Every finding on record at Avera Maryhouse Long Term Care

Based on observation, interview and policy review the provider failed to follow infection control practices to ensure residents' catheter bags were not lying on the floor according to the provider's policy and nasal cannula (NC) tubing was disinfected or replaced before placing it on a resident's face for one of one sampled resident 7 observed with NC tubing and a catheter bag lying on the floor.Findings include: 1. Observation on 9/9/25 at 10:28 a.m. in resident 7's room, revealed the resident's catheter bag was lying on the floor next to her bed without a covering or a barrier under it.Observation on 9/9/25 at 12:17 p.m. in the dining room area revealed resident 7's catheter bag was uncovered and lying under her wheelchair, touching the floor.Observation on 9/9/25 at 2:29 p.m. in resident 7's room revealed her nasal cannula (NC) [flexible tubing with prongs that delivers oxygen through the nose] and oxygen tubing were lying on the floor.2. Observation and interview on 9/10/25 at 8:40 a.m. with registered nurse (RN) H and licensed practical nurse (LPN) I in resident 7's room revealed:*Resident 7's NC tubing was lying on the floor and coiled under the wheel of her bedside table next to her bed.*Her catheter bag had a cover on it and was lying on the floor under her bed.*RN H had picked the NC tubing off the floor and used and wiped the NC prongs off with an incontinent care wipe and reapplied it to resident 7's face. *RN H confirmed that was her usual process for cleaning NC tubing found on the floor.*She knew it was considered dirty and wanted to ensure it was clean before putting it back on the resident.*She checked the electronic medical record (EMR) which indicated that resident 7's NC tubing had been changed last 22 days ago, and it was ordered to be changed every Monday at 2:30 p.m.*RN H exited the room and returned with new NC tubing for resident 7.*LPN I then picked resident 7's catheter bag up off the floor and hung it on the bed frame. Interview on 9/9/25 at 12:22 p.m. with resident aide (RA) E revealed that catheter bags should all be covered for privacy, and they should not be lying on the floor. Interview on 9/9/25 at 12:25 p.m. with LPN C revealed that catheter bags should have a covering on them, and they should not be lying on the floor. Interview on 9/11/25 at 11:11 a.m. with RN/Minimum Data Set (MDS)/infection preventionist (IP) J revealed:*When NC tubing was observed lying on the floor, she would expect it to be replaced with new tubing.*Catheter bags should not have been lying on the ground.-She expected catheter bags to be hung for drainage and covered for dignity whenever residents with catheter bags were outside of their rooms. 3. Review of the provider's revised 5/25 Respiratory Equipment policy revealed:*Change oxygen tubing and mask per MIFU [manufacturer's instructions for use]. Review of the provider's revised 3/13/25 Perineal Care policy revealed:*Purpose to provide best practice for perineal care to prevent skin breakdown and infection.D. Residents with an indwelling urinary catheter (IUC)e. Hang drainage bag:-Below the bladder.-Ensure bag is not touching the ground.6.Urine collection bag.b. should not touch the floor. d. the spout should never touch the floor .

Based on observation, record review, interview, and policy review the provider failed to ensure self-administration of medication assessments had been completed on two of three sampled residents (3 and 24) who self-administered medications were assessed for their ability to safely self-administer medications and the resident's care plans reflected that according to the provider's policy.Findings include:1.Observation and interview on 9/9/25 at 8:55 a.m. of resident 3 in her room revealed:*She had opened her bedside stand drawer and there was a bottle of PreserVision AREDS (an eye supplement) and a bottle of Lutein (vitamin supplement) in the top drawer of the stand.*She indicated she took them occasionally, not every day.*There was no label indicating use on either bottle. Observation and interview on 9/9/25 at 9:47 a.m. with resident 24 in his room revealed:*There was a bottle of Fluticasone Propionate nasal spray sitting on his windowsill.*He said he had not used it in a couple of weeks. 2. Review of resident 3's electronic medical record (EMR) revealed:*Her Brief Interview for Mental Status (BIMS) assessment score dated 9/8/25 was 15 which indicated her cognition was intact.*There was no order for Lutein included in her current physicians' orders.*There was no order for PreserVision AREDS included in her current physicians' orders.*There was no self-administration medication assessment completed to determine the resident's ability to safely self-administer medications. Review of resident 24's EMR revealed:*His BIMS assessment score dated 6/23/25 was 10 which indicated his cognition was moderately impaired. *He had a 3/19/25 physician's order for him to self-administer his fluticasone propionate nasal spray.*There was no self-administration assessment completed to determine his ability to safely self-administer the fluticasone propionate medication.*His care plan did not indicate that he self-administration medications. 3.Interview on 9/11/25 at 8:31 a.m. with licensed practical nurse (LPN) G revealed:*If a resident wanted to self-administer medication an order was to be obtained from the doctor.*A nurse was to complete a self-administration assessment of the resident.*The intradisciplinary team (IDT) would make the final decision if the resident was able to safely self-administer the medication.*The resident's care plan was to be updated to reflect the resident's self-administration of medications.*She was not aware that resident 3 had medications in her room.*She was aware that resident 24 had an order dated 3/19/25 to self-administer his fluticasone propionate medication.*The self-administration of medications was then added to the worklist for the nurse to check off daily for the resident's that self-administered medications. Interview on 9/11/25 at 8:59 a.m. with registered nurse (RN)/Minimum Data Set (MDS) G revealed:*Floor nurses would sometimes initiate the self-administration assessment.*The resident was to be educated on administration safety and the medication.*The interdisciplinary team (a group of healthcare professionals who collaborate patient care) were to have an informal discussion about the resident's ability to safely self-administer the medication.*They were to then update the resident care plan to reflect that information.*Care plans were to be updated quarterly and as needed (PRN). Interview on 9/11/25 at 9:12 a.m. with director of nursing (DON) B regarding self-administration of medications revealed:*The nursing staff would communicate with the resident's physician to order medication self-administration if it was determined the resident could safely self-administer medication.*The nursing staff would identify if that medication should be stored at the resident's bedside or in the medication cart. *A self-administration assessment should be completed to determine the resident's ability to safely self-administer medication.-A member of the interdisciplinary team (IDT) or a floor nurse could complete that assessment.*The order for self-administration of medication would be added to the worklist for the floor nurse to check off daily.*The self-administration of medications was to be added to the resident's care plan.*She agreed resident 24 did not have a self-administration assessment completed.*She was unaware of the Lutein in resident 3's room that she was taking, until she was informed on 9/10/25.*She was unaware that resident 3 had PreserVision AREDS medication which she took occasionally, in her room.*She agreed that no self-administration assessment had been completed for resident 3. 4. Review of the provider's revised 2/2017 Self Administration of Medications policy revealed:*Avera will utilize a centralized, standardized and managed process to assure Self Administration of Medications by residents who desire to do so provided the interdisciplinary team, including at least a physician, nurse, pharmacist, and social worker has determined the practice would be safe for the resident and other residents of the facility.*a. If the resident desires to self-administer medications, an assessment is conducted and recorded in the Self Administration LTC intervention. The interdisciplinary team (IDT) will be involved in the assessment. They will assess the resident's cognitive, physical and visual ability to carry out this responsibility.*c. All resident's approved for self-administration will have Self Administration addressed on the resident's care plan.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure one of one resident's incident to the SD DOH within the required time two-hour frame. The resident sustained serious bodily injury related to a fall from the whirlpool tub chair. Findings include: 1. Review of the provider's 3/31/25 SD DOH FRI regarding resident 1 revealed: *He had a Brief Interview for Mental Status (BIMS) assessment score of 10, which indicated he was moderately cognitively impaired. *On 3/30/25 at 6:40 p.m., resident 1 had fallen off the whirlpool tub's chairlift while being transferred out of the whirlpool by certified nursing assistant (CNA) D after his bath. -The CNA notified other staff and the resident was assessed by licensed nursing staff and had been unconscious and bleeding noted to the resident's forehead. -He was sent to the emergency room via ambulance for evaluation and treatment. -He had sustained two subarachnoid hemorrhages (a type of stroke caused by bleeding into the space between the brain and the tissue that covers it), a closed fracture (broken bone that does not penetrate the skin) of nasal bones, one laceration (skin cut or tear) on the right side of his forehead, and one laceration on his right lower extremity (leg). *Notes in the report indicated that: -Prior to the transfer the safety belt was secured within the tub-chairlift and fastened around resident 1's waist. *During the transfer resident 1 requested from CNA D that the safety belt be removed, and stated it was too tight. *The safety belt had been loosened by CNA D, but was not removed. *On 3/31/25 at 4:40 p.m. social worker C submitted an SD DOH FRI. 2. Interview on 7/1/25 at 11:15 a.m. with resident 1 in his room revealed: *He recalled when he fell off the whirlpool tub-chairlift on 3/30/25 at 6:40 p.m. *He denied he had removed the safety belt on the whirlpool tub chair. *He denied CNA D had removed the safety belt either. 3. Interview on 7/1/25 at 2:39 PM with social worker C revealed: *She had interviewed resident 1 at the hospital on 3/31/25 regarding his fall on 3/30/25. *She had submitted the initial FRI that involved resident 1 to the SD DOH. 4. Interview on 7/2/25 at 11:25 a.m. with administrator A and director of nursing B revealed: *They expected that a resident fall with a major injury to be reported by the nurse to the nurse leader who was to be on call at that time. *An email was to be sent out to the leadership staff to notify them of a resident fall with a major injury to notify them. * In accordance with the facility's policy, a report of a resident's fall with a major injury must be completed no later than two hours of the (incident or known major injury?) to the SD DOH. *Administrator A had indicated that the facility is not Very good about getting incidents with a major injury reported within the required time two-hour frame. 5. Review of the provider's 2/2025 Long Term Care Abuse, Neglect, Mistreatment and Misappropriation of Resident Property-System Standard Policy revealed: *All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. -Immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.

Based on observation, interview, and policy review, the provider failed to: *Maintain the following in one of one service kitchen in a clean and sanitary manner: -Two of three silverware holders on one of one dish drying rack. -One of one plastic wrap dispenser. -One of one beverage dispenser station. -One of one stack of uncovered kitchen towels. -One of one plastic bag of to go food containers. Findings include: 1. Observation and interview with nutrition and food service employee E on 3/19/24 at 11:15 a.m. during the initial kitchen tour revealed: *Attached to the dish drying rack next to the three-compartment sink were three plastic silverware holders. -Inside one of the two white plastic holders were several utensils pointed downward inside of the holder and touching the bottom of it. --The bottom of that holder was rust-colored in appearance. -The second plastic holder was empty and the bottom of that holder was rust and black-colored in appearance. *On the counter next to the steam table was a plastic wrap dispenser. -The top of the dispenser had clear-colored build-up on it and the device that slid across the plastic wrap to cut it had several brown stains on it. 2. Observation on 3/19/24 at 11:25 a.m. of the dining room beverage station revealed: *The stainless-steel station was located next to the kitchen serving window. *Between the coffee and juice machines was a folded white towel. -The side of the towel closest to the coffee machine was stained brown. *Beneath the coffee machine was an open storage area. -On the bottom shelf there were two separate rows of coffee cups. --Between those two rows near the front of that shelf were several coffee-stained areas. -On the top shelf there were two separate rows of coffee cups and coffee carafes. --Between those two rows near the front of that shelf were several coffee-stained areas. 3. Continued observation and interview on 3/19/24 between 11:30 a.m. and 11:40 a.m. with nutrition and food service employee E in the service kitchen revealed: *Inside the hallway door entrance was a tall, opened cardboard box. -An opened plastic bag inside of that box held disposable to-go food storage containers stacked as high as the opening of the box. --The containers were used by residents to transport food items. *Behind the door that opened into the kitchen from the dining room was a garbage can with a lid able to be flipped. -Directly behind that garbage can were uncovered, stacked kitchen towels on a cart. --Those towels were used to wipe off wet meal trays or to cover food items during transport. 4. Observation and interview on 3/20/24 at 8:00 a.m. with nutrition and food service employee E regarding kitchen and dining area cleaning revealed: *The areas in the service kitchen and at the beverage station referred to above remained unchanged from the observations made on 3/19/24. *There was a cleaning checklist completed daily by food service staff who worked the evening shift. -Those staff consisted of mostly high school students. *There was no cleaning checklist form food service staff to complete during the day. -Those staff were long-time employees and knew what was expected to have been completed. 5. Interview on 3/20/24 at 11:50 a.m. with nutrition and food services manager F regarding the kitchen and beverage station observations referred to above revealed: *The areas described above in the kitchen and dining areas were not maintained in a sanitary manner. *There was currently no process for auditing the completed evening cleaning checklists to ensure compliancy. -The cleaning checklist might need re-evaluation and a day time cleaning checklist might need to be initiated. 6. Review of the revised March 2024 LTC (Long Term Care) Food Safety and Sanitation-System Standard policy revealed: Maintaining high standards of sanitation and prevention infection in Nutrition Services Department require health personnel, properly maintained equipment, uncontaminated supplies and an ongoing awareness, practice, and monitoring of proper sanitation and hygiene.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) (G) implemented a pain management intervention for one of one sampled resident (7) who complained of left foot pain before a dressing change. Findings include: 1. Observation and interview on 3/19/24 at 9:40 a.m. with resident 7 in his room revealed he: *Was seated in a recliner reviewing customer account information for his business. *Had a history of a fall that resulted in fractured back vertebrae. -Used a pain patch to manage his back pain. *Had left foot pain that was more bothersome to him than his back pain. -A blister on the top of that foot had popped and the bandage covering his foot was changed daily. Observation on 3/19/24 at 10:03 a.m. of licensed practical nurse (LPN) G completing resident 7's left foot dressing change revealed: *She asked the resident before starting the dressing change what number between zero and ten on a pain scale that rated his foot pain. -Zero was no pain and ten was the worst possible pain. *He rated his pain an 8. *Without offering him any pain relief options or interventions LPN G initiated and completed the resident's dressing change. *Pain medication was offered after the dressing change was completed. -LPN G gave medication options including tramadol or Tylenol for pain and the resident requested tramadol because Tylenol doesn't do anything for my discomfort. Interview and record review on 3/19/24 at 10:20 a.m. regarding resident 7's March 2024 Medication Administration Record with LPN G after leaving his room following the dressing change revealed: *I didn't know it [the dressing change] was going to be painful [to the resident]. I should have given him something prior to the treatment. *Tramadol was last administered at 12:53 a.m. on 3/19/24 and was able to have been administered every six hours as needed. Interview on 3/19/24 at 10:22 a.m. with resident 7 in his room while LPN G administered his tramadol revealed he: *Re-iterated his foot pain score was an 8. -Described his foot pain as jolting like electricity and felt like nerve pain. Review of resident 7's electronic medical record (EMR) revealed: *His diagnoses included: chronic peripheral venous insufficiency, chronic kidney disease, and chronic lower extremity edema. *Between 3/1/24 and 3/20/24 the resident was administered at least one tramadol dose daily except for five days. *Tylenol was last administered on 3/2/24. *His 1/25/24 care plan interventions related to pain revealed: -His pain was controlled with a Lidocaine patch, scheduled muscle relaxants, and as needed tramadol. -No non-pharmacological interventions for pain management were identified. -The resident will have an acceptable-to-resident 7-pain level during TCU [transitional care unit] stay. --There was no indication of what the resident considered to have been an acceptable pain level. 2. Interview on 3/20/24 at 8:15 a.m. with resident 7 revealed: *His left foot dressing change was just completed. *His pain post-dressing change was a 7 or 8. -The onset of his pain occurred at the time the dressing was removed off the top of his foot and the bare skin was exposed to the air. Interview on 3/20/24 at 8:20 a.m. and again at 11:30 a.m. with registered nurse I revealed: *Tramadol was administered to the resident at 6:25 a.m. that morning for a reported left foot pain score of a 4. *She completed the resident's left foot dressing change at about 8:00 a.m. that morning. *The resident activated his call light at 8:30 a.m. after the dressing change and complained of back and foot pain. -It was too soon to administer an additional tramadol and non-pharmacological interventions including leg elevation and relaxation were encouraged. Interview on 3/21/24 at 11:30 a.m. with director of nursing B and administrator C revealed: *LPN G was expected to have addressed resident 7's pain complaint before initiating his dressing change. *The resident's pattern of tramadol use should have been reviewed to determine if he would have benefited from some type of scheduled pain relief plan. *Specific non-pharmacological pain management interventions were expected to have been identified on the resident's care plan. *A definition of what the resident considered to have been acceptable pain was expected to have been reflected in his care plan. Review of the December 2018 revised Pain Management policy revealed: *10. Management of pain: In collaboration with the physician/prescriber, the facility staff develops, implements, monitors and revises as necessary interventions to prevent or manage the individual resident's pain, beginning at admission. *13. Monitoring, reassessment, and care plan revision. Monitor the resident over time to determine the extent to which pain is being controlled. Revise plan if needed.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Disinfection of the rubber seal on one of one sampled resident's (31) insulin vial by one of one licensed practical nurse (LPN) (H) before inserting the syringe needle. *Proper glove use during one one of one sampled resident's (7) dressing change by one of one LPN G. Findings include: 1. Observation and interview on 3/19/24 at 8:20 a.m. with LPN H preparing resident 31's insulin administration revealed she: *Did not wipe the rubber seal on his Levemir insulin vial with an alcohol pad before piercing it with a syringe. -Was expected to have wiped the seal with an alcohol pad prior to piercing it. 2. Review of resident 7's electronic medical record revealed: *His diagnoses included chronic peripheral venous insufficiency, chronic kidney disease, and chronic lower extremity edema. *He developed an eight-centimeter by nine-centimeter blister on the top of his left foot that opened up on 2/28/24. -Dressing changes to that foot occurred twice daily and as needed. *Wound assessments described the top of his foot as pink and moist with scant to moderate clear drainage and no signs of wound infection. Observation on 3/19/24 at 10:03 a.m. of LPN G performing resident 7's left foot dressing change revealed: *The resident was seated in a recliner in his room. *LPN G performed hand hygiene, put on a gown, and a clean pair of gloves then: -Lifted a red metal box sitting on top of the chair in front of the resident's recliner and moved it. -Moved the chair the box sat on out of the way. -Lifted the resident's walker by its handles from in front of him and moved it. -Removed the resident's left sock. *Without changing her gloves, performing hand hygiene, and putting on a clean pair of gloves she removed the pad from the top of his foot. *After discarding the pad she removed her gloves, performed hand hygiene, put on a clean pair of gloves and completed the dressing change. Interview on 3/19/24 at 10:30 a.m. with LPN G after resident 7's dressing change was completed revealed she should have removed her gloves, performed hand hygiene, and put on a pair of clean gloves after handling high-touch items like the red box, the chair, the walker, and the sock before touching the Vaseline gauze pad on the resident's foot. Interview on 3/21/24 at 11:00 a.m. with director of nursing B and administrator C regarding the observations referred to above revealed: *Insulin preparation practices including disinfection of the rubber seal of the insulin vial were not followed according to the policy regarding safe injection practices. *Glove removal, hand hygiene, putting on a pair of clean gloves after handling high-touch surfaces and before removing resident 7's dressing was expected to mitigate the risk of exposing contaminants to the resident's opened skin on his foot. Review of the revised December 2023 Safe Injection Practices-Medication Injections policy revealed: *IV Frequently Asked Questions Regarding Safe Practices for Medical Injections: -A. 1. b. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it. Review of the November 2023 revised [NAME] LTC (Long Term Care) Standard Precautions policy revealed: Gloves may need to be changed during the care of an individual patient [resident]. -Gloves should be changed after contact with a contaminated site and before contact with a clean site on the same resident.

Based on observation, interview, record review, and policy review, the provider failed to develop comprehensive person-centered plans of care for two of two sampled residents (17 and 27). Findings include: 1. Observation and interview on 3/14/23 at 3:31 p.m. with resident 17 revealed: *He was seated in his wheelchair watching the television in his room. *He stated he had been living in the facility for many years. *When asked if he participated in the activities offered by the provider he stated not really, but he enjoyed visiting with a few of the other male residents and he goes out to eat every once in a while with family. Review of resident 17's medical record revealed: *He was admitted on [DATE]. *His diagnoses included cerebrovascular accident, diabetes mellitus type II, pain, and depression. *His most recent brief interview for mental status (BIMS) indicated he was cognitively intact. *His most recent score on the mood assessment indicated minimal depression. *He was taking an antidepressant medication daily. *His 2/24/23 care conference progress note included the resident requested a men's group every week or so . Review of resident 17's 3/15/23 care plan regarding activities, diabetes, and mood revealed: -No intervention was listed for his insulin injection. -No intervention addressed his antidepressant medication. -No intervention addressed his preference and request for socializing with other male residents. Interview on 03/15/23 02:59 PM with activity coordinator (AC) F revealed: *She had just started a men's group last month on 2/28/23 at 2:00 p.m. and resident 17 attended. *She stated she completed the assessments on the residents but is not involved in developing or revising the activity care plan. -She stated MDS nurse coordinator D developed the resident care plan from the assessments she completed. 2. Observation and interview on 3/14/23 at 11: 24 a.m. with resident 27 revealed she: *Was laying in bed with her bed clothes on with the television on and crossword puzzle books were on her overbed table next to her bed. *Had lived in the facility almost one year. *Stated she did not care to attend the group activity programs but preferred to watch television and do crossword puzzles in her room. Further interview with resident 27 on 3/14/23 at 1:28 p.m. revealed: *She was concerned with putting on weight, stated she has gained 30 pounds since being here, and that she mentioned she would like to lose weight to the nurses. Review of resident 27's medical record revealed: *She admitted on [DATE]. *Her diagnoses included arthritis and frequent pain. *Her most recent BIMS coded her as cognitively intact. *Her 7/8/22 nutrition evaluation documented a three pound weight gain in the last 30 days and 11 pounds, 9.6 ounces weight gain since her admission. Review of resident 27's 3/16/23 care plan regarding activities and nutrition revealed: -No intervention addressed her preference to watch television and do crosswords in her room. -No intervention addressed her concern with gaining weight. Interview on 3/15/23 at 3:25 p.m. with MDS nurse coordinator D regarding care planning revealed she: *Developed and revised the care plans for the most part. *Agreed resident 17's care plan was not individualized for his: -Diabetes problem which had not included an intervention for his insulin injections he received daily. -Mood state which had not included an intervention for his antidepressant medication he received daily. *Agreed resident 27's care plan had not addressed the resident's concern with gaining weight. -She agreed with the 30 pounds of weight gain since her admission. -She was not aware of the resident's weight concerns. *Agreed there could be more collaboration with activities staff in the activity care plan. *Agreed the care plans needed to be more individualized. 3. Interview on 3/16/23 at 8:33 a.m. with food service manager G regarding care planning revealed he attended the care conferences but the dietary department did not formulate the care plan. Interview on 3/16/23 at 9:00 a.m. with social services associate E revealed: *She completed the social service assessments. *She did not develop care plans for social service concerns, but relied on MDS nurse coordinator D to develop and revise individual care plans from the computerized assessments she completed. Interview on 3/16/23 at 9:58 a.m. with MDS coordinator C revealed she agreed the care plans could be more individualized. Interview on 3/16/23 at 11:17 a.m. with DON B revealed she: *Agreed the care plans are generic. *Stated their computer system made it easy to be generic and that it took effort to individualize the care plans. 4. Review of the provider's 8/2020 Care Planning policy revealed: *Policy: The interdisciplinary team will develop a baseline and comprehensive care plan for each resident, based on the admission assessments, assessment tools and the MDS assessment to provide effective and person-centered care of the resident that meet professional standards of quality care and to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being. *Definitions: -'Person-centered care' - to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home.

Based on observation, interview, and document review, the provider failed to prevent one of one sampled resident (46) mattress from shifting diagonally on the bed frame, thereby creating a potential area for injury or entrapment between the mattress and the bed frame. Findings include: 1. Observation and interview on 3/14/23 at 9:31 a.m. with resident 46 in her room revealed: *She had a cane-like grab bar on her bed frame in the up position. *Her mattress was positioned diagonally on the bed frame. -There was approximately a five- to six-inch gap between the mattress and the edge of the bed frame. -The metal springs of the bed frame were exposed. *She had not wanted to injure her skin on the metal springs or get stuck between the mattress and the grab bar, so she put one of her pillows in between the mattress and the grab bar. *Staff would at times readjust the mattress to be in line with the bed frame. *The mattress had been positioned diagonally for a couple of days. 2. Observation on 3/14/23 at 4:47 p.m. of resident 46's bed revealed the mattress was still positioned diagonally on the bed frame. 3. Observation and interview on 3/15/23 at 11:14 a.m. with resident 46 in her room revealed: *Her mattress was in line with the bed frame. *She expressed that she was glad someone had fixed it. -She stated someone must have adjusted the mattress when her bed was made that morning. 4. Interview on 3/15/23 at 3:36 p.m. with administrator A and resident 46 about the resident's bed revealed: *Administrator A had been assisting the maintenance department with bed frame safety checks. -She had checked resident 46's bed frame on 2/17/23 and found that everything was in order. *Resident 46 said, it was ridiculous, in reference to the sizable gap between the mattress and the edge of the bed frame. *Administrator A agreed that the mattress shifting around on the bed frame was a hazard. 5. Review of the provider's undated Procedure Detail Report for Bedrail Safety Inspections revealed: *Inspect and [check] the [mattresses] and bedrails for areas of possible entrapment. *Mattress should not have a gap wide enough to entrap a resident's head or body (4 3/4 [inches]). *Check rails quarterly to ensure installed correctly and ensure rail has not shifted and loosened over time.

Based on observation, interview, and policy review, the provider failed to prevent potential cross-contamination when checking the temperatures of the food by nutrition and food service (NFS) staff H during one of one meal service observation. Findings include: 1. Observation on 3/15/23 at 4:53 p.m. of NFS H in the dining room service kitchen revealed: *After preforming hand hygiene, he retrieved two thermometers off of a shelf. *Without cleaning or sanitizing the first thermometer he: -Put the probe of the thermometer into the vegetable soup. -Without cleaning or sanitizing the probe he then placed the probe into the mashed potatoes and then the gravy. *Without cleaning or sanitizing the second thermometer he: -Put the probe of the thermometer into the corn. -Without cleaning or sanitizing the probe he then placed the probe into the breaded pork cutlet and then the pureed port cutlet. *When he had completed taking the food temperatures, he cleansed the probes with an alcohol-based thermometer wipe and placed the thermometers back on the shelf. 2. Interview on 3/15/23 at 5:59 p.m. with NFS H about his process for checking food temperatures for the meal service revealed: *Before starting the food service, he would have washed his hands. *He would poke a hole in the plastic and/or aluminum foil covering over each food item. *He would wait until the temperature reading on the thermometer slowed down and he would record the food temperature on the temperature sheet. *He would repeat the process until all the food temperatures had been checked. *To justify not cleaning or sanitizing the thermometer probe in between each food item, NFS H stated he would temp the foods with the highest amount of potential allergens last so as not to contaminate the other foods with allergens. 3. Interview on 03/16/23 at 8:50 a.m. with food service manager G about the above observation and interview with NFS H revealed he: *Was not aware NFS H was not sanitizing the thermometer probes between each food temperature check. *Expected NFS H to perform appropriate food temperature checks due to his extensive food service experience. *NFS staff needed more training on food safety and preventing cross-contamination. 4. Review of the provider's February 2021 Food Preparation policy revealed: *Under the PROCEDURE section: -11. Wipe post of thermometer with disposable alcohol swab - wait 30 seconds to insert post into food. Wipe post between all items to prevent possible cross contamination.

Based on observation, interview, manufacturer instructions, and policy review, the provider failed to ensure appropriate infection control precautions had been followed for: *One of one observation of housekeeper (M) while cleaning one of one resident (23) room. *One of one registered nurse (RN) (I) hand hygiene in two out of ten opportunities during medication pass. *One of one observation of glucometer use by registered nurse (RN) G with a resident (42) on transmission based precautions. *One of one observation of certified nursing assistant (CNA) C and physical therapist (PT) D during transfer of one of one resident (14) during personal care. Findings include: 1. Observation and interview on 11/17/21 from 10:48 a.m. to 10:55 a.m. with housekeeper M cleaning resident 23's room revealed she: *Placed cleanser from a bottle into the bathroom sink using gloved hands. *Took a sponge out of her cleaning caddy, scrubbed the sink and rinsed it out. *Placed the sponge back into the caddy. *Placed liquid disinfectant solution onto the freestanding toilet riser and into the toilet bowl. *Continued cleaning with disinfectant wipes and wiped down the area above the sink, mirror and grab bar beside the toilet. *Took the toilet brush in both hands and squeezed out the excess liquid. *Leaned onto the sink with her left gloved hand while she cleaned the toilet and toilet riser. *Finished cleaning the toilet and toilet riser, and placed the toilet brush back into the caddy. *She confirmed: -She had not disinfected the sink after she touched it with her gloved hand. -Was not sure how long the wait time was for the disinfectant used. -Had not timed the wait time for the disinfectant. -She cleaned other things until she thought it had been long enough time to disinfect. -She should know the wait time of the chemical used. -She had been trained to use one sponge to clean all resident sinks and then toss it at the end of the shift. -At the start of the shift a new sponge is placed on her cart to use for the day. -Agreed it would be a better practice to use a clean cloth or sponge for each resident sink instead. Interview on 11/18/21 at 8:21 a.m. with housekeeping supervisor N revealed: *The sponges had a scrubbing surface on the other side for getting soap scum buildup off the sinks and that is why they were used. *She was aware the housekeepers used a clean sponge at the beginning of their shift and threw it away at the end of the day. *The sponge would be reused for all resident rooms for the day unless the resident was on contact precautions. *The housekeepers did not go into the resident rooms with COVID. -The nurses and CNAs cleaned those rooms unless a request was made for a more thorough cleaning by a housekeeper to avoid exposure. -If requested, the housekeepers used full protective personal equipment to go into those rooms. *She agreed reusing sponges between residents rooms could be an infection control concern and source of cross contamination. Review of the provider's revised July 2021 Environmental Services Cleaning Policy revealed: *Carefully adhere to environmental cleaning guidelines. *Use and [sic] approved health care disinfectant, in concentrations established by housekeeping policies. *Strip room of linen items- take to the place where linen department collects items. *Provide special attention to decontamination of frequently-touched surfaces [e.g. over-bed tables, bed-rails, remote control, call buttons, telephones, lavatory surfaces, commodes, ventilators, over-bed bars, etc.]. *Disinfectant solutions for rags/mops should be discarded after use. *Mops and rags may be routinely laundered, using the health care facility's laundry. *Keep the environment around the patient free of unnecessary supplies and equipment to minimize contamination. *Infection control will advise staff of additional or different protocol. 2. Observation on 11/17/21 at 10:00 a.m. of RN I during medication pass revealed she had missed two out of ten opportunities to perform hand hygiene between residents. Interview on 11/18/21 at 9:21 a.m. with director of nursing (DON) B regarding the above observations revealed she had expected all staff to perform hand hygiene after administering medications to a resident and before moving on to the next resident. Review of the provider's revised October 2021 Hand Hygiene policy revealed: *Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. *A. HH, either with soap and water or with alcohol-based hand rub (ABHR)[.] -1. Immediately before touching a resident[.] -4. After touching a resident or the resident's immediate environment[.] 3. Observation on 11/17/21 at 12:50 p.m. revealed a Stat Strip (blood glucose monitoring machine):*Had been laying on paper towel, on canister of disinfectant wipes, in the hall by resident 42s room: *There had been a strip of paper taped on the top of the machine that stated, clean after each use (3 min wet time). -This strip of taped paper was peeled back approximately one inch from left edge of the glucometer. --This peeled taped had exposed paper underneath, making it an uncleanable surface. Interview on 11/17/21 at 1:08 p.m. with RN G revealed: *She had used the glucometer to test the blood sugar of resident 42, who was on transmission based precautions. -She had attempted to clean the glucometer by using a disinfectant wipe. *She had placed the glucometer on a docking station at the nurses desk. *The glucometer was shared with residents, needing their blood sugar checked, on the same wing as resident 42. Interview and observation on 11/17/21 at 4:21 p.m. with DON B regarding glucometer cleaning revealed: *They had utilized hospital grade glucometers. -The glucometers were placed on a docking station after use. --The information from the glucometer would be downloaded from the docking station into the resident's electronic medical record. -Each floor had one glucometer. *Glucometers had been shared between residents. -They had been disinfected between residents using them. -They had provided training to staff. Observation on 11/17/21 at 4:26 p.m. with DON B and RN F revealed: *The glucometer had been on the medication cart. *DON B and RN F agreed there was taped paper that had been peeling off the glucometer on one side. -DON B agreed this had made the glucometer a non-cleanable surface. -RN F removed the peeling taped paper. --She had not realized it had been on the glucometer. ---Agreed it should not have been on the glucometer. 4. Observation and interview on 11/16/21 at 4:34 p.m. with CNA C and PT D while assisting resident 14 revealed: *Resident was assisted onto the toilet with the mechanical lift. *CNA reported the facility did not have enough slings for every resident to have their own. *Staff shared cloth slings between the residents. *CNA explained staff had been wiping the harnesses down with sanitizer wipes. -She demonstrated cleaning the mechanical lift and harness by wiping them down with Kimtech Wettask System wipes. *CNA reported residents on transmission based precautions had their own harness. Interview on 11/18/21 at 10:00 a.m. with DON B revealed: *A new mechanical lift with additional harnesses had been ordered. *There had been conversations regarding if residents should each have their own harness. *Residents on transmission based precautions had their own harness. *Cleaning with the Kimtech Wettask System wipes would not disinfect the harness as they are cloth. *Harnesses had been shared amongst residents, the facility did not have enough harnesses for each resident to have their own. *She agreed harnesses should not have been shared amongst residents. Review of the EZ Way, Inc. manufacturer instructions for washable slings and harnesses revealed: *Washable EZ Sling and Harness Laundering instructions -To get the longest life out of your product: --1. Do not bleach --2. To prevent stains from setting, rinse 5 min. in 80-100 degree F. Stains will set when temp is over 105 degrees F. --3. Wash temp 160 degrees F. max. --4. RINSE THOROUGHLY in 100 degree F. If high alkaline detergent (with pH greater than 11.0) is used, rinse twice. --5. Tumble dry, temp. 110 degrees F. max. high heat will weaken the fabric. --6. If applicable, snap the buckle together before washing and drying. this will prevent any damage to the plastic buckle. --7. If available, use a laundry bag to wash and dry the sling or harness. *Manufacturer instructions did not include the use of disinfectant wipes. 5. Review of the provider's July 2021 [NAME] LTC - Disinfection of Non-Critical Patient Care Equipment policy revealed: *I. PURPOSE -A. Cleaning, disinfecting and storing equipment and supplies is important in preventing the transmission of potential pathogens within the long-term care facility. -B. In order to more easily control quality, cleaning, disinfection, and sterilization of re-usable patient care equipment, whenever possible, critical and semicritical disinfection will be completed by a facility in which sterilization practices are provided. Processes for handling and transport of equipment are designated by the receiving site. Sterile single use equipment will be utilized when appropriate. -C. For the safety and comfort of residents, all reusable(non-critical) resident care items will be cleaned, disinfected, and maintained in a safe manner between resident uses. *II. INFORMATION -A. Reusable resident care equipment/items fall into 3 different classification categories for disinfection and sterilization: non-critical, semi-critical, and critical. --1. Non-Critical items are those that come into contact with intact skin but not mucous membranes. these are divided into resident care items and environmental surfaces. ---a. Non-critical resident care items (Examples include blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) are cleaned between/after each resident use. They require Low level disinfection by cleaning following manufacturer instructions with an EPA-registered disinfectant, detergent, or germicide that is approved for healthcare settings. ---3. Critical items (Examples include needles, intravenous catheters, indwelling urinary catheter) enter sterile tissue or the vascular system. These items or equipment must be sterile when used, based on one of several accepted sterilization procedures. Most items in this category for LTC [long term care] are purchased sterile. -D. Non-critical items rarely, if ever, transmit disease but could contribute to secondary transmission by contaminating HCW (health care worker) hands or by contact with medical equipment that will subsequently come in contact with patients. Consequently, cleaning with a facility approved disinfectant is sufficient. *III. POLICY -A. Community/facility items removed from a resident's room need to be disinfected prior to use by a different resident. -E. All reusable resident care equipment removed from a resident room/procedure room is disinfected before use on another resident. -K. Disinfection recommendations- 1. Reusable resident care equipment: All applicable label instructions on EPA-registered [Environmental Protection Agency] disinfectant products must be followed. (Examples are use-dilution, shelf life, storage, material compatibility, safe use and disposal.) -a. Between each resident use and when soiled -e. Glucometer or re-useable point of care testing labeled for multiple resident[.]

Based on interview, record review, and policy review, the provider failed to ensure medication disposal for one of two sampled residents closed record (47) had been completed by a registered nurse (RN) and a witness. Findings include: 1. Closed record review of resident 47's record revealed: *He had died on [DATE]. *There was no documentation of what had been done with his medications. Interview on [DATE] at 10:58 a.m. with director of nursing (DON) B regarding medication destruction for deceased residents revealed their process was to: *Destroy controlled substance medications with one licensed nurse and the DON. *All other medications were sent back to the pharmacy for destruction. -This was to be documented in the resident's electronic medical record [EMR]. -She could not find any documentation of the destruction of medications for resident 47. -She stated the pharmacy did not keep a record of what had been sent to them for destruction. Interview on [DATE] at 11:38 a.m. with assistant director of nursing E revealed she: *Had been unable to find any documentation of the destruction of medications for resident 47. -Stated their policy required this to be completed and they had not been doing it. Review of provider's ,d+[DATE] Medication Administration policy revealed: *Purpose: 1. To ensure safe medication administration, and proper control, storage and accountability of medications within the facility. *Policy -XX. Disposition of Outdated or Discontinued Medications. --c. Outdated or discontinued medications (including medications that are left when a resident expires) are to be returned to [NAME] pharmacy by placing them in a return to pharmacy tote in the 2nd floor/TCU (Transitional Care Unit) med [medication] room. --e. The nurse will document in the progress notes the name and dose of each medication followed by the number returned to the pharmacy. Review of provider's ,d+[DATE] Checklist for Nurses at time of Death of a Resident/Patient revealed: *Medications need to be returned to pharmacy. A medication reconciliation progress note listing the medications returned should be placed in Meditech [EMR].

Based on observation, interview, record review, and policy review, the provider failed to ensure six of twelve sampled residents (15, 27, 28, 29, 37 and 48) had: *Received risks versus benefits education for side rail use. *Obtained signed informed consent forms for side rail use. *Performed regular safety checks for the proper installation of side rails. Findings include: 1. Observation and interview on 11/17/21 at 3:37 p.m. with resident 15 revealed she: *Had a side rail on the upper part of her bed which was in the upright position. *Used it to reposition or roll over in bed. *Stated the staff put the side rail up and down for her as she could not. *Could not remember staff educating her on the risks or benefits of the side rails or signing a consent form for their use. *Thought the side rails had always been on her bed. Review of resident 15's medical record revealed: *She had admitted on [DATE]. *Her brief interview for mental status (BIMS) was 15 and indicated her cognition was intact. *She had a 6/23/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use. 2. Observation and interview on 11/17/21 at 3:41 p.m. with resident 29 revealed: *He had bilateral side rails on the upper portion of his bed. *The outside rail was in the upright position. *The side rails assisted him to get in and out of bed. *The staff put the rails up and down for him because he could not move them. *He could not remember the staff educating him on the use of the side rails or signing an informed consent form for their use. *He was unsure when the side rails were put in place. Review of resident 29's medical record revealed: *He had admitted on [DATE]. *His BIMS was 15 and indicated his cognition was intact. *His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *He had a 9/13/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use. 3. Observation and interview on 11/17/21 at 12:05 p.m. with certified nursing assistant (CNA) K while making resident 48's bed revealed: *A bed rail, in upright position, on the left side of the bed. *CNA K stated the resident used the side rail to reposition and get in and out of the bed. Review of resident 48's medical record revealed: *He was admitted on [DATE]. *His BIMS was 5, indicating his cognition was moderately impaired. *His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *He had a restraint assessment completed on 8/23/21 that indicated the side rail was used for bed mobility. *No documentation that education for risks and benefits of side rail use. *No signed consent from the resident or representative for side rail use. 4. Observation and interview on 11/17/21 at 12:03 p.m. with CNA J regarding resident 27 revealed she: *Had a side rail on the upper part of her bed which was in the upright potion, resident not in bed. *CNA J stated, she used it for repositioning. Review of residents 27 medical record revealed: *She had been admitted on [DATE]. *She was rarely understood, and BIMS could not be completed. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *No documentation that education for risks and benefits of side rail use. *No signed consent from the resident or representative for side rail use. 5. Observation on 11/16/21 at 10:01 a.m. of resident 28's room revealed a bedside pole next to his bed that extends from the floor to the ceiling. Interview on 11/17/21 at 11:22 a.m. with resident 28 revealed: *He does use the positioning pole to get in and out of bed. *He does not recall getting any education on the risks and benefits of side rail use. Review of resident 28's medical record revealed: *He had been admitted on [DATE] *His BIMS score was 11 and indicated moderate cognitive impairment. *His last revised care plan stated he may use grab bar on bed for bed mobility. *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use. 6. Observation on 11/16/21 at 3:06 p.m. of resident 37's bed revealed a single side rail near the head of the bed in the upright position. Review of resident 37's medical record revealed: *He had admitted on [DATE]. *His BIMS score was 10 and indicated moderate cognitive impairment. *An 8/10/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *A 10/18/21 restraint evaluation stated: -The device was used to assist the resident to stand up. -The question, Can the individual easily remove the device? was answered not applicable it is on the bed, not the resident; he uses it to improve his independence. Interview and observation on 11/17/21 at 10:46 a.m. with resident 37 revealed: *He had not recalled getting any education on side rails. *He relied on staff to put the side rail up and down. 7. Interview on 11/17/21 at 9:30 a.m. with registered nurse (RN)/minimum data set (MDS) coordinator assistant H revealed: *They had not: -Provided education to the residents or their representatives on the risks and benefits of side rails. -Requested informed consent from the resident or their representative. -Performed regular safety assessments for the proper installation of side rails. Interview on 11/17/21 at 10:06 a.m. with MDS Coordinator L revealed: *They had not provided education to the resident or their representative on risks and benefits of side rails or obtained a signed informed consent form. *They received a request from the therapy department or from the resident themselves for side rails. *If the resident was cognitively appropriate they got a physicians order for side rail use. Surveyor : Interview on 11/18/21 at 11:19 a.m. with administrator A and director of nursing (DON) B revealed: *Side rail assessments for residents were completed with the quarterly minimum data set assessments. *Were not aware of a side rail policy in place. *They confirmed: -Education to residents or their families had not taken place regarding the risks and benefits of side rail use. -Consent forms had not been received from residents or their families for use of the side rails. -They had not put the side rails on a schedule to be checked for safety and proper placement. On 11/18/21 at 11:42 a.m. DON B gave surveyor a copy of their facility policy for side rails. *She confirmed they had not followed their policy. 8. Review of the provider's revised September 2016 Safety Policy revealed: Patient beds are equipped with: 1. Side rails only after the following criteria have been met: a. Upon the resident's admission or as the need is identified, staff assessment will determine if a bed equipped with side rails is necessary for mobility, and whether it is safe for that individual. b. The resident's care plan must document the need/use for side rails if the side rails are implemented. 2. Removable head boards [headboards]. 3. Mattresses and side rails are assessed so gap is no more than 4.75 inches. 4. Locking device to attain a secure stationary position. 5. Mechanism for adjustable positions.

Based on observation, interview, record review, policy review, and review of the Centers for Disease Control and Prevention (CDC) 11/20/20 publication Preparing for COVID-19 in Nursing Homes, the provider failed to: *Ensure staff and residents in the facility were not exposed to COVID-19. *Use appropriate precautions on four of four (1, 2, 3, and 4) residents who were recently admitted to the facility. Findings include: 1. Observation on 2/16/21 at 11:40 a.m. of resident 1, 2, 3, and 4's rooms revealed: *Each room had a sign outside the door indicating: -Those residents had been on quarantine and staff were to use standard precautions of a universal mask and eye protection. -If blood or body fluid exposure could occur staff were to add gloves and a gown. *Each sign listed the date the quarantine period ended. *The doors to the rooms were open. Interview on 2/16/21 at 11:45 a.m. with certified nursing assistant C regarding residents 1, 2, 3, and 4 revealed: *They were new admissions and were being quarantined for fourteen days. *They were not to come out of their rooms during the quarantine period. *The doors to their rooms had always been left open. *The only personal protective equipment (PPE) required when entering a quarantine room was a face mask and face shield. *The staff did not change the face mask or disinfect the face shield when exiting the room or prior to caring for other residents. *She wore the same face mask and faceshielf to care for all residents regardless of quarantine status. Interview on 2/16/21 at 3:30 p.m. with administrator A and registered nurse B regarding quarantined residents' revealed: *The provider did not have a policy for quarantine. *New admissions were put on quarantine for 14 days as a precaution to ensure they did not have or develop COVID-19. *The doors were not required to be closed. *The only PPE required when entering their room was a face mask and face shield. *The staff did not change the face mask or disinfect the face shield when exiting the room or prior to caring for other residents. *They had not agreed the staff should be wearing a gown and gloves along with a face mask and face shield when entering the rooms. *The residents were screened for signs and symptoms of COVID-19 twice a day. -If they became symptomatic staff would have been required to wear face mask, face shield, gown, and gloves. *There was not a shortage of PPE. -Recently they had enough gowns to change from washable to disposable gowns. *They were not aware of the CDC recommendations for new admissions and readmissons. Review of the Centers for Disease Control and Prevention (CDC) 11/20/20 publication Preparing for COVID-19 in Nursing Homes found at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed: *Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. *HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. *Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. *Testing at the end of this period can be considered to increase certainty that the resident is not infected.

Based on observation, record review, and interview, the provider failed to ensure proper sanitation practices including hair net accessibility, hand sink cleaning, dishwasher cleaning, water line maintenance, and temperature probe calibration had occurred in the nursing home dish room and kitchen. Findings include: 1. Observation and interview on 8/6/19 at 11:05 a.m. with dietary staff person F during the dish room tour revealed: a. Hairnets: *There were no hairnets available in the dish room. -Dietary staff person F had stated those who entered the dish room usually were already wearing a hair covering. b. Hand washing sink: *The white porcelain hand washing sink was a dirty off white and yellowish color. *There were small bits of brown debris stuck inside the sink bowl and its perimeter. -The bits could be removed by scraping them with a fingernail. *The sink drain had a two to three inch ring of orange around it. c. Dishwashing machine: *The top of the machine was covered with a raised off white to light brown crusty substance that could not be removed by swiping a finger across it. *Along the back edge of the dishwashing machine were two separate dark brown areas between six and 10 inches in length and approximately three to four inches in width. -The shape of those areas suggested liquid had sat and dried there. -The hardware along that back edge was crusty with what looked like a lime build-up. *On top and to the front of the dishwashing machine were wash, rinse, and final rinse gauges. -There was a thick hard raised black substance that ran a length of about twelve inches in front of those gauges. d. Dishwashing machine cleaning: *Dietary staff person F had stated he de-limed and thoroughly cleaned the dishwashing machine every other weekend. -He had stated there was no dishwashing machine cleaning schedule. -The dishwashing machine vendor came at the end of each month to assess the condition of the dish machine. e. Dishwashing machine water lines: *There were two water lines visible beneath the area where dishware exited the dishwashing machine. -There were three to four feet sections of covering on those lines that were torn and exposed the insulation. -Those sections would have been uncleanable surfaces. 2. Observation and interview on 8/6/19 at 11:45 a.m. with dietary staff person [NAME] during the kitchen tour revealed: a. Hairnets: *Hairnets were not accessible upon entering the kitchen. -It was necessary to walk through the kitchen near the serving and food preparation areas to get them. -She agreed the hairnets should have been near the hand washing sink at the kitchen entrance. b. Temperature probes: *Dietary staff person [NAME] had stated she calibrated the kitchen temperature probes one time a week. -She was unsure if there was a policy regarding the frequency of temperature probe calibration. 3. Interview on 8/7/19 at 8:15 a.m. with the dietary manager regarding the dish room and the kitchen revealed: *She was aware of the condition of the hand washing sink. -She said the discoloration was related to chemicals in the local water. *She was aware of the lack of cleanliness on top of the dishwashing machine and agreed it should have been taken care of. *She said she had not noticed the torn covering and exposure of insulation on the water line pipes. -She did not believe that had been reported to maintenance. *She did not realize hair nets were not readily accessible in either the dish room or the kitchen but agreed they should have been. *She was uncertain how frequently temperature probes should have been calibrated. *She stated there were cleaning and duty checklists for the dish room and kitchen. Review of the undated, unused dish room cleaning checklist revealed: *Item to be Cleaned: -Clean sinks at end of shift. --That was to be completed daily. -De-lime dishwashing machine/wipe down entire machine. --That was to be completed weekly. *There was an area at the bottom of the checklist for daily supervisor sign-off. Interview on 8/7/19 at 1:30 p.m. and again at 2:30 p.m. with the administrator and the dietary manager revealed: *There were no policies for dishwashing machine cleaning and maintenance or temperature probe calibration. *There was not a dishwashing machine operator's manual. *The dish room and kitchen cleaning and duty checklists had not been reviewed, revised, or implemented since some time in (YEAR).

Based on observation, record review, and interview, the provider failed to develop and revise individual care plans to reflect the current needs for 2 of 14 sampled residents (3 and 31). Findings include: 1. Multiple random observations on 8/6/19 from 9:00 a.m. through 5:30 p.m. and again on 8/7/19 from 8:30 a.m. through 2:00 p.m. of resident 3 revealed he: *Sat in his slightly reclined Broda chair. *Had pink foam boots on both heels. *While he sat with the pink foam heel protectors on his heels had been firmly pressed against his chair. That would have offered no pressure relief or off loading for his heels. *Both of his legs were contracted. *There had been no protection for his lower legs and knees for pressure relief. Review of resident 3's revised 8/2/19 care plan revealed: *A problem area stated: Skin integrity. -The goal for the above focus area regarding the resident's heels and legs had been: Maintain. -Interventions for the above had been: --Heel protectors on while in bed and/or offload heels on pillows. --Place cushion/pillow between knees to provide protection from his knees pressing on each other. Interview on 8/7/19 at 4:00 p.m. with the administrator and director of nursing regarding resident 3 revealed they: *Confirmed the resident had a right heel pressure ulcer. *Agreed the pink foam boots did not offer pressure relief when they had been constantly pressed on the foot and leg area of the Broda chair. *Agreed the resident was to have had a cushion and pillow between his knees for preventative pressure relief. Review of the provider's last revised (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed its purpose had been: *To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers; to systematically assess and document skin risk factors; to implement skin-protection components of care, and to provide appropriate treatment when indicated. *Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. 2. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She was on a renal diet with a 1500 milliliter fluid allowance per day. Observation on 8/6/19 at 2:22 p.m. and at 4:30 p.m. of resident 31 revealed: *She was sitting on her bed watching television. *Her room had a foul odor. *There was a moderate amount of feces on the floor next to her bed in front of the garbage can. *Had witnessed her throw an empty paper package on top of the feces on the floor. Interview on 8/6/19 at 2:58 p.m. with registered nurse (RN) I regarding resident 31 revealed: *She often had feces on the floor in her room. *She would also throw garbage and paper on the floor in her room. Review of 6/10/19 the registered dietician's nutrition information note regarding resident 31 revealed: *Her husband had brought food in to her including fluids. *Both the resident and her husband had been educated on dietary recommendations. *Husband just wants her to be happy, and she agrees with this. Review of the last reviewed 6/27/18 care plan for resident 31 revealed no behaviors and non-compliance with diet had not been identified. Review of a 7/18/19 nurses note regarding resident 31 revealed: *The [MEDICAL TREATMENT] center had sent nutrition education with the resident after her [MEDICAL TREATMENT] treatment. *The nurse had asked her husband if he wanted to review the education. -He had not reviewed the information. -He told the nurse that the resident was going to do what she wanted. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31's care plan revealed: *She had agreed the non-compliance with diet and fluid allowance and the behaviors such as defecating on the floor should have been on the care plan. *She had not put the behaviors on the care plan, because she did not have interventions to add that would help decrease the behavior. A care plan policy was requested on 8/7/19 at 11:30 a.m from the administrator. A policy for Baseline Care plans was received but not for care plans. The administrator stated they did not have one.

Based on observation, interview, record review, and review of the Resident Information Handbook, the provider failed to ensure one of one sampled resident (52) was dressed in a dignified manner. Findings include: 1. Observation on 8/5/19 at 5:45 p.m. of certified nurse aide (CNA) G and CNA H revealed: *They had transferred resident 52 with a mechanical lift. *The backside of the resident's pants had been cut from the center of the waistband to the crotch. *CNA G had stated that made it easier to remove the resident's pants when she was toileted. *CNA G had given the resident two plastic clips to secure her shirt to the pants after the lift was completed. Interview on 8/5/19 at 5:52 p.m. with resident 52 regarding those pants revealed: *She had stated I hate it. *The modified pants made her feel self-conscious. *She said staff had told her they were working on a modification to make the cut pants more discreet. -She had been told that over a month ago. Interview on 8/6/19 at 2:15 p.m. with resident 52 revealed: *She had gone into the community today and had been dressed in a regular pair of pants. *She was re-dressed upon returning to the facility into a pair of cut pants. -The cut pants were not her own and had been provided to her by the facility. *She had stated They (the pants) keep falling down. -The plastic clothespin and another plastic clip she had used to keep her pants up were her own. Interview on 8/7/19 at 1:20 p.m. with the social services designee revealed: *She was aware of resident 52's dislike of the cut pants. -That had been discussed at her 7/3/19 interdisciplinary care conference. -She had thought a staff member was working on a modification to the pants. *She was unaware the resident had been using her own plastic clothespin and clip to secure her top to her pants. -She had thought the clothespin and clip were appropriate to use if it works. *She was unaware of the resident's concern for skin exposure when she wore the cut pants. -She had stated I don't know if it looks so good dignity wise and if we could find something better that would be good. Review of resident 52's medical record revealed her Brief Interview for Mental Status assessment score was fifteen indicating her cognition was intact. Review of the 7/3/19 care conference progress note revealed: *Resident Comments: -Wants to wear her own un-modified pants, but now that she is unable to stand to bear weight, must use the maxi lift and has been unwilling to roll side to side, has been trialing split pants but she doesn't like these; we are willing to modify these for her with a strap/connector, but she still wants to wear unmodified pants. A Dignity policy was requested on 8/7/19 at 11:30 a.m. from the administrator, however she stated the facility did not have one. Review of the provider's undated Resident Information Handbook revealed: *Emotionally: -The daily goal of our nursing facility is to encourage residents and patients to live at their highest level of physical, emotional, and mental capabilities. Respect for the dignity of the human person is basic to our philosophy of care.

Based on interview and record review, the provider failed to ensure communication between a [MEDICAL TREATMENT] center and the provider was documented, that nursing staff were assessing the resident for change of condition, and they were following physician orders [REDACTED]. Findings include: 1. Review of resident 31's medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of fifteen indicating she was cognitively intact. *Her [DIAGNOSES REDACTED].>-Type two diabetes. -End stage [MEDICAL CONDITION]. -Dependence on [MEDICAL TREATMENT]. -[MEDICAL CONDITION]. -Heart failure. -[MEDICAL CONDITION]. *She had been receiving [MEDICAL TREATMENT] three times per week. *She had an arteriovenous (AV) fistula place on 7/31/19. *[MEDICAL TREATMENT] post-assessment had not been completed since 7/18/19. Review of resident 31's 7/31/19 nurses note revealed: *She had returned from an appointment for the AV fistula placement. *The dressing was to be removed after forty-eight hours. *She was to do stress ball exercises twenty times every hour while awake. Review of resident 31's last reviewed 6/27/18 care plan revealed a [MEDICAL TREATMENT] post assessment was to be completed on [MEDICAL TREATMENT] days. Interview on 8/7/19 at 10:14 a.m. with registered nurse (RN) B regarding resident 31 revealed: *An assessment was to be done in the electronic medical record when she returned from [MEDICAL TREATMENT]. -She did know how to find and complete assessment. -She did not know where the assessment was to review it after it had been completed. *The resident had a fistula placed a couple days ago on 7/31/19. Interview on 8/7/19 at 10:23 a.m. with resident 31 and her husband revealed that they did not know if a post-[MEDICAL TREATMENT] assessment had been done after her [MEDICAL TREATMENT] treatments. Interview on 8/7/19 at 11:40 a.m. with RN A regarding resident 31 revealed the [MEDICAL TREATMENT] post-assessment should have been completed by a nurse after each [MEDICAL TREATMENT] procedure. Interview on 8/7/19 at 3:19 p.m., at 3:28 p.m., and at 4:19 p.m. with the assistant director of nursing regarding resident 31 revealed: *She had went to an appointment on 7/31/19 for afistula and had returned with new physician orders [REDACTED]. -She could not find the physician orders [REDACTED]. -They would not have documented that stress ball exercises had been completed. *When the resident returned from [MEDICAL TREATMENT] appointments the [MEDICAL TREATMENT] center would send a communication sheet back with her. -The communication sheet had before and after [MEDICAL TREATMENT] run weight and vital signs on it. It would have also contained any new orders. -The nurse reviewed the sheet upon return. -The weights were recorded in the electronic medical record, and then the sheet was shredded. *The resident's treatment record was requested during the interview, but it had not been provided by the end of the survey. *Requested the policy on [MEDICAL TREATMENT] and assessment post-[MEDICAL TREATMENT] treatment. -She stated the provider did not have a policy on that. *She had done a training on [MEDICAL TREATMENT] with staff. -The training material was requested during the interview, but it had not been provided by the end of the survey. Interview on 8/7/19 at 3:43 p.m. with RN I regarding resident 31 revealed: *When the resident returned from the [MEDICAL TREATMENT] center she looked at the dressing and did an assessment. *She reviewed the communication sheet from the [MEDICAL TREATMENT] center. *After she reviewed the sheet she put it in a file to be scanned into the medical record. *She did not document her assessment. *She did not know about the [MEDICAL TREATMENT] post-assessment that was to be completed.

Surveyor: Based on observation, interview, and record review, the provider failed to ensure adequate pain control was monitored, reviewed, and appropriate interventions were implemented for one of one sampled resident (33) who had complaints of increased pain after a facility acquired injury occurred. Findings include: 1. Observation and interview on 5/15/18 at 9:27 a.m. of resident 33 revealed: *She repeated I'm hurting terrible. *It was heard by this surveyor all the way down the hallway. *Certified nursing assisted (CNA) G was applying an ice pack on her left lower leg on an oval shaped bruise approximately five inches by four inches. *CNA G hesitated to apply the ice pack because of her yelling. *CNA G and H elevated her legs in the recliner. *She continued to yell and grimace in pain. *CNA G and H stated she had started yelling out more with movement this weekend after her leg had been bumped into the door. Interview on 5/15/18 at 9:47 a.m. with resident 33 revealed when the surveyor asked what happened to her leg she stated: *I'm afraid that its broke. *Some girls did it when they were getting me up. *Hurts all over. Interview on 5/16/18 at 4:45 p.m. with the director of nursing (DON) revealed: *Resident 33's injury had been reported immediately by CNA I to registered nurse (RN) F on 5/12/18. *CNA I reported she had brushed resident 33's leg against the wall in the hallway. *The DON stated she had not examined the injury. Interview on 5/16/18 at 6:30 p.m. with RN/MDS assessment coordinator and RN/MDS assistant revealed: *There was no incident report and investigation completed after the injury had been reported by CNA I. *The physician had not been notified of the incident and injury to the resident's left leg. Review of resident 33's complete medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She: -Had a Brief Interview Mental Status (BIMS) score of twelve indicating her memory recall was slightly impaired. -Had been capable of making her needs known. *There was no documentation to support: -An incident report was completed after the injury had been reported by CNA I on 5/12/18. -A formal investigation was completed to rule out abuse and ensure no major injury had occurred to the resident's left leg. -Systems, protocols, and education were provided and implemented to ensure this type of incident and injury would not have occurred again. *The physician had not been notified of: -The incident and injury that had occurred to the resident's left leg. -The resident's complaints of increased pain and discomfort -The ineffectiveness of the pain medications the staff had given her for those complaints of discomfort. Review of resident 33's 5/14/18 hospice nurse's notes revealed: *The resident had been complaining of her legs hurting earlier that day. *The staff had reported to the hospice nurse that the resident's leg was twisted during a transfer yesterday (5/13/18). *The resident had not required extra pain medication for discomfort. *The resident's pain control had been assessed with [REDACTED]. *A trace amount of [MEDICAL CONDITION] was observed to both of her lower legs, ankles, and feet. *No documentation to support a bruise was observed on her lower left leg. Review of resident 33's 5/14/18 hospice social services note revealed: *The resident had said she was having a lot of pain in her hip, and she had stated she Thinks it is broke. *An unidentified nurse had reported to her that the resident's Knee got bumped on the door frame over the weekend. *She had pain medication for it, and it should have taken effect shortly. *Staff feel it is not broke, more of a muscle pull. Review of resident 33's 5/15/18 registered nurse (RN) F's nursing documentation revealed: *She had completed a late entry for her interview and assessment of the resident that had occurred on 5/12/18 at 4:45 p.m. *On 5/12/18: -CNA I reported she had bumped the resident's left foot on the wall while taking her to the dining room in her Broda chair. -Resident 33 had complained of pain in her right foot, and then she had said it was her left foot. -There was swelling, but that had been usual for her. -Will monitor and report to (physician's name), any changes or signs of fracture. *Her late entry for the resident's incident with CNA I had occurred three days later and had occurred during the facilities recertification survey. *No documentation to support: -Where the swelling had been observed. -An incident report had been completed. Review of resident 33's 5/15/18 RN D's nursing documentation revealed: *She had completed a late entry for her assessment of the resident that had occurred on 5/12/18. *On 5/12/18 at 4:45 p.m.: -Resident was in so much pain when she was sit (sat) up from bed and place in the recliner. -The resident had complained her foot hurt, and RN D had checked her left leg from the knee down to her foot. *She had noted: -A fading bruise on the lower part of her shin. -Very tender to touch, the resident was yelling and grimacing when her legs had been elevated. -[MEDICATION NAME] had been given for discomfort. -She was still agitated and grimacing an hour after the pain medication had been given. -The resident stated I don't get relief and Put me up. *The nurse noted that was excruciating pain. *Her late entry of that assessment was three days later after the incident and had occurred during the facilities recertification survey. *No documentation to support: -An incident report had been completed. -The physician had been notified: --Of her assessment of the resident's leg and increased pain. --The pain medication was ineffective. Review of resident 33's 5/16/18 RN E's nursing documentation revealed: *She had completed a late entry for her assessment of the resident that had occurred on 5/14/18. *On 5/14/18 at 1:08 p.m.: -The resident had pain when the staff were assisting her with getting up. -The resident had stated It hurts, its hurts. -She had been medicated with Tylenol, [MEDICATION NAME], and [MEDICATION NAME]. --The [MEDICATION NAME] had been given again after an hour. -A warm pack had been applied to her left lower leg. *Her late entry of that assessment was two days later and occurred during the facilities recertification survey. *No documentation to support: -The nurse had assessed what the resident's left leg looked like. -The physician was notified of her increased pain with no relief after several pain medications had been given. Review of the provider's undated RN/Charge Nurse job description revealed: *Responsiveness: -Follow through and follow up. -Anticipate and respond to individual's needs. *Task 1 - Performs Nursing Task: -Contacts physician, establishes working relationship and initiates ongoing information exchange. -Provides professional nursing care to residents. -Administer professional services. -Monitor seriously ill residents as necessary. -Notify physician and next-of-kin when there are any changes in resident's condition. *Task 2 - Care Planning and Record Keeping: -Consistently & thoroughly completes documentation in a timely manner, including initiating medication & treatment administration records. -Completes/supervises medical record. *Task 3 - Supervisory Duties/Roles Knowledgeable status and needs of residents and communicates effectively with team members. Review of Potter/Perry's 2013 ninth edition; Fundamentals of Nursing; Chapter 44 page 1,022 on Pain Management revealed: *Knowledge of pain physiology and the many factors that influence pain help you manage a patient's pain. Critical thinking attitudes and intellectual standards ensure the aggressive assessment, creative planning, and thorough evaluation needed to obtain an acceptable level of patient pain relief while balancing treatment benefits with treatment-associated risks. Successful pain management does not necessarily mean pain elimination but rather attainment of mutually agreed-on-pain-relief goal that allows patients to control their pain instead of the pain controlling them. *Nurses approach pain management systemically to understand and treat a patients pain. *The American Nurses Association (ANA, 2005) upholds that pain assessment and is within the scope of every nurse's practice. Review of Potter/Perry's 2013 ninth edition; Fundamentals of Nursing; Chapter 44 page 1,023 on Pain Management revealed: *Routine Clinical Approach to Pain Assessment and Management: ABCDE: -A: Ask about pain regularly. Assess pain systematically. -B: Believe patient and family in their report of pain and what relieves it. -C: Choose pain control options appropriate for the patient, family, and setting. -D: Deliver interventions in a timely, logical, and coordinated fashion. -E: Empower patients and their families. Enable them to control their course to the greatest extent possible.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (44) who required staff assistance with care had not developed a facility acquired pressure injury. Findings include: 1. Observation on 5/15/18 at 8:30 a.m. of resident 44 revealed she: *Had been: -In the dining room eating her breakfast. -Sitting in a Broda wheelchair (w/c) with pressure relieving boots on both of her feet. -Wearing a specialty brace that started at her neck and extended down to her waist. -Able to move her arms without difficulty, but no spontaneous movement of her legs was noted. -Complaining of discomfort and requested an unidentified staff member to take her back to her room. *Appeared weak, frail, and her hair was unkempt. Observation and interview on 4/15/18 at 8:45 a.m. with resident 44 revealed: *She had been: -In her room and sitting in her Broda w/c. -Alert with some confusion to date and time. -Listening to country music on her television and watching the activities going on outside of her window. *She: -Had just received some pain medication and was feeling better. -Continued to wear the speciality brace and pressure relieving boots to both of her feet. -Was not able to remember why she had to wear a specialty brace or boots to both of her feet. *Her: -Feet had been resting on the footrest of the w/c. -Left foot and leg were slightly turned inward. Interview on 5/15/18 at 9:10 a.m. with licensed practical nurse (LPN) J regarding resident 44 revealed: *She had: -Been recently admitted with a compression fracture in her back. -Required the use of a specialty brace for safety and support while the fracture healed. -A wound located on her left heel. -Acquired that pressure injury while she had been receiving care and services in the facility. *LPN J stated She has a black area on her left heel. *The surveyor had: -Informed LPN J and certified nursing assistant (CNA) B she would like to watch them with personal care throughout the day. -Been informed by the staff the resident would turn on her call light if she needed assistance to go to the bathroom or wanted to lay down in her bed. Random observations on 5/15/18 from 8:30 a.m. through 4:30 p.m. of resident 44 revealed: *From 8:30 a.m. to 10:00 a.m. she had been in her room sitting in her Broda w/c as observed above. *From 10:10 a.m. through 11:15 a.m. she continued to sit in her Broda chair as observed above but had been taken outside for an activity. *At 11:50 a.m.: -She continued to sit in her Broda w/c but had been brought back to her room. -CNAs A and B approached the surveyor to watch personal care on her and another resident. --They provided personal care for the other resident first. *At 12:30 p.m. CNAs A and B had prepared to assist the resident with personal care and toileting. -The resident was not in her room and had been taken down to the dining room for dinner. *At 12:35 p.m. she had been observed in the dining room eating her dinner. *At 1:30 p.m. CNAs A and B assisted the resident with laying down in her bed and personal care. -They positioned her onto her back, left the pressure relieving boots on, and elevated her feet off of the bed with a pillow. --She remained in that position from 1:30 p.m. until 4:30 p.m. *At 4:30 p.m. CNAs K and L assisted the resident to get out of the bed and into her Broda w/c. *From 8:30 a.m. through 4:30 p.m. she had been assisted with repositioning twice. Interview on 5/15/18 at 12:33 p.m. with CNA A regarding their policy for repositioning residents who required staff assistance stated: *We have an every two hour repositioning schedule to follow. *We didn't get to her this morning before she went outside and down to the dining room. Observation on 5/15/18 at 1:45 p.m. of resident 44's left heel with CNA B revealed: *There was a blackened area on her left heel. *The pressure injury was: -Located on the inner aspect of the left heel. -Approximately 2 centimeters (cm) in length and 1.5 cm wide. -Uncovered and opened to the air. Review of resident 44's medical record on 5/16/18 at 12:50 p.m. with the Minimum Data Set (MDS) assessment coordinator revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to: -Assist her with all of her mobility needs (transferring from place-to-place and moving in bed) and activities of daily living (ADL). -Implement any preventative interventions to ensure skin breakdown would not have occurred. *Her 4/5/18 admission nursing physical assessment identified no skin concerns to her left heel. *She had: -A Brief Interview Mental Status (BIMS) score of fourteen indicating she had good memory recall. -Been capable of making her needs known. -Been admitted with no opened wounds or pressure injuries to her left heel. *Her Braden Scale score on 4/15/18 had been a sixteen. --That score had indicated she was at mild risk for skin breakdown. *On 4/16/18: -A pressure relieving distribution mattress had been applied to her bed. -The staff were to have elevated and off-loaded her heels when in bed. *On 4/23/18: -The charge nurse had documented an area of concern to her left heel. -The left heel was pink and boggy. -The size, type, and stage of the pressure injury had not been documented. -There was no documentation to support the family and physician were notified. -That area of concern had been eighteen days after her admitted . *On 5/2/18: -The left heel wound measured 2 cm x(by) 3.5 cm, and the skin underneath of the pink area was light purple in color. -The staff had been directed to apply Hydrogaurd to the wound and relieve pressure using heel protectors and pillows. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. *On 5/4/18: -A weekly skin assessment had been completed by the charge nurse. -The wound had been dark purple in color. -No documentation to support: --The family or physician had been notified of the wound. --The type and stage of the pressure injury. *On 5/10/18 and 5/11/18: -The charge nurse had documented the wound was black in color, dry, and had no change in size. -The physician assessed the wound on 5/10/18 and had ordered Hydrogaurd to be applied to the left heel ulcer twice a day. --That order had not identified what type of ulcer the wound was nor the stage. *On 5/10/18 was the first documentation to support the physician had been notified of the wound to her left heel. -That was eighteen days after the area of concern to her left heel had been identified. Review of resident 44's 4/25/18 initial care plan summary revealed: *The summary had been completed by the MDS assessment coordinator and was reviewed with the resident's daughter on that date. *The summary had identified an area of concern to her left heel and it required close monitoring. *The staff were to have off-loaded her heels with pillows or use foam heel protectors. -No documentation in the medical record to support those heel protectors were initiated before 5/2/18. *The resident was using a pressure redistributing mattress. Review of resident 44's 4/16/18 comprehensive care plan revealed: *A focus area: Skin integrity: -That focus area was not developed until 4/25/18 and was two days after an area of concern had been identified to her left heel. *The goal for that focus area was: Skin integrity-maintain. *Interventions for that focus area: -Were the same as documented above by the charge nurses. -Supported the dates for initiation as documented above by the charge nurses. *The dietary department had not updated the care plan to reflect nutritional interventions were put in place to support and promote healing of the wound. Interview on 5/16/18 at 12:50 p.m. with the MDS assessment coordinator at the time of the medical record review for resident 44 revealed she had confirmed: *Preventative measures were not implemented in a timely manner to ensure an adverse event for the resident had not occurred. *The staff were reactive versus proactive in ensuring preventative measures were in place, so that a pressure injury had not occurred during the resident's care in the facility. *The staff should have included the resident's health condition upon admission when utilizing the Braden Score assessment to determine the risk level of skin breakdown. *The resident had been at risk for skin breakdown and should have been repositioned every two hours. *We have been trying to keep her life as real as we can. *I never thought about off-loading while sitting in a Broda w/c. *Yes, the Braden Score is a good resource, but we should really be reviewing the resident as a whole. *Yes, the residents do have the right to not acquire a wound or have a wound worsen while under our care. *I can't say I agree that her wound worsened. I believe a wound has to evolve to see what it really is first and her wound was never open. *The charge nurse had been responsible to notify the physician, family, and dietician upon the identification of a wound. *The dietary department should have updated their care plan to support their involvement with the wound healing process. Interview on 5/16/18 at 3:40 p.m. with the director of nursing and administrator regarding resident 44 confirmed and supported the interview above with the MDS assessment coordinator. Review of the provider's (MONTH) (YEAR) Pressure Ulcer Prevention and Wound Treatment policy revealed: *Purpose: To improve resident safety by identifying individuals at risk for healthcare-acquired pressure ulcers to: -Systematically assess and document skin risk factors. -Implement skin-protection components of care. -Provide appropriate treatment when indicated. *Policy: -Interventions were to be implemented based on the Braden Scale Score assessment. -At Risk: Braden Scale Score: 15 to 18 - weekly head-to-toe skin inspection by licensed nurse. -Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition, and hydration, and minimizing pressure. -When a pressure ulcer or wound is discovered, whether upon admission or thereafter, the licensed nurse on duty is responsible for notifying the physician, the resident's family, the Clinical Care Coordinator, Assistant Director of Nursing, and dietician. *Assessment and Documentation: -Documentation should include: location, stage, size, undermining/tunneling, wound bed tissue type. *Treatment: A physician order [REDACTED].

Based on observation, interview, and policy review, the provider failed to ensure infection control practices and protocols were followed when providing: *Personal care for two of seven sampled residents (44 and 52) by two of two certified nursing assistants (CNA) (A and B). *Foley catheter care for one of one sampled resident (4) by one of one CNA (A). Findings include: 1. Observation on 5/15/18 at 11:48 a.m. of CNAs A and B during personal care for resident 52 revealed: *He had been laying in his bed and was ready to get up for dinner. *They had sanitized their hands and put on a clean pair of gloves. *With those gloves on they had: -Pushed a mechanical transfer lift over to his bed. -Adjusted his covers and clothes to expose his upper and lower body. -Removed his soiled incontinent brief. *CNA B had: -Assisted the resident to lay on his right side. -Retrieved and opened a package of wet wipes. -Taken several wet wipes out of the package and cleansed his bottom with them. --He had been incontinent with a small amount of bowel movement. -Not removed her soiled gloves and washed/sanitized her hands after performing perineal care for the resident. *CNA A had: -Opened the top drawer of his bedside stand and removed a tube of barrier cream and bottle of powder. -Taken a small amount of barrier cream from the tube and applied it to his bottom. -Opened the bottle of powder and sprinkled some on his bottom over the barrier cream. -Removed her gloves and without washing/sanitizing her hands put on a clean pair of gloves. *With those gloves on they had: -Put a clean incontinent brief on the resident. -Placed a sling underneath of him, pulled the mechanical lift closer to the bed, and attached it to the sling. *They both had assisted the resident out of his bed and into his wheelchair with use of the mechanical lift. *At that time they both removed their soiled gloves and washed their hands. 2. Observation on 5/15/18 at 1:30 p.m. of CNAs A and B during personal care for resident 44 revealed: *The resident had been sitting in a Broda w/c and was ready to lay down on her bed. *They had washed their hands and put on a clean pair of gloves. *With those gloves on they had: -Used a mechanical lift to transfer her from the w/c onto the bed. -Pulled down her pants and removed her soiled incontinent brief. *With those same gloves CNA A had: -Opened the top drawer on the bedside table. -Retrieved a package of wet wipes, a tube of barrier cream, and a package of skin prep swabs. *CNA B had: -Retrieved several wet wipes from the package and cleaned the resident's bottom. -Opened the tube of barrier cream and applied some to her bottom. *CNA A had: -Retrieved several wet wipes from the package and cleaned her perineal area. -Changed her gloves without sanitizing/washing her hands. *They had removed a pressure relieving boot and sock from the resident's left foot. -That pressure relieving boot had been sitting on a soiled footrest attached to the w/c. -There had been a black colored area on the resident's left heel. *With the same gloves that CNA B had used to: -Handle/move a mechanical lift and w/c. -Transfer a resident into her bed. -Remove clothes and an incontinent brief. -Clean the bottom of a resident. -Remove a pressure relieving boot and sock from a foot. *CNA B had proceeded to: -Open the package containing skin prep swabs. -Get a skin prep swab from that package. -Wipe the skin prep over the wound on the resident's left foot. -Put the resident's sock and pressure relieving boot back on. *They finished positioning the resident in her bed. *At that time they both removed their soiled gloves and washed their hands. 3. Observation on 5/16/18 at 8:00 a.m. of CNA A during Foley catheter care for resident 4 revealed: *The resident had: -Been laying in his bed. -A Foley catheter in place with a collection bag attached to it, and it was hanging from the bedframe. *The CNA washed her hands and put on a clean pair of gloves. *With those gloves on CNA A had touched multiple unclean surfaces prior to the catheter care. *Those surfaces had been: -A plastic basin containing a Foley catheter leg bag. -A package of wet wipes, a bottle of perineal cleansing spray, and several packages of alcohol wipes. -A clothes hanger with a shirt on it. --She showed it to the resident to ensure it was the shirt he had picked out to wear for the day. -The bed covers to expose the catheter and perineal area. *With those soiled gloves on CNA A: -Detached the Foley collection bag from the catheter tubing and attached the Foley catheter leg bag to it. -Retrieved several wet wipes and cleaned the front perineal area and Foley catheter insertion site. -Cleaned the catheter tubing in an upward and downward motion. *The CNA removed her gloves, washed her hands, and assisted the resident to get dressed for the day. Interview on 5/16/18 at 8:29 a.m. with CNA A regarding the above observations revealed she: *Had not recognized the processes above as unsanitary until being reviewed with the surveyor. *Agreed the processes above could have created the potential for cross-contamination of germs to the resident. *Had not recognized the outside surfaces of all the items touched above would have been considered unclean. *Confirmed her hands should have have been washed/sanitized between glove change. *Could not remember the last time the staff had been trained on proper protocols and processes for personal and Foley catheter care. 4. Interview on 5/16/18 at 3:40 p.m. with the director of nursing and administrator confirmed: *The above observations had not been completed in a sanitary manner. *There was the potential for cross-contamination of germs to have been transmitted to those residents. *Hands should have been washed/sanitized between glove change. *With those processes used above the residents had been at risk for facility acquired infections. Review of the provider's (MONTH) (YEAR) Hand Hygiene policy revealed: *Hand hygiene was the single most important procedure for the control of infection. It was a critical component of patient and employee safety. *Policy: -Wash hands with system approved soap and water when hands are visibly soiled with blood or other body fluid. -Hand hygiene with Alcohol Hand Rub (antisepsis) after contact with inanimate objects in the immediate vicinity of the patient (resident) and after glove removal. Review of the provider's 2007 Catheter Care policy revealed: *Purpose: To prevent infections. *Procedure: Wash the catheter from the meatus down the tube about three inches.

Based on observation, interview, resident record review, care plan review, floor assignment form review, and policy review, the provider failed to balance resident determined choice and resident safety to ensure one of one sampled resident (1) who had jumped from his third floor window had appropriate: *Safety measures in place to prevent his elopement. *Social services consultation. Findings include: 1. Review of the reporting form sent by social service designee (SSD) F on [DATE] at 9:00 a.m.to the South Dakota Department of Health Complaint and Reporting coordinator's attention regarding resident 1 revealed: "At approximately 20:30 (8:30 p.m.) on [DATE] (name of resident 1) was found out on the grass yelling for help. He had slit the window screen in his room and jumped out the window. 911 was called; police and guardian. (resident's name) was taken by ambulance to the ER (emergency room ). ( Facility name ) rec'd a call from our hospital that (resident's name) had passed away. DSS is (resident)'s guardian." Observation on [DATE] at 4:00 p.m. of resident 1's room on the third floor revealed: *The door had been closed, and no one was to enter until further notice per a posted sign. *The double window took up much of the exterior wall of the room. -The locking mechanism of the window was broke. -The window screen was torn away on the right side with varied jagged-like edges, and appeared like it had been cut. It was approximately 18 inches in length and almost the whole length of the screen. -There was an empty screw hole in the window sill approximately 4 to 6 inches from the slide of the window. -On the window sill there were two stacks of magazines, two half and half creamers, half a ham sandwich, LED star light, angel globe, phone directory open to the City, County, State, and U.S. Government offices page, and an ink pen. *There was a wall register in front of the window. -The register was still puttingout heat. -On top of the register there was a stack of mail, box of tissues, and the TV controller. -Toward the bottom of the register there was what appeared to be a filter running the length of the register with a blue sponge like material on each side with an approximate one and one-half inch nail through it. *There was a nightstand with assorted items to the right of the window as well as a tray table and walker. *There was a folding chair positioned between the night stand and the window sill. *There was a large recliner to the left of the window. *There was a pink straight-edge disposable razor and a large silver nail clipper lying on top of the dresser. Interview on [DATE] at 4:15 p.m. with the director of nurses (DON) regarding resident 1 revealed: *She was unaware how the window screen had been cut. *She understood the certified nurse assistant (CNA) and registered nurse (RN) working on second floor had heard someone calling for help. Their search had led them to discover the resident outdoors lying on the ground. *The resident was not identified as an elopement risk when he had been admitted on [DATE]; he had been wheelchair bound following surgery for [REDACTED]. *Once he became mobile and able to be up walking around, he made it clear to everyone he did not want to be in the building "He wanted out." Review of the floor assignment form for [DATE] revealed RN A, RN B, CNA C, CNA D, and CNA I had worked with resident 1 that evening. Interview on [DATE] at 4:45 p.m. with RN A regarding resident 1 revealed: *She worked on all the floors as the facility needed her to, so she did not work on third floor everytime she was scheduled. *He had never been aggressive or violent toward her, but she had heard he could be aggressive. She recalled she had heard he had struck out and hit a CNA. *On the evening of [DATE] she had brought in her puppy, that he had enjoyed. -He was in a good mood when she returned from taking the puppy home. -He had indicated he had talked to a lawyer, and they would not take him. -He talked like usual that he was "in jail here." -He had asked for his medications early around 7:30 p.m. *Later after 8:00 p.m. on the evening of [DATE] she heard RN B "on the walkie" telling her to come outside near the "old exit door." *When she arrived outside she saw RN B and CNA C with him. -He was lying on the ground a "good distance" from the window. -His brace was still on his right foot, there was blood above it when we pulled up his pant leg. -He had a bag of clothes near him. The other bag was below the window. -We called 911, the DON, and tried to get his guardian. -Received orders to send him to the emergency room (ER). *After resident 1 left by ambulance she took the police officer up to his room to look at everything. His billfold was lying on the window sill. *They were notified later that night he had died in the ER. Interview on [DATE] at 5:05 p.m. with licensed practical nurse (LPN) E regarding resident 1 revealed: *She was a traveling nurse who had been coming to the facility for a few months and was familiar with him. *She knew he had memory problems "He had no recall ten minutes later after discussion about something." *In the period of time she had been assigned to third floor and providing care to him she had only been able to complete two skin assessments on him. "He would tell you later, forget and then not allow me to assess him." *She identified him as "a person who loved dogs and enjoyed talking about them." "He was a prayful person and asked the priest to visit when he wasn't able to go to chapel." *She felt he "didn't fit in here, he missed his dog, he felt he was in a cage here, and just wanted to go home." *He had asked for help finding a lawyer, she had given him the yellow pages, and had written down a number for him. She had been told not to assist him with his request to find a lawyer. *His activity participation or involvement "was up to his guardian." *She was aware there was a screw placed in his window, so it could not be opened wide. *He was very mobile, and able to get around well with his walker. In a continued phone interview on [DATE] at 11:30 a.m. with LPN E about a phone call from resident 1's guardian on [DATE] she revealed: *Guardian K had called and stated he was not to leave the third floor. *He had told her he would rather be in jail, and he did not belong here. *She had felt he was scheming to leave the facility. *She was told by Guardian K he was not allowed off the third floor and was not allowed to have visitors. *No one had thought he would ever go out the window. Interview on [DATE] at 5:30 p.m. with CNA D regarding resident 1 revealed: *At times he was "crabby and would yell at people." He "did not want to be here. Everybody knew it." *They (her and other staff) were supposed to play games with him or give him magazines to look at. She knew he did "play cards sometimes." *He sat in a chair in the lounge a lot. "Watched TV." *On the evening of [DATE], she recalled, "it was strange, he went to bed early." "He usually went to bed at 10:00 p.m. or later." *When she responded to the call from second floor they had found him outside, he was on the ground. -He was trying to get up, he "was part sitting up and part laying down." -He had a bag beside him, his glasses were found in the grass away from him. There was another bag under the window. Review of resident 1's [DATE] Elopement Risk Assessment revealed: *He had cognitive (mental/memory, judgment and reasoning processes) impairment with poor decision making skills. *He had possible schizophrenia (mental disorder often characterized by abnormal social behavior), with a history of alcoholism. *He was independently mobile in a wheelchair. *He did not want to be in the facility and wanted to go home. *No new behaviors identified. *All family members were concerned he would leave the facility. *He had a history of [REDACTED]. *He had a Wanderguard (an alarm device that sounded when he came close to an exit door) placed on his wheelchair. Review of resident 1's [DATE] care plan standard of care and additional interventions revealed: *"Problem:...is classified as a vulnerable adult and has a court appointed guardian. He has instructions to remain at (facility name initials) and participate in skilled therapy until his ankle is fully healed, but he has limited judgement and limited understanding of his need to reside in the facility until his ankle is fully healed and a strong desire to go home." *"Goal:...will remain safely in the facility until right ankle is healed." *"Approaches: (1) ... has a room on third floor with a Wanderguard on his walker. (2) ... is to remain on 3rd floor for meals and activities until Tuesday February 3rd 2015. (3) On February 3rd 2015 he can resume meals and activities off third floor with staff supervision. (4) Monitor his whereabouts with all opportunities." Review of resident 1's [DATE] Elopement Risk Assessment revealed: *He was now ambulating (walking) independently. *He had a history of [REDACTED]. *He had expressed a desire to go home, had packed his belongings, and had stayed near exits. He had wanted to leave, wanted to "get out of here" constantly. *Staff were concerned about him leaving without anyone realizing he was gone. *"Incident yesterday [DATE] where he went out the back door of (restaurant name) while using the bathroom, was there accompanied by (a social worker from an outside agency) who were there supervising him; police was contacted, he was found inside a bank within walking distance of restaurant name), and they returned to the (facility name); (facility name) staff were asked by his guardian to come out and talk him into returning to facility; he eventually did, and (facility name) adjusted the plan of care to keeping him on 3rd floor through the next 7 days because of his very high elopement risk." Review of resident 1's care plan standard of care and additional interventions revealed: *On [DATE] "He can go down to meals and or activities if staff is available to stay with him at all times. If staff has to leave the area he is in and another staff cannot take over (resident's name) will need to return to 3rd floor. If (resident 1's name) makes any comments about leaving or gives the staff a difficult time about going back up to 3rd floor it may affect later opportunities he may have to go downstairs. His legal guardian states our staff can't give any information to anyone regarding (resident 1's name). This includes family, friends, or attorneys." *On [DATE] "he must stay on the floor at all times-(initials)." Review of resident 1's [DATE] Elopement Risk Assessment revealed: *He had cognitive impairment with poor decision making skills. *He had schizophrenia and was a vulnerable adult. *He was ambulating independently. *He had continued to express a desire to go home, packed his belongings, and stayed near exit doors. *There were no new behaviors identified. *Guardian K had expressed elopement concerns. *He was at risk for elopement. *He was to remain on third floor per guardian K's request. Interview on [DATE] at 8:25 a.m. with maintenance man G about resident 1 revealed: *Approximately two to three weeks ago social service designee (SSD) F had asked him to place a screw in the window to prevent the window from being opened no more than a small distance. *The screw was a Phillips head screw, he used a drill to put it in, and indicated it had been sticking up approximately a quarter of an inch. Interview and observation on [DATE] at 8:40 a.m. with SSD F about resident 1 revealed: *She had wanted him to be safe, and they had used a screw before in a window. She was not aware of the facility Safety policy indicating the modification of windows on third floor. *She had not provided instruction to staff about the screw placed in the window frame. *He had been secluded to the third floor after his return to the facility following an incident on [DATE] where he had eloped outside, had become agitated, and had hit staff. He was taken to jail. They were instructed (by whom, not sure) they had to take him back. *He had made it very clear with staff he wanted to leave the facility. *There had been no consistent resident safety checks on him. He had been checked by staff at meal times and during medication administration times. *She agreed he had been a high risk for elopement. *She had not shared her concerns with the social service consultant during weekly meetings or away from the meeting. *She had retrieved the screw that had been placed in the window. It had been found lying in the window tract. She produced the screw; it measured one and one quarter inch in length. Interview on [DATE] at 9:35 a.m. with clinical care coordinator H about resident 1 and the Elopement Risk Assessment used by the provider revealed: *When he had first been admitted guardian K had visited frequently, then it had tapered off, and guardian K would keep in contact by phone. *She agreed it had been very important for him to see his dog. Someone from social services had brought his dog in four times in December, three times in January, and one time in February. *She acknowledged and agreed there was nothing to create a score or to quantify with a number or definition and identify who was at risk or not at risk for elopement. The summary allowed for a comment by the assessor. She stated "It is less than a desirable system." Review of facility policy and procedure ,[DATE] Safety, section I Safety Precaution Practices, sub section C Facility, number 5 with an effective date of [DATE] and a review/revised date of ,[DATE] revealed: For safety of residents on third floor, windows have been modified so they will only open a small distance. Interview and observation on [DATE] at 10:00 a.m. with CNA C about resident 1 revealed: *She had been a CNA for twenty years, and she had never experienced such an event as what she had witnessed on [DATE]. *She had worked on second floor that evening. *Sometime after 8:00 p.m. RN B had asked her if she heard anyone calling for help. She checked the residents on second floor, and no one needed any help. *She could hear someone yelling, she opened the door onto the deck, and it was louder. It was very dark, so she grabbed a flashlight. She and the nurse went down and outside. *He was yelling "get me outta here, get me outta here." *He was sitting at a 45 degree angle kind of slumped with his feet facing toward the street. *We called on the walkie-talkie to the third floor. *He said he jumped out the window; he was going home. *He had a bag with him. She took the jeans out and rolled them up and put them under his head. *We called 911, and when the ambulance came they parked on the street until the police directed the driver into the yard. *We found another bag under the window, and his glasses were in the grass between the building and the tree. *When the area was observed with CNA C, the area was on the west side of the facility in a grassy area where the two sidewalks come together and was several yards from the window and the building. Observation on [DATE] from 10:30 a.m. through 10:50 a.m. of the windows in residents' rooms with exception of room 305 and windows in the staff charting area and resident dining area revealed there were screw holes in multiple windows with no screws in them. There were multiple windows with no evidence of a screw hole. The large window at the end of the hall that was over a roof had a Phillips head screw in the window with approximately 1 inch of it exposed. It was positioned approximately 4 to 5 inches from the slider. Interview on [DATE] at 11:00 a.m. with CNA I about resident 1 revealed: *She had been a CNA for eighteen years. She had worked a short shift on third floor 6:00 p.m. through 10:00 p.m. on [DATE]. *She stated "In hindsight there was something different about him that night." *Some time around "7:00ish" he had asked for a Band-Aid; he had cut his finger. She had not been able to get a Band-Aid for him; and had not ask what he had cut his finger on. *He usually went to bed after 9:30 p.m.; that night he went to bed after he had his medications. *She had been providing care to other residents, so "it was all over by the time I was done." Interview on [DATE] at 11:10 a.m. with guardian K about resident 1 revealed: *She had gotten an impression on [DATE] he was up to something and had called back and communicated that to staff. She asked they not allow him to attend Mass that evening, to keep him on third floor. *She reported his dog had been brought in for visits, but not daily. *He had communicated from the beginning of his stay he did not want to be there. He had been scheduled for a re-evaluation and alternate placement was being reviewed. Interview on [DATE] at 11:25 a.m. with business office person K confirmed there had been communication from the nurse to her on [DATE] to notify the DON and administrator about the concerns conveyed by guardian K. Interview on [DATE] at 1:00 p.m. with the DON about resident 1 and the events of [DATE] revealed: *She had been called; she had contacted the administrator, the SSD, and another member. *She had come in to talk with staff and had checked to see how they were handling the after effects of the situation. She made contact by phone of the staff that had already left that shift. *She thought it was around 10:45 p.m. when she had come in. The SSD came in on the next day to talk to staff and start the investigation. *She had never had this kind of situation to investigate. *RN A and RN B had added some additional notes that were recorded as late entries. *When asked if she had gone into resident 1's room since he had eloped out the window or looked at the outdoor area where he was found on [DATE], she replied "No."

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) who had eloped through his third story window in his room, was found outside the facility lying on the ground, was taken to the hospital by ambulance, and later died from his injuries had the appropriate: *Safety measures in place to prevent the elopement. *Monitoring of his anti-psychotic medication. *Social services consultation. Findings include: 1. Review of resident 1's medical record revealed he had: *Been admitted on [DATE] and was sixty-six years old. *A [MEDICAL CONDITION] on [DATE]. *A long standing history of alcoholism and (a phychiatric disorder that can take a person away from reality at times) lived alone with his dog. *Depression, anxiety, [MEDICAL CONDITION], dementia, cognitive (memory) disorder, heart failure, hypertension (high blood pressure), [DIAGNOSES REDACTED] (an enlarged heart). *Been prescribed the anti-psychotic medication (med) [MEDICATION NAME] 80 milligrams (MG) daily, and was admitted with that med. *Fallen at home and fractured his right ankle. *Jumped from the third story window of his room to the ground below on [DATE], was taken to the emergency room , and died on [DATE]. Observation on [DATE] at 4:00 p.m. of resident 1's room on third floor revealed: *There was a large cut in the window screen, approximately one and one-half feet in length and almost the whole length of the window on the right side of the screen. *There was an ink pen lying on the window sill. *There were a large silver nail clippers and a pink straight-edge razor lying on the top of his dresser. *There were two nails approximately one and one-half inches long that were placed in a blue material by the heating and cooling register. *The black mechanism to lock the window was broken. Interview on [DATE] at 4:15 p.m. with the director of nursing (DON) regarding resident 1 revealed: *She stated she was unsure as to how the screen had been cut. *A certified nursing assistant (CNA) working on the second floor that evening had heard a cry for "Help", the CNA then notified the nurse on the second floor. The CNA and the nurse both verified they had heard a cry for "Help." They both went outside and discovered resident 1 lying on the ground. *When the resident was wheelchair bound after his surgery to fix his right ankle fracture he had not tried to leave the facility. *After he had become mobile and walking around that was when the resident had attempted to leave and made it clear to staff "He wanted out." Interview per telephone on [DATE] at 6:30 p.m. with registered nurse (RN) B regarding resident 1 revealed: *She only worked part-time as an RN. She usually worked four hours a week. *On [DATE] she was working the 6:00 p.m. to 10:00 p.m. shift on second floor. *She heard yelling for help as she was setting at the nurses station at approximately 8:00 p.m. or maybe a little later. She thought she was hearing things, so she went to get CNA C to confirm the yelling for help. *She and CNA C went outside and found resident 1 lying on the ground. His legs were in front of him, his arms were underneath him, and he was half-way setting up. He was talking and alert. *RN B asked the resident what he had been doing, and the resident stated "I am leaving, no one would let me leave." *The resident told her he had jumped from his window. *She was aware the resident's window had been screwed shut to prevent the resident from opening the window. That information had been discussed in nursing report. Staff were concerned about him opening the window. *Resident 1 always wanted to leave and go home. He had a plastic bag full of his clothes and an envelope of money with him when she and CNA C found him lying outside. *She had been contacted by the DON earlier in the week to come to the facility and thoroughly document the incident on [DATE]. She had completed that documentation on [DATE]. Interview on [DATE] at 8:25 a.m. with maintenance man G regarding the window in resident 1's room revealed: *He had been asked by social service designee F to place the screw in the window to prevent the window from being opened approximately two or three weeks ago. *The screw was a one inch screw with a Phillips head, and he had placed it directly into the metal window frame. The screw was missing after resident 1 had jumped out the window on [DATE]. He thought the screw had been sticking out approximately a quarter of an inch. Interview on [DATE] at 8:40 a.m. with social service designee F regarding resident 1 revealed: *She wanted the resident to be safe. *She had not instructed the staff about the screw placed in the metal frame of his window. *He had been secluded to the third floor after the [DATE] incident where he had eloped outside, had become agitated, and had hit staff. He was then taken to jail. *She stated the staff were instructed they had to take resident 1 back after he had gone to jail on [DATE]. *She had not contacted social service consultant L in regards to her concerns. *She had retrieved the screw that had been placed in his window. The screw had been found lying in the window sill in the window tract after he had jumped out the window on [DATE]. *Resident 1 wanted to leave the facility; he had made that very clear to staff. *There had been no consistent resident safety checks on resident 1. He had been checked by staff at meal times and during medication administration. *She agreed he had been a high risk for elopement. Review of an e-mail on [DATE] at 1741 (5:41 p.m.) regarding resident 1 revealed "When this nurse reported for duty, resident had been to Lutheran services then to activities. He requested pain med for leg and refused to go to 3rd floor. [MEDICATION NAME] (pain med) was given to him @ (at) 1630 (4:30 p.m.) for lower, leg pain. He had gone to Mass then was escorted to supper. One on one watch at all times while off 3rd floor. The plan is that after he returns to 3rd floor he will not be allowed to go to meals or activities off 3rd floor until he is evaluated on Tuesday ,[DATE]. The window to his room has been adjusted so that it may only be opened a short distance." Review of resident 1's [DATE] Elopement Risk Assessment revealed: *He was cognitively impaired with poor decision making skills. *He had possible [MEDICAL CONDITION] with a history of alcoholism. *He could independently get around in his wheelchair. *He did not want to be at the facility and wanted to go home. *No new behaviors were noted. *All family members were concerned he would leave the facility. *He had a history of [REDACTED]. *He had a Wanderguard (an alarm system that would sound when he came close to an exit door) on his wheelchair. Review of resident 1's [DATE] Elopement Risk Assessment revealed: *He was now ambulating independently. *He had a history of [REDACTED]. *He had expressed a desire to leave and go home, had packed his belongs, and had stayed near exits. He had wanted to "get out of here" constantly. *Staff were very concerned about his leaving without anyone realizing he was gone. *"Incident yesterday [DATE] where he went out the back door of (name of the restaurant) while using the bathroom, was there accompanied by (a social worker from an outside agency) who were there supervising him; police was contacted, he was found inside a bank within walking distance of the (restaurant name), and they returned to the (facility name); (facility name) staff were asked by his guardian to come out and talk him into returning to facility; he eventually did, and (facility name) adjusted the plan of care to keeping his on 3rd floor through the next 7 days because of his very high elopement risk." Review of resident 1's [DATE] (one day before he eloped and jumped from the third story window) Elopement Risk Assessment revealed: *He was cognitively impaired with poor decision making skills. *He had [MEDICAL CONDITION] and was a vulnerable adult. *He was ambulating independently. *He had continued to express a desire to go home, had packed his belongs and stayed by exit doors. *There were no new behaviors were noted. *His guardian K had expressed elopement concerns. *He was at risk for elopement. *He was to remain on third floor per guardian K's request. Review of resident 1's [DATE] Mood and Behavior sheet typed in all capital letters revealed "RESIDENT STATES HE DOES NOT KNOW WHY HE WAS PUT HERE, HE DOES NOT BELONG IN A NURSING HOME, HE DOES NOT LIKE TO BE ASKED QUESTIONS, HE DOES LIKE PEOPLE TELLING HIM WHAT TO DO. YELLING AND UPSET". *The intervention was to "leave" the resident safe. Review of resident 1's [DATE] Mood and Behavior sheet revealed "saying he does not want to be here refusing to eat, he said he is not hungry when he is this lonely." *The interventions were: -One on one staff. -Give food. -Give fluids. -Back rub. -Leave resident safe. -Come back later. Review of resident 1's [DATE] Mood and Behavior sheet revealed "I will do whatever it takes to get out of here, and I will hurt someone to get out of here, I am going to kill myself." He stated to social worker (F) "If I had aids and contaminated people would I be able to leave? If I smoke in my room will you kick me out of if I drink in my room will you kick me out?" The resident followed the nurse to several rooms while this nurse was giving pills and kept saying over and over how he hates it here and he is treated like a prisoner and wants to be able to leave. This nurse told him that is something he needs to take up with his guardian (name of the guardian) and (name of the counseling service)." *There were no interventions documented. Review of resident 1's [DATE] Mood and Behavior sheet revealed: *"While giving (resident's name) his morning medications (resident name) stated, "I am sad about being here, I need to get out, I would rather be in jail. I am going to get a power of attorney so I can get out of here". He was also asking what he could do to get kicked out of the facility. *The interventions were one on one, give fluids, TV, and come back later. Review of an e-mail from social services from a call from the provider's DON on [DATE] at 8:28 a.m. but documented as a late entry for, [DATE] revealed: *The DON kept reiterating that (name of the resident 1) did not want to be at (name of the facility). *The DON had felt the provider could not meet his need because the unit was not secure. *"(DON name) stated she was not comfortable with this situation, and I (social service person) suggested they may need to make adjustments to make sure (name of the resident) remained safe and somewhat content while he was there, like having the activities director come up to see him since he couldn't leave the floor." Interview on [DATE] at 9:15 a.m. with clinical care coordinator H regarding resident 1 revealed: *His guardian was the Department of Social Services. *When he had first been admitted guardian K visited frequently, but then the visits had tapered off. Guardian K would keep in contact by phone. *She agreed it was very important for resident 1 to see his dog. Social services had brought his dog out four times in December, three times in January, and one time in February. *He had been admitted on anti-psychotic med [MEDICATION NAME]. Signs and symptoms of adverse reactions were to have been monitored by the nursing staff weekly. She agreed the weekly monitoring had not been consistent. He had been on [MEDICATION NAME] prior to the [MEDICATION NAME], and she had been unsure why it had been discontinued. She was unsure has to when the [MEDICATION NAME] 80 mg had been started or what dose he had been started at when the medication was first ordered by the physician. Review of information from www.drugs.com/[MEDICATION NAME] revealed: *It was an anti-psychotic med. *The medication should have been taken with at least 350 calories of food. *The side effects were: -Agitation. -Hostility. -Confusion. -Thoughts about hurting yourself. -Feeling restless. Interview per telephone on [DATE] at 2:00 p.m. with social service consultant X regarding resident 1 revealed: *She was aware of resident 1 because of his hospitalization for his fractured ankle. *He had been falling at home, and it was felt that he needed extra assistance. *He was adamant about going home. He had been refusing to go to a long term care facility for further assistance after his surgery. *He had been taken to another long term care facility for admission, but when he had gotten to the facility there were no physician's orders and they had refused to take him. He then was returned to his home town, admitted to the hospital under observation status, and was admitted to the current provider for care. *She met weekly with social service designee F. *Social service designee F had never mentioned any concerns regarding resident 1. Interview per telephone on [DATE] at 11:00 a.m. with social service guardian K regarding resident 1 revealed: *He had made a comment on [DATE] at 1:30 p.m. during their conversation he was thinking of doing something. *Restrictions had been put in place to confine him to the third floor, because he was an elopement risk. He wanted to go home. *She had spoken to the charge nurse that evening to convey the above information regarding resident 1. Interview per telephone on [DATE] at 11:30 a.m. with licensed practical nurse E regarding the phone call from resident 1's guardian K above revealed: *Guardian K had called and stated he was not to leave the third floor. *He had told her he would rather be in jail, and he did not belong here. *She felt he was scheming to leave the facility. *No one thought he would ever go out the window. *She was told by the guardian he was not allowed off the third floor, and was not allowed to have visitors. Review of resident 1's social service documentation from his guardianship revealed on [DATE] at 1:30 p.m. "During conversation (resident's name) did mention he was "thinking of doing something." But he would not tell what that plan was. He had mentioned earlier he would leave the facility. Review of resident 1's Phych Medication Tracking (would track any adverse reactions or side effects of the medication [MEDICATION NAME]) documentation from [DATE] through [DATE] revealed: *There was no documentation on [DATE]. There was documentation on [DATE]. *There was no documentation from [DATE] through [DATE]. *There was no documentation from [DATE] through [DATE]. Review of resident 1's [DATE] comprehensive care plan revealed: *He was an elopement risk. *He was on resident safety checks. *On [DATE] "He can go down to meals and or activities if staff is available to stay with him at all times. If staff has to leave the area he is in and another staff cannot take over (resident's name) will need to return to 3rd floor. If (resident's name) makes comments about leaving or gives the staff a difficult time about going back up to 3rd floor it may affect later opportunities he may have to go downstairs." *On [DATE] Problem: "(residents name) is classified as a vulnerable adult and has a court appointed guardian. He has instructions to remain at (facility name) and participate in skilled therapy until his ankle is fully healed, but he has limited judgement, and limited understanding of his need to reside in the facility until his ankle is fully healed, and a strong desire to go home." *The Goal: " (resident's name) will remain safely in the facility until right ankle is healed." *Approaches: "(resident's name) has a room on third floor with a Wandergard on his walker. (resident's name) is to remain on the 3rd floor for meals and activities until Tuesday, February 3, 2015. On February 3, 2015 he can resume meals and activities off third floor with staff supervision. Monitor his whereabouts with all opportunities." *On [DATE] "he must stay on the floor at all times." Review of resident 1's [DATE] Minimum Data Set (MDS) assessment revealed: *He scored a fifteen with cognition (memory) which meant he was alert and orientated to person, place, and time. *He had no physical or verbal behaviors . *He had no wandering tendencies *It was very important to him to be around his pet. *It was very important to him to participate in religious services or practices. Review of resident 1's [DATE] MDS revealed: *He was cognitive (memory) impaired. He had a score of ten out of fifteen. *He was feeling down, depressed, and hopeless. *He was not classified as a wandering resident. *He was independent with locomotion on the unit with supervision. *He required supervision off the unit. *He had not had any signs of [MEDICAL CONDITION] (very abnormal behaviors such as hallucinations). *He had some physical and verbal behaviors noted. Review of his ,[DATE] Care Area Assessment revealed: *His BIMS (brief interview for memory status) was 10. A score of 15 would mean orientated to person, place, and time. *He had gone to jail due to hitting a staff person after trying to leave the building. *He was always verbalizing his desire to leave. *He was not feeling bad about himself, but he just wanted to leave the nursing home. Review of resident 1's nursing notes from [DATE] through [DATE] revealed: *On [DATE] at 1442 (2:42 p.m.) "Call from (guardians name), asked us not to allow (resident's name) to attend Mass this eve. (evening) at 4:00 p.m. After thinking about her visit with him earlier today, she feels he is scheming. Relayed this to eve. nurse, and asked (name of office person) in office to give the message to the DON." *On [DATE] at 1753 (5:53 p.m.) "(resident's name) is requesting someone to help him fill out application for (name of legal service) as he wants an attorney to help him to regain his own guardianship so he can leave (the name of the facility)." *On [DATE] at 1054 (10:54 a.m.) No problems were noted. *There was no documentation until [DATE] at 2202 (10:02 p.m.) "At approximately 20:30 (8:30 p.m.) as I was charting in the 2nd floor nurses station, and I heard someone yelling, "help me." After looking on our floor and not finding anyone awake and hollering I sat back down, I then heard "help me." At the time (certified nursing assistant's name) open the screened porch door where I saw resident laying in the grass yelling "help me." At that time I called for third floor nurse to meet me outside. Upon assessment (nurse's name) call 911 and the DON." *Then there were late entries made after the resident's death as follows: -On [DATE] (four days after his death) "On Friday Feb. (February) 13 at 1930 (7:30 p.m.) resident caught me and asked me for his medication. He stated he wanted to go to bed early. At 2030 (8:30 p.m.) 2nd floor nurse calls and says that resident is outside. Ran to front door and outside and did not see staff or resident. 2nd floor nurse calls me to lawn at the lower west side of the building. Note that resident is lying on the ground. He is talking. He said he thinks he broke his leg. We tell him to be still and that we are going to call the ambulance. Area was dark and not able to see what or how he was injured. Called 911 at 2048 (8:48 p.m.). Notified DON at 2050 (8:50 p.m.) Police here and he lifted resident's pant leg and bleeding noted to leg that he had previously injured. Police wanted to see resident's room. Took him to room ____ and noted the window to the outside was open and the screen had been torn. Noted that resident may have pulled himself to the area on lawn from below his window to area close to the old patio exit door that is now boarded up. Resident then taken to the ER (emergency room ) via ambulance. Sent contact info (information) and order with ambulance crew. ER had contacted us about code status. Was able to tell them that he was a full code. (Name) spiritual care stopped by to let us know that this resident had passed away prior to 2300 (11:00 p.m.) in the ER." Review of the provider's [DATE] Elopement (Patient/Resident) policy revealed: *The purpose was to prevent patient/resident injury due to elopement, and to report/investigate all incidents of missing patients/residents. *It was the responsibility of all personnel to prevent patient/resident elopement. Review of the provider's [DATE] Psychopharmacological Medications policy revealed: *The purpose of the policy was to promote quality of life and optimization of functional abilities for residents who demonstrated mood and behavior disturbances. *When antipsychotic medications were being used to treat enduring conditions, targeted behaviors must be clearly documented before increasing or implementing new medications. Monitoring must ensure behavioral symptoms were not due to medical conditions, or problems, environmental stressors, or psychological stressors that could be addressed or resolved without medication adjustments. *There must be documentation in the medical record demonstrating the condition persisted and that other approaches had been attempted and failed to adequately address the symptoms. Direct care staff would document effectiveness of the medication and any noted adverse effects using the Psych Medication Tracking intervention with Meditech. Review of the provider's undated Social Service Designee job description revealed: *The full time position provided social work services to the residents in order to meet the resident's psychosocial needs. *The position was to provide crisis interventions, and provide individual and group psychosocial programs. *The social service designee was to: -Follow through and follow-up. -Anticipate and respond to individual's needs. -Anticipate and correct problems before they became complaints. -Were innovative, and find solutions. -Collaborated with others to deliver the highest quality of care or services. -Encouraged correspondence, visits, and telephone calls from families. -Provided support to the resident. Review of the provider's undated Director of Nursing Service job description revealed: *That position was responsible for assessing, planning, directing, coordinating, and evaluating services and activities. *The director of nursing was to: -Follow through and follow-up. -Anticipate and respond to individual's needs. -Anticipate and correct problems before hey became complaints. -Own each situation. -Was innovative, and found solutions. -Collaborated with others to deliver the highest quality care or service. Review of the provider's undated Registered Nurse (RN/Charge Nurse) job description revealed: *Consistently and thoroughly completed documentation in a timely manner. *Required knowledgeable status and needs of the residents and communicated effectively with team members. Review of the provider's February 2015 Nursing Documentation policy revealed: *The purpose of the policy was to have established a system of documentation compliant with long term care regulations and to ensure continuity and delivery of safe, quality healthcare to each resident. *When there were any new complaint or a change in condition the nurse would perform an assessment and document the finding in the resident's medical record. *Documentation should have been completed as soon as possible, and before the end of the shift. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8 th Ed., St. Louis, Mo., 2013, p. 23 and pp. 369 through 371 revealed: *"Safety is a critical part of quality health care. *Cognitive impairment associated with [MEDICAL CONDITION], dementia, and depression place patients at greater risk for injury. *Patient safety continues to be one of the most pressing health care challenges in the nation. *Specific risks to a patient's safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. The nurse assesses for these four potential problems areas and, considering the developmental level of the patient, takes steps to prevent or minimize accidents. *Successful critical thinking requires a synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards. Clinical judgements require the nurse to anticipate necessary information, analyze the data, and make decision regarding patient care. Critical thinking is an ongoing process. *In the case of safety, the nurse integrates knowledge from nursing and other scientific disciplines, previous experiences in caring for patients who had an injury or were at risk. The American Nurses Association (ANA) standards of for nursing practice address the nurse's responsibility in maintaining patient safety."

Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate and ongoing assessments, monitoring, physician notification, and documentation was maintained for three of four sampled residents (1, 2, and 3) with pressure ulcers. Findings include: 1. Review of resident 1's closed medical record revealed she had been admitted on [DATE] following knee replacement surgery. She had been discharged on [DATE] to the hospital for debridement (removal of damaged tissues) of a pressure ulcer. Review of her 5/1/14 physician's admission history and physical (H&P) revealed she had been admitted for : *Physical therapy following a total knee replacement. *Diabetes. *Anticoagulation (decreasing the time it takes blood to clot) management. *Pain management. There was no mention in that H&P of any concerns regarding skin integrity issues. Review of her 5/1/14 admission basic skin assessment revealed: *Her skin was warm and dry. *Her skin color was normal for her race. *Her skin turgor (tension) was adequate. *She had a skin irregularity with an incision to the right knee. -That incision was not observable due to a dressing. -There was no drainage or odor noted. *There was no documentation of any other skin irregularities found. Review of resident 1's next basic skin assessment on 5/4/14 revealed the same information as above. Review of her 5/5/14 nurse's note revealed "Incontinent of stool. When peri care (wiping the bottom) was provided a lesion on her coccyx (tail bone) measuring 6 cm (centimeters) by 2.5 cm was noted. The lesion could not be staged (method of identifying the severity of skin ulcer) because it is dark blue to black. PIN (physician inter-departmental notification) will be sent and nursing administration notified." Review of the above faxed PIN to the physician revealed the physician responded with treatment for [REDACTED]. Review of her next basic skin assessment on 5/7/14 revealed: *A wound to the coccyx that was "red with black spot." *That wound was open with scant drainage and measured 7.0 cm in length and 3.0 cm in width. *There was no odor noted. Review of her next basic skin assessment on 5/9/14 revealed: *A wound to the coccyx that was "red with black spot." *That wound was purple and black/brown in color. *The wound was intact (no open areas) and measured 4.0 cm in length and 3.0 cm in width. *There was no drainage and no odor. Review of a 5/9/14 nurse's note revealed the nurse had "described the eschar (dead tissue) central between the buttocks over the coccyx to the physician. Agrees she was sleeping in a seated position at home and that moisture is a huge factor along with leaking bm. Already seen by _________, PT (physical therapist) and no other treatment can be identified at this time. Will continue with barrier creams and no dressing as would be contaminated nearly constantly." There was no indication the physician viewed the lesion on the coccyx at that time. Review of a 5/12/14 nurse's note revealed the "eschar area is firm/non-yielding to the touch, hardened, flat on both sides of inner buttocks; dark brown/black. Intact, non-moveable, not open, no drainage, no odor. Surrounding skin is fragile, moisture is affecting is as she is incontinent of urine and the odor of the urine is quite foul." There was no indication the physician had been notified of the above finding. Review of her next basic skin assessment on 5/13/14 revealed: *A wound to the coccyx that was "red with black spot." *The edges of the wound had separated, and the area was open. *That wound was red and dark red/purple in color. *The wound was hard and measured 9.0 cm in length and 4.0 cm in width. *There was some drainage, and a foul odor noted. The physician had been notified regarding that wound. Review of resident 1's 5/14/14 at 7:15 a.m. nurse's note revealed: *There was a moderate amount of brown bloody drainage from the wound. *There was black eschar with sloughing (release of dead tissue). *The area surrounding the eschar was red, inflamed, and hard. Review of an 8:05 a.m. nurse's note on the same day revealed: *The wound was looking worse and draining. It had an increasingly foul odor. *A request was made for a consultation by the wound team. Review of the 12:45 p.m. physical therapist note on that same day revealed: *The resident's buttocks had needed to be spread in order to complete a thorough assessment. *The visible area was hardened and red. *The area between the buttocks was dark purple. *There was an odor noted, and a dressing was applied to absorb the drainage and assist with the odor. *Nursing planned to notify the physician. Review of the 2:05 p.m. nurse's note on that same day revealed the physician's assistant was there to assess the wound. There was a moderate amount of brown, bloody, foul drainage noted from the wound. Review of the 2:40 p.m. nurses' note on that same day revealed the physician was there to check on resident 1. The wound was measured as a 7.2 cm by 8.2 cm black eschar with sloughing and brown drainage noted. She was pale, sweaty, and somewhat slow to respond. Some shaking was noted. Orders were received to admit the resident to the hospital for wound management. Review of information provided to the South Dakota Department of Health by the receiving hospital revealed the wound was measured at 12 cm in length, 11 cm in width, and 6 cm in depth after surgical removal of the dead tissue. She was subsequently transferred to a higher level of care for wound management and antibiotic therapy. Interview on 7/10/14 at 3:00 p.m. with the assistant director of nursing revealed she confirmed a thorough skin assessment at the time of resident 1's admission on 5/1/14 was not documented. She stated a proper skin assessment was difficult to complete due to the resident's extreme obesity. She stated it would have been necessary to have two people present in order to do a complete assessment: one to spread the buttocks "cheeks" apart, and another to complete a measurement. She was unsure how often that took place. She confirmed the area was not assessed accurately and in a timely manner to prevent further breakdown. She confirmed there was no consistency in the nurses assessing that area to ensure accuracy in measurement or assessment criteria. Interview on 7/10/14 at 8:50 a.m. with MDS (Minimum Data Set) coordinator B revealed the electronic medical record (EMR) basic skin assessment did not lend itself to extensive documentation of a full body assessment. She stated she felt confident a full body assessment had been completed on resident 1 at the time of admission. She confirmed the documentation did not indicate that had been completed. She stated she was the nurse that visited with the physician on 5/9/14 regarding the wound. She confirmed the physician did not visually assess the wound at that time. She did not recall if she had suggested he should look at it. Review of the provider's February 2014 admission checklist revealed a detailed head to toe skin assessment was to have been completed at the time of admission. 2. Review of resident 2's EMR revealed: *He had been admitted on [DATE] from the hospital. *His [DIAGNOSES REDACTED]. -[MEDICAL CONDITION] (the heart does not pump efficiently and fluid builds up in the lungs and in the lower extremities (legs)). -Weakness. -Dependent gait and mobility (required the assistance of staff for walking and moving). -Renal (kidney) failure. -[MEDICAL CONDITION] (swelling in the lower extremities). -[MEDICAL CONDITION] (poor circulation). *On 6/20/14 the nursing skin assessment on admission revealed he had a stage 2 pressure ulcer on his medial left buttock (in the mid area of his left buttock region). The measurement was 1 centimeter (cm) by 2 cm with scant drainage. *The treatments to the left medial buttock area were as follows: -6/22/14 [MEDICATION NAME] and CombiDERM dressing. -6/29/14 [MEDICATION NAME] lotion. -7/2/14 Wipe the area with SurePrep. *On 7/6/14 he had an abrasion to his midline buttocks area that was 0.5 cm by 1 cm and was left open to air. There was no documentation the physician had been notified. There was no treatment specified for the area. Review of resident 2's 7/4/14 Minimum Data Set (MDS) fourteen day assessment revealed he was: *An extensive assistance of two staff for transfers. *Non-ambulatory. *An extensive assistance of two staff for bed mobility. Review of resident 2's undated Activity of Daily Living care plan revealed: *He was independent with assistance of one staff person. *He was an assistance of one or two staff with transfers. *He used a wheeled walker. *He was dependent (needed help) with all personal hygiene. *No further information had been provided regarding his current skin issues. Review of resident 2's undated Personal Evaluation Sheet revealed: *He was forgetful and needed to be cued (prompted). *He had a wheelchair and a chair cushion. *There was no information provided regarding his skin issues. Review of the comprehensive care plan for his skin issues dated 7/8/14 revealed: *"Monitor skin with all opportunities and notify charge nurse for any new s/s (signs and symptoms) of break down. *Weekly head to toe skin observation by licensed nurse. *PRESSURE REDISTRIBUTION: Pressure redistributing mattress for bed and cushion for chair. Encourage frequent positioning. *Assist to toilet at regular intervals to help promote bowel continence. Provide protective undergarment as needed and meticulous skin care after any incontinent episode. *Refer to eMAR (electronic medical records) for the most updated information on medication and cares." *There was no information in the above care plans that would indicate he was totally dependent on staff for transferring and repositioning. Observation and interview on 7/10/14 at 8:55 a.m. with certified nursing assistants (CNA) C and D during personal care for resident 2 revealed: *The CNAs were assisting him from his wheelchair to his recliner. *The resident's buttocks area was visualized during the transfer after partial removal of his disposable brief. *There were several open areas noted on the left and the right buttock area. *The CNAs stated SurePrep (alcohol solution) was placed on the wounds, then SensiCare cream was applied during their shift, but there was no regularity to the application of the solution or the cream. *The CNAs transferred the resident with a stand aide (a mechanical lift that assisted in the transferring of the resident) to his recliner. It was noted there was no cushion in his recliner, and the cushion was in his wheelchair. When asked about the cushion in his recliner the CNAs agreed the cushion should have been placed in his recliner prior to his transfer. They both stated they had not toileted him regularly, because he had a Foley catheter (a tube placed in the bladder to drain urine into a bag). So they were unsure as to how many times a day they would apply the SurePrep and the SensiCare cream. Review of resident 2's Braden scale assessments (an assessment performed to predict pressure ulcer risk) revealed: *On 6/20/14 his score was seventeen (mild risk). *On 6/27/14 his score was fifteen (moderate risk). *On 7/4/14 his score was fifteen (moderate risk). Review of resident 2's twice daily nursing assessments on the EMR regarding positioning revealed: *There was documentation he was independent with positioning from 6/20/14 through 6/26/14. *On 6/27/14 there was documentation he was repositioned every two hours. *There was no nursing documentation as the reason he had become dependent on repositioning and/or required staff assistance. *There was no documentation in the nursing assessments he had been repositioned for the following dates and times: -6/29/14 at 9:14 p.m. -7/4/14 at 10:32 p.m. -7/5/14 at 8:00 p.m. -7/6/14 at 8:00 p.m. The following treatments and observations were documented in the nursing assessments: -6/20/14 [MEDICATION NAME]/CombiDERM dressing to left medial buttock. -6/22/14 [MEDICATION NAME]/CombiDERM dressing to left medial buttock. -6/29/14 Wipe area with SurePrep and leave open to air. -7/2/14 Wipe area with SurePrep and leave open to air. -7/6/14 No dressing, open to air, wet, red, and scaly. 3. Review of resident 3's complete electronic medical records revealed: *On 6/13/14 she had been admitted from the hospital. *Her [DIAGNOSES REDACTED]. -Diabetes. -Obesity. -Right heel ulcer with surgical debridement (removal of dead tissue so new tissue can grow) on 6/10/14. -Cellulites (redness and swelling) of the lower extremities (legs). -Heart failure. -Peripheral [MEDICAL CONDITION] (numbness and tingling on the skin). -Chronic venous stasis (poor circulation that could cause open area). *Her Braden Score assessments had been: -On 6/13/14 her score was 12 (high risk) for pressure ulcers. -On 6/21/14 her score was 13 (moderate risk). *On 6/29/14 there was documentation there was a new open area in the crease of her buttocks. There was no documentation the physician had been notified, no current interventions had been put in place to prevent skin breakdown, and no communication regarding the newly observed area to other staff. *There was no consistent documentation in the nursing assessment that the repositioning of the resident had occurred multiple times from 6/13/14 through 7/4/14. Review of resident 3's 6/27/14 fourteen day MDS assessment revealed she was: *Completely dependent on the staff for all transfers. *Non-ambulatory. *An extensive assistance of two staff persons for bed mobility. *An extensive assistance of one staff person for all personal hygiene. *At risk for the development of pressure ulcers. Review of resident 3's 6/13/14 care plan revealed: *"Monitor skin with all opportunities and report any abnormal bruising/bleeding or new areas of concern to the charge nurse. *Weekly head-to-toe skin observations by the nurse. *PRESSURE REDISTRIBUTION: Pressure redistributing mattress for bed and cushion for her chair. Heel protectors and floating of the heels (keep the heels off the bed) to avoid pressure, friction, or shearing." *There was no documentation regarding the frequency of repositioning or her history of circulatory problems, numbness, and tingling. 4. Interview on 7/9/14 at 3:30 p.m. with MDS coordinator B regarding Braden scale assessments for all residents revealed: *The assessment was done on all residents. *The residents were scored, and the risk of developing a pressure ulcer was identified. *There were no interventions put in place for those residents at risk of developing a pressure ulcer. *The MDS nurse would assess the fourteen day assessment information after admission. She then would make a determination for any interventions that might have been needed. Interview on 7/10/14 at 10:00 a.m. with the ADON regarding pressure ulcers revealed: *Pressure ulcers were not staged, because every nurse might interpret the ulcer differently. *The nurses would document the description and the treatment of [REDACTED]. *She agreed the consistency of the treatments and the description of those pressure ulcers were minimal. *The staff would have used the Patricia A. Potter and Anne Griffin Perry, Pocket Guide to Nursing Skill and Procedures, 7 th Ed., 2007, for reference to nursing standards of practice. Interview on 7/10/14 at 9:15 a.m. with MDS coordinator B regarding resident 2's pressure ulcer revealed: *The charge nurses were responsible for measuring the areas weekly. *The direct care staff would be notified of changes in regards to the treatments during a shift change report. *The measurements would have been documented weekly in the nursing assessments electronic medical records. Interview on 7/10/14 at 9:30 a.m. with registered dietician A regarding supplements for residents with pressure ulcers revealed: *Nutritional assessments were completed on admission and weekly for residents with skin issues. *Resident 2 had refused to take his supplements. *There had been no request for a multivitamin, because she stated "Physicians were not ordering the multivitamins anymore." *She could not provide documentation in the EMR that resident 2 had refused his supplements. *Resident 2 was not eating well, the dietary department would provide a selective menu and would allow him to eat what he wanted to eat, so he could have received protein in his diet. Observation and interview on 7/10/14 at 11:30 a.m. with registered nurse (RN) E and MDS coordinator B during resident 2's transfer and inspection of his buttock area revealed: *The area was on his left buttock was 4 cm by 3 cm. *There were two new areas observed below the above pressure ulcer that measured 1 cm X 2 cm and 2 cm X 1 cm. *The right buttock pressure ulcer was 1 cm X 2 cm. *The RN agreed the 4 cm X 3 cm area on his left buttock was much larger than previously documented in the nursing assessments, and the right medial area was larger then previously documented on 7/6/14. Interview on 7/10/14 at 1:00 p.m. with the DON regarding residents with pressure ulcers revealed: *The documentation system that was currently in place was not able to provide consistent and accurate assessments. *The Braden scale assessments were performed on admission, but there was no specific interventions for at risk residents. *The resident's individualized care plans were not specific for the current status and interventions in place for skin issues. *The physician notifications regarding identified skin concerns were not always completed. *The current reviewed 7/10/12 Pressure Ulcer policy had minimal information and would not have provided necessary information to the nursing staff. Review of the provider's revised 5/17/14 Pressure Ulcer Prevention policy revealed: *The purpose of the policy was to have improved patient/resident safety by identifying inpatient/residents at risk for healthcare-acquired pressure ulcers, to systematically assess and document skin risk factors; and to have implemented the skin-protection components of care. *Interventions: Implement interventions based on Braden Scale score: -At risk: Braden Score 15 to 18. -Moderate risk: Braden Scale Score 13 to 14. -High: Braden Scale Score 10 to 12. -Very High Risk: Braden Scale Score 9 or below. *There was no indication in the policy of the interventions that were to have been put in place from the above scores. *Communication: A mechanism must have been in place for CNA to RN/LPN (licensed practical nurse) to MD (medical doctor) communication regarding the discovery of pressure ulcers. *Documentation: Documentation must have been in the patient/resident record: -Risk Assessment-Braden Scale with timing/frequency as listed. -Malnutrition Screening Tool. -Skin Assessment. -Pressure Ulcer Assessment. -Plan of Care - Interventions documented according to the intervention schedule. -Notification of physician if the pressure ulcer was present on admission or thereafter. *There was no further information in the policy in regards to interventions for those at risk, or for those that had a current pressure ulcer. Review of the provider's June 25 and June 26, 2014 agenda for skills stations education revealed there was a skin assessment skills station provided to the entire nursing staff. Review of the provider's 7/25/13 reviewed and revised Nursing Documentation policy revealed: *The purpose of the policy was to establish a uniform and timely system of documentation for all patients/residents. *To have incorporated as many hand written documents as possible into the [MEDICATION NAME] system. *Nurses would document by exception. Other staff would document care provided. *Document pertinent, factual, objective data and correct any errors in documentation. *Skin assessment and documentation should have been completed upon return from any hospital/ER visit regardless of the cause or duration. Review of the provider's November 2013 revised Nutrition Documentation policy revealed: *Documentation of the resident's nutritional care was the responsibility of the dietary professional. *The registered dietitian would document whenever there was a change in patient/resident's food texture, and addition or elimination of nutritional supplements. Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8 th Ed.,2009, p. 1184, revealed: *"A major aspect of nursing care is the maintenance of skin integrity. Consistent, planned skin care interventions are critical to ensuring high-quality care. Nurses constantly observe their patients' skin for breaks or impaired skin integrity. Impaired skin integrity occurs from prolonged pressure, irritation of the skin, and /or immobility, leading to the development of pressure ulcers. *Several instruments are available for assessing patients who are at risk for developing a pressure ulcer. By identifying at-risk patients, you are able to put interventions into place for the at-risk patient and spare patients with little risk for pressure ulcer development the unnecessary and sometimes costly preventive treatment. Prevention and treatment of [REDACTED]. *Preventing pressure ulcers is a priority in caring for patients and is not limited to patients with restriction in mobility; impaired skin integrity is not usually a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients."

Based on observation, record review, policy review, and interview, the provider failed to ensure nursing services met professional standards for 8 of 15 sampled residents (1, 3, 5, 8, 10, 11, 12, and 13) by not: *Clarifying and following physician's orders [REDACTED]. *Completing full and accurate documentation on the medication administration record (MAR) and treatment administration record (TAR) for residents 1, 3, 5, 8, 10, 11, 12, and 13. *Documenting administration of medications after administration for one of five nurses (H) observed during the medication pass. *Following physician's orders [REDACTED]. Findings include: 1. Record review of resident 3's physician's orders [REDACTED]. Refer to F314, finding 1. 2. Record review of resident 3's physician's orders [REDACTED]. *A signed physician's hospital discharge order dated 10/12/11 stated "TED hose for [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME] (prevention)." *A signed physician's orders [REDACTED]. Review of resident 3's following MARs revealed: *October 2011 MAR had a start date of 10/12/11 for TED hose daily. They were to be removed for two hours twice daily. There were multiple days no initials were noted. *November 2011 MAR had no initials documented for daily TED hose. *December 2011 MAR had no initials documented for daily TED hose. A hand written note stated "? D/C (discontinue)." *January 2012 MAR had initials documented for two days. Interview on 1/25/12 at 9:00 a.m. with registered nurse (RN) coordinator A revealed after dressings had been applied to resident 3's heels the TED hose had not fit her. She agreed an order should have been received from the physician to discontinue the TED hose after discovering the problem. 3. Review of resident 3's January 2012 MAR revealed multiple days with no documentation of medications administered or treatments completed. Some of those medications/treatments included: *[MEDICATION NAME] four units twice a day. *[MEDICATION NAME]twice daily per blood sugar and sliding scale. *[MEDICATION NAME] inhalation twice daily. *[MEDICATION NAME] 80 milligrams (mg) twice daily. *K-Dur 20 milliequivalents twice daily. *[MEDICATION NAME] 50 mg three times a day for pain. *[MEDICATION NAME] to heels twice daily. *Fluid restriction shift totals. *Signs/symptoms of pain per shift. *Weekly skin observation every Monday evening. *Monitor two abrasions on the buttocks and apply skin barrier cream three times daily. 4. Review of resident 11's January 2012 MAR revealed multiple days with no documentation of blood sugar testing that was to be done twice daily. The resident had been admitted on [DATE] and had been started on a daily [MEDICATION NAME]injection of 12 units. It had been changed to 14 units on 1/16/12 based on the documented blood sugar tests. Interview on 1/25/12 at 1:00 p.m. with the director of nursing (DON) revealed she agreed: *Orders for resident 3 should have been clarified and followed. *Documentation on the MARs should have been completed after each medication/treatment had been administered. There also should have been documentation why a medication/treatment had not been administered. 5. Review of resident 1's January 2012 MAR as needed (PRN) response sheet revealed: *From 1/8/12 through 1/22/12 Tylenol 650 milligrams (mg) by mouth had been given fifteen times. The pain observation response had not been documented as having been completed for five times. *From 1/8/12 through 1/22/12 [MEDICATION NAME] 1.0 mg by mouth had been given nine times. The anxiety observation response had not been documented as having been completed for four times Interview on 1/25/12 at 3:45 p.m. with registered nurse (RN) C revealed she would have expected follow-up documentation on medicatioin effectiveness by the nursing staff on the as needed (PRN) response sheet. She further stated she expected the nurses to have included initials, date, and time the follow-up assessment had been completed. 6. Review of resident 8's January 2012 TAR revealed: *an order for [REDACTED]. -From 1/1/12 through 1/24/12 the pain observation had not been documented as completed for fourteen times. *an order for [REDACTED]. -From 1/1/12 through 1/6/12 when the rash had resolved the antifungal had not been documented as completed for nine times. *An order received 1/20/12 to monitor the resident's level of consciousness (LOC) on all three shifts. -From 1/20/12 through 1/24/12 the LOC had not been documented as completed for eight times. 7. Review of resident 13's January 2012 TAR revealed: *An order to monitor scab to right outer foot daily and to report signs or symptoms of infection, redness, or drainage. -From 1/1/12 through 1/23/12 it had not been documented as having been completed for five times. *An order to monitor antidepressant side effects weekly on Mondays. -From 1/1/12 through 1/23/12 it had not been documented as having been completed one time. *An order to monitor antipsychotic side effects weekly on Mondays. -From 1/1/12 through 1/23/12 it had not been documented as having been completed for one time. *An order to monitor anxiolytic (anxiety relieving medications) side effects weekly on Mondays. -From 1/1/12 through 1/23/12 it had not been documented as having been completed for one time. *An order to check Ace wraps four times daily. -From 1/1/12 through 1/23/12 it had not been documented as having been completed for seventeen times. 8. Review of resident 5's January 2012 TAR revealed: *an order for [REDACTED]. -From 1/1/12 through 1/23/12 the pain observation had not been documented as having been completed for thirteen times. *An order to monitor the right fourth toenail at bedtime and to apply a dressing if needed. -From 1/1/12 through 1/23/12 the monitoring or dressing had not been documented as having been completed for twelve times. *An order to monitor the right great toenail at bedtime and to apply a dressing if needed. -From 1/1/12 through 1/23/12 the monitoring or dressing had not been documented as having been completed for twelve times. *an order for [REDACTED]. -From 1/1/12 through 1/23/12 the treatment had not been documented as having been completed for seven times. 9. Review of resident 10's January 2012 TAR revealed: *A handwritten order dated 1/14/12 to monitor an open area on the left buttock. -From 1/14/12 through 1/23/12 the treatment had not been documented as having been completed for twelve times. *A handwritten order to assess the fistula every shift for bruit and thrill (blood flow through the fistula). -From 1/14/12 through 1/23/12 the treatment had not been documented as having been completed for eight times. 10. Interview on 1/25/12 at 11:00 a.m. with the director of nurses revealed she would have expected documentation by the nursing staff on the reverse side on the TAR or MAR. That documentation would have indicated why the treatment had not been completed or the medication had not been administered. She also stated they did not have a policy specific to treatment documentation. 11. Review of the provider's policy for medication and administration, control and accountability 6312-72 dated 8/9/11 revealed: *If a medication was refused or held for any reason the appropriate square on the medication record was not to have been left blank. *An asterisk was to have been entered in the square, and the reason was to have been documented on the reverse side of the form. 12. Review of resident 12's physician's orders [REDACTED]. *Exact times feeding started and stopped. *Mark the appropriate box with an asterisk when the feeding was not tolerated and explain on the back side. *Indicate "NEW" in the units box when the bag/tubing was new. *Record the total amount of the feeding received (stated in milliliters (ml)) in the results box. Review of resident 12's January 2012 TAR from 1/1/12 through 1/23/12 revealed there were: *Fourteen times the exact start time had not been documented. *Twenty times the exact stopping time had not been documented. *Twenty-four times when the total amount of ml had not been documented. *No explanations on the back side to describe the areas where there was no documentation or when documentation seemed to show the feeding had been refused or not administered. Interview on 1/25/12 at 9:15 a.m. with RN I revealed nurses should have documented on the TAR with their initials and time when the feeding was started. She also stated there should have been documentation when the feeding had been refused. She stated there were times in January 2012 when resident 12 had refused his feeding. Interview on 1/25/12 at 12:40 p.m. with RN E revealed: *Resident 12 had refused his feedings a number of times in January 2012. *Nurses often documented resident 12's refusals in the nurse's notes. *The proper procedure was to also include documentation of the refusals on the TAR. *The dietary department used the amounts consumed as documented on the TAR to establish proper intake. 13. Observations on 1/24/12 at 8:30 a.m. and at 11:00 a.m. revealed RN H administered medications to four different residents. Each time she prepared medications for the residents she documented administration of the medication on the MAR prior to actually administering the medication. Following administration she did not go back to the MAR and do any other documentation to indicate the medications had been administered. Interview on 1/24/12 at 2:30 p.m. with RN H revealed she sometimes documented administration of medications before she actually administered them. She stated if there was some reason why the resident would not have consumed the medication, she would have gone back to the MAR to document the reason why the medication has not been consumed. She stated she thought the provider's policy was for documentation of medication administration to take place after the medication had actually been administered. Review of the provider's policy for nursing documentation dated 3/1/06 revealed a statement referring readers to the policy for medication administration, control, and accountability policy 6312-72 for specific details related to medication documentation. Review of the policy 6312-72 revealed there was no reference to when the documentation of administration of medications should have taken place. Review of a resolution issued by the South Dakota Board of Nursing at its September 12-13, 2006 meeting revealed: *Approved nursing education programs in the state had verified the standard for documentation of medication administration taught in nursing education was that documentation occurred following the administration of medication. *It was the position of the South Dakota Board of Nursing that the standard for safe administration of medication included the practice of documenting medication following administration to the patient. 14. Review of resident 12's physician's orders [REDACTED]. The orders also stated the resident should have received 80-100 ml of water by flushing the [DEVICE] before and after each medication pass. Observation on 1/24/12 at 5:50 p.m. of licensed practical nurse (LPN) J administering medications by [DEVICE] to resident 12 revealed the LPN in the following order: *Crushed one-half of a [MEDICATION NAME] tablet and placed the contents in a medication cup containing water. *Opened a [MEDICATION NAME] capsule and sprinkled the contents into a medication cup containing water. *Placed a syringe on the end of the resident's [DEVICE] line. *Without checking for placement or flushing the [DEVICE] with water she administered the above [MEDICATION NAME] solution into the syringe attached to the [DEVICE]. *Without flushing the [DEVICE] with water she administered the above [MEDICATION NAME] solution into the syringe attached to the [DEVICE]. *Flushed the syringe and [DEVICE] with approximately 100 ml of water. *Turned on the pump for feeding. Interview at the above time with LPN J revealed she had not checked for placement of the [DEVICE]. She stated she could see the residual [MEDICAL CONDITION] contents in the [DEVICE] line. She stated she usually flushed the [DEVICE] line before administering each medication but had not done so this time. Review of the provider's policy for administering medication through a [DEVICE] reviewed on 3/8/11 revealed the policy did not have any information about checking for placement or flushing the [DEVICE] before administering medications. Review of the American Society for [MEDICATION NAME] & Enteral Nutrition ( A.S.P.E.N.) enteral nutrition practice recommendations, published online January 26, 2009, revealed the following medication administration guidelines: *Prior to administering medication stop the feeding and flush the tube with at least 15 ml water. *Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe at least 30 ml in size. *Each medication should have been administered separately through an appropriate access. *Flush the tube again with at least 15 ml of water taking into account the patient's volume status. *Repeat with the next medication (if appropriate). *Flush the tube one final time with at least 15 ml of water.

Based on record review, interview, and policy review, the provider failed to ensure a pressure ulcer was properly assessed, monitored, and treated to prevent further injury and pain for one of four sampled residents (3) with pressure ulcers. Findings include: 1. Review of the resident 3's 1/9/12 podiatrist's follow-up appointment documentation revealed: *The appointment was a follow-up to the 1/3/12 debridement of both heels. *"She states that she has been having quite a bit of pain. Nursing has not been applying [MEDICATION NAME] daily and the dressing has not been changed since surgery." *"Examination of the wounds reveals the [MEDICATION NAME] to have all dried out. Essentially, we are now again dealing with black eschar tissue. No active [MEDICAL CONDITION] is seen, but the wounds are painful." Review of resident 3's January 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *An entry for [MEDICATION NAME] sulfate sustained release 15 milligram (mg) tablet every two hours as needed for pain. *Eight doses were noted as given from 1/1/12 through 1/23/12. *Three of those doses were noted for pain in the resident's heels. *One of those doses was noted for general discomfort. *One of those doses was noted for "pain crying." No pain location was noted. *[MEDICATION NAME] 50 mg was scheduled three times per day for acute pain. *Tylenol 500 mg was given every eight hours for fracture pain. Refer to F314, finding 1.

Based on record review, policy review, and interview, the provider failed to ensure a pressure ulcer received the proper care to prevent further injury for one of four sampled residents (3) with pressure ulcers. Findings include: 1. Review of resident 3's electronic medical record (EMR) and paper medical record revealed: *[DIAGNOSES REDACTED]. Review of resident 3's event reports from 10/12/11 through 12/27/11 revealed: *A 10/12/11 event report stated "resident was found on floor in front of recliner, recliner was raised up - beyond sitting position." That fall resulted in a right tibia (lower leg) fracture. *A 10/12/11 medication reconciliation for discharge from the hospital stated: -Two bones in the right lower leg were broken. -Activity: Non-weight-bearing right lower leg for 12 weeks. Knee immobilizer to right lower leg. -Treatments: Frequent skin assessments especially heels and knee immobilizer pressure points. Stockings to prevent blood clots for the deep veins of the legs. *A 10/16/11 event report described her heels as purple in color with the top layer of skin still intact and rated the ulcers at Stage 1. Measurements of the right heel area was 5 centimeters (cm) by 4 cm and the left heel was 10 cm by 5 cm. Her pain was rated as being moderate or distressing/miserable. -On 10/16/11 a physician & interdepartmental notification (PIN) was sent to the physician describing the above event. No documentation was noted as received from the physician regarding that event. *An event report dated 11/28/11 described an open area to the left heel at 6 cm by 10 cm with a depth of 0.1 cm. The shape of the lesion was oval with bloody drainage. A Combiderm dressing was applied. *On 12/2/11 an order was received for a daily left heel dressing with [MEDICATION NAME], an abdominal pad, and Kerlix gauze wrap from physical therapy. -No weekly skin assessments were noted in the nursing progress notes from 12/5/11 until a podiatry appointment on 12/27/11. The podiatrist ordered a debridement for the right heel to be done by the physician. Review of resident 3's 1/3/12 debridement documentation revealed: *A nursing progress note dated 1/3/12 stated the resident had gone to the same day surgery and had both heels debrided. She came back with "a little pain in her heels so her PRN (as needed) MS ([MEDICATION NAME]) was given." "Bandages on heels are not to be touched, Dr. _______ will take care of them at her appt (appointment) on 1-9-12." *A Post Operative Home Care Instructions sheet was sent back with the resident after the surgery. On that sheet "Do not remove the bandages to inspect the operated area for any reason" was circled. The words "Dr (doctor) will do" was hand written after that sentence. The form was not signed by the podiatrist or a physician. It was signed by a nurse from the surgery center and a ward clerk from the provider. *The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"hold dressing change till 9th." Review of resident 3's 1/9/12 podiatrist's follow-up appointment documentation revealed: *The appointment was a follow-up to the 1/3/12 debridement of both heels. *"She states that she has been having quite a bit of pain. Nursing has not been applying [MEDICATION NAME] daily and the dressing has not been changed since surgery." *"Examination of the wounds reveals the [MEDICATION NAME] to have all dried out. Essentially, we are now again dealing with black eschar tissue. No active [MEDICAL CONDITION] (skin infection) is seen, but the wounds are painful." *Plan: "I am not sure why dressing changes were not performed daily. I have to look at the postoperative notes to see if this order was overlooked or if it was not followed. We will try to hydrate the wounds with [MEDICATION NAME] b.i.d (twice daily). I will check her back in a week and see what we are left with. Dressing changes were performed." *No nursing progress notes were noted for that appointment. *The January 2012 MAR indicated [MEDICATION NAME] to heels b.i.d. Cover with [MEDICATION NAME] ABD Kerlix." That entry had only four initialed areas noting the dressing had been done from 1/11/12 through 1/16/12. It was noted as discontinued on 1/17/12. Review of documents related to resident 3's 1/17/12 podiatrist's follow-up appointment revealed: *An appointment encounter sheet dated 1/17/12 had signed orders from the podiatrist stating "Leave wounds alone for now. Monitor for infection q (every) day. Will debride 2/7/12." *A nursing progress note dated 1/17/12 stated "(Resident) went to see Dr ____ for an appointment. She came back with orders to leave alone but to monitor everyday. A clarification was called about the order. He wants us to discontinue the [MEDICATION NAME] but dress with clean dressings everyday to protect the wounds. This way we can monitor the wounds for infection. She will go back to see Dr. ____ on 2/7/12 to have both heels debride(d)." *That clarification order had not been entered into the computer so it would have printed out on the next month's physician order [REDACTED]. *There was no PIN signed by the physician for that clarification order. *That order was not found on the January 2012 MAR indicated [REDACTED] Review of resident 3's care plan with a conference date of 11/2/11 revealed one entry dated 11/28/11 with: *A problem of an open area on the left heel that was 6 cm x 10 cm. *A goal to prevent further damage, heal the area, and prevent pain. *An approach to monitor two times daily, contact wound team, pain medication as needed, and dressing as indicated. *The discipline was nursing. *No other updates for changes to the open area or dressing change was noted. Interview on 1/25/12 at 9:00 a.m. with coordinator A revealed: *The resident had slid out or her chair and had broken two bones in her right lower leg. *The 10/16/11 event report described her heels as purple in color. It was thought when she had slid from her chair her heels had slid along the floor in her room causing that injury. *She was unable to find any communication from the physician regarding the 10/16/11 PIN. No further nursing follow-up communication was noted regarding that PIN. *Skin assessments should have been done weekly by the nurses and documented in the EMR. No other forms were utilized for those assessments. *The resident had gone on 1/3/12 for debridement of the right heel, but the physician had decided to debride both heels. The Post Operative Instruction sheet sometimes came back from that physician unsigned and without any further physician communication. The witness on that form had been a registered nurse (RN) from the surgery center. The ward clerk from the facility had signed for the resident and had brought the resident back to the facility. An RN had taken that instruction sheet and noted it as the resident's current orders for care. She had not clarified it with the physician. *When the resident came back from her 1/9/12 follow-up appointment new dressing change orders were noted. She had not known about the podiatrist's comment of why there had been no dressing changes from 1/3/12 to 1/9/12 until the progress notes were faxed to her on 1/16/12. She had then called the podiatrist regarding the problem. He stated orders had been written for dressing changes, and he was unsure why they had not been sent back with the resident. The coordinator stated there was no documentation regarding that conversation with the podiatrist. *She agreed for the 1/17/12 follow-up appointment clarification the nurse should have entered the order in the computer, sent a PIN for the physician to sign, and entered the order on the MAR/TAR. Instead the dressing change was communicated to the nurses through the communication/shift report book. *Whenever telephone orders were taken from physicians or an event was communicated to a physician a PIN should have been faxed for the physician's signature. Interview on 1/25/12 at 9:00 a.m. with RN B revealed dressing changes for resident 3 were done daily. She had thought it was on the MAR/TAR but was unable to find it. Interview on 1/25/12 at 1:00 p.m. with the director of nursing regarding resident 3 revealed she agreed: *The post operative instructions should have been clarified with the physician. *Any clarifications should have been entered into the computer, had a PIN sent for the physician's signature, and had the order noted on the MAR/TAR. *The care plan should have been updated with the care and treatments for the resident during Minimum Data Set time. Any updates between those assessments should have been written on the care plan. Review of the pressure ulcer prevention policy dated 5/17/11 revealed "Documentation should have been in the resident record for skin assessment, pressure ulcer assessment, plan of care interventions documented according to the intervention schedule, and notification of the physician if the pressure ulcer is present on admission or thereafter." Review of the Comprehensive Plan of Care Policy revised 3/8/11 revealed: *"The comprehensive care plan will contain measurable patient/resident-centered objectives that focus on attaining or maintaining the highest practicable physical, mental, and psychosocial well-being." *"Care Plans will be revised as necessary to reflect change in the patient/resident and the care they are receiving. Revisions to the comprehensive care plan will take place on the paper copy in between MDS assessments."