 2, 3 and 5), which created the potential for more than minimal harm should the residents' existing PUs worsen or new PUs develop. On 11/17/14, the facility's Administrator was informed verbally and in writing of the IJ. The Administrator was provided with details regarding the failures related to Resident #4's worsened and unstageable PUs and the overall lack of appropriate care and treatment of [REDACTED]. On 11/18/14 at 4:00 p.m., the facility's Administrator provided the survey team with an acceptable abatement plan and the immediate jeopardy was abated. The abatement plan noted Resident #4 had been discharged and included review and head to toe skin checks for all current residents with PUs, licensed staff in-services regarding PU care and treatment, and weekly visual review of residents with PUs. The date of compliance was November 17, 2014. Findings included: During the complaint investigation, the facility's PU policies and procedures (P&P) were reviewed. They included: PU Prevention; Assessment and Intervention; treatment of [REDACTED]. The facility did not follow these P&Ps for the identified residents. physician's orders [REDACTED]. Standing Orders for treatment of [REDACTED]. There was no documented evidence that residents' physicians were always notified about negative PU changes. Residents' clinical records lacked documentation of thorough initial and at least weekly PU assessments for tracking and monitoring. The facility did not consistently provide the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 1. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 10/5/14 Transfer Orders to Subacute Care and his Physician order [REDACTED]. The resident's 10/6/14 Admission Assessment documented 3 Stage II PUs. They were: coccyx - 2 x (by) 0.5 cm; left (L) buttock - 1.5 x 1.5 cm; and right (R) buttock - 4 x 1.5 cm. Dry and flaky areas were also noted: L buttock - 1.5 x 1.5 cm and R buttock - 2.5 x 2.5 cm. "Granulation tissue" was documented. The Admission Assessment did not include other PU characteristics, such as depth; condition of the wound bed, wound edges and surrounding skin; and, whether or not there was drainage, odor, or associated pain. A 10/6/14 Braden Risk Assessment Scale documented the resident's risk for PUs was 13, or moderate risk. The goal for the resident's 10/6/14 interim PU Risk Protocol/Care Plan was, "...decreased risk of developing pressure ulcers with appropriate interventions..." The interventions included: * Minimal Risk - "Pressure Reducing Mattress, Standard Wheelchair Cushion, Weekly Skin Assessment by LN (licensed nurse), PT/OT (physical and occupational therapy) Eval(uation) & (and) Treatment, Patient Education." * Low Risk - Assist/prompt Turn Q (every) 2 hours (and) Barrier Ointment." * Moderate Risk - "...Air Mattress." A 10/9/14 Short Physician order [REDACTED]." A 10/13/14 admission MDS assessment documented the resident had intact cognition with a BIMS score of 15; extensive assistance was needed for bed mobility, transfers, and toileting; he was unsteady moving from a seated to standing position and surface-to-surface transfers without staff assistance; limited range of motion in both upper and lower extremities; indwelling urinary catheter was in place; and 3 Stage II PUs present on admission. The resident's undated initial care plan included: * Problem: "Risk for impaired skin integrity. Approaches: "Pressure reducing mattress, Cushion to wheelchair, Encourage and/or assist to reposition at least every 2 hours...Monitor skin daily during cares and report changes to LN/MD (licensed nurse/physician)...Barrier ointment QS (every shift) PRN (as needed)." * Problem: "Actual Impaired Skin Integrity related to: Site 1: 2 unstageable wounds to (R) & (L) buttock, Site 2: 2 stage II pressure wounds to (R) & (L) upper buttock, Site 3: Stage II to coccyx (and) Spinal incision" Approaches: "Treatment per current MD orders, Monitor for increased redness, change in skin temp(ature), or abnormal exudates, Measure wound area(s) at least weekly to monitor response to treatment, Keep affected areas clean, dry and minimize irritation and pressure, Request supplements and increased protein to promote healing per RD (registered dietitian) and MD order, Air Mattress to bed, Pressure Displacement Cushion to w/c (wheelchair)...Barrier Ointment QS (every shift) and PRN (and) Encourage and assist patient to reposition at least every 2 hours." Resident Progress Notes (RPNs) documentation, dated 10/6/14 - 10/27/14, included: * 10/6 at 1:46 p.m., 5:58 p.m., 8:47 p.m. and 11:45 p.m. - PUs were not mentioned. * 10/7 at 10:53 a.m. - "...Miller's Mix applied to buttocks..." * 10/8 at 11:35 a.m. - "...Open areas to buttocks cleansed and Miller's mix applied as per MD order..." Note: Miller's Mix was not included in any physician's orders [REDACTED]. * 10/9 at 8:28 a.m. - Physician saw resident. * 10/11 at 11:51 a.m. - sent to an ED, returned to the facility at 5:00 p.m., the buttocks and coccyx were, "...dark red, and has dry peeling flaking skin. (R) Buttock has 5.5 x 3.5 cm open areas (with) deep purple tissue 9 x 6 cm surrounding open areas. Left buttock has a 3.5 x 1.5 cm open area surrounded by dark red to purple area 9 x 5 cm..." * 10/12 at 2:39 p.m. - "...Buttocks open areas and deep tissue areas were cleaned..." * 10/12 at 10:24 p.m. - "...Buttocks skin is excoriated and dark red to purple in color..." * 10/13/14 at 1:40 a.m. - "...Buttocks excoriated bilat(eral), darken areas unstageable..." * 10/13/14 at 7:51 a.m. - NP saw resident. * 10/14/14 at 6:23 p.m. - "...Bedsore on the bottom was cleaned, protective skin lotion applied with a silver cloth. Ulcers is (sic) partially covered with black color Escher (sic), open area is red and seeping. Note: Silver cloth was not included in any physician's orders [REDACTED]. * 10/20/14 at 9:12 a.m. - NP saw resident. * 10/21/14 at 9:25 a.m. - "...right buttock with black area measuring 6 x 4 cm and with open area measuring 6 x 5.5 cm...left buttock has black/deep tissue injury measuring 6 x 5 cm and open area measuring 4 x 4.5 cm. The open areas are surrounding the black/deep tissue injury parts, and they have new tissue and active bleeding...." * 10/21/14 at 10:56 p.m. - "...On an air cushion at the buttocks and on a (sic) air mattress..." * 10/24/14 at 11:01 p.m. - "...Buttocks wound cleansed as ordered...Left buttock with large area of eschar and the right buttock has improved with pink tissue that readily bleeds with cleansing..." * 10/26/14 at 9:13 p.m. - "...Buttocks wound cleansed and silver cloth applied. Pt is on air mattress and a donut..." * 10/27/14 at 7:22 a.m. - NP saw resident and "Discharging to (name of other LTC facility) today...They are aware of his wound on his buttocks/coccyx and will continue to treat..." * 10/27/ at 11:50 a.m. - "...change in his wound this am r/t (related to) noted drainage in his attends (with) foul odor. Measurements...(L) Buttock unstageable area 10 x 4 cm...Black/Brown Eschar full thickness, (R) buttock unstageable area 6 x 7 cm full thickness Black/brown eschar. (R) buttock outer edge of eschar 1.8 x 5.5 @ (at) end of buttock...active bleeding (with) dressing change (with) pink tissue, (L) buttock outer edge of eschar @ the bottom 2.5 x 1.7 cm...active bleeding noted (with) dressing change. Sacral area note (sic) to have new area (with) redness, warm to touch, blanchable...Notified...NP...who seen (sic) him earlier this am...update to (name of other facility) that he would need to see skin specialist for possible debridement of wound. Notified patient of wound change...spoke (with) (name of other facility staff)...gave report..." On 11/13/14 at 3:30 p.m., the Nurse Manager (NM) was interviewed about the resident's PUs. The NM stated, "I may go in to peek at residents' skin when the med (medication) nurses are doing skin checks but I do not actually do the assessments." The NM said the nurses gave her PU wound assessment information and she entered it on the Weekly Skin Report-PU (WSR-PU). She added, "The med nurses don't usually stage pressure ulcers." The NM provided 4 WSR-PU forms dated 10/10/14, 10/16/14, 10/24/14, and 10/31/14 with information regarding Resident #4 and other residents (the other residents' names and information were redacted). The reports included areas to note where PUs were acquired, location, actual stage, size, "visual stage," drainage/amount, description, current treatment orders, frequency of treatment, drainage type, other interventions, and date resolved. The WSR-PU reports noted the following for Resident #4: * 10/10/14 - Four Stage II PUs: 2 on (L) buttock, 1 on (R) buttock, and 1 on coccyx, all with scant drainage. Treatment was normal saline (NS)/Critic-aid gel. * 10/16/14 - Two Unstageable and 2 Stage II PUs at (L) and (R) buttocks and 1 Stage II PU at coccyx. (L) Unstageable: "10 x 5 dark color skin non blanchable from ER (emergency room ) visit" and (R) Unstageable: "93.5 cm dark color skin nonblanchable from ER visit." "Barrier cream" 3 times/day and PRN" was the treatment for [REDACTED].T. with dry flaky skin(;) R inner buttock, open, raw, with dry flaky skin(;) Coccyx open redness." Scant drainage noted for all and the treatment was NS/Critic-aid 3 times/day and PRN. All were noted as "worsened." * 10/24/14 - Two Unstageable and 2 Stage II PUs at the (L) & (R) buttocks. "Barrier cream, Silver cloth" was the treatment. The Stage II PUs had scant serosanguinous drainage. Protective devices included a "donut." The coccyx PU was not mentioned. NOTE: The Hartford Institute for Geriatric Nursing (HIGN) and Wound, Ostomy, and Continence Nurses Society (WOCN) are in "agreement that donut-type devices should not be used for pressure redistribution ... The use of a pressure-reducing device (not a donut), is recommended by both groups for chair-bound clients." (http://www.guideline.gov). * 10/31/14 - Essentially the same documentation as the 10/24/14 WSR-PU. The interview with the NM continued. The NM reviewed the resident's RPNs then acknowledged that staging and other PU characteristics were not consistently documented in the RPNs. The NM stated, "It should be in there." The NM said she put the stages and other PU characteristics on the WSR-PU reports herself "because I did see the resident's pressure ulcers but I did not make an entry of my observations except on 10/27/14." When asked about the donut, the NM stated, "There's no order for the donut." When asked when the donut was implemented, the NM stated, "I honestly don't know where it came from." When asked for wound care orders, the NM stated, "There are none. I know it's not there." When asked if silver cloth should be used without an order, the NM stated, "No." When asked for documentation that Critic-aid was applied to the buttocks/PUs, the NM reviewed the Treatment Record (TR) and stated, "It's not here." There was no documented evidence in the clinical record that the facility notified the physician about the PUs when the resident was admitted , when the physician saw the resident on 10/9/14, or when the NP saw him on 10/13/14, 10/20/14, and 10/27/14; nor, when the staff noted deep tissue injury, then eschar and weeping. In addition, there was no evidence that the facility conducted a thorough PU assessment when the resident was admitted and at least weekly thereafter. Note: Please refer to F157 for details about the lack of physician notification. On 11/13/14 at 12:30 p.m., the DON was asked for the order for Miller's Mix. The DON stated, "I didn't see one. I wonder if they got the Miller's Mix mixed up with the Critic-aid." When asked if there was any place, other than Resident Progress Notes, to document about PUs, the DON stated, "No." All physician orders [REDACTED]. On 11/13/14 at 2:30 p.m., the DON provided Standing Orders signed by the resident's physician on 10/9/14. It included the order, "Open wounds: Select per...Wound Dressing Selection Guide protocol." The DON also provided the Compound Template for Miller's Mix which listed [MEDICATION NAME] 0.1% cream, [MEDICATION NAME] ointment, and Lubri-skin lotion as the ingredients. She was asked to provide the wound care protocol. On 11/14/14 at 10:30 a.m., the DON was again interviewed. When asked about the WSR-PU reports and the lack of PU information in the resident's clinical record, the DON said the WSR-PU reports were not part of the resident's clinical record, but rather they were a tool for the NM to monitor PUs. She stated, "It's important for the measurements." When asked if PU measurements/information was documented in any other place, the DON stated, "It's supposed to be in the nurses' notes. I hope." On 11/14/14 at 11:25 a.m., LN #1 was interviewed. The LN said she did the resident's admission assessment and that all 3 of the Stage II PUs were superficial. On 11/14/14 at 12:40 p.m., LN #2 was interviewed. The LN said she was on duty when the resident returned from the ED on 10/11/14 and she assessed him after dinner. The LN stated, "He had some darkness, darker areas, it seemed like, since the last time I took care of him. There were open areas on it and dry flaking areas around the open areas. It looked darker red. The overall size didn't seem bigger, it just seemed deeper, redder." The LN said the resident told her he had been on a gurney the entire time while in the ED. When asked what deeper and redder meant to her, the LN stated, "It would be a cause for concern." When asked if she reported the change, the LN stated, "I can't remember." The LN was asked what the process was for reporting a problem. She stated, "You would alleviate the pressure and monitor. Unfortunately for him it got worse." When asked about the use of Critic-aid, the LN reviewed the TR and stated, "I'm not seeing it. I know we cleaned him every night after bowel care with wound cleanser. There was not a dressing per se, just a silver cloth." When asked if silver cloth was documented, the LN reviewed the TR again and said, "I don't see it on there. It's not on there." The LN stated, "It seemed to me it was darker in color the next day." When asked if she notified the resident's physician then or at any time regarding the changes in the resident's PUs, the LN stated, "I did not call the physician. I believe I just talked to my nurse manager about his skin." On 11/14/14 at 3:07 p.m., the DON and NM were interviewed together. The DON provided a document, which she labeled as "Wound Care protocol." It listed a variety of products for use according to wound color (black, yellow, red, red-pink, and pink), description, exudate, and depth. The DON said, however, there were no specific orders for the resident's PUs. When asked if they had PU care/treatment orders when the resident was admitted to the facility, the NM stated, "Maybe we didn't have orders but we were treating him." Regarding the PUs, the NM stated, "It merged when it became the bad one when he came back from the hospital." When asked if the resident's physician or NP were informed, the NM stated, "No, that was a weekend." When asked if the on-call physician was notified, the NM stated, "There's always someone on call." Regarding the use of a donut, the NM stated, "Nursing thought it was (Physicial) Therapy. Therapy does not have anything." They were again asked if the physician or NP was notified at any time. The NM stated, "Not that it's documented." When asked who oversaw the skin program, the NM stated, "I guess it would be me." When asked if the Wound Care Protocol was followed, the DON stated, "No." The physician's 10/9/14 visit note and the NPs visit notes for 10/13/14, 10/20/14, and 10/27/14 did not contain any documented evidence that either of them (physician or NP) assessed the PUs during the resident's stay in the facility. Note: Refer to F386 for details regarding physician visits. On 11/17/14 at 12:10 p.m. the NP was interviewed per telephone. The NP recalled the resident and said she had assessed him in the facility. When asked if she had assessed the resident's PUs, the NP said that if she did "it would be documented in the physical assessment and I would have included characteristics, like size, etc." The NP said if it was not documented in the physical assessment or assessment/plan, "I wouldn't have physically seen it then." The NP added, "I knew about the issues on his backside. They were communicating with me. I want to say he was improving." When asked if "improving" was based on communication with the staff, the NP stated, "Right. Yeah, I don't think I physically saw it." On 11/18/14 at 2:15 p.m., the Administrator indicated the facility was not responsible for the worsened condition of the resident's PU because the resident came back to the facility with unstageable PUs after a hospital visit. When asked if the facility notified the resident's physician of the worsened condition of the PU's, the Administrator stated, "We don't have that." The Administrator said the first time the facility realized there was a problem was when the resident "was going out the door when he was discharged ." The resident was transferred to another LTC facility (Facility #2) on 10/27/14. Clinical records from the receiving facility, Facility #2, documented: * 10/27/14 Initial Data Collection Tool/Nursing Service - large area of eschar and redness over most of the buttocks. * 10/27/14 at 6:24 p.m. Progress Notes (PNs) - "...wound to coccyx, which is eschar in color, redness noted around the edges, with some bleeding noted..." * 10/28/14 at 2:18 a.m. PN - "Coccyx is eschar in color with red around the edges. Some bleeding was noted..." * 10/28/14 at 9:31 a.m. PN - "...admitted yesterday with a very large, complex, unstageable pressure wound to entire sacrum and down buttocks...buttocks is black eschar, soft and unstable with some openings that weep foul [MEDICAL CONDITION] and small amt (amount) of sanguineous drainage...Unable to dress area d/t (due to) size and location. I have contacted wound MD for tx (treatment) options. (Wound physician's name) feels that [MEDICATION NAME] paints BID (twice/day)...to try and dry out eschar...was in the process of asking PCP (primary care physician) for these order, but staff noted resident to be quickly declining with poor color, temp, very low b/p (blood pressure) and (increased) pain...sent out to ER (emergency room )..." The 10/28/14 ED/ER records documented, "History of Present Illness: ...has had a decubitus ulcer on his sacral area...fever to 103 and blood pressure of 60/40. He is awake and alert...he does have sacral pain... Physical Examination: Back: ...does have pain at the sacral region and a large necrotic appearing pressure ulcer...approximately 10 cm x 12 cm...black with crepitance to palpation... Emergency Department Course and Medical Decision Making: ...evidence for [MEDICAL CONDITION] with fever, [MEDICAL CONDITION] and [MEDICAL CONDITION] wound shows evidence for crepitance and subcu air...CT shows diffuse soft tissue air and stranding consistent with necrotizing gangreous wound...infused 2 liter of normal saline...and covered broadly with antibiotics of [MEDICATION NAME] and [MEDICATION NAME]. The CT was obtained emergently...The patient was termed a [MEDICAL CONDITION] and (physician's name) from the Intensive Care Unit evaluated the patient... After the findings on the CT scan, (physician's name) from General Surgery was consulted...and took him promptly to the Operating Room (OR) for a wound debridement. Diagnostic Impression: 1. Septic shock. 2. Necrotizing gangrenous sacral wound. The 10/28/14 Hospital History and Physical documented, "Objective: ...Backside: ...large eschar roughly 8 cm x 8 cm with warm [DIAGNOSES REDACTED]tous skin surrounding...also exhibits some crepitus. It is severely foul smelling... Assessment and Plan: ...found to be in severe septic shock with extensive necrotizing soft tissue infection. 1. Sacral pressure ulcer with secondary necrotizing soft tissue infection... Assessment and Plan by System: ... Skin: ...severe necrotizing skin infection. Surgery was consulted in the emergency room ...and decided to take him directly to the OR for debridement...placed on [MEDICATION NAME], and [MEDICATION NAME] continue antibiotic therapy once admitted to the ICU. He likely will need serial operations to debride this extensive injury, possibly involving reconstructive surgery..." Resident #4 was harmed when the facility failed to notify the physician when deep tissue injury, then eschar and weeping occurred, used a donut at the resident's buttocks, did not obtain PU care/treatment orders upon admission or obtain specific orders when Standing Orders were signed 3 days after admission, applied medications/dressing to the buttocks/PU without orders, did not conduct thorough PU assessments upon admission and at least weekly thereafter, and did not ensure the physician or NP assessed the resident's PUs. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 10/13/14 Admission Assessment documented 2 Stage II PUs as follows (L) buttock - 1 x 2 cm "open area" and (R) buttock - 1 x 0.5 cm "open area" with "surrounding dryness bilat(terally). However, no other PU characteristics, such as depth; condition of the wound bed, edges and surrounding skin; and whether or not there was drainage, odor, or pain were documented. A 10/13/14 Braden Risk Assessment Scale documented the resident's risk for PUs was 20, or low risk. A 10/13/14 interim PU Risk Protocol/Care Plan documented the resident was at risk to develop PUs related to impaired mobility. The goal was, "...decreased risk of developing pressure ulcers with appropriate interventions..." Minimal and Low risk interventions were both marked, they included: * Minimal Risk - "Pressure Reducing Mattress, Standard Wheelchair Cushion, Weekly Skin Assessment by LN (licensed nurse), PT/OT (physical and occupational therapy) Eval(uation) & (and) Treatment, Patient Education." * Low Risk - Assist/prompt Turn Q (every) 2 hours (and) Barrier Ointment." The resident's undated initial care plan included: * Problem: "Risk for Impaired Skin Integrity related to: decreased Mobility." Goals: "...will not develop additional pressure ulcers..." Approaches: Monitor skin daily during cares and report changes to LN/MD." * Problem: "Actual Impaired Skin Integrity related to: Site 1: admitted (with) 2 Stage II pressure ulcers to (R) (and) (L) buttocks." The problem was crossed out with a single line and noted as "healed 10/27/14." The resident's Physician order [REDACTED]. * 10/13/14 - Weekly skin assessments on Mondays, document "(positive) results" in nursing notes; and, * 10/14/14 - "Millers Mix to open/dry areas to buttocks" every shift. The resident's 10/20/14 admission MDS assessment documented intact cognition with a BIMS score of 15; extensive assistance needed for bed mobility, transfers, and toileting; unsteady moving from a seated to standing position, moving on and off a toilet, and surface-to-surface transfers without staff assistance; limited range of motion in both lower extremities; and 2 Stage II PUs were present on admission. The resident's Treatment Administration History (TRH) dated 10/13/14 - 11/12/14 documented weekly skin assessments were done every Monday during that time frame with the comments, "buttom (sic) has healed" noted on 10/27 and "bottom is healed, no open soars (sic)" noted on 11/3/14. It also documented that Miller's Mix was administered 3 times/day (every shift) from 10/14/14 through 11/12/14. Per the surveyor's request, on 11/13/14 at 2:30 p.m., the DON provided a Compound Template for Miller's Mix which listed [MEDICATION NAME] 0.1% cream, [MEDICATION NAME] ointment, and Lubri-skin lotion as the ingredients. RPNs dated 10/13/14 - 11/13/14 documented the Stage II PUs decreased to 0.5 x 0.5 cm on the (L) and 0.2 x 0.2 cm on the (R) by the next day, 10/14/14. No other PU characteristics were documented that day and no PU assessments were documented after 10/14/14. Thirteen days later, on 10/27/14, the PUs were noted as "healed" and "Zero redness and zero open areas." On 11/13/14 at 10:00 a.m., with the resident's permission, the surveyor observed while LN #4 assessed her skin. The resident's buttocks, sacrum, and coccyx were intact without redness or dry skin. On 11/14/14 at 1:50 p.m., the DON and NM were interviewed. When asked if the resident's PUs were thoroughly assessments on admission and thereafter, the NM stated, "No. It's not documented." The DON nodded her head "yes" in agreement. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged from the facility on 9/25/14. The resident's 8/12/14 Admission Assessment documented one Stage II PU with [MEDICATION NAME] tissue was present on the resident's right heel. It was noted as a blister that measured 2 x 2.3 cm. No other PU characteristics, such as depth; condition of the surrounding skin; and whether or not there was drainage, odor, or pain were documented. One healed Stage II PU was also documented but there was no indication where the healed PU was. An 8/12/14 Braden Risk Assessment Scale documented the resident's risk for PUs was 18, or low risk. An 8/12/14 PU Risk Protocol/Care Plan documented the resident had current PUs related to impaired mobility. The goal was, "...decreased risk of developing pressure ulcers with appropriate interventions...(and) ...current pressure ulcer(s)...will heal...within 30 days..." Interventions included: "Low Risk" with "Assist/Prompt Turn Q (ever) 2 Hours (and) Barrier Ointment." Minimal Risk and Moderate Risk were not marked themselves; however, all interventions under minimal risk were checked, "Pressure Reducing Mattress, Standard Wheelchair Cushion, Weekly Skin Assessment by LN (licensed nurse), PT/OT (physical and occupational therapy) Eval(uation) & (and) Treatment, Patient Education" and "Heelz Up" under moderate risk was checked. The resident's initial care plan included: * Problem: "Risk for Impaired Skin Integrity related to: decreased Mobility." Goals: "...will not develop pressure ulcers..." Approaches: "Monitor skin daily during cares and report changes to LN/MD." * Problem: "Actual Impaired Skin Integrity related to: Site 1: admitted (with) 2 Stage II (R) heel de-roofed blister. Goals: "Area(s) of concern will heal...within 30 days." Approaches: "Treatment per current MD orders(,) Multi-Podus Boot: (R)." The approach, "Measure wound area(s) at least weekly to monitor response to treatment" was not checked. The resident's Physician order [REDACTED]. * 8/12/14 "Right heel-cleanse with NS, change Allevyn drsg Q3d & PRN (right heel-cleanse with normal saline, change Allevyn dressing every 3 days and as needed)" and * 8/12/14 "Weekly Skin Assessment" on Mondays with instructions to document "(+) (positive) results" in nursing notes. The resident's Treatment Administration History for 8/12/14-9/11/14 and 9/12/14-9/25/14 documented: * Skin assessments were done every Monday with negative results except on 9/25/14 when "heels boggy, heel lift applied" was noted. Note: The resident was discharged [DATE]. * Right heel cleanse with NS and change Allevyn drsg was done every 3 days. RPNs for 8/12/14-9/25/14 contained documentation that subsequent right heel Stage II PU assessments were incomplete and inconsistent through 8/25/14. In addition, the righ heel PU was not mentioned after 8/25/14 even though skin assessments and wound care/dressing changes were documented through 9/23/14. On 11/14/14 at 2:20 p.m., the DON and NM were asked if there actually was a dressing on the resident's heel after 8/25/14. The DON pointed to the TRH and stated, "According to this there was (a dressing) after 8/25/14. When asked if either of them assessed the PU, the NM stated, "At some point I did." When asked if she documented the assessment, the NM stated, "No, not unless I did it myself. I go in with my nurses usually and the nurse usually does the documentation." The DON and NM reviewed the resident's RPNs and confirmed there were no PU assessments documented after 8/25/14. The also acknowledged that PU assessments before 8/25/14 were not thorough. 4. Resident #2 was recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 11/5/14 Braden Risk Assessment Scale documented the risk for PUs as a 17 or moderate risk. The resident's 11/5/14 Admission Assessment documented areas of concern: Red and blanchable coccyx, 2 dressings on the right hip, 3 sections on the right hip with staples, and a left foot with discoloration and faint pedal pulse. Resident #2's PU Risk Protocol/Care Plan documented the resident at risk for developing pressure ulcers related to impaired mobility. The goal was, "...decreased risk of developing pressure ulcers with appropriate interventions..." Interventions included: "Minimal Risk" with "Pressure Reducing Mattress, Standard Wheelchair Cushion, Weekly Skin Assessment by LN (licensed nurse), PT/OT (physical and occupational therapy) Eval(uation) & (and) Treatment"; "Low Risk" with interventions "Assist/Prompt Turn Q (every) 2 Hours (and) Barrier Ointment."; and "Moderate Risk" with interventions "Heelz Up and air mattress." The resident's interim Care Plan dated 11/5/14 documented: * Problem: "Risk of or Actual Alteration in Skin Integrity." Goals: "...will have decreased risk of developing (additional) areas of altered skin in