Every finding on record at Bibb Medical Center Nursing Home

Based on observations, interviews, the facility policy Proper Labeling of Food items , and the 2022 Food Code from the United State (U.S.) Food and Drug Administration (FDA); the facility failed to ensure: 1) food stored in the freezer was covered and sealed properly, outdated food was discarded and; 2) the temperature of blended (puree) foods was measured before serving to residents. This had the potential to affect 114 of 114 resident receiving food from kitchen. Findings Include: 1. The 2022 U.S. FDA Food Code included the following: 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (2) Where it is not exposed to splash, dust, or other contamination . On 11/27/2023 at 10:45 AM, during the initial kitchen tour an observation was made of food stored in the freezer. Salisbury steak was exposed to the air in an unsealed aluminum container. The lid to the container was not sealed properly and there was ice observed on the meat. The freezer contained roast beef in a plastic eight-quart container with use by 11/26/2023 date and four-quart plastic container of plain pork with use by date of 10/25/2023. An interview was conducted with Dietary Aide (DA) #20 on 11/27/2023 during the initial tour. DA #20 stated the Salisbury steak should have been covered with lid sealed. DA #20 stated the concern of the Salisbury steak not being sealed was freezer burn and further said the food had ice on it. DA #20 stated the pork with the use by date of 10/25/2023, should have been discarded before 10/25/2023 and the roast beef with the use by date of 11/26/2023 should have been discarded on 11/26/2023. DA #20 stated both foods items should not have been in the freezer beyond the use by dates. DA #20 stated the concern of outdated food being in freezer was staff could use it and food could make residents sick. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated Salisbury steak should have been stored in its original container and properly sealed. The DM stated the concern of lid not being sealed was food poisoning and freezer burn. The DM stated outdated food should have been discarded. The DM stated the concern of outdated food being in freezer was staff could not look at date and serve food to residents. A telephone interview was conducted with the Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. The RD stated food should be stored in sealed intact container. The RD stated the concern of stored food not being sealed was a reduced quality of food and opened to the risk of contamination. She stated it could be a food safety issue. The RD stated food should be discarded by use by date. RD stated the concern of outdated food being in freezer was risk of foodborne illness. 2. The 2022 U.S. FDA Food Code included the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C [Centigrade/Celsius] (135 F [Fahrenheit]) or above . During the tray line observation on 11/29/2023 at 11:20 AM the surveyor observed that the temperature was not measured for the prepackaged blended items on the steam bar. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated food should be served with a temperature of at least 135 degrees Fahrenheit (F). He stated the concern of serving cold food was it could allow for bacteria to grow. The DM stated the reason the temperature for blended food was not measured was because it was prepackaged, and staff were not to [NAME] the containers. A telephone interview was conducted with Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. RD stated prepackaged food temperature should be checked by piercing the package immediately before serving. RD stated the concern of not checking the temperature on prepackaged food is food safety, staff did not know if food was heated properly.

Based on observations, interviews, and review of a facility policy titled Hand Hygiene, Laundry/Linen Distribution, and Handling Clean Linen the facility failed to ensure: 1) staff performed hand hygiene when a Certified Nursing Assistant (CNA) delivered meal trays, picked an item off the floor, and touched a resident's food, when a Laundry Aid (LA) delivered clean linen to eight different resident's rooms on the 200 hall, and before a Laundry Assistant (LAS) handled clean linen; 2) a LAS did not hold clean linens against her personal clothing; and 3) clean linen was covered while being transported on the 200 hall. These failure had the potential to affect Resident Identifier (RI) #53, RI #25, residents on the 200 hall, and all residents in the facility who received linen from the laundry room. Findings include: The facility policy with an effective date of 02/2001 and a review/revision date of 05/2021 titled Hand Hygiene revealed . POLICY: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. PROCEDURE: . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. An undated facility document titled Hand Hygiene Table revealed . Condition . Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled . linens . An undated facility policy titled Laundry/Linen Distribution revealed . PURPOSE: To provide guidelines for the proper distribution of laundry, linen, and resident clothing to appropriate areas . POLICY: All laundry, linen and resident clothing will be distributed and stored appropriately . PROCEDURE: 1. Use only clean laundry hampers to transport clean laundry, linen, etc. 3. Keep clean laundry carts covered with covers at all times. A facility policy with a revised date of 05/2021 titled Handling Clean Linen revealed .POLICY: It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. DEFINITIONS . Linen includes sheets . and similar items . PROCEDURE: . 2. Linen can become contaminated with pathogens from contact with intact skin . or contaminated hands. 3. Separate carts will be used for transporting clean and contaminated linen. Carts will be cleaned when visibly soiled, and routinely according to facility schedule. 6. Carry clean linen with clean hands away from your body. On 11/27/2023 at 12:28 PM an observation was made of CNA #13 delivering meal trays. After CNA #13 delivered a meal tray to RI #42 and without performing hand hygiene, he entered RI #53's room, picked up a chip from the floor, picked up a blanket from a wheelchair, placed the blanket over the RI #53, and then positioned the bedside table in front of RI# 53. CNA #13 then walked to the meal tray cart, did not perform hand hygiene, picked up tray for RI #25, and then delivered and set up the meal tray for RI #25. While setting up the tray for RI #25, CNA #13 took the cover off of the plate, touched the cornbread on the tray with his bare hands, and then exited the room without performing hand hygiene. On 11/27/2023 at 12:35 PM an interview was conducted with CNA #13. CNA #13 stated that he did not perform hand hygiene by sanitizing or washing his hands after picking up the chip that was on the floor, after leaving RI #53's room, or before picking up and setting up RI #25's tray. CNA #13 stated that there was a risk for infection control for not washing or sanitizing his hands after picking up the chip off of the floor. CNA #13 stated that he should have washed his hands in between each resident. On 11/29/2023 at 08:50 AM during an observation of the laundry room, LAS #17 picked up a pillowcase from the floor and placed on a cart with cleaned linen and designated for clean linen. LAS #17 removed the pillowcase from the cart, took the pillowcase to the dirty linen room, and cleaned the linen cart. After cleaning the linen cart LAS #17 did not perform hand hygiene before she began handling clean clothing from the dryer. LAS #17 began folding sheets without gloves and without performing hand hygiene. While folding the sheets LA #17 held the sheets against her body and clothing. LA #17 folded eight flat sheets and two fitted sheets by holding the clean sheets against her clothing and without performing hand hygiene. On 11/29/2023 at 09:09 AM during an interview with LA #17 she stated she should wash or sanitize her hands between each load especially if she handled something that was dirty. LA #17 said, she did not wash or sanitize her hands after cleaning the contaminated linen cart. LA #17 stated, her gloves were considered to be dirty after cleaning the contaminated linen cart and she should have washed her hands. LA #17 stated, when folding linen, the linen should be held away from her body. LA #17 stated, clean linen should never be held against her clothing because it was a risk for germs. LA #17 stated, a pillowcase that was on the floor should not have been placed on the clean linen cart. LA #17 stated, there was a risk for spreading germs by putting the dirty pillowcase on the clean linen cart. LA #17 stated, she should have washed or sanitized her hands after picking up the pillowcase from the floor and after cleaning the linen cart. On 11/29/2023 at 09:24 AM an interview was conducted with the Housekeeping and Laundry Service Manager (HSM). The HSM stated, staff should wash or sanitize their hands before taking clothes or linen out of the dryer, and after they touched something dirty or something on the floor. The HSM stated staff should wash or sanitize hands after taking off gloves because there was a risk of infection control. The HSM stated, staff should hold clean linen at least a foot away from their body and linen should not touch their body. The HSM stated there was a risk of infection control issues if staff held clean linen against staff clothing. The HSM said staff should not pick up linen off of the floor and put it on the clean cart because there was a risk for infection. The HSM stated, clean linens should be transported covered with plastic. On 11/27/2023 at 12:53 PM, Laundry Aid (LA) #18, was observed staff bringing an uncovered clothing rack (or cart) inside the building. The front flap was up leaving the clothing uncovered. LA #18 distributed resident's clean clothing by entering residents' rooms, using hands to open the closet doors, and placing the clothing in their closets. LA #18 entered four resident's rooms without performing hand hygiene. After the fourth delivery, LA #18 returned clothes hangers from the resident's closet to the clean clothing rack. LA #18 delivered clothing to two more resident's rooms without performing hand hygiene. LA #18 returned clothes hangers from a resident's room to the clean clothing rack and then delivered clothing to two more resident's rooms without performing hand hygiene. During the surveyor's observations, LA #18 did not perform hand hygiene and did not cover the clean clothing rack. LA #18 delivered clothing to resident rooms 213, 211, 210, 208, 207, 204, 203, and 202, a total of eight residents' rooms without performing hand hygiene. On 11/28/2023 at 08:40 AM during an interview with LA #18, she said while distributing resident's clothing, she touched the closet doors and clothes hangers. LA #18 said she should have sanitized her hands before and after touching dirty items. LA #18 said carts should be covered when transported to the units and the front flap was up while she transported and distributed residents' clothing 11/27/23. The laundry aide said the harm in transporting clothing uncovered was a risk for contaminating the clean laundry. On 11/29/2023 at 09:40 AM during an interview with the Laundry Supervisor (LS), she said the laundry staff should use hand sanitizer when they entered or exited a resident's room. The LS said linens and clothing should be covered when on the hall. The LS said the risk of not washing or sanitizing hands was infection control issues, and the risk of not covering the laundry in the hallways was concerns of germs. On 11/29/2023 at 04:45 PM during an interview with the Infection Preventionist (IP), she stated, clean laundry should be held away from the staff's body and with clean hands. The IP stated, the risk of holding laundry against the body was cross-contamination. The IP said, laundry staff should perform hand hygiene before they touch laundry, after and in-between doing the laundry, and after taking off the gloves, because there was a risk for infection. The IP stated staff not washing or sanitizing their hands after cleaning a linen cart created a risk of contaminating laundry with chemicals and dirt. The IP said staff should never pick something up from the floor and put it on a clean cart while clean linen was on the cart, because it was a risk of contamination. The IP stated staff should wash their hands before and after entering a room, because there was a risk of contamination. The IP stated while serving meal trays staff should perform hand hygiene before they picked up the tray and after exiting a resident's room. The IP said staff should wash their hands when they picked up anything from the floor, because cross-contamination.

Based on observation, interviews, the Resident Council Meeting on 11/29/2023, a test tray on 11/29/2023, and a facility policy titled, Food Service, the facility failed to ensure food was served warm, palatable and enjoyable. This had the potential to affect 114 of 114 residents receiving meals from the kitchen. Findings include: The facility's undated policy, Food Service documented: . PROCEDURES: . 4. A conscientious effort is made to make the food, trays, and service as attractive as possible. Resident Identifier (RI) #22 was admitted to the facility on [DATE]. During tour of the facility on 11/27/2023 at 12:06 PM, RI #22 stated, most of the time food was cold, especially breakfast. RI #27 was admitted to the facility on [DATE]. On 11/28/2023 at 5:15 PM RI #27 was eating dinner in his/her room. When asked about the food, RI #27 said, the food was cold but he/she was going to eat it because of being hungry. RI #27 said, the food was served cold frequently. During the Resident Council Meeting, held on 11/29/2023 10:00 AM, three of 15 residents in attendance stated food was cold by the time it got to the units. A tray line observation on 11/29/2023 revealed the following: At 12:30 PM kitchen staff started plating cart one of seven. At 1:25 PM the last tray was placed on Cart seven and the test tray was placed on the cart. At 1:35 PM the last tray was served from the cart. Temperatures on the test tray were as follows: Regular: fish 103 (degrees) Farnehiet (F), Corn 110 F hushpuppies 88 F Mechanical soft meal: fish 88 F, Corn 113 F, hushpuppies 88 F Puree meal: Roast beef 114 F, Carrots 116 F, mashed potatoes 102 F. The meals were tasted and were not warm. An interview was conducted with the Dietary Manager (DM) on 11/30/2023 at 9:45 AM. The DM stated food should be served at a temperature of at least 135 . The DM stated the concern of serving cold food was it could allow bacteria to grow. A telephone interview was conducted with Registered Dietitian (RD) on 11/30/2023 at 11:50 AM. The RD stated the concern of serving cold food was the food was less palatable, less enjoyable, and there may be less intake of food if not warm.

Based on observations, interviews, resident record review, and review of the facility policy Promoting/Maintaining Resident Dignity During Mealtimes, the facility failed to ensure Resident Identifier (RI) #38's lunch meal was not served on Styrofoam on 11/27/2023 and the staff delivering laundry gained permission to enter residents' rooms before entering on 11/27/2023. This had the potential to affect RI #38, one of 10 sampled residents observed at mealtime and residents residing on the 200 hall. Findings include: On 11/27/2023 at 12:53 PM, Laundry Aide (LA) #18 was observed delivering resident's clothing to room numbers 213, 211, 210, 208, 207, 204, 203, and 202, entering each room without knocking, announcing herself, or waiting for permission before entering. On 11/28/2023 at 8:40 AM during an interview with LA #18, she said, she should knock or ask to enter a resident room before going in. When the laundry aide was asked if she knocked on residents' doors before entering, she said, she did not. When asked why she did not knock or announce herself, she said she did not think about it. When the LA #18 was asked what was the harm in not knocking or asking for entry to residents rooms, she said, it would be a dignity issue. On 11/29/2023 at 9:40 AM the Laundry Supervisor #8 said, before staff enter resident rooms they should knock on the door and the concern of not knocking before entering was that it was disrespectful. 29671 A facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes, with a review date of 5/2021, documented: Policy: It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. RI #38 was admitted to the facility on [DATE]. During the lunch observation on 11/27/2023 at 12:15 PM, RI #38's meal was served on Styrofoam or plastic. RI #38 explained, they had previously switched to Styrofoam or plastic due to a recent medical diagnoses, but it was supposed to have been temporary. RI #38 expressed a preference for having meals served on a regular plate and using plastic utensils could sometimes be challenging. On 11/29/2023 at 10:00 AM the Director of Nursing (DON) was interviewed and she said RI #38's lunch meal on 11/27/2023 should have been served on a regular plate instead of an isolation tray. The DON said, the isolation tray should have ended on 11/21/2023 and it could be a dignity issue for residents to receive meals on Styrofoam instead of plates.

Based on interviews, resident record reviews, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, the facility failed to ensure Resident Identifier (RI) #64's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2023 was accurately coded for weight loss or gain and RI #114's quarterly MDS assessment with an ARD of 10/24/2023 was accurately coded to reflect RI #114 did not receive an anticoagulant medication during the assessment period. This had the potential to affect two of 29 sampled residents whose MDS assessments were reviewed. Findings include: The Long-Term Care Facility Resident Assessment Instrument User's Manual documented: . Steps for Assessment for K0200B, Weight 1. Base weight on the most recent measure in the last 30 days. K0300: Weight Loss . Code 2, yes, .: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, . K0310: Weight Gain . Code 2, yes, .: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, . N0415: High-Risk Drug Classes: Use and Indication . E. Anticoagulant ( . warfarin, heparin, or low-molecular weight heparin) . Do not code antiplatelet medications such as aspirin . as N0415E, Anticoagulant . 1.) RI #64 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #64's annual MDS assessment with an ARD of 11/15/2023 reflected RI #64 had experienced both weight loss and weight gain. RI #64's weights were reviewed and from June 2023 to November 2023 RI #64 gained five percent or more from October to November and had not lost five percent in one month or 10 percent in six months. On 11/30/2023 at 2:18 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator said, the annual MDS with an ARD of 11/15/2023 for RI #64 should not have been coded for both weight loss and weight gain. The MDS Coordinator said, when the MDS was completed RI #64 had a weight gain and the MDS was not coded accurately and the significance of accurately coding the MDS was to reflect the resident's current condition. 2.) RI #114 was admitted to the facility on [DATE]. RI #114's quarterly MDS assessment with an ARD of 10/24/2023 documented the use of anticoagulant medication. Review of RI #114's October 2023 physician orders revealed an order for aspirin but no orders were found for anticoagulants that would need to be coded on the MDS assessment. On 11/30/2023 at 2:25 PM, an interview was conducted with the MDS Coordinator who said, the quarterly MDS with an ARD of 10/24/2023 for RI #114 was coded for the use of anticoagulant medication. The MDS Coordinator stated, RI #114 was not actually receiving anticoagulant medication and the MDS assessment was coded incorrectly. The MDS Coordinator said, RI #114 was prescribed aspirin, which was not classified as an anticoagulant medication and the significance of accurately coding the MDS was to reflect the resident's current condition.

Based on interview, document review and a facility policy titled, Continuing Education, the facility failed to ensure 27 CNA's (Certified Nursing Assistants) had the required 12 hours of CEUs ( Continuing Education Units) training per year. This deficient practice affected 27 out 29 CNA's whose training records were reviewed. Findings Include: A review of a facility policy titled, Continuing Education, with an review/revision dated of 6/2001 documented: PURPOSE: To maintain sufficient continuing competence of Nurses Aides. POLICY: All Nurses Aides will be offered twelve (12) hours of continuing education per year .PR[NAME]EDURE: .3. Each must receive .twelve(12) hours .training per year . On 8/22/19 at 11:00 a.m, the Surveyor reviewed the CEU's training records for the CNA's employed by the facility from the last twelve months between their hire date (month/date). There was no documentation of the required 12 hours of CEU's, during a twelve month span, for 27 CNAs. On 8/22/18 at 11:23 a.m., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nurses). EI #1 was asked who was responsible for ensuring the CNA's had the required 12 hours of CEUS. EI #1 said the DON. EI #1 was asked what was the facility's policy regarding the CNA's having 12 hours of CEUs. EI #1 said they(CNA's) are required to have 12 hours of CEU's per year. EI #1 was asked how many of CNA's did not have the required 12 hours of CEU's. EI #1 said 26 EI #1 was asked if she had any documentation of the CNA's having the required 12 hours of CEU's. EI #1 said, No Ma'am. EI #1 was asked what was the potential concern with CNA's not having required 12 hours of CEU's per year. EI #1 said, Failure of the CNA's to provide appropriate up to date care.

Based on observations, interviews and a review of residents' tray slips, the facility failed to ensure the salt or sodium restricted diets were followed. This affected two of three residents, Resident Identifier (RI) #72 and RI #62 for whom a salt restricted diet was ordered. Findings Included: The facility's Low Sodium Diet or 2300 mg Sodium (undated) included the following: Use . This diet is useful in preventing or controlling [MEDICAL CONDITION] or hypertension. Diet Principles include: 1. Prepare all foods without salt and do not add salt at the table. Avoid all processed and prepared foods and beverages high in sodium . 1) RI #72 was re-admitted to the facility on [DATE]. RI #72 [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) assessment, date 6/24/19, identified this resident to have a cognitive (Brief Interview for Mental Status) score of 15 of a possible 15, indicating intact cognition. The Physician order [REDACTED]. On 08/21/19 during the 12 noon meal, the surveyor observed RI #72's lunch tray as it was served. The tray included a package of salt on the tray. When questioned, RI #72 stated a packet of salt was sent on every tray. The surveyor observed RI #72's 08/22/19 breakfast tray. The tray included a packet of salt, in contrast to the Specified Diet Order on the tray slip of .No Added Salt. 2) RI #62 was admitted to the facility on [DATE]. RI #62'2 [DIAGNOSES REDACTED]. The Physician order [REDACTED]. On 08/21/19 at 5:54 PM, the surveyor observed RI #72 eating a supper tray in the resident's room. The tray slip indicated Low Sodium however, the tray included: 1 bowl of Chicken Noodle Soup (which the resident said was delicious), a sandwich, diet soft drink, and three packages of salt. When the surveyor asked the resident if he/she used the salt, RI #62 said, Sometimes. At this point, the surveyor called into the room one of the Certified Nursing Assistants, responsible for the care of this resident. CNA (Employee Identifier/EI #7) confirmed the presence of the salt, and stated, I don't think he/she's supposed to have it (the salt). On 08/22/19 at 8:20 AM, the surveyor again observed the tray of RI #62, which included a package of salt.

Based on observation, interviews and review of meal tray slips, the facility failed to honor each resident's specified food preferences. This affected Resident Identifier (RI) #72 and #85, two of 15 residents observed during meals. Findings included: 1) RI #72 was re-admitted to the facility on [DATE]. This resident was assessed on the 06/24/19 Quarterly Review Minimum Data Set (MDS) as cognitively intact with a score of 15 of a possible 15. On 08/21/19, during the 12 noon lunch meal, the surveyor observed RI #72 receive a lunch meal which included Spaghetti with Meat Sauce (not eaten), as well as a slice of toasted, buttered French Bread (not eaten), and a spinach salad, among other food items. The tray slip designated in the Notes section: Send crackers with salads.No bread as side item. The resident did not eat the bread sent on the tray, and no crackers had been included with the meal. 2) RI #85 was admitted to the facility on [DATE]. The most current Annual MDS assessment, date 7/20/10, documented this resident to have a BIMS of 15 of a possible 15, indicating intact cognition. On 08/21/19 at 5:35 PM, RI #85 received a supper tray. The tray slip specified (hand-written on the slip) Grilled Cheese, Vegetable Soup, and a Bag of Chips. A bowl of [NAME]ato Soup was served instead of the Vegetable Soup, and no Chips were provided. Rather than a 3-Compartment Plate, as specified on the tray slip's FEEDING ASSISTANCE DEVICES, the meal was served on an plate with no divided sections. On 08/22/19 at 10:32 AM, the surveyor interviewed the tray line starter, Employee Identifier (EI) #6, who was responsible for calling out the orders on each tray slip to the tray line staff. When asked who checked behind her to ensure the accuracy of each tray, EI #6 stated no one checked behind her, except when the Dietary Manager occasionally did spot checks. On 08/22/19 at 10:50 AM, the surveyor questioned the Dietary Manager, Employee Identifier (EI) #5 about the monitoring of meal trays for accuracy in complying with resident preferences. EI #5 explained the previous evening that had new people in training on the line.

Based on observations, interviews and a review of facility policies titled, Steamtable temperatures, Cleaning of food carts, and Handwashing Guidelines-Dietary Employees, the facility failed to ensure: 1) the temperatures were taken of all foods on the tray line; 2) food carts used to transport residents meals were not dirty and; 3) staff washed their hands when entering the kitchen. This had the potential to affect 113 of 113 residents who received meals from the kitchen. Findings Include: 1) Review of a facility policy titled, Steamtable temperatures, with no date revealed: .POLICY: All steamtable temperature will be checked and documented prior to food service. PR[NAME]EDURES: 1. All foods held on the steamtable will be checked and all temperature will be documented by the assigned dietary personnel prior to service. On [DATE] at 11:54 rice was brought to the steam table by (Employee Identifier) EI #4. Dietetic Assistant. EI #4 did not take the temperature of the rice, nor did EI #1, the Cook. On [DATE] at 2:46 p.m., the surveyor conducted an interview with EI #1, the Productive Supervisor/Cook. EI #1 was asked who took the temperature of the second pan of rice. EI #1 replied, no one. EI #1 was asked how often were temperatures taken on the tray line. EI #1 replied, every time they ran out of something and had to get something else. EI #1 was asked why was it important to take food temperatures. EI #1 replied, to make sure the food was hot for the residents. EI #1 was asked what did the facility policy say regarding taking food temps on the tray line. EI #1 replied, make sure they are at the right temperature and serve the proper way. EI #1 was asked when they replenished food on the tray line should the food temperature be taken. EI #1 replied, yes ma'am. EI #1 was asked what was the potential harm to the residents when all food temperature were not taken on the tray line. EI #1 replied, she would not know the temperature of the foods. On [DATE] at 10:12a.m., an interview was conducted with EI #4, Dietetic Assistant. EI #4 was asked who was responsible for taking the temperatures of foods that were placed on the tray line. EI #4 replied, the cook and production supervisor. EI #4 was asked who checked the rice temperature before placing it on the steamtable on [DATE]. EI #4 replied, EI #6, Dietary Cook. EI #4 was asked what was the potential harm to the residents when food temperatures were not taken. EI #4 replied, it would make the residents sick. EI #4 was asked did she take the temperature of the second pan of rice. EI #4 replied, no she did not. On [DATE] at 10:57 a.m. an interview was conducted with EI #6, dietary cook. EI #6 was asked who took the temperature of the second pan of rice when it came out of the steamer. EI #6 replied, no one took it. EI #6 was asked when foods were brought from the warmer to the tray line who took the temperatures. EI #6 replied, the cook. EI #6 was asked should food temperatures be taken when foods were brought from the steamer to the tray line. EI #6 replied, yes ma'am. EI #6 was asked why was it important that food temperature be taken. EI#6 replied, because she did not want to make anyone sick. EI #6 was asked when should food temperatures be taken. EI #6 replied, after it come out of the steamer/oven, before you get to the tray line, and every time you bring it out of the warmer, the temperatures need to be taken. 2) A review of a policy titled, Cleaning of food carts, with no date, revealed: PURPOSE: To ensure food carts are cleaned properly.PR[NAME]EDURES: Daily: 1. Clean all spills right away . On [DATE] at 12:17 p.m., the surveyor observed dirty carts with food debris on them. EI #2 tray hostess, wiped food debris from the cart and a brown like substance. EI #5 wiped food debris from the cart and a white looking substance. The resident trays were being placed on the carts. After leaving the kitchen and going to the 200 hall, the surveyor observed a dirty cart with died white food substance on the hall. On [DATE] at 3:01 p. m., an interview was conducted with EI #2, tray hostess. EI #2 was asked what was on the food cart that she wiped down on ,[DATE] and ,[DATE]. EI #2 replied, food. EI #2 was asked why was it there. EI #2 replied, they did not have time to wipe them off. EI #2 was asked how often were carts cleaned. EI #2 replied, after breakfast they washed them, after lunch they washed them and the evening shift were supposed to wash them off. EI #2 was asked why was it important that carts were cleaned. EI #2 replied, so the residents would not get sick or get germs. EI #2 was asked who was responsible for making sure carts were cleaned. EI #2 replied, the person who washed pots and pans and the ,[DATE] staff. EI #2 was asked were resident trays being placed on the carts. EI #2 replied, yes. EI #2 was asked where was the food debris located on the carts. EI #2 replied, on the shelves and on the side of the carts. On [DATE] at 3:18 p.m., the surveyor conducted an interview with EI #3, CNA (Certified Nursing Assistant). EI #3 was asked what did she observe on the carts on [DATE]. EI #3 replied, a lot of different spots and dried food. EI #3 was asked were the carts clean. EI #3 replied, no ma'am. EI #3 was asked should resident trays be on dirty carts. EI #3 replied, no ma'am. EI #3 was asked what was the potential harm to the residents when food carts were dirty. EI #3 replied, cross contamination and germs. EI #3 was asked were the carts with resident trays on them dirty. EI #3 replied,yes ma'am. On [DATE] at 10:43 a.m., an interview was conducted with EI #5 Dietary Manager/Dietician. EI #5 was asked what did she observe on the carts on ,[DATE] and ,[DATE]. EI #5 replied, it looked like they missed some spots of food when they cleaned it. EI #5 was asked how often were carts cleaned. EI #5 replied, after each meal service. EI #5 was asked who was responsible for cleaning carts. EI #5 replied, tray hostess', ladies who did the beverages. EI #5 was asked why was it important that food carts were cleaned. EI #5 replied, a risk of cross contamination. 3) A review of a policy titled, Handwashing Guidelines-Dietary Employees, with a date of [DATE] revealed: Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses.1. Frequency of Handwashing: Hands should be washed in the following situations: a. Every time an employee enters the kitchen; . On [DATE] at 5:02 p.m., the surveyor met the Dietary Manager (DM) EI #5, in the hallway. When entering the kitchen the DM did not wash her hands. The following observations were made of EI #7, tray hostess, on [DATE]: 12:12 p.m., EI #7, was observed leaving the kitchen with gloves on. 12:17 p.m., EI #7 returned to the kitchen pulling carts in. She did not wash her hands when coming back in the kitchen. 12:19 p.m., EI #7 left the kitchen again. 12:20 p.m., EI #7 returned to the kitchen and did not wash her hands. On [DATE] at 10:49 a.m., an interview was conducted with EI #5, DM. EI #5 was asked when coming into the kitchen on [DATE], did she wash her hands. EI #5 replied she did not remember if she did. EI #5 was asked why was it important that she wash her hands in the kitchen . EI #5 replied, for infection control purposes. EI #5 was asked what did the facility policy say on washing hands when entering the kitchen. EI #5 replied, hands should be washed every time an employee entered the kitchen. EI #5 was asked who should wash their hand when entering the kitchen. EI #5 replied, everyone. On [DATE] at 11:10 a.m., an interview was conducted with EI #7, tray hostess. EI #7 was asked when going in and out of the kitchen to deliver carts to the hall did she wash her hands when returning to the kitchen. EI #7 replied, no ma'am. EI #7 was asked why she did not wash her hands when entering the kitchen after returning from the hall. EI #7 replied, she did not know she was suppose to wash her hands. EI #7 was asked did she turn the kitchen door knob to get to the hallway with gloves on. EI #7 replied, yes ma'am. EI #4 was asked what did the facility policy say regarding washing hands in the kitchen. EI #7 replied, scrub them, use warm water, make sure you wash for 15 second, do not touch the paper towel box, use paper towel to turn water off and use a paper towel to open the door and put the paper towel in the trash. EI #7 was asked what was the potential harm to the residents when you touch dirty carts and kitchen doors with gloved hands and do not change your gloves or wash your hands. EI #7 replied, cross contamination.

Based on observations of residents' wheelchairs, medical record review and interview, the facility failed to ensure the wheelchair arm rests of Resident Identifiers (RI) #15, 16, 17 and #20 were intact and/or in place. This affected four of 11 sampled residents who used a wheelchair (w/c). Findings Included: During a Resident Group meeting on 06/07/17 at 9:30 a.m., the right and left arm rests of three wheelchair-bound residents were cracked, including RI #s: 15, 16, and 17. The arm rests on the wheelchair of RI #20 were missing. 1. RI #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented the use of a w/c for mobility. 2. RI #16 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #16's Quarterly MDS dated [DATE], documented this resident used a w/c for mobility. 3. RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #17's Quarterly MDS dated [DATE], documented RI #17 used a w/c for mobility. On 06/07/17 at 4:08 p.m., RI #17 and #20 were observed at the front hall nursing station. RI #17's left and right w/c arm rests were cracked. RI #20's w/c was missing both the left and the right arm rests. 4. RI #20 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #20's Quarterly MDS dated [DATE], documented RI #20 used a w/c for mobility. On 06/08/17 at 1:50 p.m., the surveyor showed the Environmental Service Director, Employee Identifier (EI )#9 the missing wheelchair arm rests on the chair of RI #20. EI #9 agreed there should be some. On 06/08/17 at 1:35 p.m., Employee Identifier (EI) #9, the Environmental Services Director, was asked who was responsible to monitor wheelchairs for repairs. EI #9 replied that housekeeping took the chairs outside once a month and pressure washed them. She further explained the staff had been instructed to let her know if repairs were needed. EI #9 was asked what could be a concern with cracked arm rests. EI #9 replied it could cause skin tears.

Based on observation, interviews and a review of facility policies, titled: Hand Hygiene and Incontinent Care, the facility failed to ensure Certified Nursing Assistants (CNAs) wiped from the pubis to the sacrum during incontinent care. The facility further failed to ensure a second CNA assisting in the same incontinent care, washed her hands or changed her gloves prior to touching the resident's clean linen and clean brief. This affected Resident Identifier #11, one of one resident observed during the provision of incontinent care. Findings include: RI #11 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/17, indicated RI #11 had a Brief Interview for Mental Status score of 3 out of a possible 15 points to indicate severe impairment in cognitive decision making. This MDS also revealed that RI #11 required extensive assistance with all activities of daily living. The facility policy Hand Hygiene implemented 04/26/17 revealed: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. The policy related to Incontinent Care (undated) specified: Purpose: 1. To provide cleansing of the perineum . Procedure: . 8. Wipe from the pubis to the perineum . 11. Dry the area from the pubis to the perineum . On 06/08/17 at 9:40 a.m., Employee Identifier (EI) #8, a CNA, was observed to turn down RI #11's bed covers, release the side rail, move the bedside table, and move an arm chair away from the bedside. EI #8 then rolled RI #1 over to the right side. All of these actions were performed wearing the same gloves. At 9:45 a.m., EI #7 (another CNA assisting in the same care) washed RI #11 with a soapy wash cloth, starting from the sacrum, moving (in the wrong direction) down through the crease between the buttocks, over the rectum, continuing in a downward motion to the perineum. EI #7 repeated this with a second, soapy cloth. Then, without rinsing the soap from the resident's skin, EI #7 dried the resident beginning at the sacrum, drying downwards over the rectum and continued down to the perineum. EI #7 removed the soiled linen and brief from under the resident, and placed them into the linen bag at the foot of the bed. At 9:52 a.m., EI #8 placed the clean linen and clean brief under the resident without washing her hands or changing her gloves. On 06/08/17 at 10:00 a.m., an interview was held with EI #7. The surveyor asked what was the correct way to wipe the resident when cleaning the genital area. EI #7 replied one should wipe up from the perineum toward the sacrum. EI #7 was then asked if he had done this during RI #11's care. EI #7 incorrectly replied that he had. When questioned further, EI #7 did recall he had wiped the resident in the wrong direction. EI #7 was asked what was the potential harm to the resident of cleaning the genital area incorrectly. EI #7 stated that it could lead to infection and one really needed to move everything away from the genital openings. On 06/08/17 at 10:10 a.m., an interview was held with EI #8. The surveyor asked what should have been done prior to placing clean linen and a clean brief under RI #1 1 after incontinent care. EI #8 stated she should have removed her gloves and washed her hands. When asked what was the potential harm of not washing your hands and changing your gloves before touching clean linen and a clean brief for use on a resident. EI #8 stated the potential harm was spreading germs from one place to another. On 06/08/17 at 3:40 p.m., an interview was held with the Infection Control Nurse, EI #6. EI #6 was asked when cleaning the genital area was it correct to wipe downwards from the sacrum through the buttock crease over the rectum continuing in a downward motion to the perineum. EI #6 answered no. EI #6 was then asked, once the assisting CNA had turned down the resident's covers, removed a chair from the bedside, moved the bedside table, and rolled the resident onto their side, what should this CNA have done prior to placing the clean linen and a clean brief under the resident. EI #6 stated prior to handling the clean linen and clean brief, the CNA should have changed her gloves and washed her hands. EI #6 was then asked what was the potential harm to residents when the correct procedure was not followed during incontinent care and pericare. Secondly what was the potential harm when gloves were not changed and hands were not washed before handling clean linen and clean briefs. EI #6 stated, infections.

Based on observation, medical record review and interviews, the facility failed to provide staff who could regularly communicate with a resident for whom sign language was the primary mode of communication. This affected Resident Identifier (RI) #10, one of three deaf/mute residents in the facility at the time of this survey. Findings included: RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current (quarterly review) Minimum Data Set assessment with an Assessment Reference Date of 05/08/17, identified RI #10 as having no useful hearing, no speech, sometimes understood, and sometimes understanding of others' communication with a response to simple, direct communication only. On 06/07/17 at 4:00 p.m., a family member indicated RI #10 could read, but not write due to hand tremors. The family member stated RI #10 was somewhat depressed, and was slowly deteriorating. On 06/07/17 at 5:00 p.m., one of the surveyors used sign language to ask RI #10 if he/she had anyone with which to sign. RI #10 replied, no. When asked how that made him/her feel, RI #10 responded, Makes me sad. At the conclusion of the interview, RI #10 thanked the surveyor and smiled. On 06/08/17 at 10:10 a.m., the Social Services Designee (Employee Identifier/EI #4) was questioned about RI #10's ability to write (on the white wipie board). EI #4 explained she did all the writing; the resident had never written on the white board for her. EI #4 explained the resident could say some simple words, nod head and read lips if she was close enough. When asked if anyone in the facility could sign with the resident, EI #4 said she did not know of anyone. On 06/08/17 at 2:40 p.m., another surveyor (unable to sign) used the resident's wipie board to ask if RI #10 would like someone to sign with. RI #10 immediately nodded yes. When asked if he/she could write (using the wipie board), RI #10 conveyed he/she could not write. On 06/08/17 at 3:00 p.m., the Social Worker (Employee Identifier/EI #1) was asked how the facility had implemented the use of sign language, which the resident could understand. EI #1 explained she knew a little sign language, but used the wipie board and the resident's ability to read lips to communicate. EI #1 explained they could possibly get someone to sign with RI #10; no one signed with RI #10 on a consistent basis. When asked how the communication limitations could affect RI #10's mood and socialization, EI #1 stated it could affect both. The care plan of RI #10 (dated 05/10/17) specified: Use gestures with speech, sign language, visual cues and communication board and/or cards as needed to enhance communication. On 06/08/17 at 3:15 p.m., the Licensed Social Worker, EI #5, was asked when they would use sign language as needed. EI #5 explained the intervention was put in the care plan if the staff could not understand the resident. When asked of any concerns with RI #10's inability to use sign language with others, EI #5 said the resident could lose the ability to sign, as well as frustration for both the resident and for staff.

Based on observation, interviews and medical record review, the facility failed to implement the care plan of Resident Identifier (RI) #10 regarding the provision of sign language. This affected RI #10, one of three deaf/mute residents. Findings included: RI #10 has resided in the facility since 07/31/15 with [DIAGNOSES REDACTED]. The most recent quarterly review Minimum Data Set assessment, dated 05/08/17, identified this resident as highly impaired in hearing (no useful hearing), sometimes understood by others, limited to making concrete requests only, and sometimes able to understand others--responding adequately to simple, direct communication only. The resident was care planned on 05/10/17, to Use gestures with speech to enhance communication and sign language as needed. On 06/07/17 at 5:00 p.m., a state surveyor used sign language to ask RI #10 if he/she had anyone to sign with. RI #10 replied (by sign), no. When asked how it made RI #10 feel not to be able to sign his/her needs, the resident signed it made him/her feel sad. On 06/08/17 at 3:00 p.m., the Social Services Designee (Employee Identifier/EI #1) was asked how the facility had implemented the use of sign language for RI #10. EI #1 explained she knew a little sign language but used the resident's wipie board (to write messages) and relied on RI #10 to read her lips. EI #1 stated no one signed with RI #10 on a consistent basis. On 06/08/17 at 3:15 p.m., the Licensed Social Worker, EI #5, was asked why there were no staff to speak sign language with the deaf residents. EI #5 explained they had communicated through the use of gestures and simple measures. EI #5 explained the care plan intervention was put in place by nursing, if staff could not understand him/her. When asked what concern might there be in the lack of sign language use for RI #10, EI #5 stated the resident could lose the ability to sign, or it might cause frustration for both the resident and staff.

Based on record review and interview, the facility failed to ensure the required 12 hours of continuing education units (CEUs) were completed by two of five sampled Certified Nursing Assistants (CNAs). Findings included: A review of the facility's training logs revealed: 1) Employee Identifier (EI) #2 (CNA), only received 11 hours of CEUs over a 12 month/one year period. 2) CNA, EI #4 only received 9 hours of CEUs over a 12 month/one year period. On 06/08/17 at 3:15 p.m., EI #10, the Director of Nursing, stated that for these two employees she could not show they had received the required 12 hours of continuing education. EI #10 stated better tracking of these in-service hours were needed.

Based on observation, interview and document review, the facility failed to ensure the doors to the dumpster on both sides were not open exposing the garbage to potential pests on 06/21/16. This affected one of three dumpsters. Findings include: The facility's policy for CLEANING THE DUMPSTER AND AREA, with a revised date of 1-2012, included the following: . the janitor hoses and cleans the dumpster area with a multipurpose cleaner and washes it down. This keeps down odors, flies, ect (etc). The dumpster lids are to be kept closed all the time. The 2013 Food Code by the United States Public Health Service and Food and Drug Administration included the following: . 5-501.15 Outside receptacles. (A) Receptacles . units for REFUSE . containing FOOD residue and used outside . shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles . REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective . On 06/21/16 at 2:50 PM, the surveyor was accompanied by Employee Identifier (EI) #8 the (Dietary Manager) DM to the dumpster area. The surveyor observed three dumpsters, one dumpster with the doors opened on both sides, exposing garbage bags, boxes and refuse. The surveyor also observed flies in the dumpster. EI #8 was interviewed on 06/21/16 at 3:00 PM. EI #8 was asked should the dumpster doors be open. EI #8 replied, No. EI #8 was asked who is responsible for ensuring the doors on the dumpsters are closed. EI #8 replied every department is responsible for ensuring dumpsters are closed when they put trash in it. EI #8 was asked what is the potential harm in leaving the doors open on the dumpster. EI #8 replied rodents, insects and smell.

Based on observations, interviews and record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #5, 7, 15 and 16 the lunch meal on 06/22/16. This affected RI #5, 7, and 15, three of four residents sampled for dignity. Findings include: 1. RI #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/17/16, assessed RI #5 to have short and long term memory problems and severely impaired cognitive skills for daily decision making skills. Under Section G - Functional Status, RI #1 was assessed to be totally dependent on staff for eating. On 06/22/16 at 12:15 PM, the surveyor observed a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1 was standing while she fed RI #5 the lunch meal. On 06/22/16 at 5:17 PM, the surveyor attempted to conduct an interview with RI #5. RI #5 did not respond to the surveyor's questions. On 06/23/16 at 12:15 PM, the surveyor conducted an interview with EI #1. The surveyor shared with EI #1 that on yesterday (06/22/16) the surveyor observed EI #1 feed RI #5 the lunch meal. The surveyor asked EI #1 what position she was in when she fed RI #5. EI #1 replied, Standing. The surveyor asked EI #1 what was it considered when you stand and feed a resident. EI #1 said rushing the resident. 2. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment, with an ARD of 05/30/16, assessed RI #7 to have short and long term memory problems and severely impaired cognitive skills for daily decision making skills. Under Section G - Functional Status, RI #7 was also assessed to be totally dependent on staff for eating. On 06/22/16 at 12:25 PM, the surveyor observed RI #7 being fed the lunch meal by EI #3, a CNA. EI #3 was standing while she fed RI #7 the lunch meal. On 06/22/16 at 5:20 PM, the surveyor attempted to conduct an interview with RI #7. RI #7 did not respond to the surveyor's questions. On 06/23/16 at 12:41 PM, the surveyor conducted a phone interview with EI #3. The surveyor asked EI #3 what position was she in when she fed RI #7 the lunch meal on 06/22/16. EI #3 replied, I was standing up but should have been sitting down. The surveyor asked EI #3 what was it considered when you stand to feed a resident. EI #3 replied, It's a dignity issue. On 06/23/16 at 2:01 PM, the surveyor conducted an interview with EI #4, a Registered Nurse Unit Manager Station II. The surveyor asked EI #4 how should staff be positioned when feeding a resident. EI #4 said staff should be at eye level with the resident whether sitting or standing. The surveyor asked EI #4, when the resident is not being fed at eye level whether sitting or standing, what kind of issue could that be. EI #4 replied, a dignity issue. 3. Resident Identifier #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 08/24/15 identified RI #15 as being dependent for eating and required the assistance of one person. On 06/22/16 at 12:45 PM, during the lunch meal, Employee Identifier (EI) #12 was observed in RI #15's room feeding RI #15 while standing at the resident's bed side. While speaking in a loud voice, EI #12 stated I don't sit to feed anymore. The last time I did, a resident coughed and spit in my face. That was it for me. EI #12 continued to feed RI #15 while standing over the resident. On 06/23/16 at 1:30 PM, EI #13 a Licensed Practical Nurse was asked to describe her observation of RI #15 being fed on 06/22/16 at the lunch meal. EI #13 stated the CNA was standing to feed RI #15's lunch. She further stated EI #12 should have been sitting at eye level since the resident needs to feel un-intimidated and will eat better if not feeling rushed. On 06/23/16 at 2:30 PM, when EI #12 was asked how she was taught to feed the residents she stated, you are to sit facing them at eye level. When asked why, EI #12 stated, They say you tend to feed them too fast and a resident thinks you are rushing, and too fast and they may choke.

Based on observations, interviews, and record review, the facility failed to ensure: (1) Certified Nursing Assistants (CNA) did not use gloves from the pocket of a CNA's uniform to provide incontinent care to RI #7 on 06/22/16; (2) a CNA changed her contaminated gloves before touching the clean incontinent pad/soft diaper of RI #7 on 06/22/16; (3) a CNA changed her contaminated gloves before applying a moisture barrier to the buttocks of RI #7 on 06/22/16; (4) a licensed nurse, Employee Identifier (EI) #10 did not touch medication with her bare fingers while administering medications to Resident Identifier (RI) #19 on 06/22/16; and (5) laundry staff did not store clean clothing in a plastic bag on the floor and have four bundles of new/clean towels on the floor of the laundry department. This affected RI #7, one of one resident observed for incontinent care and EI #10, one of two nurses observed during the medication pass observation. Findings Include: 1. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/30/16, assessed RI #7 to have short and long term memory problems and severely impaired cognitive skills for daily decision making skills. Under Section G - Functional Status, RI #7 was assessed to be totally dependent on staff for personal hygiene. Under Section H- Bladder and Bowel, RI #7 was assessed as always being incontinent of bladder and bowel. On 06/22/16 at 11:34 AM, the surveyor observed CNAs, EI #3 and EI #1, prepare to provide incontinent care to RI #7. EI #1 removed gloves from the pocket of her uniform, donned a pair and gave a pair to EI #3, who then put them on. After EI #3 provided incontinent care, she removed her gloves. EI #1 gave EI #3 another pair of gloves from her pocket and EI #3 put them on. On 06/23/16 at 12:15 PM, the surveyor conducted an interview with EI #1. The surveyor asked EI #1 when the surveyor observed her provide incontinent care to RI #7 on 06/22/16, where did she get the gloves to put on. EI #1 replied, From my pocket. The surveyor asked EI #1 was the pocket considered a dirty or clean area. EI #1 replied, Probably dirty. The surveyor asked EI #1 what was it a potential for if the pocket is considered dirty. EI #1 replied, Bacteria and infection. On 06/23/16 at 12:41 PM, the surveyor conducted a phone interview with EI #3. The surveyor asked EI #3 when the surveyor observed her and EI #1 provide incontinent care to RI #7 on 06/22/16, where did she get the gloves from. EI #3 said out of EI #1's pocket. The surveyor asked EI #3 is the pocket considered a dirty or clean area. EI #3 replied, Dirty, because it contaminates the gloves. On 06/23/16 at 1:24 PM, the surveyor conducted an interview with EI #2, the infection control nurse. The surveyor asked EI #2 where would she expect the CNAs to get their gloves from when applying them. EI #2 replied, From the box on the wall where the gloves are set up. The surveyor asked EI #2 should the CNAs use gloves from their uniform pockets. EI #2 replied, No. The surveyor asked EI #2 what would that be considered, using gloves from a pocket. EI #2 replied, They would possibly be contaminated or dirty. 2. On 06/22/16 at 11:34 AM, the surveyor observed EI #1 don a pair of gloves after removing them from the pocket of her uniform. After EI #3 provided incontinent care to RI #7, she put on a clean pair of gloves, picked up a clean incontinent pad/cloth diaper and placed them under RI #7's back/buttocks. RI #7 was positioned to the right side. EI #1 removed the dirty incontinent pad/cloth diaper and placed them in a plastic bag. Without removing her contaminated gloves, EI #1 pulled the clean incontinent pad/cloth diaper under RI #7. On 06/23/16 at 12:15 PM, the surveyor conducted an interview with EI #1. The surveyor read back the observation from the incontinent care provided to RI #7 on 06/22/16. The surveyor asked EI #1 what should she have done after she removed the dirty incontinent pad/cloth diaper from under RI #7 and before touching the clean incontinent pad/cloth diaper. EI #1 replied, I should have took off the gloves and washed my hands. The surveyor asked EI #1 when this was not done, what is this considered. EI #1 replied, You have contaminated the clean area. On 06/23/16 at 1:24 PM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what should a CNA do after touching a dirty incontinent pad and soiled adult brief and before touching a clean adult pad and clean adult brief. EI #2 replied, She needs to dispose of dirty gloves, wash her hands and apply clean gloves. 3. On 06/22/16 at 11:34 AM, the surveyor observed CNAs, EI #3 and EI #1, prepare to provide incontinent care to RI #7. EI #3 wiped RI #7's right buttock times two in upward motion using a different wash cloth each time. EI #3 wiped RI #7's left buttocks times two in upward motion. EI #1 placed a container of Soothe and Cool Protector Moisture Barrier on the bed. EI #3 then picked up the container of Soothe and Cool Protector Moisture Barrier from the bed and opened the tube. EI #3 then squeezed the cream on her right glove, applied it to the sacral area and the left and right buttocks area. The contaminated gloves remained on during the entire application. On 06/23/16 at 12:41 PM, the surveyor conducted a phone interview with EI #3. The surveyor asked EI #3, when you picked up the moisture barrier cream what should you have done with your contaminated gloves. EI #3 replied, Rolled them up and washed my hands. On 06/23/16 at 1:24 PM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what should a CNA do with their contaminated gloves before touching anything clean. EI #2 replied, They need to throw them away and wash their hands. The surveyor asked, does this apply to picking up anything like a container of moisture barrier. EI #2 replied, Yes, you are contaminating the container. You should change gloves before picking it up. The FUNDAMENTALS of NURSING eighth edition POTTER PERRY stockert hall chapter 31 Medication Administration page 613 documented: i. Prepare solid forms of oral medications: (1) To prepare tablets or capsules from a floor stock bottle, pour required number into bottle cap and transfer medication to medication cup. Do not touch medication with fingers . Avoids contamination of medication and avoids waste . 4. Resident Identifier (RI) #19 was admitted to the facility on [DATE], [DIAGNOSES REDACTED]. RI #19's Physician order [REDACTED]. Vitamin B12 500 micrograms, [MEDICATION NAME] 40 Milligrams (MG), [MEDICATION NAME] 10 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 5 mg (2) = 10 mg, Potassium 10 Milliequivalents, [MEDICATION NAME] 10 mg, Tecfidera 240 mg, Vitamin D3, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 10 mg and [MEDICATION NAME] 100 mg. On 06/22/16 at 8:40 AM, the surveyor observed a Licensed Practical Nurse (LPN), EI #10, during the morning Medication Administration Observation to administer the above medications to RI #19. The surveyor asked EI #10 how many pills were in the medications cup. EI #10 counted the pills and used her bare finger to touch the pills during the count. After the the count EI #10 said 14 pills. On 06/22/16 at 1:18 PM, the surveyor conducted an interview with EI #10. The surveyor asked EI #10 should the nurse touch the medications with her bare finger and administer the medications to a resident. EI #10 said no. The surveyor asked EI #10 if she touched the medications with her bare fingers what is this called. EI #10 said germs, cross contamination. On 06/22/16 at 4:57 PM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 should the nurses touch the medication with their bare fingers. EI #2 said no. On 06/22/16 at 1:18 PM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what is this called when the nurses touch the medications with their bare fingers and administer the medications to a resident. EI #2 said contamination. On 06/23/16 at 2:00 PM, the surveyor observed 2 bags of clothes stored on the floor in the laundry department. Also, there were four bundles of new towels observed stored on the floor in the washing area. EI #9, the Environmental supervisor said they received the towels five days ago and that is where supply put the towels. On 06/23/16 at 2:40 PM, the surveyor conducted an interview with EI #9. The surveyor asked EI #9, where should she/staff store clean clothing and towels. EI #9 said in a laundry cart off the floor.

Based on observations, record review and interviews, the facility failed to ensure there was padding on the Oxygen (02) tubing behind the ears of Resident Identifier (RI) #'s 2, 3, 5, 7, 17 and 18, residents at risk of pressure ulcers. This affected RI #'s 2, 3, 5, 7, 17 and 18, six of seven sampled residents on Oxygen Therapy. Findings Include: 1. RI #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/17/16, assessed RI #5 under Section M - Skin Conditions as being at risk of developing pressure ulcers. On 06/22/16 at 12:15 PM, the surveyor observed RI #5 lying in bed with O2 infusing by way of a nasal cannula/concentrator at 2 liters per minute. There was no padding on the O2 tubing behind RI #5's ears. On 06/22/16 at 5:17 PM, RI #5 remained in bed. The surveyor did not observe padding on the O2 tubing behind RI #5's ears. On 06/23/16 at 8:29 AM, the surveyor accompanied EI #6, the Licensed Practical Nurse (LPN) assigned to care for RI #5 on the 7-3 shift into RI #5's room. The surveyor asked EI #6 to remove the O2 tubing from behind RI #5's ears. The surveyor asked EI #6 was there padding on the O2 tubing. EI #6 replied no. The surveyor asked EI #6 what was there a potential for when there was no padding on the O2 tubing behind the ears. EI #6 said breakdown. On 06/23/16 at 1:45 PM, the surveyor conducted an interview with EI #2, the Registered Nurse (RN) Unit Manager on the unit RI #5 resided on. The surveyor asked EI #2 did RI #5 wear O2. EI #2 replied, Yes Ma'am. The surveyor asked EI #2 had RI #5 ever had padding on the O2 tubing behind the ears. EI #2 said not to her knowledge. The surveyor asked EI #2 what was there a potential for when the O2 tubing is not padded behind the ears. EI #2 replied, Skin breakdown. 2. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment, with an ARD of 05/30/16, assessed RI #7 under Section M - Skin Conditions as being at risk of developing pressure ulcers. On 06/21/16 at 3:15 PM, during the initial tour of the facility, RI #7 was observed lying in bed with O2 infusing at 2 liters a minute. The surveyor did not observe padding on the O2 tubing behind RI #7's ears. On 06/22/16 at 8:50 AM, the surveyor observed that RI #7's O2 tubing remained without padding behind the ears. On 06/22/16 at 4:00 PM, the surveyor observed that the O2 tubing behind RI #7's ears still did not have any padding. On 06/23/16 at 2:01 PM, the surveyor conducted an interview with EI #4, the RN Unit Manager on the unit RI #7 resided on. The surveyor asked EI #4 did RI #7 wear O2. EI #4 said yes Ma'am. The surveyor asked EI #4 did RI #7 have padding on the O2 tubing behind the ears. EI #4 said he did not know for a fact that RI #7 did. The surveyor asked EI #4 what was there a potential for when the O2 tubing is not padded behind the ears. EI #4 replied, Skin breakdown. 3. Resident Identifier (RI) #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 08/07/15 revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating RI #2 is cognitively intact for daily decision making. Also RI #2 was assessed under Section O - Special Treatments, Procedure, and Programs to have been on Oxygen Therapy during this assessment period. RI #2's June 2016 Physicians Order documented: O2 @ (at) 2L/Min (liters per minute) as needed for Shortness of Breath . On 06/21/16 at 3:15 PM, the surveyor observed RI #2 in her room receiving oxygen therapy at the rate of 2 liters per nasal cannula. Surveyor asked RI #2 if he/she had any padding on his/her O2 tubing. RI #2 replied no and removed the O2 tubing. There was no padding on the O2 tubing for RI #2. 4. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3 was assessed under Section M-Skin Conditions as being at risk for developing pressure ulcer. RI #3's June 2016 physician's orders [REDACTED]. On 06/22/16 at 8:15 AM, the surveyor observed RI #3 sitting up in bed eating breakfast, O2 concentrator on infusing at 2 liters per minute, O2 tubing not on resident. O2 tubing laying on resident's lap. Surveyor asked resident if his/her O2 tubing had padding for ears. RI #3 said, no, it don't and picked it up to show the surveyor, there was no padding on O2 tubing for RI #3. On 06/23/16 at 8:30 AM, the surveyor observed RI #3 sitting on side of bed. O2 on infusing at 2 liters per minute per nasal cannula. Surveyor asked resident if his/her O2 tubing had padding for his/her ears. EI #3 removed the tubing and said, no. Surveyor did not observe any padding for O2 tubing for RI #3's ears. 5. RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 05/27/2016 revealed a BIMS (Brief Interview for Mental Status) score of 5 indicating RI #17 had severe impairment for daily decision making. Also RI #17 was assessed under Section M Skin Conditions, RI #17 was assessed as being at risk for developing pressure ulcers. On 06/21/2016 at 3:11 PM during the initial tour RI #17 was observed to not have padding on the Oxygen tubing behind the ears. On 06/22/2016 at 4:05 PM RI #17 was observed wearing O2, the surveyor asked the resident if he/she could remove the Oxygen tubing from behind the ears. RI #17 stated, It's sore, the surveyor did not observe any padding on the Oxygen tubing. On 06/23/2016 at 11:05 AM, RI #17 O2 tubing was lying on the Oxygen concentrator. The surveyor did not observe any padding on the Oxygen tubing. 6. RI #18 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 05/31/2016 revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating RI #18 was cognitively intact for daily decision making. Also RI #18 was assessed under Section M Skin Conditions, RI #18 was assessed as being at risk for developing pressure ulcers. On 06/21/2016 at 3:11 PM during the initial tour RI #18 was observed to not have padding on the Oxygen tubing behind the ears. On 06/22/2016 at 4:05 PM, RI #18 was observed wearing O2, the surveyor asked the resident if he/she could remove the Oxygen tubing from behind the ears. The surveyor did not observe any padding on the Oxygen tubing. On 06/23/2016 at 11:03 AM, RI #18 was observed lying in bed wearing O2. The surveyor asked RI #18 to remove the Oxygen tubing from behind the ears, surveyor did not observe any padding on the Oxygen tubing.

Based on interviews and record review, the facility failed to ensure a care plan was developed: (1) when Resident Identifier (RI) #1 was identified with a Urinary Tract Infection [MEDICAL CONDITION] on 03/15/16; (2) for RI #2's Oxygen (02) usage; (3) when RI #3 was identified with a UTI on 06/15/16; (4) when RI #6 was identified with a UTI on 05/10/16; (5) for RI #7's 02 usage; (6) for RI #9's Hydration; and for (7) for RI #7's 02 usage. These deficient practices affected RI #1, 2, 3, 6, 7, 9 and 17, seven of 21 sampled residents whose plan of care was reviewed. Finding Include: 1. RI #6 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #6's Telephone physician's orders [REDACTED]. U/A (Urinalysis) c (with) C&S (Culture and Sensitivity) . Another Telephone physician's orders [REDACTED]. . Start [MEDICATION NAME] 100 mg (milligrams) 1 tab (tablet) p.o. (by mouth) BID (twice a day) x (times) 7 days. A third Telephone physician's orders [REDACTED]. (1) Keflex 500 mg po BID x 7d (days). A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 05/23/16, identified RI #6 to have had a UTI within the past 30 days. On 06/23/16 at 2:01 PM, the surveyor conducted an interview with Employee Identifier (EI) #4, the Registered Nurse (RN) Unit Manager of the unit RI #6 resided on. The surveyor asked EI #4 did RI #6 have a history of UTI's. EI #4 said he was sure RI #6 had one in the past since she/he had been at the facility. The surveyor asked EI #4 should RI #6 have a care plan for the UTI. EI #4 replied, Yes Ma'am. The surveyor asked EI #4 who would be responsible for developing the care plan. EI #4 said the MDS Coordinator. On 06/23/16 at 3:21 PM, the surveyor conducted an interview with the MDS Coordinator, EI #5. The surveyor asked EI #5, when a resident has been diagnosed with [REDACTED]. EI #5 replied, We have never care planned for that since I have been here. The surveyor asked EI #5 who was responsible for developing care plans for the residents. EI #5 said she developed the nursing care plans. The surveyor asked EI #5, what was the purpose of having a care plan. EI #5 said to make sure the resident is being cared for appropriately and make sure the resident gets what they need, the care they need. 2. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment, with an ARD of 05/30/16, assessed RI #7 under Section O - Special Treatments, Procedures, and Programs to have been on Oxygen Therapy during this assessment period. RI #7's June 2016 Physician order [REDACTED].> . 02 @ (at) 2LPM (liters per minute) PER (by) NC (nasal cannula) KEEP SAT (saturation) ABOVE 94% (percent) . On 06/23/16 at 3:21 PM, the surveyor conducted an interview with the MDS Coordinator, EI #5. The surveyor asked EI #5 did RI #7 wear 02. EI #5 said RI #7's 02 should be PRN (as needed). The surveyor asked EI #5 was RI #7 care planned for the 02 usage. EI #5 said RI #7 did not have a care plan for the 02. The surveyor asked EI #5 should RI #7 have a care plan for the 02 usage. EI #5 replied, Yes. 3. RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's June 2016 Physician order [REDACTED]. [MEDICATION NAME] 10 milligrams (MG) an [MEDICATION NAME], a diuretic, [MEDICATION NAME] POWDER, a bulk laxative/fiber, [MEDICATION NAME] 500 MG . These medications are risk factors for dehydration. A review of RI #9's plan of care did not reveal the facility had developed a care plan to address RI #9's Hydration status from the admitted [DATE] until the dates of the survey 06/21/16 -06/23/16. On 06/23/16 at 3:00 PM, the surveyor conducted an interview with the Minimum Data Set (MDS)/Care Plan Coordinator, EI #5. The surveyor asked EI #5 if there was a care plan for RI #9's Hydration. EI #5 said she did not develop (one for the resident). EI #5 said there is just a diuretic care plan and it did not address the hydration. EI #5 said the RD (Registered Dietitian) determined the fluids that is to be on the residents tray. The surveyor asked EI #5 who was responsible for updating the care plans. EI #5 said all of us. EI #5 said anyone can update the care plan. 4. Resident Identifier (RI) #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 08/07/15 revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating RI #2 is cognitively intact for daily decision making. Also, RI #2 was assessed under Section O - Special Treatments, Procedure, and Programs to have been on Oxygen Therapy during this assessment period. RI #2's June 2016 Physicians Order documented: O2 @ (at) 2L/Min (liters per minute) as needed for Shortness of Breath . A review of RI #2's care plan revealed there was no care plan for RI #2's O2 usage. On 06/23/16 at 2:53 PM, the surveyor conducted an interview with EI (Employee Identifier) #2, Registered Nurse (RN) Unit Manager Station I. EI #2 was asked did RI #2 wear/use O2. EI #2 said, yes RI #2 uses O2 PRN (as needed). EI #2 was asked if RI #2 was care planned for the O2 usage. EI #2 replied, No. EI #2 was asked should RI #2 have a care plan for O2 usage. EI #2 said, yes RI #2 should have a care plan for O2 usage. EI #2 was asked what is the potential harm in not having care plans to address residents current medical status or problems. EI #2 replied residents not being taken care of in a proper way. 5. RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #3's June 2016 Physician order [REDACTED]. A physician's orders [REDACTED]. results. Another physician's orders [REDACTED].o. (by mouth) BID (two times a day) x (times) 7 days. A Physican's Order for RI #3 dated 06/19/16 documented: [MEDICATION NAME] 100 mg po BID x 7 days. A review of RI #3's care plan revealed there was no care plan for RI #3's UTI. The surveyor conducted an interview with EI (Employee Identifier) #2 RN (Registered Nurse) Unit Manager Station I on 6/23/16 at 2:37 PM. EI #2 was asked if RI #3 was being treated for [REDACTED].#2 replied yes. EI #2 was asked how long has RI #3 been treated for [REDACTED].#2 replied, RI #3 had been treated for [REDACTED].#3 was [MEDICATION NAME] three days while pending culture, when the culture came back RI #3 was started on [MEDICATION NAME]. EI #2 was asked who is responsible for initiating the care plan when residents have a new problem. EI #2 said, EI #5, the MDS Coordinator. EI #2 replied, the care plan would be updated when there is a problem and yes there should have been a problem of UTI added to RI #3 care plan. 6. Resident Identifier (RI) #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An Annual MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 04/09/2016 revealed a BIMS (Brief Interview for Mental Status) score of 12 indicating RI #1 was moderately impaired for daily decision making. Also RI #1 was assessed under Section I - Active Diagnoses, and was checked for Urinary tract infection [MEDICAL CONDITION] (Last 30 days) during this assessment period. A Urine Culture, Routine collected on 03/11/2016 and reported 03/15/2016 that RI #1's final report revealed an abnormal results of [DIAGNOSES REDACTED] pneumoniae; 50,000 -100,000 colony forming units per ml (milliliter). A review of RI #1's care plan revealed there was no UTI care plan for RI #1. On 06/23/2016 at 2:45 PM an interview with EI #5, Registered Nurse (RN) MDS Coordinator was conducted. EI #5 was asked if she was responsible for developing care plans and putting them on the chart. EI #5 replied, I am. EI #5 was asked if RI #1 has a UTI care plan on the chart. EI #5 replied, No ma'am, I have never done UTI care plans . EI #5 was asked why does RI #1 not have one, EI #5 replied, Cause I've never done one, we have never done UTI care plans since I've been here. The surveyor asked EI #5 what was the potential harm for not having one on the chart, EI #5 replied, the Certified Nurse Assistant (CNA) would not know if they have a UTI. EI #5 also stated the CNA would try to push extra fluids if they knew. 7. RI #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].> (greater than) 90 % (percent) AS NEEDED. An Annual MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 05/27/2016 revealed a BIMS (Brief Interview for Mental Status) score of 5 indicating RI #17 had severe impairment for daily decision making. Also RI #17 was assessed under Section O - Special Treatments, Procedures, and Programs to have been on Oxygen Therapy during this assessment period. On 06/23/2016 at 2:04 PM an interview with EI #5, Registered Nurse (RN) MDS Coordinator was conducted. The surveyor asked EI #5, are you responsible for putting care plans on the care plan book. EI #5 replied, whoever admits the resident is responsible for putting it on kiosk. The surveyor asked EI #5, are you responsible for following up to make sure that the care plan is on the chart. EI #5 replied, yes. The surveyor asked EI #5, are you responsible when it is time for review of the care plan to check to make sure they are on the chart, EI #5 replied, yes. The surveyor asked EI #5, Is there an O2 care plan on RI #17's chart or in the care plan book, EI #5 replied, No. The surveyor asked EI #5, what would be the harm in not having the O2 care plan on the chart for staff access, EI #5 replied, Cause harm to the resident.

Based on interview, record review and review of a facility policy titled Resident Change Reporting, the facility failed to ensure the family of Resident Identifier (RI) # 5 was notified of RI #5's elevated white blood count and the [DIAGNOSES REDACTED]. This affected one of 21 sampled residents. Findings include: The Policy and Procedure titled Resident Condition Change Reporting, Purpose, no date, documented: The facility must immediately inform the resident; consult with the resident's physician and if known, notify the resident's sponsor of any change in condition. Policy: Physician, Resident and/or sponsor are notified of changes in resident's condition. Procedure: . 5. All notifications of residents, sponsor, and physician notifications must be documented in the clinical record . Resident Identifier (RI) #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set identified RI #5 with long and short term memory problems and severely impaired decision making skills. During the review of the medical record for RI #5, lab results dated 06/01/16, revealed a White Blood Cell count was noted to be 16.3, which is elevated from the normal range of 10-12. Further review of the medical record revealed a physician progress notes [REDACTED].#5 had a rash that has moved to the L LE (left lower extremity) and appeared to be [MEDICAL CONDITION] in nature. On 06/01/16, a prescription for Bactrim twice a day for ten days was started for the [MEDICAL CONDITION]. There was no evidence in RI #5's medical record that the sponsor was notified of the increased white count, the new [DIAGNOSES REDACTED]. On 06/23/16 at 12:45 PM, Employee Identifier (EI) #4, Registered Nurse (RN) Unit Manager Station II, was asked about the process of notifying sponsors of resident changes. EI #4 stated the information was documented in the nurses notes. EI #4 also stated the family should be notified of changes in orders or new treatments. On 06/23/16 at 2:40 PM, when EI #2, RN Unit Manager Station I, was asked if anyone had notified RI #5's sponsor she replied, I don't know. It should have been documented.

Based on observations, interviews, and record reviews the facility failed to adhere to professional standards of practice, follow facility's policies/procedures and physician orders [REDACTED]. a) A licensed staff allowed a Certified Nursing Assistant (CNA) to apply a prescribed medication ([MEDICATION NAME]) to RI #1's bilateral heel pressure ulcers twice in October 2010; b) The licensed staff failed to provide wound treatment as ordered by the physician for a [MEDICATION NAME] dressing to the right heel every third day and as needed. EI #5 reported that she received the order for [MEDICATION NAME] dressing to be applied to the right heel on 08/02/10. EI #5 verified that she applied the [MEDICATION NAME] dressing on 08/02/10 but failed to transcribe the order to the Treatment Administration Record (TAR), causing the treatment not being carried out for the time period of 08/02/10 to 10/16/10; c) The licensed staff failed to administer Zinc 220 mg (milligram) for 15 days as ordered by the physician. The October and November 2010 Medication Administration Record (MAR) revealed that RI #1 received 11 doses instead of the 15 doses of Zinc; and d) The nursing staff failed to consistently float RI #1's heels as ordered by the physician on 10/16/10. For four consecutive days of the survey (11/09/10 through 11/12/10), the State Surveyors observed RI #1's not floating as ordered; These deficient practices placed the health of RI #1, one of seven sampled residents, in immediate jeopardy as it is likely to cause serious injury, harm or death to RI #1. On 11/12/10 at 4:25 PM, the facility's Chief Operating Officer (COO), Chief Financial Officer (CFO), Medical Director, Director of Nursing (DON), Director of Quality Assurance, Director of Environmental Service, Director of Social Service, and Registered Nurse Supervisor were notified of the findings of immediate jeopardy. Findings include: Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 09/28/10 identified RI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #1 is assessed as requiring extensive assistance with bed mobility and being totally dependent on staff for all other Activities of Daily Living (ADLs). RI #1 is further assessed as having no pressure ulcers during this assessment period. A review of RI #1's "Physician's Telephone Orders" dated 08/02/10, documents "D/C (discontinue) previous tx (treatment) to (R) (right) heel Apply [MEDICATION NAME] to (R) heel P/U (pressure ulcer) q (every) 3rd day & PRN (as needed)." This verbal order was received and signed by EI #5, the Licensed Practical Nurse (LPN) Charge Nurse. According to the National Pressure Ulcer Advisory Panel "Pressure Ulcer Treatment Quick Reference Guide" page 25 documents "Dressings Wound dressings are a central component of pressure ulcer care. The selection of the dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure ... [MEDICATION NAME] Dressing 1. Use [MEDICATION NAME] dressings for clean Category/Stage II pressure ulcers in body areas where they will not roll or melt ... ." The "Wound Care Information Network" http://www.medicaldu.com/hydrochp.htm, documents "... [MEDICATION NAME] are occlusive and adhesive wafer dressings which combine absorbent [MEDICATION NAME] materials with adhesive [MEDICATION NAME] to manage light to moderate amounts of wound exudate. Most [MEDICATION NAME] react with wound exudate to form a gel-like covering which protects the wound bed and maintains a moist wound environment ... ." In an interview on 11/12/10 at 9:35 AM, while reviewing RI #1's medical record, the State Surveyor asked EI #5, to read RI #1's physician order [REDACTED]." The State Surveyor asked EI #5, on 10/07/10 what was the treatment in place for RI #1. EI #5 answered, "it should be the 08/02/10 treatment of [REDACTED]." The State Surveyor then asked EI #5, if RI #1's [MEDICATION NAME] dressing was being put on every third day and prn as ordered. EI #5 replied, "no ma'am not according to the documentation." The State Surveyor asked EI #5, who is responsible for ensuring the order was brought over to the treatment record and EI #5 explained, "I would have been because on 8/2/10 I received the order from (EI #10) and it would have been my responsibility to make sure it got put on the treatment sheet." The State Surveyor then asked EI #5, if she applied the [MEDICATION NAME] dressing as ordered. EI #5 answered, "I do recall from memory putting it on that day I got the order but I did not after that." When the State Surveyor asked EI #5, why, she stated, "probably because I didn't put (it) on treatment sheet." The State Surveyor and EI #5 reviewed RI #1's August treatment sheet and the physician order [REDACTED]. A review of RI #1's Medication and Treatment Administration Record for October 2010, does not indicate a physician order [REDACTED]. The facility's undated policy titled "Skin Care" documents "Purpose: To provide guidelines concerning the evaluation and management of residents with pressure areas. Policy: All nursing staff will follow guidelines in the prevention and treatment of [REDACTED]. A physicians order will be obtained and followed for treatment of [REDACTED]. The facility's undated policy titled "Wound monitoring" documents " ... Procedure: ... 3. Interventions will be carried out in an effort to promote progression of healing ... ." In an interview on 11/14/10 at 9:15 AM, EI #4, a Registered Nurse (RN) Supervisor, was asked, who is the nurse assigned to quality assurance. EI #4 replied that at some point it could be him. The State Surveyor read the facility's policy titled "Transcription of Physician Orders" and asked how was it that RI #1's 08/02/10 physician order [REDACTED]. EI #4 explained that the order should have been caught in the chart audit and maybe RI #1's chart was not audited at that time. The State Surveyor then asked, if there was a system to determine whose chart gets audited at what time. EI #4 replied that he was unfamiliar with that system. The facility's policy titled "Transcription of Physician Prescriptions" with a revision date of June 2001, documents "Purpose: To provide guidelines for transcription of physician prescriptions Policy: ... 9. The nurse assigned to Quality Assurance is responsible for checking the order sheet to see that all prescriptions from the previous seventy-two (72) hours have been transcribed accurately to the Medication Administration Record (MAR), Treatment Record or other appropriate place ... ." On 11/08/10, the State Agency received a third party complaint that revealed EI #9, a Certified Nursing Assistant (CNA), treated RI #1's bilateral wounds on her heels with [MEDICATION NAME], a prescribed medication. RI #1's "Nurses Progress Notes" dated 10/16/10 7-3 (7:00 AM to 3:00 PM) documents "Areas to both heels remain darkened ... Tx (treatment) of [MEDICATION NAME] spray applied to both heels. Protective boots applied & heels floating ... ." RI #1's "Physician's Telephone Orders" dated 10/16/10, documents "1) D/C (discontinue) previous order to (R) (right) heel 2) Apply [MEDICATION NAME] spray to both heels q (every) shift 3) Float heels." Contained within the facility's investigation file is a typed letter that documents, "... Final Investigation: (RI #1) ... Findings of allegation of neglect: ... While interviewing (EI #5), she confirmed that she had asked C.N.A. to apply [MEDICATION NAME] mixed with Vaseline to (RI #1) heels, during the 3 days prior to October 16, 2010 ... ." In an interview on 11/10/10 at 3:00 PM, the State Surveyor asked EI #5 (LPN), to tell when she gave EI #9 (a CNA) the [MEDICATION NAME] spray to apply on RI #1's bilateral heels. EI #5 explained that she didn't know exactly what day it was but that she did recall one time giving EI #9 (a CNA) the [MEDICATION NAME] spray to put on RI #1's bilateral heels. EI #5 explained that it was strictly her fault and that she has since corrected the problem. In a follow up interview on 11/12/10 at 9:35 AM, EI #5 was asked, if [MEDICATION NAME] was a medication. EI #5 answered that it was. In an interview on 11/10/10 at 2:00 PM, EI #9 (CNA) acknowledged that on two occasions she applied [MEDICATION NAME] (a prescribed medication) to RI #1's bilateral heels. EI #9 further explained that EI #5 looked at RI #1's heel and applied [MEDICATION NAME] spray. Then a couple of days later, EI #5 gave her (EI #9) the [MEDICATION NAME] spray to put on RI #1's right heel. EI #9 then explained how she observed a vaseline jar with what appeared to be [MEDICATION NAME] in the jar in RI #1's room. EI #9 stated that she was pretty sure it was [MEDICATION NAME] because it had a horrible smell. EI #9 said that she applied this mixture to RI #1's right heel. The State Surveyor asked EI #9 the number of times she applied [MEDICATION NAME] on RI #1. EI #9 answered, "one time I sprayed and one time I used the mixture." EI #9 explained that after speaking with the Ombudsman she learned that [MEDICATION NAME] was a prescription medication and that she could not apply. EI #9 commented that if she had known she would have corrected EI #5. EI #9 further stated, " ... I know now not to use it. I regret it ... ." "Potter Perry Fundamentals of Nursing 7th Edition" page 704 documents " ... Nurse's Role ... Do not delegate any part of the medication administration process to assistive personnel ... ." The "Disciplinary Report" for EI #5 dated 10/20/10, documents " ... Details of Counseling Session: Employee gave prescription medication to CNA and asked CNA to apply to resident, Employee failed to adminster (administer) medication per physician order [REDACTED]. RI #1's "Nursing Home ADL" sheet for September and October 2010, contains resident care activities to be carried out by the CNAs. This document instructs the CNA staff to apply heel protector and float RI #1's heels while in bed. In an interview on 11/10/10 at 2:00 PM, EI #9 who works 7 -3 was asked if she would find RI #1's heels floating when she came in to work. EI #9 replied that she would not. EI #9 explained that one of the first things she did was to check on RI #1. According to EI #9, RI #1's heels would be flat in the bed with the comforter and sheet tucked in the corners of the bed; RI #1's heels were not floating. EI #9 stated that she did not know who to blame because it could have been someone from 3 to 11 shift (evening shift)or the 11 to 7 shift (night shift). On 11/09/10 at 3:52 PM, RI #1 was observed in her room lying in bed on her back with a pillow under her knee and the heels not floating. On 11/10/10 at 5:00 PM, the State Surveyor accompanied EI #7, a LPN, to RI #1's room. RI #1 was observed laying in bed with both heels in bootie heel protectors and resting directly on the bed. The State Surveyor asked EI #7 if RI #1's heels are floated. EI #7 answered that RI #1 has on booties and her feet are floating. When asked if the resident's heels were touching anything. EI #7 responded that RI #1's heels are touching the inside of the booties and resting on a water mattress. The State Surveyor asked EI #7, if she considered RI #1's feet to be floating. EI #7 answered that she did since there was a pillow underneath the calf of RI #1's leg. In an interview on 11/11/10 at 2:00 PM, EI #10, the facility's Medical Director, was asked the definition of floating the heels. EI #10 replied completely off the bed. The State Surveyor shared with EI #10, observations of RI #1 on 11/10/10 of RI #1 wearing heel protectors with her heels in the protectors resting directly on the water mattress. EI #10 then stated that's not floating. On 11/11/10 at 9:10 AM, RI #1 was observed lying flat in bed on her back with her heels in booties (heel protectors) . The booties were positioned on top of a rolled towel (not floating). On 11/12/10 at 9:45 AM, EI #13, a CNA, accompanied the State Surveyor to RI #1's room. The State Surveyor asked EI #13, if RI #1's heels were floating when they entered the room. EI #13 stated that they were not. She described RI #1's heel as being down against the geri-chair, not extended in the air. In an interview on 11/12/10 at 8:40 AM, EI #3, a Registered Nurse Supervisor, was asked, how RI #1 developed pressure ulcers to her heels if the facility was floating her heels. EI #3 replied, "Apparently they weren't floated all the time; we are responsible for letting this happen." RI #1's "Physician's Telephone Orders" dated 10/21/10 documents "Zinc 220 mg (milligram) po (by mouth) qd (everyday) x 15 days ... ." RI #1's "Care Plan" for the problem/need of "Risk for skin breakdown" has a handwritten entry dated 10/21/10 that documents "Zinc 220 mg po every day x 15 days." According to the "2010 Mosby's Nursing Drug Reference 23rd Edition" pages 1139 - 1139, Zinc is a medication used for the "prevention of zinc deficiency, adjunct to vit (vitamin) A therapy." "Unlabeled uses: wound healing." A review of RI #1's "Medication Administration Record" for October 2010, documents that RI #1 received Zinc 220 mg every day from 10/21/10 to 10/31/10, a total of 11 days. A review of RI #1's "Medication Administration Record (MAR)" for November 2010, does not list Zinc as an ordered medication. In an interview on 11/14/10 at 9:30 AM, EI #2 (Director of Nursing) confirmed that RI #1's physician order [REDACTED].#1 did not receive the remaining four doses. The facility's undated policy titled "Physician Orders" documents "Purpose: To ensure that each resident receives medical treatment through accurate physician's orders [REDACTED]. Procedure: ... 2. All Medication Administration Records will be updated every 30 days for accuracy ... 6. All physician orders [REDACTED]. Any changes will be added to the MAR and/or physician's orders [REDACTED]. The "Nurse Review" signature and date section of RI #1's November 2010 "Physician Orders" is blank. The "Medication Discrepancy Form" dated 11/14/10 10:55 AM, documents "Medication Incident ... Patient Name: (RI #1) ... Date: 11/14/10 ... Describe Incident: Zinc 220 mg ordered on 10-21-10 for 15 days was given 11 days in [DATE]. When MAR for [DATE] started Zinc 220 mg not carried over to [DATE] MAR CHECK OR COMPLETE ALL SECTIONS AS THEY APPLY TO THE MEDICATION INCIDENT (A) TYPE OF ERROR (X) Charting/transcription error (B) ROUTE OF ADMINISTRATION (X) PO (C) SOURCE OF ERROR (X) Nursing did not administer (D) REPORTING TIME (X) 6 hours or longer (E) CLASSIFICATION OF DRUG/IV SOLUTION (X) MAJOR Zinc 220 mg (F) RECOMMENDATIONS/COMMENTS (EI #10) notified & orders given Zinc 220 mg PO x 4 days ... ." This deficiency is cited as a result of the investigation of complaint/report number AL 442. ************************************* On 11/14/10 at 12:00 PM, the facility submitted an allegation of credible compliance for F 281, which documents: "This allegation of compliance constitutes a written allegation of substantial compliance with federal and Medicaid requirements. F281 a. The unlicensed person that applied the medication to RI #1 bilateral heels will be counseled/educated on 11/13/10 that this was not in her scope of certification. The LPN who gave the unlicensed person the medication to apply received a written warning and was educated on 10/20/10. The direct care staff available were inserviced on 11/12/10 regarding the proper position of floating RI #1 heels. The remainder of the direct care staff will be inserviced by 11/19/10 b. The facility conducted a facility wide room check on 11/13/10 to ensure that there was no medication in the resident's room. The facility will inservice all available nursing staff to include CNA's LPN, & RN on the proper positioning to float heels on 11/12/10 by RN supervisor or designee. The remainder of the nursing staff will be inserviced by 11/19/10. The facility conducted a chart audit beginning on 11/12/10 to ensure that all MD orders were being carried out. Any order dating back since Oct. 1 2010 that has not been carried out the MD will be contacted so he or she will continue the order or discontinue. Approximately 30 charts have been completed so far. c. Licensed personnel were inserviced on proper medication administration by 11/1/10 by RN supervisor or designee. All certified nursing assistants will be inserviced by 11/19/10 not to apply medications for any resident. Inservice will be conducted by RN supervisor or designee. For all residents identified requiring heels to be floated the facility CNA staff will conduct and reposition heels as needed every 2 hours to ensure compliance and document on the ADL's. The charge nurse will conduct compliance rounds 2x a shift to ensure heels are positioned properly floated and document on the compliance round forms. The RN supervisor will review the change in condition report for new MD orders to be transcribed to the MAR & TAR and carried over from month to month if not discontinued. d. The QA or designee will monitor the condition form 2x a week for 4 weeks and weekly thereafter until substantial compliance is met. The QA or designee will make random unannounced observations on 10% of the residents with requirements to float heels 5x per week for 1 month covering different days and shifts ensuring heels are floated and CNA's are not applying medications. The QA of designee will observe 2x per week for 2 months to ensure licensed staff is performing wound care as ordered by MD." On 11/14/10, the State Surveyors reviewed the facility's information provided in their allegation of credible compliance, in-service records and conducted staff and resident interviews completed as of 11/14/10, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 11/14/10 at 1:20 PM, with the scope and severity being lowered to a D level, to allow the facility time to monitor/revise their corrective actions to sustain compliance.

Based on interviews and record reviews, the facility's administration failed to provide sufficient oversight of the direct care staff to ensure that Resident Identifier (RI) #1's pressure ulcer treatments and preventive measures were being consistently implemented in accordance with facility's policy/procedure and the resident's plan of care. Refer to F 314. The Chief Operating Officer, Employee Identifier (EI) #1, reported that he relies on the Director of Nurses (EI #2) to communicate to him issues within the facility. EI #1 and EI #2 failed to ensure that the direct care staff had wound care policies and procedures established that guided the staff on how to accurately measure pressure ulcers. Additionally, EI #1 and EI #2 failed to establish a system for conducting medical record chart audits. A Registered Nurse (RN) Supervisor (EI #4) reported that the facility did not have a system for determining when a resident's medical record is checked for accuracy. These deficient practices placed the health of RI #1, one of two sampled residents reviewed for pressure ulcers, in immediate jeopardy as it is likely to cause serious injury, harm or death to RI #1. On 11/12/10 at 4:25 PM, the facility's Chief Operating Officer (COO), Chief Financial Officer (CFO), Medical Director, Director of Nursing (DON), Director of Quality Assurance, Director of Environmental Service, Director of Social Service, and Registered Nurse Supervisor were notified of the findings of immediate jeopardy in F 490. The immediate jeopardy began on 10/07/10 and was relieved on-site on 11/14/10, when the facility implemented their immediate corrective actions to remove the immediacy and prevent any future recurrence. Findings include: In an interview on 11/12/10 at 3:10 PM, EI #1 was asked how he monitors the DON (EI #2). EI #1 stated he monitors the DON just like any other manager. He said he has an open door policy and he expects the DON to come to him with issues within the facility. The State Surveyor asked EI #1 how the problems with RI #1 occurred. EI #1 answered that there are always going to be problems whenever people are involved. EI #1 commented that when people don't do things they are suppose to do, there are going to be problems. On 11/11/10 at 2:00 PM, EI #10, the facility's Medical Director, stated that the facility has to follow protocol until they get in touch with her. The State Surveyor asked EI #10, if these protocols are written protocols and she answered yes. On 11/11/10 at 3:00 PM, EI #2, the Director of Nurses was asked for the protocols that EI #10 referenced during her interview with the State Survey on 11/11/10. At 3:20 PM, EI #2 returned and stated that she contacted EI #10 and there are no protocols which instruct staff on what treatment to do for different stages of wounds. EI #2 commented that it (treatment) is on an individual basis. The "Bibb Medical Center Job Description" for Director of Nursing (updated 03/16/06), lists the following essential duties and responsibilities: " ... Establishes standards of nursing care and mechanisms for evaluating such care to ensure that the optimum achievable quality of nursing care is rendered to all residents. Develops, implements, evaluates and revises departmental policies and procedures that affect direct patient care, provide effectiveness and promote safety ... Ensures nursing compliance with standards established by regulatory agencies ... ." In a follow up interview on 11/12/10 at 3:10 PM, EI #2 was asked how she monitors staff to ensure that physician orders [REDACTED]. EI #2 answered that she reviews the Quality Assurance (QA) book weekly and has interdisciplinary meetings. In an interview on 11/14/10 at 9:15 AM, EI #4, a Registered Nurse (RN) Supervisor, was asked to identify the nurse assigned to quality assurance. EI #4 replied that at some point it could be him. The State Surveyor read the facility's policy titled "Transcription of Physician Orders" and asked how was it that RI #1's 08/02/10 physician order [REDACTED]. EI #4 explained that the order should have been caught in the chart audit and maybe RI #1's chart was not audited at that time. The State Surveyor then asked if there was a system to determine whose chart gets audited at what time. EI #4 replied that he was unfamiliar with that system. This deficiency is cited as a result of the investigation of complaint/report number AL 442. ******************************************************** On 11/14/10 at 12:00 PM, the facility submitted an allegation of credible compliance for F 490, which documents: "This allegation of compliance constitutes a written allegation of substantial compliance with federal and Medicaid requirements. F490 - DON failed to provide oversight to nursing staff In order to ensure the allegation of substantial compliance is met, the facility administrator shall use the quality assurance department, QA designee/CRNP reports to monitor the implementation of our allegation of substantial compliance. The quality assurance department will provide written reports of all findings to the Administrator. The administrator will monitor compliance with our submitted allegation of compliance on a daily basis by utilizing the written reports from the QA Department until Plan of Correction is accepted and approved and we receive notification from Licensure & Certification of substantial compliance. Facility administrator will require DON to attend a mandatory inservice provided by Alabama Nursing Home Association entitled " The Nursing Home Survey Process " on 11/30/10. On 11/12/2010 facility administrator educated DON on importance of following Policies & Procedures and ensuring that our Nursing staff is following all Policies and Procedures in order to provide quality care to our residents." On 11/14/10, the State Surveyors reviewed the facility's information provided in their allegation of credible compliance, in-service records and conducted staff and resident interviews completed as of 11/14/10, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 11/14/10 at 1:20 PM, with the scope and severity being lowered to a D level, to allow the facility time to monitor/revise their corrective actions to sustain compliance.

Based on observations, interviews and record reviews, the facility nursing staff failed to consistently implement pressure sore treatment and preventive measures to promote healing and prevent further skin breakdown to Resident Identifier (RI) #1; when: a) The licensed staff failed to consistently complete weekly skin assessments in accordance with the facility's policies and procedures and the resident's plan of care. The facility was unable to provide evidence that seven of the resident's weekly assessments were completed. RI #1's medical record was missing weekly assessments for 07/22/10, 08/05/10, 09/09/10, 09/23/10, 10/14/10, 10/28/10 and 11/04/10; b) A licensed staff allowed a Certified Nursing Assistant (CNA) to apply a prescribed medication ([MEDICATION NAME]) to RI #1's bilateral heel pressure ulcers twice in October 2010; c) The licensed staff failed to promptly notify RI #1's sponsor and physician of the identification of pressure ulcers to RI #1's bilateral heels to obtain appropriate treatment orders. On 10/07/10, Employee Identifier (EI) #5 (a Licensed Practical Nurse (LPN), documented that RI #1 had darken decubitus (pressure ulcers) to her right and left heel. On 10/17/10 (10 days later), RI #1's sponsor was notified and on 10/19/10 (12 days later), RI #1's physician was notified. EI #5 acknowledged that when she first observed the darken decubitus areas on RI #1's bilateral heels, she did not contact the physician for treatment orders; rather she continued with the present treatment of [REDACTED]. d) The licensed staff failed to provide wound treatment as ordered by the physician for a [MEDICATION NAME] dressing to the right heel every third day and as needed. EI #5 reported that she received the order for [MEDICATION NAME] dressing to be applied to the right heel on 08/02/10. EI #5 verified that she applied the [MEDICATION NAME] dressing on 08/02/10 but failed to transcribe the order to the Treatment Administration Record (TAR), causing the treatment not being carried out for the time period of 08/02/10 to 10/16/10. e) The nursing staff failed to consistently float RI #1's heels as ordered by the physician on 10/16/10. For four consecutive days of the survey (11/09/10 through 11/12/10), the State Surveyors observed RI #1's not floating as ordered; f) The Director of Nurses failed to ensure that licensed staff was properly trained in how to accurately measure the size of pressure ulcers. EI #12, a LPN reported that when she measured RI #1's pressure ulcers on 11/09/10, she only measured the necrotic area instead of the entire wound. She also reported that she measured the pressure ulcers in inches but erroneously documented the measurements in centimeters. This failure led the facility to believe that RI #1's pressure ulcers were improving with treatment. g) The licensed staff failed to administer Zinc 220 mg (milligram) for 15 days as ordered by the physician. The October and November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. h) The licensed staff failed to provide documented evidence that [MEDICATION NAME] spray to RI #1's bilateral heels was applied every shift as ordered. The July 2010 TAR revealed seven blank spaces for the 7 to 3 shift and 17 blank spaces for the 3 to 11 shift. EI #5 reported that she noticed the blanks and commented that if it wasn't signed off then it wasn't done. Additionally, the facility failed to determine the reason RI #1's sponsor refused to allow RI #1 to be sent out to the local and nearby hospital for evaluation of her pressure ulcers. RI #1's sponsor reported that when the facility spoke with her about sending RI #1 out of the facility, she refused because she thought the facility was recommending inpatient treatment instead of outpatient treatment and she feared the nursing home would not accept her back into the facility if hospitalized . On 10/07/10, the facility documented that RI #1 had darken decubitus (pressure ulcers) on her right and left heel. On 10/13/10, RI #1's right heel was described as an unstageable, draining, necrotic decubitus ulcer that measured 7.5 cm by 6 cm. RI #1's left heel was described as an unstageable necrotic tissue that measured 3 cm by 2 cm. On 10/20/10, the facility identified a new unstageable pressure ulcer on RI #1's left heel. During wound care observation on 11/10/10, EI #5 (LPN) measured RI #1's right heel to be 8 cm of redness with 5 cm of necrotic tissue in width, with 5.5 cm of redness and 4 cm of necrotic tissue in length. RI #1's left heel outer area (area #1) measured 2.5 cm by 2 cm of necrotic tissue. Area #2 measured 1.3 cm by 1.4 cm. These deficient practices placed the health of RI #1, one of two sampled residents reviewed for pressure ulcers, in immediate jeopardy as it is likely to cause serious injury, harm or death to RI #1. On 11/12/10 at 4:25 PM, the facility's Chief Operating Officer (COO), Chief Financial Officer (CFO), Medical Director, Director of Nursing (DON), Director of Quality Assurance, Director of Environmental Service, Director of Social Service, and Registered Nurse Supervisor were notified of the findings of immediate jeopardy in F 314. The immediate jeopardy began on 10/07/10 and was relieved on-site on 11/14/10, when the facility implemented their immediate corrective actions to remove the immediacy and prevent any future recurrence. Findings include: Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), with an assessment reference date of 09/28/10, identified RI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #1 is assessed as requiring extensive assistance with bed mobility and being totally dependent on staff for all other Activities of Daily Living (ADLs). RI #1 is further assessed as having no pressure ulcers during this assessment period. RI #1's "Braden Scale for Predicting Pressure Sore/Risk" dated 09/29/10, identified RI #1 as being at risk for developing pressure sores with a score of 15. According to this document, a score of 15-18, indicates the resident is at mild risk for developing pressure sores. RI #1's typed "Care Plan", last reviewed on 10/21/10 for the problem/need area of "skin breakdown" includes the approaches: "Assess skin daily with morning care and report any abnormals to charge nurse ... Weekly skin assessments by LPN charge nurse. Notify MD of any changes in resident's condition." On 11/08/10, the State Agency received a third party complaint that documented, " ... The complainant alleges her mother, resident (RI #1), developed pressure wounds to her heels that is described as the "entire right heel was totally black and a small pressure sore was developing on resident's left heel." The wounds developed in house and were not reported to the resident's sponsor, (name), when the wounds first developed ... The report alleges the pressure wound to resident (RI #1)'s heel was being treated with [MEDICATION NAME] spray and vaseline. The report reveals CNA (EI #9) admitted to identifying the wound a month earlier and treating the wound with the prescribed treatment mixed in Vaseline 2-3 times daily. There were concerns that (EI #9) is not qualified to administer the prescribed treatment and if she was administering the medication as ordered ... ." On 11/10/10 at 2:00 PM, EI #9, the Certified Nursing Assistant (CNA) who routinely assigned to care for RI #1 on the first shift until three weeks ago, was interviewed. She (EI #9) explained that during the middle of October, she noticed that RI #1's right heel was getting soft and red. EI #9 reported this to EI #5 (a Licensed Practical Nurse) and was instructed to keep RI #1's heels floated and the heel booties on. EI #9 stated that she reported this to the evening shift as well. The State Surveyor asked EI #9, on the 7:00 AM to 3:00 PM shift, if she would find RI #1's heels floating when she came in to work. EI #9 replied that she would not. EI #9 explained that one of the first things she did was to check on RI #1. According to EI #9, RI #1's heels would be flat in the bed with the comforter and sheet tucked in the corners of the bed; RI #1's heels were not floating. EI #9 stated that she did not know who to blame because it could have been someone from 3 to 11 shift (evening shift) or the 11 to 7 shift (night shift). According to EI #9, EI #5 (LPN) looked at RI #1's heel and put [MEDICATION NAME] spray on it. EI #9 stated then a couple of days later, EI #5 gave her the [MEDICATION NAME] spray to put on RI #1's right heel. EI #9 stated that when she applied the [MEDICATION NAME] spray on RI #1's right heel, there was nothing on RI #1's left heel. EI #9 further stated that both of RI #1's heels were red but the right heel had started to break down and look worse than the left heel. The State Surveyor asked EI #9 to describe the breakdown she observed. EI #9 commented, "just really soft and squishy; not like our heels." EI #9 then explained how she observed a Vaseline jar with what appeared to be [MEDICATION NAME] in the jar in RI #1's room. EI #9 stated that she was pretty sure it was [MEDICATION NAME] because it had a horrible smell. EI #9 acknowledged that she applied this mixture to RI #1's right heel. EI #9 commented that at the time both of RI #1's heels were red, but that the right one looked worse. The State Surveyor then asked EI #9, when RI #1's right heel became black. EI #9 answered that it wasn't long, within a matter of days. EI #9 stated this was reported to EI #5, who just applied the Vaseline and [MEDICATION NAME] mixture to RI #1's heels. The State Surveyor asked EI #9, the number of times she applied [MEDICATION NAME] on RI #1. EI #9 answered, "One time I sprayed and one time I used the mixture." EI #9 explained that she did not know that [MEDICATION NAME] was a prescription medication and that she could not apply [MEDICATION NAME]. EI #9 further stated, " ... I know now not to use it. I regret it ... ." RI #1's "Physician Telephone Orders" dated 03/01/10, documents "D/C (discontinue) Vaseline c (with) [MEDICATION NAME] to heels." In an interview on 11/10/10 at 3:00 PM, EI #5, the Licensed Practical Nurse (LPN) Charge Nurse, was asked, how she was notified of RI #1's breakdown on the heels? EI #5 answered, "EI #9 had reported it to me when they (RI #1's heels) started to get red." EI #5 further stated that RI #1's right heel was the first one to become red. The State Surveyor asked EI #5, when was she notified by EI #9 and she commented that she could not be specific without looking at RI #1's chart. The State Surveyor gave EI #5, RI #1's medical record and EI #5 began to flip through RI #1's nurses notes and stated that on 10/07/10 she put on RI #1's "Weekly Assessment Sheet" that RI #1's heels had darken areas. EI #5 acknowledged that when she first noticed that RI #1's heels were darkening, that she did not contact the physician, rather she continued with the current treatment order of [MEDICATION NAME]. RI #1's "Physician Telephone Orders" dated 07/07/10, documents "Apply [MEDICATION NAME] to both heels q (every) shift." The State Surveyor asked EI #5, if the darken areas to RI #1's heels were decubitus? EI #5 answered that RI #1 has a history of decubitus ulcer and anytime an area gets dark and doesn't blanche that as an LPN it's a decubitus. The State Surveyor asked EI #5, did RI #1's heels blanche and she answered "I'm going to say no because I would not have marked decubitus." EI #5 explained, "When (EI #9) came to me think 10/7 as evidenced by weekly assessment - heels darken. I didn't write nurses notes regarding heels I just documented the urinalysis and temp (temperature). I don't recall calling (the doctor). I didn't document it. Already using [MEDICATION NAME] just continued and instructed (EI #9) to float (RI #1's) heels. (RI #1) has a history of decubitus these are things we should be doing anyway. She (RI #1) already had the water mattress." The State Surveyor asked EI #5, to tell when she gave the CNA (EI #9) the [MEDICATION NAME] spray to apply on RI #1's bilateral heels. EI #5 explained that she didn't know exactly what day it was but that she did recall one time giving EI #9 the [MEDICATION NAME] spray to put on RI #1's bilateral heels. EI #9 further explained that she has corrected that problem and that she went to EI #9 and said "it was strictly my fault." The State Surveyor asked EI #5, when the facility went from using [MEDICATION NAME] spray to the [MEDICATION NAME]/Vaseline mixture. EI #5 stated that the [MEDICATION NAME]/Vaseline mixture was ordered first and then the [MEDICATION NAME] spray was ordered on [DATE]. The State Surveyor asked EI #5, if she measured RI #1's heel wounds on 10/07/10. EI #5 replied that she did not and commented that the first measurements were completed on 10/13/10 (6 days later). EI #5 commented that she classified RI #1's pressure ulcer on the left heel as unstageable; however, both left and right heels have eschar. EI #5 was asked did she contact RI #1's sponsor on 10/07/10 and she replied, "No." The State Surveyor asked EI #5, if she had to call the doctor for wound care treatment or were there standing orders. EI #5 answered, "We have to call the doctor." "Potter Perry Fundamentals of Nursing 7th Edition" page 704 documents " ... Nurse's Role ... Do not delegate any part of the medication administration process to assistive personnel ... ." The "Disciplinary Report" for EI #5 dated 10/20/10, documents " ... Details of Counseling Session: Employee gave prescription medication to CNA and asked CNA to apply to resident, Employee failed to adminster (administer) medication per physician order [REDACTED]. RI #1's "Weekly Assessment Sheet" dated 09/30/10 documents that RI #1 has bruises on the left arm and left side of chest, with no problems identified with the resident's lower legs and feet. RI #1's "Weekly Assessment Sheet" dated 10/07/10, documents that RI #1 has bruises and decubitus with dark areas to both heels. A review of RI #1's "Physician's Telephone Orders" dated 08/02/10, documents "D/C (discontinue) previous tx (treatment) to (R) (right) heel Apply [MEDICATION NAME] to (R) heel P/U (pressure ulcer) q (every) 3rd day & PRN (as needed)." This verbal order was received and signed by EI #5, the Licensed Practical Nurse (LPN) Charge Nurse. According to the National Pressure Ulcer Advisory Panel "Pressure Ulcer Treatment Quick Reference Guide" page 25 documents "Dressings Wound dressings are a central component of pressure ulcer care. The selection of the dressing should be based on the tissue in the ulcer bed, the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing or closure ... [MEDICATION NAME] Dressing 1. Use [MEDICATION NAME] dressings for clean Category/Stage II pressure ulcers in body areas where they will not roll or melt ... ." The "Wound Care Information Network" http://www.medicaldu.com/hydrochp.htm, documents "... [MEDICATION NAME] are occlusive and adhesive wafer dressings which combine absorbent [MEDICATION NAME] materials with adhesive [MEDICATION NAME] to manage light to moderate amounts of wound exudate. Most [MEDICATION NAME] react with wound exudate to form a gel-like covering which protects the wound bed and maintains a moist wound environment ... ." In a follow up interview on 11/12/10 at 9:35 AM, EI #5 was asked, if she reported to the physician and sponsor when she documented that RI #1's heels were darken decubitus on the Weekly Assessment Sheet on 10/07/10. EI #5 answered, "No I did not." When EI #5 was asked the reason she didn't ' t, she responded, "I just didn't; not going to make excuses." The State Surveyor asked EI #5, if she documented the location, stage and appearance of the darken areas on 10/07/10 and she answered, "No ma'am" and then commented " ... I just documented it was on the heels." EI #5 explained that she did not obtain a physician order [REDACTED]. EI #5 pointed to RI #1's July 2010 Treatment record, which read "[MEDICATION NAME] to both heels q (every) shift." This document had seven blank spaces for the 7 to 3 shift and 17 blank spaces for the 3 to 11 shift. EI #5 stated she just reinforced the treatment that was already in place. EI #5 commented that she reinforced this treatment because she could not be certain it was being done because there were multiple blanks on the Treatment Record. According to EI #5, if the treatment wasn't signed off it wasn't done. After reviewing RI#1's physician orders, EI #5 stated that she could not provide the State Surveyor with the physician order [REDACTED]. EI #5 replied that she was not sure since the QA (Quality Assurance) nurse (EI #14) is semi retired. EI #5 stated that when she completes her assessments she takes them to EI #4 (a RN Supervisor) or lays them on his (EI #4) desk if he is not in the facility. EI #5 explained that the nurses on the hall are responsible for providing wound treatment, when there is no assigned treatment nurse. EI #5 further explained that on first shift there are two nurses on Station One and three nurses on Station Two. She explained that when there is an extra nurse, the extra nurse is assigned to do wound treatment. The State Surveyor asked EI #5, if the facility provided any formal training on how to measure and assess wounds. EI #5 replied that she could not recall any training; however, she had worked as a treatment nurse in another facility. While reviewing RI #1's medical record, the State Surveyor asked EI #5, to read RI #1's physician order [REDACTED]." The State Surveyor asked EI #5, what treatment was in place on 10/07/10 for RI #1. EI #5 answered, "It should be the 08/02/10 treatment of [REDACTED]." The State Surveyor then asked EI #5, if RI #1's [MEDICATION NAME] dressing was being put on every third day and prn as ordered. EI #5 replied, "No ma'am not according to the documentation." The State Surveyor asked EI #5, who is responsible for ensuring the order was brought over to the treatment record and EI #5 explained, "I would have been because on 8/2/10, I received the order from (facility's Medical Director) and it would have been my responsibility to make sure it got put on the treatment sheet." The State Surveyor then asked EI #5, if she applied the [MEDICATION NAME] dressing as ordered. EI #5 answered, "I do recall from memory putting it on that day I got the order but I did not after that." When the State Surveyor asked EI #5 why; EI #5 stated, "probably because I didn't put (it) on treatment sheet." The State Surveyor and EI #5 reviewed RI #1's August 2010 treatment sheet and EI #5 verified that the physician order [REDACTED]. The facility's undated policy titled "Skin Care" documents "Purpose: To provide guidelines concerning the evaluation and management of residents with pressure areas. Policy: All nursing staff will follow guidelines in the prevention and treatment of [REDACTED]. A physicians order will be obtained and followed for treatment of [REDACTED]. The facility's undated policy titled "Wound monitoring" documents " ... Procedure: ... 3. Interventions will be carried out in an effort to promote progression of healing ... ." Also during this same follow up interview on 11/12/10 at 9:35 AM, the State Surveyor asked EI #5 the reason it took her three additional days to contact the physician for an order, since she measured RI #1's pressure wounds on 10/13/10. EI #5 replied that from memory she wanted to say that the doctor (EI #10) was out of town; however, after EI #5 read RI #1's nurses note dated 10/13/10 that stated the doctor was in the facility; EI #5 commented "so best answer is I don ' t know." The State Surveyor asked, if RI #1's heels were already being floated prior to the physician order [REDACTED]. The State Surveyor then asked how long RI #1 has had the water mattress. EI #5 replied that RI #1 has had the water mattress on her bed every since her last decubitus. EI #5 was asked, if RI #1 had the water mattress on 10/07/10 and she answered "as far as I can remember yes ma'am." EI #5 stated that when she measured RI #1's bilateral heel wounds on 10/13/10, she measured the whole wound, the outside and the eschar. EI #5 commented that the outside of the wound is just as important. The State Surveyor asked EI #5, if she completed RI #1's wound measurements on 10/26/10, which read that RI #1 has an unstageable necrotic decubitus to the right heel measuring 6 cm by 7 cm with a dark wound bed. RI #1 has two areas on the left heel. One area is described as an unstageable necrotic tissue that measured 4 cm by 2 cm with a dark blister in the center. The other area is described as an unstageable decubitus wound that measures 1 cm by 1 cm with a dark wound bed. EI #5 answered that she did not. EI #5 further stated that she did not fill out RI #1's wound measurement sheet dated 11/09/10 and commented that EI #12 was the treatment nurse on 11/09/10. The State Surveyor asked EI #5, if she agreed with the measurements from 11/09/10. EI #5 answered, "No ma'am the only thing I agree with is that the black necrotic tissue is dry with red around the area of the tissue on the right heel. I don't know which one she measured ... I don't agree with that I don't know what she (EI #12) was measuring." The State Surveyor asked EI #5, if she thought RI #1's heels are getting better or worse. EI #5 replied that appearance wise it looks worse. The State Surveyor then asked EI #5, since she thought they were getting worse, did she contact the doctor. EI #5 answered that she did not and gave no excuse for not contacting the doctor. In an interview on 11/14/10 at 9:15 AM, EI #4, a Registered Nurse (RN) Supervisor, was asked to identify the nurse assigned to quality assurance. EI #4 replied that at some point it could be him. The State Surveyor read the facility's policy titled "Transcription of Physician Orders" and asked how was it that RI #1's 08/02/10 physician order [REDACTED]. EI #4 explained that the order should have been caught in the chart audit and maybe RI #1's chart was not audited at that time. The State Surveyor then asked if there was a system to determine whose chart gets audited at what time. EI #4 replied that he was unfamiliar with that system. The facility's policy titled "Transcription of Physician Prescriptions" with a revision date of June 2001, documents "Purpose: To provide guidelines for transcription of physician prescriptions Policy: ... 9. The nurse assigned to Quality Assurance is responsible for checking the order sheet to see that all prescriptions from the previous seventy-two (72) hours have been transcribed accurately to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." RI #1's wound measurement sheet dated 11/09/10, documents that RI #1's right heel is a decubitus ulcer with necrotic tissue that measured "2.5 x 2.5 cm." The right heel's wound bed is described as "black nacrotic (necrotic) tissue (dry) red around edges." RI #1's left heel is a decubitus ulcer with necrotic tissue that measured "1 x 1 cm." The left heel's wound bed is described as "black nacrotic (necrotic) tissue (hard)." According to this document, RI #1's bilateral heels are being treated with [MEDICATION NAME] to both heel every shift. During wound care observation on 11/10/10 at 1:45 PM, EI #5 measured RI #1's right heel as 8 cm of redness with 5 cm of necrotic tissue in width; the reddened area measured 5.5 cm in length with 4 cm of necrotic tissue. RI #1's was observed to have two decubitus ulcers on her left heel. Area #1, located on the left outer heel measured 2.5 cm necrotic tissue x 2 cm ; Area #2, located just above Area #1, measured 1.3 cm x 1.4 cm. Area #2 was described as a dry scab area. In an interview on 11/13/10 at 12:15 PM, EI #12 was shown RI #1's weekly measurement sheet dated 11/09/10 , which documented that RI #1 has an unstageable necrotic decubitus ulcer on her right heel which measured 2.5 cm by 2.5 cm with dry, black necrotic tissue and red edges. The left heel was described as an unstageable decubitus with hard black necrotic tissue which measured 1 cm by 1 cm. This document listed treatment as [MEDICATION NAME] to both heels every shift. EI #12 was asked, if this was her handwriting on the RI #1's wound measurement sheet dated 11/09/10. EI #12 answered, "Yes ma'am." The State Surveyor asked EI #12, did you do the measuring and she replied, "Yes ma'am." The State Surveyor then asked EI #12, what did she measure on RI #1's right heel. EI #12 answered, "The eschar part, the black part it should be bigger than that I did it in inches but I wrote centimeter." EI #12 went to retrieve a tape measure and returned stating that the necrotic area on RI #1's right heel measured 6.5 cm x 6.5 cm. The State Surveyor asked EI #12, did she measure the red around the edges of the wound and she replied, "no ma'am." EI #12 further explained that she measured RI #1's left heel in inches as well rather than centimeters. EI #12 measured both areas on RI #1's left heel; however, in her documentation she did not differentiate which area was which. EI #12 stated that one area on RI #1's left heel, the necrotic area measured 2.5 cm x 2.5 cm and the other area was discoloration, possibly from the [MEDICATION NAME] spray, that measured 1.5 cm x 1.5 cm. The State Surveyor asked EI #12, if she had received any in-service training on wound assessments. EI #12 answered that she did not have an in-service on wound care; however, she did mention receiving an individualized in-service on the importance of documenting on the treatment records whenever treatments are rendered. EI #12 explained that she received this individualized in-service because she had been written up for not documenting on the treatment record. A review of EI #12's personnel file revealed a document titled "Disciplinary Report" dated 10/21/10 and signed by EI #12 and EI #3 (Registered Nurse Supervisor), which documents " ... DETAILS OF COUNSELING SESSION: Employee failed to document treatments given numerous times as noted on records ACTION TO BE TAKEN TO CORRECT PROBLEM: Written warning, re-education re (regarding): documentation ... ." RI #1's "Nursing Home ADL" sheet for September and October 2010 contains resident care activities to be carried out by the CNAs. This document instructs the CNA staff to apply heel protectors and float RI #1's heels while in bed. On 11/09/10 at 3:52 PM, RI #1 was observed in her room lying in bed on her back with a pillow under her knee and the heels not floating. On 11/10/10 at 5:00 PM, the State Surveyor accompanied EI #7 (a LPN) to RI #1's room. RI #1 was observed lying in bed with both heels in bootie heel protectors and resting directly on the bed. The State Surveyor asked EI #7 if RI #1's heels were floated. EI #7 answered that RI #1 had on booties and her feet were floating. When asked if the resident's heels were touching anything, EI #7 responded that RI #1's heels were touching the inside of the booties and resting on a water mattress. The State Surveyor asked EI #7, if she considered RI #1's feet to be floating. EI #7 answered that she did since there was a pillow underneath the calf of RI #1's leg. On 11/11/10 at 9:10 AM, RI #1 was observed lying flat in bed on her back with her heels in booties (heel protectors). The booties were positioned on top of a rolled towel (not floating). On 11/12/10 at 9:45 AM, EI #13 (a CNA) accompanied the State Surveyor to RI #1's room. The State Surveyor asked EI #13, if RI #1's heels were floating when they entered the room. EI #13 stated that they were not. She described RI #1's heel as being down against the geri-chair, not extended in the air. In an interview on 11/12/10 at 8:40 AM, EI #3, a Registered Nurse Supervisor, was asked, how RI #1 developed pressure ulcers to her heels if the facility was floating her heels. EI #3 replied, "Apparently they weren't floated all the time; we are responsible for letting this happen." In a telephone interview on 11/11/10 at 6:55 PM, RI #1's sponsor stated that she visited her mother every morning about 8:00 AM and in the afternoon. RI #1's sponsor explained how she received a call on 10/17/10 about 1:30 PM from EI #5 about the pressure wounds to her mother's feet. According to RI #1's sponsor she was met in the facility by EI #3 and EI #5, who both stated they were sorry. RI #1's sponsor stated that her mother was in a chair seated at the nursing station, so she didn't bother to look at her mother's feet. While visiting her mother on the next day, 10/18/10, RI #1's sponsor looked at her mother's feet and she stated that "I couldn't believe what I was looking at." According to RI #1's sponsor, the facility staff explained that they are putting [MEDICATION NAME]/Vaseline mixture on her mother's feet. RI #1's sponsor stated that she further commented in the presence of facility staff, "Lord how could they let this happen." RI #1's sponsor explain how she was called by EI #2 (Director of Nursing) on 10/19/10. RI #1's sponsor came to the facility later on 10/19/10 for a meeting with EI #2, EI #5 and EI #15 (Social Service Director). She stated that EI #2 wanted to know what they (the facility) could do to make it better. According to RI #1's sponsor, EI #15 stated she came into the meeting because she was friends with her; however, RI #1's sponsor stated that she hopes they can still remain friends but that was her mother and explained to EI #15 how she has to be her mother's eyes and ears and how in shock she was that the facility allowed her mother's feet to get like that. RI #1's sponsor stated that EI #2 told her it was neglect what they did to her mother. RI #1's sponsor stated that she voiced to the staff that she was going to call the State. According to RI #1's sponsor, EI #15 walked her to the door and asked her to pray about the situation before she makes any decisions. RI #1's sponsor stated she told EI #15 that she had already made up in her mind what she was going to do. RI #1's sponsor stated that she was kept in the meeting with them for over an hour, all the while they (facility staff) was asking her to give them another chance. RI #1's sponsor explained how she received a call on 10/25/10 from EI #3, who informed her that the Medical Director (EI #10) was out of town and that she (EI #3) had spoken with her (EI #10) about the results of the arterial study that was done. According to RI #1's sponsor, EI #3 told her the arterial study showed that RI #1 had poor circulation and that she was not a candidate for surgery. RI #1's sponsor stated that she was not aware of what kind of surgery EI #3 was speaking of. According to RI #1's sponsor, she was in the facility earlier that day (11/11/10) and the nurse reported to her that her mother's feet were getting better and how the [MEDICATION NAME] spray would help peel that black stuff off her heels. The State Surveyor asked RI #1's sponsor, if anyone at the facility has explained to her all possible treatment options, including the risks and benefits. RI #1's sponsor answered no. The State Surveyor asked, if she would want her mother seen in a wound care clinic for further evaluation. RI #1's sponsor replied, "Yes if it's going to heal her foot. I don't want her foot to get infected." RI #1's sponsor commented to the State Surv

Based on observations, interviews and record reviews the facility failed to : a) Notify Resident Identifier (RI) #1's sponsor and physician on 10/7/10 when the Licensed Practical Nurse documented on the "Weekly Assessment Sheet" that RI #1 had bruises and decubitus with dark areas to both heels. On 10/17/10, 10 days later RI #1's sponsor was notified. On 10/19/10, 12 days later, RI #1's physician was notified; and b) Notify RI #4's sponsor and physician prior to and after an indwelling foley catheter was inserted in RI #4 on 10/20/10. These deficient practices affected RI #1 and RI #4, two of five sampled residents reviewed for notification. The deficient practice related to failure to promptly notify RI #1's physician of pressure sores, placed RI #1 health in immediate jeopardy as it is likely to cause serious injury, harm or death to RI #1. Refer to F 314. On 11/12/10 at 4:25 PM, the facility's Chief Operating Officer (COO), Chief Financial Officer (CFO), Medical Director, Director of Nursing (DON), Director of Quality Assurance, Director of Environmental Service, Director of Social Service, and Registered Nurse Supervisor were notified of the findings of immediate jeopardy in F 157. The immediate jeopardy began on 10/07/10 and was relieved on-site on 11/14/10, when the facility implemented their immediate corrective actions to remove the immediacy and prevent any future recurrence. Findings include: 1) Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 09/28/10 identified RI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #1 is assessed as requiring extensive assistance with bed mobility and being totally dependent on staff for all other Activities of Daily Living (ADLs). RI #1 is further assessed as being incontinent of bowel and bladder functions. RI #1 is assessed as having no pressure ulcers during this assessment period. On 11/08/10, the State Agency received a third party complaint that documented, " ... The resident's (RI #1) pressure sores developed in house and were not reported to the resident's sponsor (name), when the wounds first developed ... ." The report further documents that on Sunday, 10/17/10 at 1:30 PM, EI #5 contacted RI #1's sponsor to report that she had noticed a place on RI #1's heel. On 10/17/10 at 2:00 PM, RI #1's sponsor went to the facility and was met by EI #5 who stated "they were sorry they missed it (referring to area on RI #1's heel)." RI #1's sponsor stated that she was told by the nurses not to worry about it, so she went home without looking at RI #1's wound. RI #1's sponsor went to facility 10/18/18 at 8:00 AM and looked at her mother's wound and said it was all black and she couldn't believe what she was seeing. RI #1's "Weekly Assessment Sheet" dated 10/07/10, documents that RI #1 has bruises and decubitus with dark areas to both heels. This document is signed by EI #5, the Licensed Practical Nurse (LPN) Charge Nurse. In an interview on 11/12/10 at 9:35 AM, EI #5 (LPN) was asked, did she report to the physician and sponsor when she identified the dark areas (decubitus) to RI #1's heels as listed on the Weekly Assessment Sheet dated 10/07/10? EI #5 answered, "No I did not." When EI #5 was asked the reason she did not, she responded, "I just didn't not going to make excuses." The State Surveyor then asked, if she documented the condition of RI #1's heels to include the location, stage and appearance. EI #5 answered that she did not. A review of RI #1's nurses notes for 10/07/10 reveals there was no documentation of skin problems. EI #5 documented on 10/07/10 that she spoke with EI #10, the facility's Medical Director, about RI #1's urine lab report and an elevated temperature. The facility's policy titled "Resident Condition Change Reporting" with a revision date of June 2001 documents: "PURPOSE: Communication with the physician about changes in a resident's condition is maintained to ensure appropriate medical follow-up. POLICY: Physicians and family members are notified of changes in residents condition. PROCEDURE: 1. The charge nurse notifies the appropriate physician and supervisor at the time of change ... 4. Family must be notified of change in condition as soon as possible. 5. Document in Clinical notes the resident's condition and that the supervisor, family, and physician were notified." In a phone interview on 11/10/10 at 6:55 PM, RI #1's sponsor was asked, when she was notified of the decubitus on RI #1's bilateral heels. According to RI #1's sponsor, EI #5 notified her on 10/17/10 at 1:30 PM (10 days later). RI #1's sponsor stated that when she arrived at the nursing home, her mother (RI #1) was seated in a chair at the nursing station. According to RI #1's sponsor, she didn't look at RI #1's bilateral heels on that day but that she returned on 10/18/10 and couldn't believe what she was looking at. RI #1's sponsor stated that she questioned the staff and asked, "Lord how could they let this happen." In an interview on 11/11/10 at 2:00 PM, EI #10, the facility's Medical Director, who is also RI #1's physician, stated that she was made aware of the areas on RI #1's bilateral heels on 10/19/10 (12 days later), the day she examined the resident, while pointing at a physician progress notes [REDACTED]. RI #1's "Physician's Progress Notes" dated 10/19/10 1:25 PM, documents "S (Subjective): Skin discoloration to both heels examined ... A (Assessment): pressure sore both heels unstageable ... ." Contained within the facility's investigation file is a typed letter that documents, "... Final Investigation: (RI #1) ... On October 19, 2010 at 3 pm, (name), Ombudsman telephoned and stated that (name), sponsor of (RI #1), reported to her that "her mother has wounds on her feet that she was unaware of and that she felt her mother has been neglected." On October 19, 2010 at 3:30 pm, ... met with (sponsor for RI #1). (RI #1's sponsor) reports that she was upset regarding her mothers wounds to bilateral heels. She also stated that she was notified on Sunday, October 17, 2010 by (EI #5) regarding areas to her mothers' heels ... Findings of allegation of neglect: ... Facility failed to follow policy regarding ... notifying sponsor of change in medical condition ... ." This document is signed by the Director of Nursing (EI #2) and dated 10/22/10. 2) Resident Identifier (RI) #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set with an assessment reference date of 08/23/10, identified RI #4 as having severely impaired cognitive skills for daily decision making. RI #4 is assessed as being totally dependent on staff for all Activities of Daily Living. RI #4 is further assessed as being incontinent of bowel and bladder. During initial tour on 11/09/10 at 4:22 PM, RI #4 was observed to have an indwelling foley catheter draining to a bedside bag with dark colored urine. RI #4's "Physician's Telephone Orders" dated 10/20/10 documents, "Insert Foley Cath (Catheter) PO (Phone Order) EI #10 (Medical Director)/EI #8 LPN (Licensed Practical Nurse)." During a phone interview on 11/11/10 at 1:10 PM, EI #8, the LPN who inserted the catheter, said she inserted the foley catheter without a physician's orders [REDACTED]. The State Surveyor asked EI #8, if she notified RI #4's family prior to or after the insertion of the foley catheter. EI #8 stated, "I do not recall doing that." The State Surveyor asked if she normally notifies the sponsor of condition changes. EI #8 answered that she normally does; however, it was at the end of her shift. RI #4's "Nurses Progress Notes" documents: "10/20/10 10pm Informed by CNA's (Certified Nursing Assistants) that resident has had no urine output this shift. Call placed to (EI #10) no answer, left message on machine ... 10/20/10 10:30 p Inserted 14 fr (french) foley cath (catheter) using sterile technique ... ." During a phone interview on 11/11/10 at 12:45 PM, RI# 4's sponsor was asked, who contacted her about the insertion of RI #4's foley catheter. RI #4's sponsor said,"No one." The surveyor asked when she became aware of the catheter and she stated about two weeks ago when she came to the nursing home. The facility's policy titled "Resident Condition Change Reporting" with a revision date of June 2001 documents: "PURPOSE: Communication with the physician about changes in a resident's condition is maintained to ensure appropriate medical follow-up. POLICY: Physicians and family members are notified of changes in residents condition. PROCEDURE: 1. The charge nurse notifies the appropriate physician and supervisor at the time of change. 2. If nursing is unable to reach attending physician, the physician on-call is notified ... 4. Family must be notified of change in condition as soon as possible ... ." In an interview on 11/11/10 at 2:00 PM, EI #10 (Medical Director and RI #4's attending physician) was asked, if it was okay to insert a foley catheter without a physician's orders [REDACTED]. This deficiency is cited as a result of the investigation of complaint/report number AL 442. ************************************* On 11/14/10 at 12:00 PM, the facility submitted an allegation of credible compliance for F 157, which documents: "This allegation of compliance constitutes a written allegation of substantial compliance with federal and Medicaid requirements. F157 a. RI # 1 sponsor was notified 10/17/10 of the wounds to bilateral heels. RI #1 MD notified on 10/19/10 of wounds to bilateral heels. RI #1 Sponsor was notified of the foley catheter 11/12/10 RI #1 MD was notified on 11/12/10 of the foley catheter. Sponsor of RI #4 was notified on 11/13/10 of foley catheter. RI #4 MD was notified on 11/13/10 b. A complete chart audit was started on 11/13/10 on all residents currently in house to ensure that there has been a timely notification of changes in condition as listed in policy of sponsor and MD from October 1 until current. Any notifications not made will be made within 24 hours of completion of the audit. Approximately 30 charts have been completed by 11/14/10. c. The licensed personnel will be inserviced by 11/19/10 by QA designee and/or CRNP of the resident condition change reporting. The facility policy will be revised by 11/19/10 to reflect the current state and federal regulations. The RN supervisor will monitor the daily shift reports and document on the QA for change in condition. Report will include the resident name, date of change of condition, what the condition is, MD notified, any new orders, sponsor notifications & what the sponsor said. And RN must look for the documentation in the medical record. d. QA or designee and or CRNP will monitor and review the RN's documentation of the shift change report 2x per week for 4 weeks then weekly thereafter until substantial compliance achieved. QA or designee/CRNP will do random review of 3 charts per each hall 2x a week x4 weeks until substantial compliance is achieved." On 11/14/10, the State Surveyors reviewed the facility's information provided in their allegation of credible compliance, in-service records and conducted staff and resident interviews completed as of 11/14/10, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was relieved on 11/14/10 at 1:20 PM, with the scope and severity being lowered to a D level, to allow the facility time to monitor/revise their corrective actions to sustain compliance.